Surrogates' and Researchers' Assessments of Prehospital Frailty in Critically Ill Older Adults.

BACKGROUND: Prehospital frailty has been associated with adverse hospital outcomes in critically ill adults. Although frailty assessment in intensive care units depends on patients' surrogates, frailty assessments by surrogates and researchers have not been compared. OBJECTIVES: To compare agreement and validity between surrogates' and researchers' assessments of frailty in critically ill older adults. METHODS: An observational cohort study of adults (aged ≥ 50 years) admitted to a medical/surgical intensive care unit was conducted. On admission, patients' surrogates quantified prehospital frailty by using the Clinical Frailty Scale (range, 1-9; scores > 4 defined as frail). Researchers blinded to surrogates' assessments also quantified frailty. Agreement was described with κ scores, McNemar tests, and Bland-Altman plots; validity was compared by using χ2 tests and logistic regression. RESULTS: For 298 patients (mean [SD] age, 67.2 [10.5] years), both surrogates' and researchers' frailty assessment scores ranged from 1 to 9, with moderate to substantial agreement between scores (g ≥ 0.40). Surrogates' frailty assessment scores were significantly lower than researchers' (mean difference, -0.62; 95% CI, -0.77 to -0.48; P < .001). Surrogates were less likely than researchers to identify as frail those patients who experienced adverse hospital outcomes (death, prolonged stay, or disability newly identified at discharge). CONCLUSIONS: Surrogates identified fewer patients as frail than did researchers. Factors involved in surrogates' assessments of patients' prehospital frailty status should be studied to see if the Clinical Frailty Scale can be modified to facilitate more accurate surrogate assessments.

Pre-hospital frailty and hospital outcomes in adults with acute respiratory failure requiring mechanical ventilation.

PURPOSE: We aimed to estimate the independent effect of pre-hospital frailty (PHF) on hospital mortality and prolonged hospital length of stay (pLOS) while adjusting for other patient level factors. METHODS: This is a cohort study of hospitalized adults with acute respiratory failure (ARF) who required invasive mechanical ventilation for ≥24h in 2013. We used inpatient/outpatient claims from a list of diagnoses from the year before index hospital admission to define PHF. Differences in characteristics/outcomes by PHF were explored using descriptive statistics; multivariable logistic regression was used to estimate association between PHF and hospital outcomes. RESULTS: Among 1157 patients (mean age (standard deviation) 67.1 [16.4]), 53.2% had PHF. PHF was independently associated with higher hospital mortality (44.2% in PHF patients vs. 34.6% in those without, adjusted Odds Ratio (aOR) (95% Confidence Interval [CI] 1.56 (1.19-2.05), p<0.001). PHF was also significantly associated with pLOS in hospital survivors (55.5% PHF patients had pLOS versus 34.2% in those without, aOR (95% CI) 2.61 (1.87-3.65), p<0.001). CONCLUSIONS: PHF, identified by frailty diagnoses from before index hospitalization, may be a useful approach for identifying adults with ARF at increased risk of hospital mortality and pLOS.

Assessing the Usefulness and Validity of Frailty Markers in Critically Ill Adults.

RATIONALE: Identifying frailty by the presence of a critical number of frailty markers has been difficult to operationalize in the intensive care unit (ICU), where patients often cannot complete performance measures or answer complex questions. OBJECTIVES: To assess the construct and predictive validity of a questionnaire-based approach to identifying frailty in adult ICU patients. METHODS: We conducted an observational cohort study of adults admitted to a medical or surgical ICU at one of two hospitals in New York. We asked patients or surrogates about demographic information, frailty markers, and prehospital disability status. ICU physicians completed the Clinical Frailty Scale (CFS), a judgment-based frailty assessment tool. We examined the relationship between individual frailty markers, CFS, and demographic correlates of frailty such as age, prehospital living arrangement, and prehospital disability. We assessed the predictive validity of possible frailty phenotypes, using hospital and 6-month outcomes. RESULTS: Among 95 study participants (mean age [SD], 57.1 [17.5] yr), 80% reported one or more of seven frailty markers (median [interquartile range], 3 [1-4]). The most common frailty markers were impaired mobility (60%), impaired physical activity (60%), and decreased strength (44.2%). Patients with more frailty markers were older (mean age [SD] of those with at least three frailty markers: 62.3 [17.7] vs. 51.6 [15.8] yr; P < 0.001) compared with those with fewer than three markers, and were more likely to be judged frail by CFS (57.0 vs. 19.6%; P = 0.001), although of the 49 patients with three or more frailty markers, CFS identified 36.7% as not frail. Malnutrition and fatigue or low energy were not significantly associated with other frailty correlates. Survivors with more frailty markers were more likely to die or report increased disability at follow-up. In multivariate models, a frailty phenotype defined as at least three of the seven frailty markers performed similarly to CFS in predicting death or increased disability at 6 months (adjusted odds ratio [95% confidence interval], 3.3 [1.2-9.0] vs. 3.8 [1.2-11.7]) for CFS. CONCLUSIONS: Asking patients or surrogates about frailty markers may be a valid approach to identifying critically ill adults with a frailty phenotype associated with increased risk of adverse outcomes. Larger studies measuring frailty markers may provide insight into factors that impact short- and long-term outcomes after ICU admission.

