Sentinel Lymph Node Mapping vs Systematic Lymphadenectomy for Endometrial Cancer: Surgical Morbidity and Lymphatic Complications.

STUDY OBJECTIVE: Sentinel lymph node (SLN) mapping has been proven to accurately stage endometrial cancer (EC). However, there is a lack of studies comparing the incidence of complications between different lymph node approaches in EC. The objective of the study was to define the complication rates of SLN biopsy in EC patients. DESIGN: A retrospective cohort study SETTING: A tertiary referral hospital PATIENTS: All patients who were surgically treated for EC form April 2013 to March 2018 INTERVENTIONS: Authors evaluated intraoperative complications and 30-day complications using the Memorial Sloan Lettering Cancer Center's Surgical Secondary Events Grading System, separating the patients into 4 groups: group I, hysterectomy (HT); group II, hysterectomy plus sentinel lymph node biopsy (HT+SLN); group III, hysterectomy plus pelvic lymphadenectomy, with or without para-aortic dissection (HT+LND); and group IV, hysterectomy plus lymphadenectomy and sentinel lymph node biopsy (HT+SLN+LND). MEASUREMENTS AND MAIN RESULTS: Authors identified a total of 250 cases. As compared with the HT group, the HT+SLN group did not show any increased risk of complications in terms of intraoperative complications (0 vs 1; p = 1.0) and 30-day complications (8 vs 7; p = .782), but surgical time was approximately 20 minutes longer (p = .016). Performing LND was associated with a greater risk of 30-day complications (hazard ratio [HR]: 3.11; 95% confidence interval [CI]: 1.62-5.98), intraoperative complications (HR: 14.25; 95% CI: 1.85-19.63), and lower-limb lymphedema (HR: 8.14; 95% CI: 1.01-65.27). CONCLUSION: SLN mapping does not increase morbidity in the surgical treatment of EC patients, and compared with comprehensive lymphadenectomy, it has a lower risk of complications. Our findings support the use of the SLN algorithm in EC patients.

"Omics" data integration and functional analyses link Enoyl-CoA hydratase, short chain 1 to drug refractory dilated cardiomyopathy.

BACKGROUND: Large-scale "omics" datasets have not been leveraged and integrated with functional analyses to discover potential drivers of cardiomyopathy. This study addresses the knowledge gap. METHODS: We coupled RNA sequence (RNA-Seq) variant detection and transcriptome profiling with pathway analysis to model drug refractory dilated cardiomyopathy (drDCM) using the BaseSpace sequencing hub and Ingenuity Pathway Analysis. We used RNA-Seq case-control datasets (n = 6 cases, n = 4 controls), exome sequence familial DCM datasets (n = 3 Italians, n = 5 Italians, n = 5 Chinese), and controls from the HapMap project (n = 5 Caucasians, and n = 5 Asians) for disease modeling and putative mutation discovery. Variant replication datasets: n = 128 cases and n = 15 controls. Source of datasets: NCBI Sequence Read Archive. STATISTICS: Pairwise differential expression analyses to determine differentially expressed genes and t-tests to calculate p-values. We adjusted for false discovery rates and reported q-values. We used chi-square tests to assess independence among variables, the Fisher's Exact Tests and overlap p-values for the pathways and p-scores to rank network. RESULTS: Data revealed that ECHS1(enoyl-CoA hydratase, short chain 1(log2(foldchange) = 1.63329) hosts a mirtron, MIR3944 expressed in drDCM (FPKM = 5.2857) and not in controls (FPKM = 0). Has-miR3944-3p is a putative target of BAG1 (BCL2 associated athanogene 1(log2(foldchange) = 1.31978) and has-miR3944-5p of ITGAV (integrin subunit alpha V(log2(foldchange) = 1.46107) and RHOD (ras homolog family member D(log2(foldchange) = 1.28851). There is an association between ECHS1:11 V/A(rs10466126) and drDCM (p = 0.02496). The interaction (p = 2.82E-07) between ECHS1:75 T/I(rs1049951) and ECHS1:rs10466126 is associated with drDCM (p < 2.2e-16). ECHS1:rs10466126 and ECHS1:rs1049951 are in linkage disequilibrium (D' = 1). The interaction (p = 7.84E-08) between ECHS1:rs1049951 and the novel ECHS1:c.41insT variant is associated with drDCM (p < 2.2e-16). The interaction (p = 0.001096) between DBT (Dihydrolipoamide branched chain transacylase E2):384G/S(rs12021720) and ECHS1:rs10466126 is associated with drDCM (p < 2.2e-16). At the mRNA level, there is an association between ECHS1 (log2(foldchange) = 1.63329; q = 0.013927) and DBT (log2(foldchange) = 0.955072; q = 0.0368792) with drDCM. ECHS1 is involved in valine (-log (p = 3.39E00)), isoleucine degradation (p = 0.00457), fatty acid ß-oxidation (-log(p) = 2.83E00), and drug metabolism:cytochrome P450 (z-score = 2.07985196) pathways. The mitochondria (-log(p) = 8.73E00), oxidative phosphorylation (-log(p) = 5.35E00) and TCA-cycle II (-log(p) = 2.70E00) are dysfunctional. CONCLUSIONS: We introduce an integrative data strategy that considers the interplay between the DNA, mRNA, and associated pathways, which represents a possible diagnostic, prognostic, biomarker, and personalized treatment discovery approach in genomically heterogeneous diseases.

Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital.

OBJECTIVES: To implement an electronic laboratory utilization management system (laboratory expert system [LES]) to provide safe and effective reductions in unnecessary clinical laboratory testing. METHODS: The LES is a set of frequency filter subroutines within the Veterans Affairs hospital and laboratory information system that was formulated by an interdisciplinary medical team. RESULTS: Since implementing the LES, total test volume has decreased by a mean of 11.18% per year compared with our pre-LES test volume. This change was not attributable to fluctuations in outpatient visits or inpatient days of care. Laboratory cost savings were estimated at $151,184 and $163,751 for 2012 and 2013, respectively. A significant portion of these cost savings was attributable to reductions in high-volume, large panel testing. No adverse effects on patient care were reported, and mean length of stay for patients remained unchanged. CONCLUSIONS: Electronic laboratory utilization systems can effectively reduce unnecessary laboratory testing without compromising patient care.

Metabolic effect and receptor signalling profile of a non-metabolisable insulin glargine analogue.

CONTEXT: Insulin glargine (GLA) is rapidly metabolized in vivo to metabolite M1, which has in vitro metabolic and mitogenic profiles comparable with human insulin (HI). OBJECTIVE: To investigate the pharmacologic and signalling profiles of a non-metabolizable analogue (A21Gly,DiD-Arg) insulin (D-GLA). METHODS: Rats were injected s.c. with 1, 12.5 or 200 U/kg of GLA or D-GLA; blood glucose and phosphorylation status of the insulin receptor (IR), Akt and IGF-1 receptor (IGF1R) in tissue samples were investigated after 1 h. Plasma samples were analysed for insulin by LC-MS/MS. RESULTS: Blood glucose lowering was prolonged with D-GLA. D-GLA comprised ≥98% of insulin after D-GLA injection; M1 comprised 76-92% after GLA injection. IR and Akt phosphorylation were comparable with GLA and D-GLA. Neither analogue stimulated IGF1R phosphorylation. CONCLUSIONS: Suprapharmacological doses of D-GLA did not activate IGF1R in vivo. Mitogenic effects of insulin and insulin analogues might be solely based on IR growth-promoting activity.

Mechanism of antimicrobial action of sodium metasilicate against Salmonella enterica serovar Typhimurium.

