Institution-Wide Retreats Foster Organizational Learning and Action at a Comprehensive Cancer Center.

Providing safe and informed healthcare for sexual and gender minority (SGM) individuals with cancer is stymied by the lack of sexual orientation and gender identity (SOGI) data reliably available in health records and by insufficient training for staff. Approaches that support institutional learning, especially around sensitive topics, are essential for hospitals seeking to improve practices impacting patient safety and research. We engineered annual institutional retreats to identify and unify stakeholders, promote awareness of gaps and needs, identify initiatives, minimize redundant projects, and coordinate efforts that promote improvements in SGM cancer care, education, and research. The 2022 and 2023 retreats employed a 4-h hybrid format allowing virtual and in-person engagement. Retreat organizers facilitated small-group discussions for brainstorming among participants. We performed descriptive statistics from retreat evaluations. The retreats engaged 104 attendees from distinct departments and roles. Participants expressed robust satisfaction, commending the retreat organization and content quality. Notably, the first retreat yielded leadership endorsement and funding for a Quality Improvement pilot to standardize SOGI data collection and clinical staff training. The second retreat provided a platform for updates on focused efforts across the institution and for receiving direction regarding national best practices for SGM care and research. We report the processes and outcomes of institution-wide retreats, which served as a platform for identifying gaps in organizational healthcare practices and research for SGM individuals with cancer. The strategies described herein may be readily scaled at other cancer hospitals seeking to learn and enact system-wide practice changes that support the needs of SGM patients and families.

The association of burnout with work absenteeism and the frequency of thoughts in leaving their job in a cohort of healthcare workers during the COVID-19 pandemic.

Introduction: During the coronavirus disease 2019 pandemic, high levels of burnout were reported among healthcare workers. This study examines the association of work absenteeism and frequency of thoughts in leaving current job with burnout among a cohort of healthcare workers during the COVID-19 pandemic. Methods: A cross-sectional survey of healthcare workers was conducted from April-May, 2022 on healthcare workers from 10 hospitals, 18 immediate care centers, and 325 outpatient practices in the Chicago area and surrounding Illinois suburbs. Logistic regression models were used to assess the association of burnout scores (Oldenburg Burnout Inventory-OLBI) and its sub-scores (exhaustion and disengagement scores) with work absenteeism and thoughts of leaving work. Results: One-fifth and 60% of respondents (n = 1,825) reported unplanned absenteeism and thoughts of leaving their job, respectively. After adjusting for covariates, higher burnout scores, especially exhaustion scores, were associated with increased odds of unplanned absenteeism (OR = 1.04, 95% CI: 1.01-1.08). Burnout scores and both sub-scores were also positively associated with the frequency of thoughts of leaving work, e.g., each unit increase in the OLBI burnout score was associated with 1.39 (95% CI: 1.34-1.43) times higher odds of thinking about leaving work "a lot/constantly" vs. "never". Discussion: Overall, this study cohort showed a positive association between burnout scores and unplanned work absenteeism (and frequency of thoughts in leaving job) during the COVID-19 pandemic. More research is needed to support healthcare worker well-being during times of stress and direct solutions to addressing unplanned absenteeism in the light of a pandemic.

Impact of COVID-19 on HIV Testing Among AIDS Institute-Funded Providers in New York State-A Time Series Analysis.

