Long-term benefits of hematopoietic stem cell-based macrophage/microglia delivery of GDNF to the CNS in a mouse model of Parkinson's disease.

Glial cell line-derived neurotrophic factor (GDNF) protects dopaminergic neurons in various models of Parkinson's disease (PD). Cell-based GDNF gene delivery mitigates neurodegeneration and improves both motor and non-motor functions in PD mice. As PD is a chronic condition, this study aims to investigate the long-lasting benefits of hematopoietic stem cell (HSC)-based macrophage/microglia-mediated CNS GDNF (MMC-GDNF) delivery in an MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) mouse model. The results indicate that GDNF treatment effectively ameliorated MPTP-induced motor deficits for up to 12 months, which coincided with the protection of nigral dopaminergic neurons and their striatal terminals. Also, the HSC-derived macrophages/microglia were recruited selectively to the neurodegenerative areas of the substantia nigra. The therapeutic benefits appear to involve two mechanisms: (1) macrophage/microglia release of GDNF-containing exosomes, which are transferred to target neurons, and (2) direct release of GDNF by macrophage/microglia, which diffuses to target neurons. Furthermore, the study found that plasma GDNF levels were significantly increased from baseline and remained stable over time, potentially serving as a convenient biomarker for future clinical trials. Notably, no weight loss, altered food intake, cerebellar pathology, or other adverse effects were observed. Overall, this study provides compelling evidence for the long-term therapeutic efficacy and safety of HSC-based MMC-GDNF delivery in the treatment of PD.

Congenital disorders of glycosylation - an umbrella term for rapidly expanding group of rare genetic metabolic disorders - importance of physical investigation.

AIM: Congenital disorders of glycosylation (CDG) belong to an expanding group of rare genetic metabolic disorders caused by defects in the complex chemical enzymatic process of glycosylation. The study is aimed at presenting a case report of a premature dysmorphic newborn, clinical presentation of the condition, the way it was diagnosed and treated, as well as its comparison with the known cases. RESULTS: The result of glycan analysis supports the assumption of a supposed glycosylation disorder and also specifies a specific subtype: CDG-1, subtype ALG12-CDG (Ig). CONCLUSION: CDG have an extremely wide clinical spectrum and should be considered in any child with unexplained developmental delay, failure to thrive, seizures, and abnormalities in liver enzymes, coagulation and immunologic factors. The treatment of most forms of CDG depends upon numerous factors such as specific symptoms present, severity of the disorder, age and overall health of the patients and tolerance to certain medications or procedures. For these reasons, the treatment is specific for every individual. It is based on the symptoms and requires a coordination of efforts of a team of specialists (Tab. 4, Fig. 3, Ref. 19).

Inherited metabolic disorders of glycoconjugate metabolism.

Inherited metabolic disorders of glycoconjugate metabolism include congenital disorders of glycosylation (CDG) - disorders in biosynthesis of glycoconjugates; and some of the lysosomal storage diseases (LSD) - disorders of their degradation. This review summarizes the brief characteristics of metabolic pathways of synthesis and catabolism of glycoconjugates as well as the latest update of relevant enzymatic defects discovered in population. Every year the number of known subtypes of these disorders dramatically increases as a result of high-throughput analytical infrastructure applied. However, due to the broad spectrum of unspecific clinical symptoms, many patients remain undiagnosed or have wrong diagnosis with ineffective treatment. Thus, disorders of glycoconjugate metabolism should be considered and ruled out in any unexplained syndrome. The collaboration between scientists and physicians plays an important role in the progress of such personalized diagnostics, that is essential mainly for rare diseases (Tab. 2, Fig. 1, Ref. 49). Keywords: congenital disorders of glycosylation, lysosomal storage disorders.

A Stitch in Time Saves Nine: Planning for Artesunate Supply with Malaria on the Rise.

