Premature Ticagrelor Discontinuation in Secondary Prevention of Atherosclerotic CVD: JACC Review Topic of the Week

Ticagrelor is a cornerstone of modern antithrombotic therapy alongside aspirin in patients with acute coronary syndrome and after percutaneous coronary intervention. Adverse effects such as bleeding and dyspnea have been associated with premature ticagrelor discontinuation, which may limit any potential advantage of ticagrelor over clopidogrel. The randomized trials of ticagrelor captured adverse events, offering the opportunity to more precisely quantify these effects across studies. Therefore, a meta-analysis of 4 randomized clinical trials of ticagrelor conducted between January 2007 and June 2017 was performed to quantify the incidence and causes of premature ticagrelor discontinuation. Among 66,870 patients followed for a median 18 months, premature ticagrelor discontinuation was seen in 25%; bleeding was the most common cause of discontinuation followed by dyspnea. Versus the comparators, the relative risk of dyspnea-related discontinuation during follow-up was 6.4-fold higher, the relative risk of bleeding was 3.2-fold higher, and the relative risk of discontinuation due to any adverse event was 59% higher for patients receiving ticagrelor. Understanding these potential barriers to adherence to ticagrelor is crucial for informed patient-physician decision making and can inform future efforts to improve ticagrelor adherence. This review discusses the incidence, causes, and biological mechanisms of ticagrelor-related adverse effects and offers strategies to improve adherence to ticagrelor.     

Release of cytokines during generation of lymphokine-activated killer (LAK) cells by IL-2.

Supernatants of IL-2-activated mononuclear cells (MNC) that displayed an optimal lymphokine-activated killer (LAK) cell activity at 48-72 hr in culture were found to contain increased levels of tumour necrosis factor alpha (TNF alpha), interleukin-1 alpha (IL-1 alpha) and interferon-gamma (IFN-gamma) when compared with supernatants from mononuclear cells cultured in the absence of IL-2. The concentration of TNF alpha and IL-1 alpha produced by MNC at 24 hr was either increased or maintained by extending the cultures to 96 hr. In contrast, TNF beta was only detected at very low levels after 72-96 hr culture, irrespective of whether IL-2 was present or absent. Optimal concentrations of IL-2 needed to induce maximum release of TNF alpha, IL-1 alpha and IFN-gamma by MNC varied among different individuals. Enriched populations of lymphocytes secreted higher levels of all measured cytokines upon activation with IL-2 in contrast to untreated cells. Supernatants from purified monocyte preparations contained high concentrations of TNF alpha and IL-1 alpha regardless of the presence of IL-2 in the cell cultures. This work suggests that in addition to the generation of LAK cell activity, by promoting the release of other cytokines with potential anti-tumoricidal activity, IL-2 may be amplifying cell-mediated cytotoxicity, which is associated with protection against neoplastic disease.     

Association of TNF-beta polymorphism with disease severity among patients infected with hepatitis C virus

The pathogenesis of chronic hepatitis C virus (HCV) infection remains unclear. Tumour necrosis factor alpha (TNF-alpha) is alleged to contribute in the pathogenesis of chronic HCV infection. Single nucleotide polymorphism in TNF-alpha and -beta genes could influence the outcome of HCV infection. The aim was to study single nucleotide polymorphism in TNF-alpha promoter region and Nco I polymorphisms in the TNF-beta gene in patients with chronic hepatitis C. Fifty-two patients with histologically proven chronic hepatitis, who had raised ALT levels (>1.5 x ULN) and were HCV RNA positive, were studied. Genotyping of -308 promoter variant of TNF-alpha was performed by PCR with primers that incorporated an Nco I restriction site. For PCR typing of the TNF-beta Nco I restriction fragment length polymorphism, sequence specific primers were used. Polymorphism in the TNF-alpha G/G, G/A and A/A allele was not different between HCV patients and healthy controls. TNF-beta A/A allele was significantly more common (P = 0.02) in patients (28.8%) as compared to controls (12.8%), whereas no significant difference was observed for TNF-beta G/A and G/G alleles [corrected]. Nco I TNF-beta A/A was strongly associated with -308 TNF-alpha G/G (RR of HCV persistence = 4.9), indicating possible linkage between TNF-beta A/A and TNF-alpha G/G allele. Patients with severe hepatic fibrosis more frequently had the TNF-beta A/A allele as compared to patients with mild disease (P = 0.04). Immunogenetic factors, such as single nucleotide polymorphisms in TNF-beta (A/A allele), may affect the natural course of HCV infection, in particular, the disease progression. Larger studies including cytokine expression profiles are needed to fully understand the contribution of the polymorphisms described in the pathogenesis of chronic hepatitis C.     