BACKGROUND: New York State (NYS) was at the intersection of the HIV epidemic and coronavirus disease 2019 (COVID-19) pandemic leading to a disruption in HIV-preventive services. This study sought to determine the impact of the COVID-19 pandemic and mitigation efforts on HIV-testing trends in NYS among AIDS Institute (AI)-funded providers. METHODS: We analyzed weekly testing data from the AI Reporting System from January 1, 2017, to June 27, 2021, to fit an interrupted time series model that predicted the expected number of HIV tests among AI-funded providers in NYS had the COVID-19 pandemic not occurred. The actual observed numbers of HIV testing that occurred from weeks beginning March 15, 2020, to June 30, 2021, were compared with the number of HIV tests predicted by the model. RESULTS: In the absence of the COVID-19 pandemic, our model predicted that there would have been 45,605 HIV tests among AI-funded providers between the weeks beginning March 15, 2020, to June 27, 2021. We observed 20,742 HIV tests, representing a 54.5% reduction. We observed percent decreases of greater than 50% for HIV testing among AI-funded providers for New York City (52.9%) and rest of state (59.8%) regions, male (50.6%) and female (66.8%) genders, as well as Black (59.2%), Hispanic (52.8%), mixed race (57.5%), other (50.3%), and White (50.1%) race and ethnicities. CONCLUSION: HIV testing among AI-funded providers in NYS has declined substantially following the COVID-19 pandemic, reflecting decreased access to, and/or demand for, testing among persons at elevated risk for HIV. Initiatives to increase HIV testing and maintain access to HIV prevention services need to be explored following COVID-19.

Is a third arterial conduit necessary? Comparison of the radial artery and saphenous vein in patients receiving bilateral internal thoracic arteries for triple vessel coronary disease.

OBJECTIVES: The use of bilateral internal thoracic arteries (BITAs) is associated with improved long-term survival after coronary artery bypass grafting (CABG). However, it is unclear whether the addition of a radial artery (RA) in patients already receiving BITA confers any additional survival benefit over that of a saphenous vein (SV). As such, we reviewed our multicentre experience and compared both strategies. METHODS: From 1995 to 2010, 1497 patients underwent primary isolated CABG for three-vessel coronary disease using BITAs. An SV was used as a third conduit in 460 (31%) patients and an RA in 1037 (69%). A total of 1258 distal anastomoses were performed using RAs and these were to the diagonal territory in 169, the circumflex in 454 and the right coronary in 635. Survival data were obtained using the National Death Index and propensity-score matching was used for risk-adjustment. RESULTS: The overall cohort was young (mean age 61 ± 9 years). Patients receiving RAs were more likely to be younger, and were less likely to have experienced a prior myocardial infarction. At 30 days, mortality was similar (BITA + SV: 5, 1.1% vs BITA + RA: 9, 0.9%, P = 0.77). At 15 years, BITA + RA patients experienced improved unadjusted survival (BITA + SV: 67 ± 4.6% vs BITA + RA: 82 ± 3.2%, P < 0.0001). Multivariable Cox regression in the entire cohort also showed the BITA + RA group to be associated with better survival (HR 0.58, 95% CI 0.44-0.75, P < 0.001). After propensity-score matching of 262 patient-pairs, BITA + RA experienced similar 30-day mortality (BITA + SV: 3, 1.1% vs BITA + RA: 3, 1.1%, P > 0.99). However, at 15 years, BITA + RA patients experienced improved risk-adjusted survival (BITA + SV: 72 ± 6.0% vs BITA + RA: 82 ± 5.2%, P = 0.021). The RA was associated with better risk-adjusted survival for grafting of the right coronary and its branches (148 matched pairs; SV-RCA: 74 ± 7.8% vs RA-RCA: 86 ± 6.5%, P = 0.0046 at 15 years). CONCLUSIONS: The addition of an RA graft even in patients already receiving BITAs is associated with a survival benefit. In younger patients with a reasonable long-term life expectancy, surgeons should strive to achieve total arterial revascularization with BITAs and radial arteries.

Use of a Machine Learning-Based High Content Analysis Approach to Identify Photoreceptor Neurite Promoting Molecules.