Background: Malaria is extremely rare in the United States. Physicians should not only be familiar with signs and symptoms, but also be aware of the available resources at their respective institutions to be able to effectively treat it. Presentation: 52-year-old female presented with worsening generalized fatigue. Vitals were stable. Labs were significant for anemia and thrombocytopenia. Peripheral smear showed ring formed parasitic trophozoites consistent with Plasmodium falciparum. Due to unavailability of antimalarial agents at our hospital, the patient was transferred to a tertiary care center. Patient was started on IV artesunate therapy. Repeat smear after 3 days showed <1% parasitemia after 3 days and the patient was discharged with artemether/lumefantrine for 3 additional days, resulting in full recovery. Conclusion: This case gives a unique insight into the challenges that hospitals in non-endemic regions may have to face, in terms of diagnosing malaria and having access to antimalarial agents.

Role of POCUS in the Management of New-onset Tachyarrhythmia in the Setting of SARS-CoV-2: A Case Report.

Introduction: SARS-CoV-2 infection is associated with myocardial inflammation, new onset cardiomyopathy, and arrhythmias. Here, we describe the utilization of POCUS and management of concurrent new onset atrial tachycardia and heart failure with reduced ejection fraction (HfrEF) in a patient with SARS-CoV-2 infection. Presentation: An 80-year-old female with multiple medical problems presented with sudden onset of shortness of breath and cough. She tested positive for SARS-CoV-2. Initially, she was hypoxic on room air and her heart rhythm was sinus tachycardia. CT angiogram of the chest showed consolidation, pleural effusion, and absence of pulmonary embolism. Because of persistent tachycardia, repeat EKGs and POCUS were performed. Subsequent EKGs showed intermittent atrial tachycardia and sinus tachycardia. Initially, home beta blockers were continued on admission, and additional dosages were considered for rate control, but Cardiac POCUS revealed HfrEF and was subsequently confirmed by comprehensive cardiac echocardiogram, consistent with SARS-CoV-2 infection-related cardiomyopathy. Beta blockers were discontinued, and treatment with amiodarone and furosemide showed improvement in symptoms. The patient was discharged with oral amiodarone and supplemental oxygen. Additionally, once the patient's hemodynamics improved, oral carvedilol was also started as part of GDMT for HfrEF. Follow-up echocardiogram 4 months later showed recovery of systolic EF to 60%. Conclusion: It is essential to consider new onset HFrEF in the evaluation and management of new onset tachyarrhythmias since IV fluids and AV nodal blocking agents can be harmful in decompensated HFrEF. With the advent of POCUS, HFrEF can be quickly identified, and therapy can be tailored to that diagnosis.

Primary Cardiac Sarcoma: Clinical Characteristics and Prognostic Factors over the Past 2 Decades.