Calbindin immunoreactivity in the developing and adult human cerebellum

Calbindin (CALB), a calcium-binding protein, is known to be expressed in the embryonic nervous system. In this study, we have examined its distribution in the cerebellum of human fetuses (11–25 weeks of gestation) and adult by immunohistochemistry. At the gestational age of 11–12 weeks, CALB immunoreactivity was present in granule and Purkinje cells throughout the cerebellum. By 16–21 weeks of gestation, immunoreactive Purkinje cells were well-differentiated in the vermis and flocculus, and their axons ran towards the deep cerebellar nuclei area, while the axon collaterals were seen to be distributed into adjacent folia. At the gestational period of 24–25 weeks, most Purkinje cells of the flocculus and vermis were arranged in one to two rows, while those of the hemispheres were still undifferentiated. A few Golgi cells of the vermis showed immunoreactivity. The neurons of the deep nuclei were immunonegative right from the gestational age of 11 weeks although a fine stippled staining of fibers was present throughout the body of all nuclei. The fibers lying close to the hilum of the dentate nucleus were strongly CALB-positive. The vestibulocerebellar fibers, being traced at the level of lower pons and upper medulla oblongata were stained as early as 11 weeks of gestation, whereas the olivocerebellar fibers were stained from 16 weeks onward. In the adult cerebellum, Purkinje cells were moderately immunopositive while granule cells were faintly stained; no other cells, including those of the deep nuclei were stained. In the medulla oblongata, the inferior olivary nucleus and olivocerebellar fibers were strongly CALB-positive. Our results indicate that CALB is expressed in early migratory Purkinje cells, and their maturation occurs in a vermal-to-hemisphere gradient. It is likely that CALB plays a significant role in the regulation of Ca²⁺-dependent activities in the developing cerebellum.     

Increased IL-2, IL-4 and interferon-gamma (IFN-gamma) in steroid-sensitive nephrotic syndrome.

We investigated the production of cytokines by peripheral blood mononuclear cells (PBMC) and serum cytokine concentrations in children with steroid-sensitive idiopathic nephrotic syndrome (SSNS). PBMC from patients off treatment were collected during remission and relapse and cultured in medium alone or stimulated with calcium ionophore plus phorbol myristate acetate. Control PBMC were taken from healthy age-matched children. IL-2 was measured by bioassay, IL-4 by immunoradiometric assay, and IL-8 and IFN-gamma by ELISA. After 24 h culture without stimulation, IL-2, IL-4 and IFN-gamma were not detectable in the supernatant in any of the children. After stimulation, the supernatant concentrations of IL-2 (median 172 U/ml at 24 h) and IL-4 (160 pg/ml at 24 h; 210 pg/ml at 72 h) were significantly increased in relapse compared with remission (IL-2 37 U/ml; IL-4 65 pg/ml and 60 pg/ml) and controls (IL-2 69 U/ml; IL-4 40 pg/ml and 40 pg/ml) (P < 0.05). The concentration of IFN-gamma was not significantly increased in relapse compared with remission and controls (600, 325, and 145 U/ml, respectively, at 72 h). IL-8 concentrations were similar in relapse, remission and controls with stimulation (median 32, 40 and 40 ng/ml, respectively) and without (30, 17 and 10 ng/ml). IL-2 was not detectable in serum, but IL-4, IL-8 and IFN-gamma were measurable in about half the patients, both in relapse and remission, though were virtually undetectable in controls. We conclude that relapse of SSNS in children is associated with T lymphocyte activation with release of IL-2, IL-4 and IFN-gamma.     