High content analysis (HCA) has become a leading methodology in phenotypic drug discovery efforts. Typical HCA workflows include imaging cells using an automated microscope and analyzing the data using algorithms designed to quantify one or more specific phenotypes of interest. Due to the richness of high content data, unappreciated phenotypic changes may be discovered in existing image sets using interactive machine-learning based software systems. Primary postnatal day four retinal cells from the photoreceptor (PR) labeled QRX-EGFP reporter mice were isolated, seeded, treated with a set of 234 profiled kinase inhibitors and then cultured for 1 week. The cells were imaged with an Acumen plate-based laser cytometer to determine the number and intensity of GFP-expressing, i.e. PR, cells. Wells displaying intensities and counts above threshold values of interest were re-imaged at a higher resolution with an INCell2000 automated microscope. The images were analyzed with an open source HCA analysis tool, PhenoRipper (Rajaram et al., Nat Methods 9:635-637, 2012), to identify the high GFP-inducing treatments that additionally resulted in diverse phenotypes compared to the vehicle control samples. The pyrimidinopyrimidone kinase inhibitor CHEMBL-1766490, a pan kinase inhibitor whose major known targets are p38α and the Src family member lck, was identified as an inducer of photoreceptor neuritogenesis by using the open-source HCA program PhenoRipper. This finding was corroborated using a cell-based method of image analysis that measures quantitative differences in the mean neurite length in GFP expressing cells. Interacting with data using machine learning algorithms may complement traditional HCA approaches by leading to the discovery of small molecule-induced cellular phenotypes in addition to those upon which the investigator is initially focusing.

Is the radial artery associated with improved survival in older patients undergoing coronary artery bypass grafting? An analysis of a multicentre experience†.

OBJECTIVES: Studies suggest that the radial artery (RA) may exhibit superior patency compared with the saphenous vein (SV). It is unclear whether older patients undergoing coronary artery bypass grafting (CABG) derive any survival benefit from the use of RAs. We sought to evaluate this using a multicentre database. METHODS: From 1995 to 2010, 6059 patients with three-vessel coronary artery disease underwent primary isolated CABG at 8 centres. A study cohort of 4006 patients was formed with 3220 (80%) receiving at least 1 RA to supplement a single in situ internal thoracic artery (RA group) while 786 (20%) received only veins to supplement a single ITA (SV group). In the RA group, bilateral RAs were used in 1418 (44%) cases, while total arterial revascularization was achieved in 1859 (58%). RAs were mostly grafted to the left circumflex and right coronary territories. Survival data were obtained using the National Death Index and propensity-score matching was used for risk adjustment. Separate propensity-score analyses were conducted for the 2149 patients (1645 RA, 504 SV) who were 70 years or older. RESULTS: Patients receiving RAs were younger (mean age in years RA: 68 ± 9.7 vs SV: 71 ± 7.9, P < 0.001) and less likely to have cerebrovascular disease, obstructive airways disease, myocardial infarction within 7 days and left-main coronary disease. At 30 days, RA patients experienced reduced unadjusted mortality (49 of 3220, 1.5% vs 25 of 786, 3.2%, P = 0.004). At 15 years, the RA group showed superior unadjusted survival (51 ± 1.1 vs 35 ± 1.9%, P < 0.001). After propensity-score matching of 507 patient pairs, there was comparable 30-day mortality between groups (RA: 9, 1.8 vs SV: 14, 2.8%, P = 0.41). However, at 15 years, the RA group still showed superior survival (42 ± 2.6 vs 35 ± 2.5%, P = 0.008). Among those 70 years and older (327 matched pairs), despite similar 30-day mortality (RA: 6, 1.8% vs SV: 10, 3.1%, P = 0.42), RA patients again exhibited improved survival (35 ± 3.3 vs 22 ± 2.8%, P = 0.004) at 15 years. CONCLUSIONS: This multicentre analysis suggests that the use of an RA is associated with a survival benefit in older patients undergoing CABG.

Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies.