BACKGROUND: Primary cardiac sarcomas (PCS) are extremely rare malignant tumors involving the heart. Only isolated case reports have been described in the literature over different periods of time. This pathology has been associated with a dismal prognosis and given its rarity; treatment options are very limited. Furthermore, there are contrasting data about the effectiveness of current treatment modalities in improving the survival of patients with PCS, including surgical resection which is the mainstay of therapy. There is a paucity of data on the epidemiological characteristics of PCS. This study has the objective of investigating the epidemiologic characteristics, survival outcomes, and independent prognostic factors of PCS. METHODS: A total of 362 patients were ultimately registered in our study from the Surveillance, Epidemiology, and End Results (SEER) database. The study period was from 2000 to 2017. Demographics such as clinical characteristics, overall mortality (OM), and PCS-specific mortality (CSM) were taken into account. A p value of <0.1 in the univariate analysis leads to the incorporation of the variable into multivariate analysis adjusting for covariates. Adverse prognostic factors were represented by a Hazard Ratio (HR) greater than one. The five-year survival analysis was carried out using the Kaplan-Meier method and the log-rank test was used to compare survival curves. RESULTS: Crude analysis revealed a high OM in age 80+ (HR = 5.958, 95% CI 3.357-10.575, p < 0.001), followed by age 60-79 (HR = 1.429, 95% CI 1.028-1.986, p = 0.033); and PCS with distant metastases (HR = 1.888, 95% CI 1.389-2.566, p < 0.001). Patients that underwent surgical resection of the primary tumor and patients with malignant fibrous histiocytomas (HR = 0.657, 95% CI 0.455-0.95, p = 0.025) had a better OM (HR = 0.606, 95% CI 0.465-0.791, p < 0.001). The highest cancer-specific mortality was observed in age 80+ (HR = 5.037, 95% CI 2.606-9.736, p < 0.001) and patients with distant metastases (HR = 1.953, 95% CI 1.396-2.733, p < 0.001). Patients with malignant fibrous histiocytomas (HR = 0.572, 95% CI 0.378-0.865, p = 0.008) and those who underwent surgery (HR = 0.581, 95% CI 0.436-0.774, p < 0.001) had a lower CSM. Patients in the age range 80+ (HR = 13.261, 95% CI 5.839-30.119, p < 0.001) and advanced disease with distant metastases (HR = 2.013, 95% CI 1.355-2.99, p = 0.001) were found to have a higher OM in the multivariate analyses adjusting for covariates). Lower OM was found in patients with rhabdomyosarcoma (HR = 0.364, 95% CI 0.154-0.86, p = 0.021) and widowed patients (HR = 0.506, 95% CI 0.263-0.977, p = 0.042). Multivariate cox proportional hazard regression analyses of CSM also revealed higher mortality of the same groups, and lower mortality in patients with Rhabdomyosarcoma. CONCLUSION: In this United States population-based retrospective cohort study using the SEER database, we found that cardiac rhabdomyosarcoma was associated with the lowest CSM and OM. Furthermore, as expected, age and advanced disease at diagnosis were independent factors predicting poor prognosis. Surgical resection of the primary tumor showed lower CSM and OM in the crude analysis but when adjusted for covariates in the multivariate analysis, it did not significantly impact the overall mortality or the cancer-specific mortality. These findings allow for treating clinicians to recognize patients that should be referred to palliative/hospice care at the time of diagnosis and avoid any surgical interventions as they did not show any differences in mortality. Surgical resection, adjuvant chemotherapy, and/or radiation in patients with poor prognoses should be reserved as palliative measures rather than an attempt to cure the disease.

Low density lipoprotein activates monocytes to express tumor necrosis factor.

We analyzed the effect of acetylated low density lipoprotein (aLDL) incubation on tumor necrosis factor (TNF) mRNA and protein expression in isolated resting human monocytes in serum free DMEM. TNF mRNA expression was about one third that of PMA and was dose dependent. The maximum stimulatory effect on TNF mRNA was at 250 micrograms/ml, while 500 micrograms/ml induced downregulation. The maximum stimulatory effect occurred at 6 hours, and by 24 hours TNF mRNA expression returned to the resting state. Acetyl LDL also induced the expression of immunoreactive TNF, reaching a sevenfold maximum above control at 12 hours following a 6 hour exposure period. The results suggest that aLDL is a potent stimulator of TNF expression in resting monocytes. This mechanism may be operational in atheroma evolution.

Growth factors in pathogenesis of coronary arterial restenosis.

Restenosis occurs in 25% to 55% of patients within 6 months of successful angioplasty. The major histologic component of the restenotic lesion is intimal hyperplasia, which is almost certainly driven by growth factors. After vascular injury, smooth muscle cells proliferate, reaching a maximum rate at day 2. Smooth muscle cell proliferation diminishes as the vessel surface is re-endothelialized at about day 7, and by week 4 the smooth muscle cell mitotic rate returns to baseline of less than 1% per day. The events of the histologic evolution of arterial injury can be used to create a hypothetical paradigm for the role of growth factors in restenosis. Restenosis might logically be prevented by an inhibitory intervention at any of the various steps in the healing process.

Detection and localization of tumor necrosis factor in human atheroma.

Tumor necrosis factor (TNF) is a secretory product of normal macrophages that can cause cell necrosis, new blood vessel formation and thrombosis. These are also 3 characteristic features of the progression of stable atheroma to endothelial disruption. Accordingly, an immunohistochemical method was developed to detect TNF in human tissue. Using this method TNF positivity was demonstrated in 57 of 65 (88%) of tissue sections classified as atherosclerotic and in 5 of 11 (45%) sections classified as minimally atherosclerotic. TNF was absent in 6 sections classified as normal. TNF positivity was found not only in the cytoplasm of macrophages, but also in the cytoplasm and attached to the cell membrane of smooth muscle cells and endothelial cells of the human atheroma. Because TNF is known to cause new vessel formation, hemorrhagic necrosis and increased thrombogenicity, it may play a role in the evolution of uncomplicated to complex atheroma.