The lipoxygenase inhibitor, baicalein, modulates cell adhesion and migration by up-regulation of integrins and vinculin in rat heart endothelial cells.

BACKGROUND AND PURPOSE: Endothelial cell proliferation, migration and adhesion are necessary for the formation of new blood vessels. We reported previously that baicalein strongly inhibited proliferation of rat heart endothelial cells and here we assess effects on migration and adhesion of these cells. EXPERIMENTAL APPROACH: Effects of baicalein on endothelial migration and adhesion were determined by in vitro wound assays and in modified Boyden chambers. Protein expression and subcellular distribution in rat heart endothelial cells were analysed by immunoblots and immunofluorescence staining. RESULTS: Pretreatment with baicalein for 48 h resulted in a concentration-dependent inhibition of endothelial migration, with an IC(50) of approximately 20 microM. Adhesion assays revealed that baicalein stimulated endothelial cell adhesion to fibronectin and vitronectin, effects blocked by the synthetic peptide Arg-Gly-Asp (RGD). Moreover, treatment with a blocking antibody against integrin alpha5beta1 drastically attenuated baicalein-mediated endothelial adhesion to fibronectin, but not to vitronectin. Furthermore, baicalein-mediated anti-migration effect and adhesion promotion could be partially reversed by the addition of 12(S)-hydroxyeicosatetraenoic acid (12(S)-HETE). Western blot analysis indicated that baicalein increased expression levels of integrin-alpha5beta1, -alphavbeta3 and vinculin proteins. Immunofluorescence staining showed that baicalein induced a marked reorganization of actin stress fibres and the recruitment of vinculin and integrins to focal adhesion plaques, with consequently increased formation of focal adhesion contacts. CONCLUSIONS AND IMPLICATIONS: Baicalein markedly inhibited the migration and enhanced the adhesion of rat heart endothelial cells, possibly by up-regulation of the integrins (alpha5beta1 and alphavbeta3) and vinculin and by promotion of actin reorganization and focal adhesion contact formation.

Resveratrol inhibits interleukin-6 production in cortical mixed glial cells under hypoxia/hypoglycemia followed by reoxygenation.

Reactive oxygen intermediates (ROIs) are important mediators of a variety of pathological processes, including inflammation and ischemia/reperfusion injury. Cytokines and chemokines are detected at mRNA level in human and animal ischemic brains. This suggests that hypoxia/reoxygenation may induce cytokine production through generation of ROIs. In this study, we investigated the cytokine induction and inhibition by antioxidants in rat cortical mixed glial cells exposed to in vitro ischemia-like insults (hypoxia plus glucose deprivation). The results showed that interleukin-6 (IL-6) mRNA and protein, but not tumor necrosis factor-alpha (TNF-alpha) or interleukin-1beta (IL-1beta), were induced during hypoxia/hypoglycemia followed by reoxygenation in the mixed glial cells. The accumulation of IL-6 mRNA was induced as early as 15 min after hypoxia/hypoglycemia and its level was further increased after subsequent reoxygenation. Among the antioxidants studied, only resveratrol suppressed IL-6 gene expression and protein secretion in mixed glial cultures under hypoxia/hypoglycemia followed by reoxygenation. These findings suggest that resveratrol might be useful in treating ischemic-induced inflammatory processes in stroke.

Antioxidants prevent amyloid peptide-induced apoptosis and alteration of calcium homeostasis in cultured cortical neurons.

Beta-amyloid ((A)beta) is a peptide of 39-42 amino acids that is the primary component of plaques in Alzheimer's disease (AD). The mechanism by which (A)beta expresses its neurotoxic effects may involve induction of reactive oxygen species (ROS) and elevation of intracellular free calcium levels. Cultured cortical cells were utilized to study the alterations in calcium homeostasis underlying the neurotoxic effect of (A)beta. Serum supplement B27 and vitamin E were effective in preventing neuronal death as assessed by lactate dehydrogenase (LDH) release, (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, and number of apoptotic nuclei. In addition, (A)beta-induced cytosolic free calcium ([Ca2+]i) was blocked by antioxidants vitamin E and U83836E, but not by N-methyl-D-aspartic acid (NMDA) receptor antagonist MK-801, or by voltage-gated calcium channel blocker nimodipine. Taken together, the results suggest that NMDA receptor and voltage-gated calcium channels are not involved in (A)beta-induced [Ca2+]i increase. This increase appeared to be the result of extracellular calcium influx by some unknown mechanisms. In addition, antioxidants such as B27 were effective in protecting cultured cortical neurons against (A)beta, and correlated with (A)beta attenuation of early calcium response.

