Burden of illness among patients with severe aplastic anemia who have had insufficient response to immunosuppressive therapy: a multicenter retrospective chart review study

Annals of Hematology - This study assessed treatment patterns and healthcare resource utilization (HRU) of patients with severe aplastic anemia (SAA) with insufficient response to immunosuppressive...     

On the use of EPID-based implanted marker tracking for 4D radiotherapy

Four-dimensional (4D) radiotherapy delivery to dynamically moving tumors requires a real-time signal of the tumor position as a function of time so that the radiation beam can continuously track the tumor during the respiration cycle. The aim of this study was to develop and evaluate an electronic portal imaging device (EPID)-based marker-tracking system that can be used for real-time tumor targeting, or 4D radiotherapy. Three gold cylinders, 3 mm in length and 1 mm in diameter, were implanted in a dynamic lung phantom. The phantom range of motion was 4 cm with a 3-s "breathing" period. EPID image acquisition parameters were modified, allowing image acquisition in 0.1 s. Images of the stationary and moving phantom were acquired. Software was developed to segment automatically the marker positions from the EPID images. Images acquired in 0.1 s displayed higher noise and a lower signal-noise ratio than those obtained using regular (> 1 s) acquisition settings. However, the markers were still clearly visible on the 0.1-s images. The motion of the phantom blurred the images of the markers and further reduced the signal-noise ratio, though they could still be successfully segmented from the images in 10-30 ms of computation time. The positions of gold markers placed in the lung phantom were detected successfully, even for phantom velocities substantially higher than those observed for typical lung tumors. This study shows that using EPID-based marker tracking for 4D radiotherapy is feasible, however, changes in linear accelerator technology and EPID-based image acquisition as well as patient studies are required before this method can be implemented clinically.     

Cone-beam CT with megavoltage beams and an amorphous silicon electronic portal imaging device: potential for verification of radiotherapy of lung cancer

We investigate the potential of megavoltage (MV) cone-beam CT with an amorphous silicon electronic portal imaging device (EPID) as a tool for patient position verification and tumor/organ motion studies in radiation treatment of lung tumors. We acquire 25 to 200 projection images using a 22 x 29 cm EPID. The acquisition is automatic and requires 7 minutes for 100 projections; it can be synchronized with respiratory gating. From these images, volumetric reconstruction is accomplished with a filtered backprojection in the cone-beam geometry. Several important prereconstruction image corrections, such as detector sag, must be applied. Tests with a contrast phantom indicate that differences in electron density of 2% can be detected with 100 projections, 200 cGy total dose. The contrast-to-noise ratio improves as the number of projections is increased. With 50 projections (100 cGy), high contrast objects are visible, and as few as 25 projections yield images with discernible features. We identify a technique of acquiring projection images with conformal beam apertures, shaped by a multileaf collimator, to reduce the dose to surrounding normal tissue. Tests of this technique on an anthropomorphic phantom demonstrate that a gross tumor volume in the lung can be accurately localized in three dimensions with scans using 88 monitor units. As such, conformal megavoltage cone-beam CT can provide three-dimensional imaging of lung tumors and may be used, for example, in verifying respiratory gated treatments.     

Arrhythmias and vagus nerve stimulation

Enhancing vagal tone by delivering electrical stimulation to the vagal nerves (VNS) is emerging as a promising novel therapy in heart failure. In addition, VNS is already an FDA-approved therapy for refractory epilepsy and depression. Besides its well-known negative chronotropic, inotropic, and dromotropic effects, VNS has profound effects on cardiac electrophysiology and arrhythmogenesis. This review summarizes current knowledge about the complex relationship between VNS and cardiac arrhythmias. Specifically, the focus is on VNS capability to become a therapeutic strategy along with important electrophysiological alterations that may constitute a potential arrhythmogenic substrate and become a clinical concern.     

Influenza surveillance on ‘foie gras’ duck farms in Bulgaria, 2008–2012

Objectives

Ducks can shed and spread influenza A viruses (IAVs) while showing no disease signs. Our objective was to clarify the role of ‘foie gras’ ducks in the circulation of IAVs in Bulgaria.

Methods

Monthly avian influenza surveillance was conducted on 63 ‘foie gras’ duck farms, 52 of which were surveyed throughout the study between November 2008 and April 2012. Virologic and serologic samples were collected and tested. During this time, wild bird samples were collected at major wild bird‐resting areas near the Black Sea coast and Danube River.