Donors with a history of cocaine use: effect on survival and rejection frequency after heart transplantation.

The frequency of cocaine use among donors is currently unknown. Cocaine has cardiotoxic effects and could affect the outcome of heart transplantation. To examine the frequency of nonintravenous cocaine use in organ donors and the outcome of heart transplantation with such donors, we retrospectively analyzed the clinical, biopsy, and donor information on 112 consecutive patients who underwent transplantation between December 1988 and August 1993. Ten patients were excluded because of incomplete information regarding the donor's cocaine status. Of the remaining 102 patients, 16 (16%) had a positive donor history for nonintravenous cocaine use (cocaine group) and 86 patients (84%) had a negative history (noncocaine group). Survival, frequency of cellular rejection (grade > or = 1B), and humoral rejection were compared between the two groups. Survival rates at 30 days (100% versus 97% +/- 2%) and at 1 year (93 +/- 7% versus 89 +/- 3%) were similar (p = not significant, cocaine versus noncocaine group). Freedom from rejection was similar at 30 days (81% +/- 10% versus 79% +/- 4% cellular rejection-free, 33% +/- 14% versus 60% +/- 6% humoral-free) and 6 months (34% +/- 12% versus 55% +/- 5% cellular-free, 16% +/- 11% versus 36% +/- 6% humoral-free) (p = not significant). No significant difference was found in donor inotropic support before procurement, ischemic time, length of stay in intensive care unit, or total stay in the hospital. In conclusion, a high incidence of nonintravenous cocaine use exists among donors. The outcome of patients who receive transplanted hearts obtained from nonintravenous cocaine users is favorable, suggesting that the use of such hearts is safe.

Combined antiviral and immunoglobulin therapy as prophylaxis against cytomegalovirus infection after heart transplantation.

BACKGROUND: Cytomegalovirus is a frequent cause of infection and morbidity after heart transplantation, especially in patients treated with antilymphocytic drugs where the incidence may be as high as 50%. METHODS: To determine the efficacy of combined antiviral and intravenous immune globulin therapy for prevention of cytomegalovirus disease in transplant recipients receiving OKT3 and to compare two different antiviral drug regimens, we reviewed 115 transplant recipients from December 1988 to December 1993 who survived for more than 30 days. Of these, 29 received oral acyclovir for 3 months (group A) and 86 received intravenous ganciclovir for 2 weeks followed by oral acyclovir up to 3 months (group G); all received six infusions of 5% intravenous immune globulin over 2 months. All patients had OKT3 for 10 to 14 days and triple-drug immunosuppression. RESULTS: Cytomegalovirus disease (pneumonitis, gastroenteritis, or leukopenia with fever) occurred in 10% of patients (12 of 115 patients) and was confirmed by positive culture, typical microscopic inclusions, or polymerase chain reaction. In 91 seropositive recipients, there was a trend to less cytomegalovirus disease in group G (3.0%, 2 of 67 patients) than in group A (12.5%, 3 of 24 patients) (p = 0.11), which was more apparent in recipients with seropositive donors where the incidence was reduced from 16.7% (group A) to 2.4% (group G; p = 0.08). In 24 seronegative recipients, cytomegalovirus disease incidence was higher overall and not significantly less in group G (26%, 5 of 19 patients) than in group A (40%, two of five patients) (p = Not significant). CONCLUSIONS: Prophylaxis with combined antiviral and immune globulin therapy produces a low (10%) incidence of cytomegalovirus disease in OKT3-treated heart transplant recipients. In seropositive recipients treated with combined therapy, ganciclovir may be more effective than acyclovir. Larger trials and more aggressive prophylactic strategies are needed in seronegative patients who receive hearts from seropositive donors.

Bradyarrhythmias requiring pacemaker implantation after orthotopic heart transplantation: association with rejection.