Blockage of amyloid beta peptide-induced cytosolic free calcium by fullerenol-1, carboxylate C60 in PC12 cells.

Amyloid beta protein (Abeta) alters signal transduction systems, including increases in the cytosolic free calcium ([Ca2+]i) response which have pathophysiological significance in Alzheimer's disease (AD). The purposes of this study were to elucidate the mechanism involved in Abeta's effect on the Ca2+ signal and to evaluate the effect of fullerenol-1, a water-soluble hydroxyl and superoxide radical scavenger, on the Abeta-induced Ca2+ response. Both Abeta and bradykinin (BK) dose-dependently elevated [Ca2+]i in PC12 cells. Fullerenol-1, at a concentration range between 100 nM and 1 microM, dose-dependently reduced the Abeta-induced [Ca2+]i response, but did not alter the subsequent BK-mediated process. Thapsigargin, an inhibitor of Ca2+-ATPase, released Ca2+ from the internal store and diminished the BK-mediated calcium spike but did not affect the Abeta-induced Ca2+ response. In the absence of extracellular calcium, the Abeta-induced, but not BK-induced, calcium spike was completely abolished. The Ca induced by Abeta did not enter through the voltage-dependent calcium channels or ligand gated calcium channels, because the peak of Abeta-evoked Ca2+ was not significantly altered by various Ca2+ channel blockers or a NMDA receptor antagonist MK801. In addition, neither cholera toxin nor pertussis toxin altered the Abeta-induced Ca response. The results demonstrated that Abeta-stimulated [Ca2+]i increase is due to Ca influx from an extracellular source rather than from the intracellular store. Alteration of the membrane lipid structure and permeability by free radicals generated by Abeta may be a major cause of Ca -influx. Furthermore, fullerenol-1, a novel antioxidant, may provide therapeutic benefits in neurodegenerative diseases such as AD.

Amyloid beta peptide impaired carbachol but not glutamate-mediated phosphoinositide pathways in cultured rat cortical neurons.

Signal transduction systems, including cholinergic pathways, which are likely to be of pathophysiological significance are altered in Alzheimer's disease (AD). Muscarinic cholinergic receptors are linked to the hydrolysis of phosphoinositide, involving the production of inositol 1,4,5-trisphosphate [Ins(1,4,5)P3] and the mobilization of cytosolic free calcium concentrations ([Ca2+]i). Effects of amyloid peptide (A(beta)) on these signals prior to neuronal degeneration were examined in cultured rat cortical cells. A(beta) increased the release of lactate dehydrogenase (LDH) in a concentration-dependent manner, however, it was blocked by B27 supplement. Prolonged exposure to a sublethal dose of A(beta) 25-35 or 1-42 disrupted carbachol-mediated release of Ins(1,4,5)P3 and [Ca2+]i, which was inhibited in media supplemented with B27 or the antioxidant vitamin E. In order to determine the specificity of the effect of A(beta), various agonists glutamate or KCl but not bradykinin which utilize the phosphoinositide cascade were investigated. Our results indicated that A(beta) did not affect the stimulation of glutamate or KCl-mediated production of Ins(1,4,5)P3 or cause elevation in [Ca2+]i. Furthermore, metabotropic agonist trans-1-amino-cyclopentane-1,3,-dicarboxylate (ACPD) elevated calcium level was not inhibited by A(beta) pre-treatment. Taken together, the results demonstrate that a sublethal dose of A(beta) selectively impaired cholinergic receptor-mediated signal transduction pathways, and antioxidant or B27 supplement attenuated this effect of A(beta). Alterations of cholinergic signaling by prolonged exposure to A(beta) could be involved in cortical neurodegeneration that occurs in AD. Because functional loss of cholinergic pathways is an important aspect of AD, the differences in susceptibility of these two types of receptors prior to other signs of A(beta) action is important and requires further investigation.

Indole-3-carbinol and tamoxifen cooperate to arrest the cell cycle of MCF-7 human breast cancer cells.