Sodium metasilicate (SMS) is an alkaline antimicrobial approved by the U.S. Department of Agriculture for use in poultry processing and ready-to-eat poultry products. The objectives of this study were to determine the effectiveness of SMS against Salmonella enterica serovar Typhimurium in suspension and to elucidate the antimicrobial mechanism of action of SMS. Salmonella Typhimurium (ATCC 14028) was exposed to 0 (positive control), 0.5%, 1%, 2% (wt/vol) SMS and 0.1 N NaOH (high pH) solutions for 1, 10, and 30 min. The viability of Salmonella Typhimurium cells treated with different SMS concentrations and high pH was determined on selective and nonselective media and by staining with fluorescent propidium iodide (PI) and SYTO9 nucleic acid stains in combination with flow cytometry. Transmission electron microscopy of Salmonella Typhimurium cells was performed to observe the changes at the cellular level following exposure to SMS and high pH treatments. Treating Salmonella Typhimurium cells with SMS (as low as 0.5%) resulted in immediate inactivation of Salmonella with no detectable survivors. The breakage in membrane integrity and loss of cell viability was observed by PI uptake by cells treated with SMS with subsequent flow cytometry. Salmonella Typhimurium cells exposed to SMS and high pH appeared wrinkled, vacuolated, and lysed with their cytoplasmic material leaking into extracellular matrix on transmission electron micrographs. The findings from this study indicate that SMS acts on the cytoplasmic membrane and causes lysis of the cells and leakage of intracellular contents.

Concentrations of insulin glargine and its metabolites during long-term insulin therapy in type 2 diabetic patients and comparison of effects of insulin glargine, its metabolites, IGF-I, and human insulin on insulin and igf-I receptor signaling.

We investigated 1) the ability of purified glargine (GLA), metabolites 1 (M1) and 2 (M2), IGF-I, and NPH insulin to activate the insulin receptor (IR)-A and IR-B and IGF-I receptor (IGF-IR) in vitro; 2) plasma concentrations of GLA, M1, and M2 during long-term insulin therapy in type 2 diabetic patients; and 3) IR-A and IR-B activation in vitro induced by serum from patients treated with GLA or NPH insulin. A total of 104 patients (age 56.3 ± 0.8 years, BMI 31.4 ± 0.5 kg/m(2), and A1C 9.1 ± 0.1% [mean ± SE]) were randomized to GLA or NPH insulin therapy for 36 weeks. Plasma concentrations of GLA, M1, and M2 were determined by liquid chromatography-tandem mass spectrometry assay. IR-A, IR-B, and IGF-IR autophosphorylation was induced by purified hormones or serum by kinase receptor activation assays. In vitro, M1 induced comparable IR-A, IR-B, and IGF-IR autophosphorylation (activation) as NPH insulin. After 36 weeks, M1 increased from undetectable (<0.2 ng/mL) to 1.5 ng/mL (0.9-2.1), while GLA and M2 remained undetectable. GLA dose correlated with M1 (r = 0.84; P < 0.001). Serum from patients treated with GLA or NPH insulin induced similar IR-A and IR-B activation. These data suggest that M1 rather than GLA mediates GLA effects and that compared with NPH insulin, GLA does not increase IGF-IR signaling during long-term insulin therapy in type 2 diabetes.

Plasma exposure to insulin glargine and its metabolites M1 and M2 after subcutaneous injection of therapeutic and supratherapeutic doses of glargine in subjects with type 1 diabetes.

OBJECTIVE: In vivo, after subcutaneous injection, insulin glargine (21(A)-Gly-31(B)-Arg-32(B)-Arg-human insulin) is enzymatically processed into 21(A)-Gly-human insulin (metabolite 1 [M1]). 21(A)-Gly-des-30(B)-Thr-human insulin (metabolite 2 [M2]) is also found. In vitro, glargine exhibits slightly higher affinity, whereas M1 and M2 exhibit lower affinity for IGF-1 receptor, as well as mitogenic properties, versus human insulin. The aim of the study was to quantitate plasma concentrations of glargine, M1, and M2 after subcutaneous injection of glargine in male type 1 diabetic subjects. RESEARCH DESIGN AND METHODS: Glargine, M1, and M2 were determined in blood samples obtained from 12, 11, and 11 type 1 diabetic subjects who received single subcutaneous doses of 0.3, 0.6, or 1.2 units · kg(-1) glargine in a euglycemic clamp study. Glargine, M1, and M2 were extracted using immunoaffinity columns and quantified by a specific liquid chromatography-tandem mass spectrometry assay. Lower limit of quantification was 0.2 ng · mL(-1) (33 pmol · L(-1)) per analyte. RESULTS: Plasma M1 concentration increased with increasing dose; geometric mean (percent coefficient of variation) M1-area under the curve between time of dosing and 30 h after dosing (AUC(0-30h)) was 1,261 (66), 2,867 (35), and 4,693 (22) pmol · h · L(-1) at doses of 0.3, 0.6, and 1.2 units · kg(-1), respectively, and correlated with metabolic effect assessed as pharmacodynamics-AUC(0-30h) of the glucose infusion rate following glargine administration (r = 0.74; P < 0.01). Glargine and M2 were detectable in only one-third of subjects and at a few time points. CONCLUSIONS: After subcutaneous injection of glargine in male subjects with type 1 diabetes, exposure to glargine is marginal, if any, even at supratherapeutic doses. Glargine is rapidly and nearly completely processed to M1 (21(A)-Gly-human insulin), which mediates the metabolic effect of injected glargine.