Patients with severe sinus-node dysfunction that required pacemaker implantation after orthotopic heart transplantation were reviewed. During a 21-month period, 42 transplantations were performed in 41 patients. Five patients (12.2%) required a permanent pacemaker because of severe dysrhythmias. Three patients had moderate-to-severe cellular and/or humoral (vascular) rejection, and two of the five patients (40%) died. In the remaining two patients, bradyarrhythmias were due most likely to trauma to the sinus node during harvesting of the donor heart, and these patients have shown no evidence of significant rejection on repeated biopsies. A strong relationship was found between moderate or severe rejection and the development of significant bradyarrhythmias that required the placement of a permanent pacemaker. The development of severe dysrhythmias during the early or late posttransplantation period should be considered a manifestation of an ongoing rejection episode until proven otherwise. In our experience this evidence of rejection may imply a poor prognostic sign because it is associated with high mortality rates.

AP-2 enhances Sp1-dependent activation of the growth-regulated human ATP/ADP translocator.

The mammalian ATP/ADP translocator isoform-2 (ANT2) gene is growth-activated. Regulation of the gene appears to involve Sp1, as an essential activator, and a suppressor through an Sp1 core element next to the transcription start. We show here that the proximal promoter also binds AP-2 strongly and specifically to two sites, one of which overlaps the Sp1 proximal suppressor site. AP-2 binds with an affinity of 10 to15 fold higher than that of Sp1. AP-2 alone does not alter the ANT2 promoter activity in transfected SL2 cells, but enhances the Sp1-dependent activation of the promoter several fold. Enhancement by AP-2 is observed only when Sp1 is limiting for transcription activation. These data suggest that the cellular AP-2/Sp1 ratio might influence ANT2 expression in developing or differentiating cells.

Combined heart and kidney transplantation with allografts from the same donor.

We present the cases of 3 patients who underwent simultaneous heart and kidney transplantation using allografts from the same donor. This combined approach offers a reasonable option for patients with coexisting end-stage heart and kidney disease. A review of all previously reported cases suggests that survival is similar to that of single-organ transplantation. In addition, there appears to be a low incidence of rejection when multiple allografts from the same donor are used. The heart and kidney can and frequently do reject asynchronously, so rejection monitoring and surveillance should be carried out separately for each transplanted organ.

Orthotopic heart transplantation with bicaval and pulmonary venous anastomoses.

We present our experience with an alternative technique for orthotopic heart transplantation. It consists of total excision of the recipient's atria, with the donor's heart implantation performed using bicaval end-to-end anastomoses as well as pulmonary venous anastomoses. Forty consecutive patients receiving transplants in this fashion were compared with 64 patients who underwent orthotopic transplantation with the standard technique. The incidence of postoperative tricuspid regurgitation was reduced in patients receiving transplants with the new surgical approach (p = 0.003). In addition, the need for pacemaker implantation for severe bradyarrhythmia in the early (0 to 6 weeks) posttransplantation period (p = 0.003) was eliminated. Although not statistically significant, there was a trend in the reduction of postoperative mitral regurgitation in patients who received transplants by the modified technique. Based on this experience, we believe this modified technique for orthotopic heart transplantation has an anatomic and physiologic advantage that may improve long-term hemodynamic results.

In vivo liposome-mediated transfection of HLA-DR alpha-chain gene into pig hearts.