OBJECTIVE: Total arterial revascularization (TAR) with internal thoracic arteries (ITAs) and radial arteries (RA) is associated with greater long-term survival compared with the use of a single internal thoracic artery supplemented by veins. The optimal conduit choice and configuration in achieving TAR remains controversial, with uncertainty regarding the individual prognostic impact of ITAs and RAs. As such, among patients solely undergoing TAR, we compared long-term survival between patients receiving single thoracic arteries and those receiving bilateral ITAs. METHODS: From 1995 to 2010, 2821 patients with 3-vessel coronary artery disease at 8 centers underwent primary isolated coronary artery bypass with TAR using ITAs and RAs. Bilateral ITAs were used in 912 patients. In 380 cases, bilateral in situ ITAs were grafted to the left coronary system. RAs were used in 848 patients (93%) receiving bilateral ITAs and 1906 patients (99.8%) receiving single ITAs. Survival data were obtained using the National Death Index. Separate 1:1 propensity score-matched analyses were performed for (1) bilateral ITA versus single ITA and (2) bilateral ITA incorporating a free right ITA versus single ITA and RAs. Among the 912 patients with bilateral ITAs, those receiving an in situ right ITA to the left coronary system were compared with those receiving a free right ITA. RESULTS: In the propensity score-matched analysis comparing bilateral versus single ITAs (591 matched pairs), there were similar rates of 30-day mortality and deep sternal wound infection. Bilateral ITA use was associated with greater 15-year survival (79% ± 3.9% vs 67% ± 4.7%, P < .001). In the analysis between bilateral ITA incorporating a free right ITA versus single ITA + RAs (380 matched pairs), bilateral ITA use demonstrated comparable survival at 15 years (79% ± 4.7% vs 67% ± 5.7%, P = .09). Among patients receiving bilateral ITAs, comparison between in situ right ITA versus free right ITA recipients (206 matched pairs) revealed comparable 15-year survival (84% ± 6.1% vs 79% ± 6.7%, P = .13). Multivariable Cox regression found bilateral ITA use to be protective from mortality (hazard ratio, 0.73; 95% confidence interval, 0.59-0.90, P = .004). CONCLUSIONS: The use of bilateral ITAs as an in situ or free conduit is associated with greater survival and seems to offer a prognostic advantage over the use of only a single ITA supplemented by RAs. Therefore, all configurations of TAR are not equivalent.

Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival.

OBJECTIVES: We sought to evaluate our experience with total arterial revascularization and compare it with the traditional approach of a single internal thoracic artery supplemented by saphenous veins. METHODS: From 1995 to 2010, 6059 patients with triple-vessel coronary artery disease underwent primary isolated coronary artery bypass grafting at 8 centers. A study cohort of 3774 patients was formed, with 2988 (79%) undergoing total arterial revascularization and 786 (21%) receiving only saphenous veins to supplement a single in situ internal thoracic artery. In the total arterial revascularization group, bilateral internal thoracic arteries were used in 1079 patients (36%) and at least 1 radial artery was used in 2916 patients (97%). Propensity score matching was used for risk adjustment. RESULTS: Patients undergoing total arterial revascularization were younger (65.0±10.4 years vs 71.3±7.9 years, P<.001) and less likely to have diabetes, cerebrovascular disease, recent myocardial infarction, and severe left ventricular impairment. At 15 years, patients who underwent total arterial revascularization experienced superior unadjusted survival (62%±1.1% vs 35%±1.9%, P<.001). Multivariable Cox regression in the entire study cohort showed the total arterial group had improved survival with a hazard ratio of 0.79 (95% confidence interval, 0.70-0.90; P<.001). After propensity score matching yielded 384 patient pairs, patients who underwent total arterial revascularization showed improved survival at 15 years than patients who underwent single arterial revascularization (54%±3.3% vs 41%±3.0%, P=.0004). CONCLUSIONS: This large multicenter study suggests that a strategy of total arterial revascularization is associated with improved long-term survival compared with the use of only a single arterial and saphenous vein grafts. Total arterial revascularization should be encouraged in patients with a reasonable life expectancy.

A high content screening approach to identify molecules neuroprotective for photoreceptor cells.