Metabolism of insulin glargine after repeated daily subcutaneous injections in subjects with type 2 diabetes.

OBJECTIVE: To investigate concentration of plasma insulin glargine after its subcutaneous dosing compared with concentration of its metabolites 1 (M1) and 2 (M2) in subjects with type 2 diabetes. RESEARCH DESIGN AND METHODS: Nine subjects underwent a 32-h euglycemic glucose clamp study (0.4 units/kg glargine after 1 week of daily glargine administration). Glargine, M1, and M2 were measured by a specific liquid chromatography-tandem mass spectrometry assay. RESULTS: Glargine was detected in only five of the nine subjects, at few time points, and at negligible concentrations. M1 was detected in all subjects and exhibited the same pattern as traditional radioimmunoassay-measured plasma insulin. M2 was not detected at all. CONCLUSIONS: After subcutaneous injection, glargine was minimally detectable in blood, whereas its metabolite M1 accounted for most (>90%) of the plasma insulin concentration and metabolic action of the injected glargine.

Antimicrobial effects of sodium metasilicate against Listeria monocytogenes.

Sodium metasilicate (SMS) is a U.S. Department of Agriculture-approved antimicrobial for use in meat and poultry processing and has been known to be effective against various foodborne pathogens. However, its antimicrobial mechanism has not yet been revealed. In this study, we attempted to elucidate the mechanism by which SMS inactivates Listeria monocytogenes, a Gram-positive bacterial pathogen encountered commonly in ready-to-eat meat and poultry products. L. monocytogenes (Scott A) cells were treated with different concentrations of SMS (1.0, 2.0, 3.0, 4.0, 5.0, and 6.0% [wt/vol]) and compared with high pH treatment (0.1, 0.2, and 0.3N NaOH solutions) for 1, 10, and 30 min. SMS exhibited concentration and time effects on inactivation of L. monocytogenes. The effect of SMS on the membrane integrity and viability of L. monocytogenes was determined by use of propidium iodide (PI) and SYTO9 nucleic acid stains with subsequent flow cytometry. The breakage in membrane integrity was observed by uptake of PI by cells treated with SMS with subsequent flow cytometry. Ultrastructural changes from corresponding transmission electron micrographs further revealed the disruption in the cytoplasmic membrane and changes in the morphology of the cells treated with SMS and high pH. The results from flow cytometry experiment and transmission electron microscopy study indicated that following SMS treatment, the membrane integrity of L. monocytogenes was compromised leading to leakage of intracellular contents and subsequent cell death.

Hic-5 promotes invadopodia formation and invasion during TGF-ß-induced epithelial-mesenchymal transition.