The antiproliferative aspects of mortalin (review)

Cellular mortal and immortal phenotypes as defined by the limited and the infinite capacity of cells to divide are the characteristics of normal and cancerous cells in culture. Numerous strategies that have been employed to understand the mechanism(s) of normal as well as tumor cell growth have revealed that these are genetically controlled, however, the genes and the synchronized regulations remain largely undefined so far. The present report reviews the identification of mortalin, a novel member of murine hsp70 family of proteins, as a gene involved in pathways that determine divisional phenotype of cells in vitro. In the present study, the anti-proliferative activity of mortalin is demonstrated also in human skin fibroblasts (TIG-73PD) by microinjection of anti-mortalin antibody. Furthermore, studies on the mortalin immunofluorescence patterns in SV40-immortalized pre-crisis and post-crisis human cells have revealed that the change in the intracellular distribution of mortalin is linked to the change in the divisional phenotype of cells. Thus, the studies to resolve the molecular basis of association of the cytosolically distributed form of mortalin with cellular mortal phenotype would be important in understanding of the mechanism(s) that determine replicative potential of cells in culture.     

Primary Obstructive Megaureter in Adults: Need for an Aggressive Management Strategy

Purpose: Primary obstructive megaureter (POM) is an uncommon disease in adults. We reviewed our experience with this disease to determine the clinical profile, management and prognosis of this disease in adults. Methods: We studied 37 adults with POM who presented from January 1989 to December 1998. Their clinical presentation, renal function, radiologic data, complications, treatment as well as the results and follow-up were studied. Results: The patients' age ranged from 13 to 52 years. Male : female ratio was 27 : 10. Seven patients had bilateral disease. All patients were symptomatic excepting 2. Complications at presentation were loin pain (26 cases), urinary infection (15 cases), calculus disease (17 cases), azotaemia (5 cases), and obstructive jaundice (1 case). Associated congenital anomalies included contralateral renal agenesis (2 cases), posterior urethral valve (1 case) and exstrophy of bladder (1 case). Thirty-four patients required surgical intervention. Of these, 26 patients underwent ureteroneocystostomy (UNC) with ureteral tailoring in 18 patients; 4 patients were treated endoscopically by ureteric meatotomy and stenting, 2 patients with nonfunctioning kidney by nephroureterectomy, 2 patients in advanced renal failure by percutaneous nephrostomy alone. In 4 out of 5 patients uraemia did not improve despite adequate drainage. Conclusion: The majority of adults with POM are symptomatic, have complications and require surgical correction. Complications of stone formation (46%) and renal failure (13.5%) are unusually common in adults. Once renal failure is advanced, intervention appears futile, therefore, it is imperative to treat these patients as soon as possible. Surgical correction by ureteric reimplantation is effective and has low morbidity.     

Bioactive suture: a novel immunotherapy for head and neck cancer.

PURPOSE: We have proposed to characterize the mechanism through which bioactive surgical sutures generate a T(H)1 immune response and to define the immune-stimulating half-life of the sutures. EXPERIMENTAL DESIGN: Bioactive sutures of interferon gamma (IFNgamma), interleukin 2 (IL-2), anti-CD3/CD28, anti-CD3/CD28 + IL-2, or anti-CD3/CD28 + IFNgamma sutures were used to stimulate lymphocytes from normal donors and from head and neck cancer patients in vitro over a 24-day period. Cell supernatants were analyzed by ELISA, and T cells were phenotyped to characterize the immune response generated. Intracellular cytokine staining was performed to measure the expansion of flu-specific T cells. Electromobility shift assay and supershift assay were used to measure the intranuclear DNA binding activity of nuclear factor kappaB and its p65 subunit in T cells activated by sutures in the presence and absence of a proteasome inhibitor, MG-132. RESULTS: Anti-CD3/CD28, anti-CD3/CD28 + IL-2, or anti-CD3/CD28 + IFNgamma generated a prolonged T(H)1 immune response for 18 days in vitro. Anti-CD3/CD28 expanded flu-specific T cells. Activated T cells demonstrated enhanced CD40 ligand (CD40L) expression within 72 hours of stimulation, which stimulated other cells to secrete IL-12. Stimulated T cells demonstrated increased intranuclear expression of nuclear factor-kappaB, which was blocked by MG-132, and also reduced CD40L and IL-12 expression. CONCLUSIONS: This is the first report to demonstrate that bioactive surgical sutures can generate a prolonged T(H)1 immune response and expand flu-specific T cells. Bioactive sutures, which are primarily a T-cell stimulant, also stimulated other cells to secrete IL-12 and prolonged the immune response. Sutures may provide a novel in situ stimulating strategy for enhancing the immune system of cancer patients.