Results

The study showed high isolation frequency of low‐pathogenicity avian influenza viruses. In the raising population (<75 days old), subtypes H3, H4, and H6 were detected monthly and H5 LPAIV, sporadically. Different subtypes (H1, H10, H11) were isolated from the fattening premises (75‐ to 100‐day‐old ducks), suggesting different routes of introduction. Only 6 of the 52 farms that were surveyed both virologically and serologically were influenza‐free throughout the study, possibly due to higher biosecurity measures implemented. No evidence of direct transmission of IAV from wild birds was found. Wild bird surveillance showed low isolation frequency of IAV. IAV prevalence of 0·55% for migratory ducks and 0·53% for migratory geese was estimated in November–December 2011 and January–February 2012, respectively, at two ornithologically important locations near the Black Sea coast.

Conclusions

The ‘foie gras’ duck farms in Bulgaria are an optimal niche where Eurasian‐like IAVs are maintained and reassorted unapparent to farmers and veterinarians.     

Inhibition of Mitochondrial Permeability Transition Pores by Cyclosporine A Improves Cytochrome c Oxidase Function and Increases Rate of ATP Synthesis in Failing Cardiomyocytes

Background: We previously showed that mitochondrial respiratory function is abnormal in dogs with chronic heart failure (HF). Mitochondrial permeability transition pores (MPTP) can affect mitochondrial inner membrane potential (Δ < eqid1 > _m) and mitochondrial function in normal cardiomyocytes. The potential impact of MPTP on Δ < eqid2 > _m and mitochondrial respiratory function in HF has not yet been determined. We tested the hypothesis that cyclosporine A, a potent blocker of the MPTP, can improve mitochondrial function in HF. Methods: Cardiomyocytes were isolated from the left ventricular myocardium of 7 dogs with HF produced by intracoronary microembolizations and from 7 normal dogs. Cardiomyocytes were treated for 24 hours with cyclosporine A. Δ < eqid3 > _m, cytochrome c oxidase protein expression, mitochondrial cytochrome c oxidase-dependent respiration (CDOR) and ATP synthesis were measured. Results: Δ < eqid4 > _m, protein expression of cytochrome c oxidase, CDOR and the rate of ATP synthesis were decreased in HF compared to normal controls. Inhibition of MPTP in failing cardiomyocytes with low dose of cyclosporine A (0.2 μM) increased Δ < eqid5 > _m, preserved expression of cytochrome c oxidase, improved CDOR and the rate of ATP synthesis. Conclusion: MPTP opening contributes to the loss of mitochondrial function observed in the failing heart. Inhibition of MPTP opening represents a potential therapeutic target for the treatment of HF. This study was supported by a grant from the National Heart, Lung, and Blood Institute PO1 HL074237-01.     