The current options for treating breast cancer are limited to excision surgery, general chemotherapy, radiation therapy, and, in a minority of breast cancers that rely on estrogen for their growth, antiestrogen therapy. The naturally occurring chemical indole-3-carbinol (I3C), found in vegetables of the Brassica genus, is a promising anticancer agent that we have shown previously to induce a G1 cell cycle arrest of human breast cancer cell lines, independent of estrogen receptor signaling. Combinations of I3C and the antiestrogen tamoxifen cooperate to inhibit the growth of the estrogen-dependent human MCF-7 breast cancer cell line more effectively than either agent alone. This more stringent growth arrest was demonstrated by a decrease in adherent and anchorage-independent growth, reduced DNA synthesis, and a shift into the G1 phase of the cell cycle. A combination of I3C and tamoxifen also caused a more pronounced decrease in cyclin-dependent kinase (CDK) 2-specific enzymatic activity than either compound alone but had no effect on CDK2 protein expression. Importantly, treatment with I3C and tamoxifen ablated expression of the phosphorylated retinoblastoma protein (Rb), an endogenous substrate for the G1 CDKs, whereas either agent alone only partially inhibited endogenous Rb phosphorylation. Several lines of evidence suggest that I3C works through a mechanism distinct from tamoxifen. I3C failed to compete with estrogen for estrogen receptor binding, and it specifically down-regulated the expression of CDK6. These results demonstrate that I3C and tamoxifen work through different signal transduction pathways to suppress the growth of human breast cancer cells and may, therefore, represent a potential combinatorial therapy for estrogen-responsive breast cancer.

Indole-3-carbinol inhibits the expression of cyclin-dependent kinase-6 and induces a G1 cell cycle arrest of human breast cancer cells independent of estrogen receptor signaling.

Indole-3-carbinol (I3C), a naturally occurring component of Brassica vegetables such as cabbage, broccoli, and Brussels sprouts, has been shown to reduce the incidence of spontaneous and carcinogen-induced mammary tumors. Treatment of cultured human MCF7 breast cancer cells with I3C reversibly suppresses the incorporation of [3H]thymidine without affecting cell viability or estrogen receptor (ER) responsiveness. Flow cytometry of propidium iodide-stained cells revealed that I3C induces a G1 cell cycle arrest. Concurrent with the I3C-induced growth inhibition, Northern blot and Western blot analyses demonstrated that I3C selectively abolished the expression of cyclin-dependent kinase 6 (CDK6) in a dose- and time-dependent manner. Furthermore, I3C inhibited the endogenous retinoblastoma protein phosphorylation and CDK6 phosphorylation of retinoblastoma in vitro to the same extent. After the MCF7 cells reached their maximal growth arrest, the levels of the p21 and p27 CDK inhibitors increased by 50%. The antiestrogen tamoxifen also suppressed MCF7 cell DNA synthesis but had no effect on CDK6 expression, while a combination of I3C and tamoxifen inhibited MCF7 cell growth more stringently than either agent alone. The I3C-mediated cell cycle arrest and repression of CDK6 production were also observed in estrogen receptor-deficient MDA-MB-231 human breast cancer cells, which demonstrates that this indole can suppress the growth of mammary tumor cells independent of estrogen receptor signaling. Thus, our observations have uncovered a previously undefined antiproliferative pathway for I3C that implicates CDK6 as a target for cell cycle control in human breast cancer cells. Moreover, our results establish for the first time that CDK6 gene expression can be inhibited in response to an extracellular antiproliferative signal.

Changes of bone markers during long-term intravenous calcitriol therapy in maintenance dialysis patients.

Twenty patients with end-stage renal failure on maintenance hemodialysis were studied for the effect of intravenous 1,25(OH)2 vitamin D3 on biochemical bone markers. Active vitamin D, 1,25(OH)2 vitamin D3, was given intravenously after hemodialysis, 1 microgram thrice weekly. Serum ionized calcium, phosphorus, alkaline phosphatase (AKPase), intact parathyroid hormone (PTH), osteocalcin (bone Gla protein), carboxy terminal propeptide of type I procollagen (PICP), cross-linked telopeptide of type I collagen (ICTP) and beta 2-microglobulin were measured before and after 3 and 6 months of treatment with 1,25(OH)2 vitamin D3. The serum ionized calcium and osteocalcin levels were significantly increased at 3 and 6 months after treatment. The serum beta 2-microglobulin level were also increased 6 months after treatment, whereas the serum levels of AKPase and intact PTH decreased after treatment. However, the serum levels of phosphorus, PICP and ICTP did not change significantly after treatment. The decreased levels of serum AKPase and intact PTH suggest reduced bone resorption. Increases of serum osteocalcin levels were caused by stimulation of the osteoblast by 1,25(OH)2 vitamin D3, baseline 20.6 +/- 12.5 micrograms/l, and 36.1 +/- 34.0 and 31.0 +/- 24.6 micrograms/l at 3 and 6 months, respectively (p < 0.01). The lower osteocalcin level at 6 rather than at 3 months may imply reduced bone resorption and/or increased bone mineralization. The meaning of the increase of serum beta 2-microglobulin in uremic patients after calcitriol treatment is unclear. It may indicate reduced deposition and is masked by increased bone resorption from secondary or tertiary hyperparathyroidism. This study did not validate PICP and ICTP measurements as bone markers in uremic patients.