UNLABELLED: Scarcity of suitable donor organs remains a major problem for organ transplantation. Transfer of recipient HLA-genes into animal donor-organs during harvest could induce graft-tolerance without suppressing the recipient immune system. OBJECTIVE: This pilot study aimed to test the feasibility of an in vivo gene transfer into pig hearts by intracoronary infusion of DNA:liposome-complexes and to detect the gene product by immunohistochemistry. METHODS: The pcDV1-pL2-vector, containing the basesequence for HLA-DR alpha-chain in plasmids (1.3 kb) was selected. The plasmids were isolated with ethidiumbromide and incubated with lipofectin in a 1:3-ratio for 10 min. The DNA:lipofectin-complex was diluted to 10 cc with physiologic saline and delivered into the left anterior descending artery of 6 farm pigs over 10 min. As a control within the same animal, the same amount of lipofectin alone was infused into the first diagonal branch. Three pigs were sacrificed after 24 h, the other 3 after 48 h. Delivery of DNA:liposome-complexes was detected by oil red 0 staining, expression of HLA-DR alpha-chain-antigen with a monoclonal anti-HLA-DR alpha-antibody. RESULTS: Transfection of the HLA-class-II DR-alpha-chain occurred in endothelial cells. Infiltrating cells around capillaries stained positively for HLA-DR-alpha. These infiltrating cells were negative for the pan B- and the pan T-cell-marker L26 and UCHL-1. There was no transfection and hypercellularity in the myocardium around the first diagonal branch. CONCLUSIONS: In vivo intracoronary infusion of the HLA-DR alpha-chain-DNA:lipofectin-complex leads to expression of the corresponding antigen on pig endothelium for 48 h. The infiltrating cells require further characterization.

When does relaxation actually begin? The early phases of relaxation.

Exact timing of relaxation within the cardiac cycle was carried out by aid of polygrams consisting of epicardial segmental length curves, contractile force, left ventricular, left atrial and aortic pressures, indirect carotid curves, apex cardiogram, their derivatives and ECG reference tracings in the open-chest dog heart. The relaxation starts in late systole before aortic valve closure, at the nadir of the epicardial segmental length curve and at the climax of the contractile force curve. Onset of relaxation is indicated by the late systolic knee of the left ventricular pressure curve and, by the apex cardiogram as well as by the start of the downstroke of the negative phase on their first derivatives. The earliest phase of relaxation, from its beginning to the isovolumic relaxation period (IVRP), is proposed to be named "auxobaric relaxation period" (ABRP). Considerable lengthening was found during both ABRP and IVRP. This lengthening may provide an explanation for pre-inflow volume increments. The higher the frequency the longer the ABRP and the shorter the IVRP. In the more severe form of ischemia there is a sudden lengthening during ABRP and IVRP (late systolic bulging) whereas in the less severe form only onset of the relaxation is postponed within the cardiac cycle. The data suggest that ischemia leads to alterations in the early phase of relaxation even before involvement of the contraction phase (hypokinesis, akinesis, dyskinesis).

Cutting balloon coronary angioplasty--initial clinical experience.

The success of percutaneous transluminal coronary angioplasty is limited by acute occlusion and late restenosis. In 25 patients (20 men, 5 women, age range 36-81 years) coronary angioplasty was performed using a new cutting balloon into which 3-4 longitudinally orientated blades are incorporated so as to reduce the rate of severe dissections. In 12 patients stenoses were reduced from 83.9 +/- 7.8% to 28.4 +/- 10.7% (mean +/- SD) by the cutting balloon alone, using predilatation with a small conventional balloon in two cases. Thirteen other patients were additionally dilated with a conventional balloon because of a residual stenosis > 50% after cutting balloon angioplasty. Here the stenoses could be reduced from 78.1 +/- 8.7% to 29.1 +/- 11.3%. Six months follow-up angiography in 14 patients showed > 50% restenosis in two of seven patients dilated with a conventional balloon in addition to the cutting balloon, and in one of seven patients dilated with the cutting balloon alone but predilated with a small conventional balloon. These results show that coronary angioplasty by the new cutting balloon results in a stenosis reduction comparable with conventional balloons at a low complication rate. Available 6 months follow-up data show three restenoses in patients either pre- or postdilated by a conventional balloon and none in stand-alone cutting balloon cases.

Effective oral ganciclovir prophylaxis against cytomegalovirus disease in heart transplant recipients.

The presented data show the combined sequential use of i.v. G for 14 days followed by PO G for 90 days is a much more effective prophylaxis for CMVD after heart transplantation than use of i.v. G for 14 days followed by PO A for 90 days. A need for hospitalization due to CMVD is significantly reduced by this new strategy. The follow-up in group II is shorter than in group I but is now at least 6 months in group II, without any new cases in the first 6 months after cardiac transplantation. Some currently unknown adverse effect of prolonged PO G, which may be present, is not identified in this analysis.