PURPOSE: Retinal degenerations are a heterogeneous group of diseases in which there is slow but progressive loss of photoreceptors (PR). There are currently no approved therapies for treating retinal degenerations. In an effort to identify novel small molecules that are (1) neuroprotective and (2) promote PR differentiation, we have developed microscale (1,536 well) cell culture assays using primary retinal neurons. METHODS: Primary murine retinal cells are isolated, seeded, treated with a 1,280 compound chemical library in a 7 point titration and then cultured under conditions developed to assay protection against an introduced stress or enhance PR differentiation. In the protection assays a chemical insult is introduced and viability assessed after 72 h using CellTiterGlo, a single-step chemiluminescent reagent. In the differentiation assay, cells are isolated from the rhodopsin-GFP knock-in mouse and PR differentiation is assessed by fixing cells after 21 days in culture and imaging with the Acumen plate-based laser cytometer (TTP Labtech) to determine number and intensity of GFP-expressing cells. Positive wells are re-imaged at higher resolution with an INCell2000 automated microscope (GE). Concentration-response curves are generated to pharmacologically profile each compound and hits identified by xx. RESULTS: We have developed PR differentiation and neuroprotection assays with a signal to background (S/B) ratios of 11 and 3, and a coefficient of variation (CV) of 20 and 9 %, suitable for chemical screening. Staurosporine has been shown in our differentiation assay to simultaneously increase the number of rhodopsin positive objects while decreasing the mean rhodopsin intensity and punctate rhodopsin fluorescent objects. CONCLUSIONS: Using primary murine retinal cells, we developed high throughput assays to identify small molecules that influence PR development and survival. By screening multiple compound concentrations, dose-response curves can be generated, and the false negative rate minimized. It is hoped that this work will identify both potential preclinical candidates as well as molecular probes that will be useful for analysis of the molecular mechanisms that promote PR differentiation and survival.

Epigenetics and cell death: DNA hypermethylation in programmed retinal cell death.

BACKGROUND: Vertebrate genomes undergo epigenetic reprogramming during development and disease. Emerging evidence suggests that DNA methylation plays a key role in cell fate determination in the retina. Despite extensive studies of the programmed cell death that occurs during retinal development and degeneration, little is known about how DNA methylation might regulate neuronal cell death in the retina. METHODS: The developing chicken retina and the rd1 and rhodopsin-GFP mouse models of retinal degeneration were used to investigate programmed cell death during retinal development and degeneration. Changes in DNA methylation were determined by immunohistochemistry using antibodies against 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC). RESULTS: Punctate patterns of hypermethylation paralleled patterns of caspase3-dependent apoptotic cell death previously reported to occur during development in the chicken retina. Degenerating rd1 mouse retinas, at time points corresponding to the peak of rod cell death, showed elevated signals for 5mC and 5hmC in photoreceptors throughout the retina, with the most intense staining observed in the peripheral retina. Hypermethylation of photoreceptors in rd1 mice was associated with TUNEL and PAR staining and appeared to be cCaspase3-independent. After peak rod degeneration, during the period of cone death, occasional hypermethylation was observed in the outer nuclear layer. CONCLUSION: The finding that cell-specific increases of 5mC and 5hmC immunostaining are associated with the death of retinal neurons during both development and degeneration suggests that changes in DNA methylation may play a role in modulating gene expression during the process of retinal degeneration. During retinal development, hypermethylation of retinal neurons associates with classical caspase-dependent apoptosis as well as caspase-3 independent cell death, while hypermethylation in the rd1 mouse photoreceptors is primarily associated with caspase-3 independent programmed cell death. These findings suggest a previously unrecognized role for epigenetic mechanisms in the onset and/or progression of programed cell death in the retina.

The right internal thoracic artery: is it underutilized?

PURPOSE OF REVIEW: The left internal thoracic artery is acknowledged as the best coronary conduit. The right internal thoracic artery (RITA) is identical to the left ITA (LITA), yet, despite excellent published results, the RITA [as part of bilateral ITA (BITA) grafting] is rarely used in coronary artery bypass graft surgery (CABG). With advances in CABG and drug-eluting stents (DESs) for coronary artery disease, it is timely to review the clinical and patency results when RITA is used in BITA, to define its role in the treatment of multivessel coronary artery disease. RECENT FINDINGS: RITA use is 4% in the USA, and 10% in the UK and Australia, although higher in some centres. Perioperative mortality of BITA is 1-3%. Morbidity is low, 1-2% for stroke and perioperative myocardial infarction, and 2-3% for postoperative bleeding. Deep sternal wound infection is also low, 1-3%. Excellent results are reported for RITA/BITA in off-pump coronary artery bypass, in patients with renal dysfunction and those with end-stage renal failure and on dialysis. BITA is well tolerated in routine diabetic patients with multivessel coronary disease and may enhance their long-term prognosis. Patencies for RITA are identical to LITA in comparable territories and superior to non-ITA grafts, resulting in enhanced long-term patient outcomes. SUMMARY: As evidence of excellent RITA results increases, strategies are required to encourage its use. Skeletonization, free, and composite grafts, associated with excellent clinical results and patencies, enhance RITA versatility and are important in improving long-term prognosis. The role of BITA/CABG versus DESs also needs further definition.