Putative chanzyme activity of TRPM2 cation channel is unrelated to pore gating

Transient receptor potential melastatin 2 (TRPM2) is a Ca²⁺-permeable cation channel expressed in immune cells of phagocytic lineage, pancreatic β cells, and brain neurons and is activated under oxidative stress. TRPM2 activity is required for immune cell activation and insulin secretion and is responsible for postischemic neuronal cell death. TRPM2 is opened by binding of ADP ribose (ADPR) to its C-terminal cytosolic nudix-type motif 9 (NUDT9)-homology (NUDT9-H) domain, which, when expressed in isolation, cleaves ADPR into AMP and ribose-5-phosphate. A suggested coupling of this enzymatic activity to channel gating implied a potentially irreversible gating cycle, which is a unique feature of a small group of channel enzymes known to date. The significance of such a coupling lies in the conceptually distinct pharmacologic strategies for modulating the open probability of channels obeying equilibrium versus nonequilibrium gating mechanisms. Here we examine the potential coupling of TRPM2 enzymatic activity to pore gating. Mutation of several residues proposed to enhance or eliminate NUDT9-H catalytic activity all failed to affect channel gating kinetics. An ADPR analog, α-β-methylene-ADPR (AMPCPR), was shown to be entirely resistant to hydrolysis by NUDT9, but nevertheless supported TRPM2 channel gating, albeit with reduced apparent affinity. The rate of channel deactivation was not slowed but, rather, accelerated in AMPCPR. These findings, as well as detailed analyses of steady-state gating kinetics of single channels recorded in the presence of a range of concentrations of ADPR or AMPCPR, identify TRPM2 as a simple ligand-gated channel that obeys an equilibrium gating mechanism uncoupled from its enzymatic activity.Transient receptor potential melastatin 2 (TRPM2) belongs to the TRP protein family and is abundantly expressed in brain neurons, bone marrow, phagocytes, pancreatic β cells, and cardiomyocytes, where it forms Ca²⁺-permeable nonselective cation channels that open under oxidative stress. On contact with pathogens, phagocytic cells produce reactive oxygen species (ROS); the resulting activation of TRPM2 provides the Ca²⁺ influx necessary for cell migration and chemokine production (1). In pancreatic β cells, TRPM2 activity contributes to glucose-evoked insulin secretion; TRPM2 knock-out mice show higher resting blood glucose levels and impaired glucose tolerance (2).TRPM2 activity is also linked to several pathologic conditions that lead to apoptosis (3). Reperfusion after ischemia results in ROS generation; consequent Ca²⁺ influx through TRPM2 causes Ca²⁺ dysregulation and cell death. Certain neurodegenerative diseases, such as Alzheimer’s disease, also involve oxidative stress and TRPM2 activation. In contrast, a loss-of-function TRPM2 mutation identified in patients with amyotrophic lateral sclerosis and Parkinson''s disease dementia (4), as well as two TRPM2 mutations associated with bipolar disorder (5), suggest loss of TRPM2 activity can also cause disease.Similar to most TRP family ion channels, the TRPM2 channel is a homotetramer, and its transmembrane (TM) architecture resembles that of voltage-gated cation channels (6, 7). In addition to the TM domain and an N-terminal cytosolic domain of unknown function, TRPM2 contains an ∼270-residue C-terminal cytosolic nudix-type motif 9 (NUDT9)-homology (NUDT9-H) domain. The latter shows high (∼50%) sequence homology to the soluble mitochondrial enzyme NUDT9, an active ADP ribose (ADPR) pyrophosphatase (ADPRase) from the Nudix hydrolase family, which splits ADPR into AMP and ribose-5-phosphate (8). TRPM2 channels are coactivated by ADPR binding to NUDT9-H (9) and by Ca²⁺ binding to unidentified intracellular binding sites (10). ADPR is the key that links TRPM2 activation to oxidative stress; in living cells exposed to ROS, ADPR is released from mitochondria (9). In the past, studying TRPM2 channel gating at steady state has been limited by rapid deactivation of TRPM2 currents in cell-free patches (10). This rundown was recently shown to involve a conformational change of the ion selectivity filter, which could be completely prevented by a pore-loop substitution. This “T5L” TRPM2 variant, which shows no rundown but preserves intact regulation of gating by Ca²⁺ and ADPR (11), provides an unprecedented opportunity to study TRPM2 gating at steady state.Early studies reported slow (∼0.1 s⁻¹) but detectable ADPRase activity of isolated purified NUDT9-H (8, 12), classifying TRPM2 into the special group of channel-enzymes (“chanzymes”) that includes TRPM6 and TRPM7 (3) and the CFTR cystic fibrosis transmembrane conductance regulator (CFTR) chloride ion channel (13). TRPM2 pore opening/closure happens on the timescale of the reported ADPRase activity (11), which is consistent with coupling between gating and catalytic activity, as demonstrated for CFTR in which pore gating follows an irreversible cycle tightly linked to ATP binding and hydrolysis at conserved cytosolic domains (14).The involvement of TRPM2 in multiple diseases has made it an emerging therapeutic target. Depending on the disease, both inhibition (e.g., stroke, myocardial infarction, Alzheimer’s disease, chronic inflammation, hyperinsulinism) and stimulation (e.g., diabetes, amyotrophic lateral sclerosis, Parkinson''s disease dementia, bipolar disorder) of TRPM2 activity might be useful therapeutically. Because TRP family channels are involved in diverse processes (3), any useful TRPM2 agonists/antagonists will need to be highly selective. This singles out the NUDT9-H domain, the component unique to TRPM2, as the most attractive drug target. The significance of understanding whether ADPRase activity and gating are coupled is that optimal strategies for modulating fractional occupancy of a particular conformational state are profoundly different for equilibrium systems than for nonequilibrium systems. For most ion channels, pore gating is an equilibrium process, and open probability is modulated simply by energetic stabilization of either open (activators) or closed (inhibitors) channel ground states. In contrast, channels that gate by a nonequilibrium cycle are most efficiently accumulated in either open or closed states by manipulating the stability of transition states for rate-limiting irreversible steps (15). The aim of this study was to examine the tightness of coupling between the ADPRase cycle and specific gating transitions in TRPM2.