Transforming growth factor ß (TGF-ß)-stimulated epithelial-mesenchymal transition (EMT) is an important developmental process that has also been implicated in increased cell invasion and metastatic potential of cancer cells. Expression of the focal adhesion protein Hic-5 has been shown to be up-regulated in epithelial cells in response to TGF-ß. Herein, we demonstrate that TGF-ß-induced Hic-5 up-regulation or ectopic expression of Hic-5 in normal MCF10A cells promoted increased extracellular matrix degradation and invasion through the formation of invadopodia. Hic-5 was tyrosine phosphorylated in an Src-dependent manner after TGF-ß stimulation, and inhibition of Src activity or overexpression of a Y38/60F nonphosphorylatable mutant of Hic-5 inhibited matrix degradation and invasion. RhoC, but not RhoA, was also required for TGF-ß- and Hic-5-induced matrix degradation. Hic-5 also induced matrix degradation, cell migration, and invasion in the absence of TGF-ß via Rac1 regulation of p38 MAPK. These data identify Hic-5 as a critical mediator of TGF-ß-stimulated invadopodia formation, cell migration, and invasion.

Reshaping the healthcare delivery network.

Challenges that most healthcare organizations face today include: falling bond ratings and the scarcity of capital resources; delivery of consistently high-quality care despite budget cuts; changes in payer mix due to unemployed patients, the uninsured, early retirees, and an increase in patients postponing care; increasing competition from nontraditional competitors; the need to prepare for healthcare reform without knowing what form it will take.

Prostaglandin D(2) sustains the pyrogenic effect of prostaglandin E(2).

Prostaglandin D(2) (PGD(2)) is involved in a variety of physiological and pathophysiological processes, but its role in fever is poorly understood. Here we investigated the effects of central PGD(2) administration on body temperature and prostaglandin levels in the cerebrospinal fluid (CSF) of rats. Administration of PGD(2) into the cisterna magna (i.c.m) evoked a delayed fever response that was paralleled by increased levels of prostaglandin E(2) (PGE(2)) in the CSF. The elevated PGE(2) levels were not caused by an increased expression of cyclooxygenase 2 or microsomal prostaglandin E synthase-1 in the hypothalamus. Interestingly, i.c.m. pretreatment of animals with PGD(2) considerably sustained the pyrogenic effects of i.c.m. administered PGE(2). These data indicate that PGD(2) might control the availability of PGE(2) in the CSF and suggest that centrally produced PGD(2) may play a role in the maintenance of fever.

The selective COX-2 inhibitor celecoxib modulates sphingolipid synthesis.

Sphingolipids such as ceramides (Cers) play important roles in cell proliferation, apoptosis, and cell cycle regulation. An increased Cer level is linked to the cytotoxic effects of several chemotherapeutics. Various selective cyclooxygenase-2 (COX-2) inhibitors induce anti-proliferative effects in tumor cells. We addressed the possible interaction of the selective COX-2 inhibitors, coxibs, with the sphingolipid pathway as an explanation of their anti-proliferative effects. Sphingolipids were measured using liquid chromatography tandem mass spectrometry. Treatment of various cancer cell lines with celecoxib significantly increased sphinganine, C(16:0)-, C(24:0)-, C(24:1)-dihydroceramide (dhCer) and led to a depletion of C(24:0)-, C(24:1)-Cer in a time- and concentration-dependent manner, whereas other coxibs had no effect. Using (13)C,(15)N-labeled l-serine, we demonstrated that the augmented dhCers after celecoxib treatment originate from de novo synthesis. Celecoxib inhibited the dihydroceramide desaturase (DEGS) in vivo with an IC(50) of 78.9 +/- 1.5 muM and increased total Cer level about 2-fold, indicating an activation of sphingolipid biosynthesis. Interestingly, inhibition of the sphingolipid biosynthesis by specific inhibitors of l-serine palmitoyltransferase diminished the anti-proliferative potency of celecoxib. In conclusion, induction of de novo synthesis of sphingolipids and inhibition of DEGS contribute to the anti-proliferative effects of celecoxib.

Celecoxib inhibits 5-lipoxygenase.

Celecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor used in the therapy of inflammatory and painful conditions. Various COX-2-independent pharmacological effects, such as a chemo-preventive and tumor-regressive activity have been suggested, but the respective non-COX-2 targets of celecoxib are still a matter of research. We now demonstrate that celecoxib inhibits 5-lipoxygenase (5-LO), a key enzyme in leukotriene (LT) biosynthesis. Celecoxib suppressed 5-LO product formation in ionophore A23187-activated human polymorphonuclear leukocytes (IC(50) approximately 8 microM). Similarly, celecoxib inhibited LTB(4) formation in human whole blood (IC(50) approximately 27.3 microM). Direct interference of 5-LO with celecoxib was visualized by inhibition of enzyme catalysis both in cell homogenates and with purified 5-LO (IC(50) approximately 23.4 and 24.9 microM, respectively). Related lipoxygenases (12-LO and 15-LO) were not affected by celecoxib. Other COX-2 inhibitors (etoricoxib and rofecoxib) or unselective NSAIDs (non-steroidal anti-inflammatory drugs, diclofenac) failed to inhibit 5-LO. In rats which received celecoxib (i.p.), the blood LTB(4) levels were dose-dependently reduced with an ED(50) value approximately 35.2 mg/kg. Together, celecoxib is a direct inhibitor of 5-LO in vitro and in vivo. These findings provide a potential molecular basis for some of the described COX-2-independent pharmacological effects of celecoxib.

Dimethylcelecoxib inhibits prostaglandin E2 production.

Dimethylcelecoxib (DMC), a derivative of celecoxib, has been developed to distinguish between the COX-dependent and COX-independent anti-carcinogenic effects of celecoxib. Although DMC has been shown to have no COX-inhibitory activity, it is important to ensure that DMC has no other influence on prostaglandin production. Interestingly, in this study we show that DMC inhibits PGE(2) production in vitro in the low micromolar range in different cancer cell lines. This effect can be at least partly explained by our findings that DMC inhibits microsomal prostaglandin E synthase-1 (mPGES-1) activity in a cell-free assay. Moreover, it prevents mPGES-1 up-regulation after stimulation of HeLa cells with IL-1beta and TNFalpha. Conversely, DMC has no effect on the expression levels of COX-1, COX-2, cytosolic PGES (cPGES) or mPGES-2 in these cells. However, in the cell-free assay DMC inhibits mPGES-1 to a maximum of 65% only and concentrations needed for inhibition of mPGES-1 activity are about 10-fold higher than needed for inhibition of PGE(2) production in cell culture. This suggests that DMC also has an impact on other proteins involved in PGE(2) production. In cell culture experiments the anti-proliferative effect of DMC, measured by the WST-1 assay, seems not to be dependent on PGE(2) inhibition, as DMC was equally effective in unstimulated HeLa cells as well as in stimulated HeLa cells, and the addition of external PGE(2) did not reverse the anti-proliferative effect of DMC in HCA-7 cells. We conclude that DMC is not a suitable non-prostaglandin-inhibiting control substance for research purposes.

Consequences of altered eicosanoid patterns for nociceptive processing in mPGES-1-deficient mice.

Cyclooxygenase-2 (COX-2)-dependent prostaglandin (PG) E(2) synthesis in the spinal cord plays a major role in the development of inflammatory hyperalgesia and allodynia. Microsomal PGE(2) synthase-1 (mPGES-1) isomerizes COX-2-derived PGH(2) to PGE(2). Here, we evaluated the effect of mPGES-1-deficiency on the nociceptive behavior in various models of nociception that depend on PGE(2) synthesis. Surprisingly, in the COX-2-dependent zymosan-evoked hyperalgesia model, the nociceptive behavior was not reduced in mPGES-1-deficient mice despite a marked decrease of the spinal PGE(2) synthesis. Similarly, the nociceptive behavior was unaltered in mPGES-1-deficient mice in the formalin test. Importantly, spinal cords and primary spinal cord cells derived from mPGES-1-deficient mice showed a redirection of the PGE(2) synthesis to PGD(2), PGF(2alpha) and 6-keto-PGF(1alpha) (stable metabolite of PGI(2)). Since the latter prostaglandins serve also as mediators of nociception they may compensate the loss of PGE(2) synthesis in mPGES-1-deficient mice.

Microsomal prostaglandin E2 synthase-1 deletion leads to adverse left ventricular remodeling after myocardial infarction.