The right internal thoracic artery: the forgotten conduit--5,766 patients and 991 angiograms.

BACKGROUND: The right internal thoracic artery (RITA) is biologically identical to the left ITA, yet is rarely used in coronary artery bypass graft surgery (CABG). We examined the results and long-term patency of RITA grafts. METHODS: Between 1986 and 2008, 991 consecutive RITA graft angiograms for postoperative cardiac symptoms were evaluated by two independent observers. Grafts were considered nonpatent if they had a greater than 80% stenosis, string sign, or total occlusion. Patency was examined over time by coronary territory, whether in situ or free RITA, and compared with other conduits. Clinical results were collected prospectively and by the National Death Index. RESULTS: A total of 5,766 patients had a RITA graft as part of a bilateral ITA CABG procedure. Operative mortality was 1.1%; deep sternal infection 1.5%. Of 7,780 coronary conduits studied, 991 RITA conduits were examined; a mean of 100±60 months postoperatively (1 to 288 months). Overall ten-year RITA patency was 90%. The RITA graft patency to the left anterior descending artery (LAD; n=149) was 95% at 10 years and 90% at 15 years. Ten-year RITA patency to the circumflex marginal (Cx; n=436) was 91%, right coronary artery (n=199) was 84% (p<0.001), and posterior descending artery (n=207) was 86%. Ten-year RITA and LITA patencies to the LAD were identical (95% vs 96%) and to the Cx (91% vs 89%), respectively. In situ RITA (n=450) and free RITA (n=541) had similar ten-year patencies (89% vs 91%; p=0.44). The RITA patency was always better than the radial artery (p<0.01) and saphenous vein grafts (p<0.001). Atheromatous changes were not seen in the RITA angiograms. Ten-year survival of patients with RITA and LITA for triple-vessel coronary disease was 89%. CONCLUSIONS: Late patencies of RITA are excellent, equivalent to the LITA for identical territories, always better than radial arteries and saphenous vein grafts, and remain free of atheroma. Use of RITA in addition to LITA is associated with excellent survival in triple-vessel coronary disease. More extensive use of the RITA in CABG is recommended.

Long-term patency of 1108 radial arterial-coronary angiograms over 10 years.

BACKGROUND: To avoid late vein graft atheroma and failure, we have used arterial grafts extensively in coronary operations. The radial artery (RA) is the conduit of second choice. This study determined the long-term patency of the RA as a coronary graft. METHODS: Two independent observers evaluated 1108 consecutive postoperative RA conduit angiograms performed between January 1997 and June 2007 for cardiac symptoms. Mean time to postoperative angiography was 48.3 months (range, 1 to 132 months). An RA graft was considered failed (nonpatent) if there was stenosis exceeding 60%, string sign, or occlusion. Patency was determined over time, by coronary territory grafted and by the degree of native coronary artery stenosis (NCAS). RESULTS: At a mean of 48.3 months, 982 of the 1108 RA grafts (89%) were patent. RA patencies for the left anterior descending were 96% (24 of 25), diagonal/intermediate, 90% (121 of 135); circumflex marginal, 89% (499 of 561); right coronary, 83% (38 of 46); posterior descending, 89% (253 of 286); and left ventricular branch/posterolateral, 86% (47 of 55). Patency was 87.5% (56 of 64) for NCAS of less than 60% compared with 89% (926 of 1044; p = 0.89) for NCAS exceeding 60%. Of 318 RAs in place more than 5 years, 294 (92.5%) were patent, and for 107 RAs in place for more than 7 years, 99 were patent (92.5%). Patency was consistent through each year of the decade. Mechanisms of failure did not involve development of atherosclerosis. Patent RA grafts were smooth, with no angiographic evidence of atheroma. CONCLUSIONS: Late patencies of RA grafts are excellent and justify continuing use of the RA in coronary operations.