BACKGROUND: Pharmacological inhibition of cyclooxygenase-2 increases the risk of myocardial infarction (MI) and stroke. Microsomal prostaglandin (PG) E(2) synthase-1 (mPGES-1), encoded by the Ptges gene, functions downstream from cyclooxygenase-2 in the inducible PGE(2) biosynthetic pathway. We caused acute MI in Ptges(+/+) and Ptges(-/-) mice to define the role of mPGES-1 in cardiac ischemic injury. METHODS AND RESULTS: Twenty-eight days after MI, Ptges(-/-) mice develop more left ventricular (LV) dilation, have worse LV systolic and diastolic function, and have higher LV end-diastolic pressure than Ptges(+/+) mice but have similar pulmonary wet-to-dry weight ratios, cardiac mass, infarct size, and mortality. The length-to-width ratio of individual cardiomyocytes is significantly greater in Ptges(-/-) than Ptges(+/+) mice after MI, a finding consistent with eccentric cardiomyocyte hypertrophy in Ptges(-/-) mice. Expression of atrial natriuretic peptide, brain natriuretic peptide, and alpha- and beta-myosin heavy chain, markers of ventricular hypertrophy, is higher in the LV of Ptges(-/-) than Ptges(+/+) mice after MI. Ptges(+/+) mice express cyclooxygenase-2 and mPGES-1 protein in inflammatory cells adjacent to the infarct after MI but do not express these proteins in cardiomyocytes. Ptges(-/-) mice express cyclooxygenase-2 in inflammatory cells adjacent to the infarct and do not express mPGES-1 in any cells in the heart. Levels of PGE(2) but not PGD(2), thromboxane A(2), PGI(2), or PGF(2alpha) are higher in the infarct and LV remote from the infarct after MI in Ptges(+/+) than Ptges(-/-) mice. CONCLUSIONS: In Ptges(+/+) mice, mPGES-1 in inflammatory cells catalyzes PGE(2) biosynthesis in the LV after MI. Deletion of mPGES-1 leads to eccentric cardiac myocyte hypertrophy, LV dilation, and impaired LV contractile function after acute MI.

Diabetes care in hospitalized noncritically ill patients: More evidence for clinical inertia and negative therapeutic momentum.

BACKGROUND: Little is known about management of hyperglycemia in inpatients. OBJECTIVE: To gain insight into caring for hospitalized patients with hyperglycemia. DESIGN: Retrospective analysis. SETTING: Teaching hospital. PATIENTS: Data on all patients discharged between January 1, 2001, and December 31, 2004 with a diagnosis of diabetes or hyperglycemia were extracted and linked to laboratory and pharmacy databases. Only the data on patients who did not require intensive care and who were hospitalized for at least 3 days were analyzed. MEASUREMENTS: Average bedside glucose during the first and last 24 hours of hospital stay and for the entire length of stay; assessment of changes in insulin regimen and dose. RESULTS: The average age of patients included in the study (n = 2916) was 69 years. Fifty-seven percent of the patients were men, 90% were white, and average length of stay was 5.7 days. More than 20% of the patients had evidence of sustained hyperglycemia. Forty-two percent of the patients who showed poor control of glycemia (glucose > 200 mg/dL) during the first 24 hours were discharged in poor control. The frequency of hypoglycemia was low (only 2.2 of 100 measurements per person) compared with hyperglycemia (25.5 of 100 measurements per person). Most patients (72%) received insulin during hospitalization, but there was high use of short-acting insulin and less than optimal intensification of therapy (clinical inertia); many patients had insulin therapy decreased despite persistent hyperglycemia (negative therapeutic momentum). CONCLUSIONS: Glycemic control in the hospital was frequently poor, and there was suboptimal use of insulin, even among patients with sustained hyperglycemia. Educational programs directed at practitioners should focus on the importance of inpatient glucose control and provide guidelines on how and when to change therapy.

Convenient medical clinics reshaping the healthcare landscape.

Many physicians are developing their own convenient medical clinic locations, but hospitals are lagging in seizing this business opportunity. Obstacles to CMC development include finding a viable partner, staffing the clinics, and overcoming legal issues. Hospitals need to decide whether they want to compete, partner, or do nothing.