Subtilisin-like proprotein convertase expression, localization, and activity in the human retina and optic nerve head.

PURPOSE: Subtilisin-like proprotein convertases (SPCs) are a family of calcium-dependent cleavage enzymes that act on dibasic sites of various peptide/protein substrates. The purpose of this study was to investigate the expression, localization, and activity of SPCs in the human retina and optic nerve head. METHODS: mRNA expression of the SPC family in the human retina and optic nerve head tissues was evaluated by quantitative reverse transcription polymerase chain reaction (QRT-PCR). Double immunofluorescence staining was performed on paraffin-embedded human posterior sections to localize SPC family members. Western blot analysis was used to identify PACE4 isoform expression within the optic nerve head and retina. In addition, a fluorogenic SPC substrate-based assay was used to elucidate SPC enzyme activity within human retina and optic nerve head (ONH) tissues. RESULTS: QPCR results indicated that PC1 and PC2 were expressed 4.1- and 5.7-fold higher in retina compared to optic nerve head, whereas PACE4 was expressed 4.1-fold higher in the ONH. PC1 and PC2 were localized primarily in neuronal cells, whereas PACE4 and PC5 were limited to the glia of the retina and optic nerve head. SPC activity in ONH lysate was significantly higher than that of retinal lysate; however, when an SPC inhibitor was added, activity in ONH decreased more than that in retina. CONCLUSIONS: These results indicate that the SPCs are expressed in distinct patterns throughout the human retina and ONH. PC1 and PC2 were primarily expressed in neurons, whereas PACE4 appeared to be largely restricted to glia. Thus, elevated PACE4 may modulate the bioactivity of proteins secreted in the ONH and retina.

Effects of TGF-beta2, BMP-4, and gremlin in the trabecular meshwork: implications for glaucoma.

PURPOSE: The primary causative factor of primary open-angle glaucoma (POAG) is elevated intraocular pressure (IOP) due to increased aqueous humor (AH) outflow resistance, which is associated with morphologic and biochemical changes in the trabecular meshwork (TM). Patients with glaucoma have elevated levels of transforming growth factor (TGF)-beta2 in their AH, and TGF-beta has been shown to increase TM extracellular matrix (ECM) production. The bone morphogenetic protein (BMP) signaling pathway modifies TGF-beta signaling in several different tissues, and a prior study demonstrated that TM cells and tissues express members of the BMP gene family. The purpose of this study was to determine whether BMPs can alter TGF-beta2 signaling in the TM and whether there are defects in BMP signaling in glaucoma. METHODS: ELISA, Western immunoblot analysis, and immunohistochemistry were used to evaluate the expression of BMP proteins in TM cells and tissues. ELISA was used to determine the effects of TGF-beta2 and BMPs on TM fibronectin (FN) secretion. Gene expression was determined by gene microarrays and quantitative (q)PCR. Perfusion-cultured human anterior segments were used to study the effects of altered BMP signaling on IOP. RESULTS: The human TM synthesized and secreted BMP-4 as well as expressed BMP receptor subtypes BMPRI and BMPRII. TM cells responded to exogenous BMP-4 by phosphorylating Smad signaling proteins. Cultured human TM cells treated with TGF-beta2 significantly increased FN levels, and BMP-4 blocked this FN induction. The expression of BMP family genes in normal and glaucomatous TM cells was profiled and significant elevation of mRNA and protein levels of the BMP antagonist gremlin were found in glaucomatous TM cells. In addition, Gremlin was present in human aqueous humor and in the perfusate medium of perfusion-cultured human eyes. Gremlin blocked the negative effect of BMP-4 on TGF-beta-induction of FN. Recombinant Gremlin added to the medium of ex vivo perfusion-cultured human eye anterior segments caused the glaucoma phenotype of elevated IOP. CONCLUSIONS: These results are consistent with the hypothesis that, in POAG, elevated expression of Gremlin by TM cells inhibits BMP-4 antagonism of TGF-beta2 and leads to increased ECM deposition and elevated IOP.

Patencies of 2127 arterial to coronary conduits over 15 years.

BACKGROUND: Use of arterial grafts in coronary surgery is based on the excellent patency of the left internal thoracic artery (LITA) and an expectation that other arterial grafts-right internal thoracic artery (RITA) and radial artery (RA)-will give similar patencies, superior to saphenous vein. We examined patencies of arterial grafts in a practice with extensive use for more than 15 years. METHODS: Consecutive postoperative angiograms of 2,127 arterial/coronary conduits were evaluated. Angiograms were performed for cardiac symptoms. Assessment was by two observers. String signs were considered as occlusions. RESULTS: There were 2127 arterial conduits. Overall patencies were as follows: LITA, 96.4% (1296 of 1345); RITA, 88.3% (534 of 605); aortocoronary RA, 89.3% (158 of 177). The LITA patency to the left anterior descending artery was 97.1% (1131 of 1165); to the obtuse marginal artery it was 91.7% (165 of 180; p 0.01). The RITA pedicled graft patency was 86% (275 of 321) compared with free RITA, 91% (259 of 284; p = not significant). For RITA there was a hierarchy of patency for coronary territory grafted (left anterior descending artery best, right coronary/posterior descending artery worst) and for degree of coronary stenosis: if stenosis was less than 60%, patency was 65% (47 of 72); if stenosis was more than 60%, patency was 90.9% (485 of 533; p = 0.0001). Similarly for the radial artery there was higher patency with greater coronary stenosis. The LITA patency at 5 years was 98%, at 10 years it was 95%, and at 15 years it was 88%. The RITA patency at 5 years was 96%, at 10 years it was 81%, and at 15 years it was 65%. The radial artery patency at 1 year was 96% and at 4 years it was 89%. For 3,714 vein grafts also studied overall patency was 61% (2266 of 3214) with patencies of 95% at 5 years, 71% at 10 years, and 32% at 15 years. CONCLUSIONS: Excellent long-term patencies of arterial grafts are noted, superior to those of vein grafts. Patencies were influenced by conduit, by distribution, and by coronary artery stenosis.

The radial artery in coronary surgery: a 5-year experience--clinical and angiographic results.

BACKGROUND: The radial artery (RA) has been used extensively by us as a way of reducing the use of the saphenous vein. It has been hoped that the RA will maintain greater late patency than the saphenous vein. We evaluated our initial 5-year experience with the RA in coronary surgery. METHODS: We studied 6,646 consecutive patients who had a single RA (4,872), or bilateral RA (1,774), as coronary grafts, from June 1995 to June 2000. Angiograms were performed mostly in symptomatic patients, or as part of a research project in asymptomatic patients. RESULTS: The patients' mean age was 65.1 years; 23% had diabetes, 14% had unstable angina, and 42% had prior myocardial infarction. An average of 3.3 grafts per patient were performed, 87% from arterial conduit. Conduits used were RA (8,420), left internal thoracic artery (6,296), and right internal thoracic artery (1,076). Operative mortality occurred in 58 (0.9%) patients, stroke in 92 (1.4%), deep sternal infection in 97 (1.4%), reoperation for hemorrhage in 56 (0.9%), and myocardial infarction in 52 (0.8%). Peak mean postoperative creatine kinase MB (CKMB) was 16.5 IU/L. Two patients developed fingertip ischemia. Postoperative angiographic RA patency was 90.2% (333 of 369 distal anastomoses). CONCLUSIONS: Good early clinical and angiographic results can be achieved by using the RA in coronary surgery.