Imbalance of APOB Lipoproteins and Large HDL in Type 1 Diabetes Drives Atherosclerosis.

BACKGROUND: Individuals with type 1 diabetes (T1D) generally have normal or even higher HDL (high-density lipoprotein)-cholesterol levels than people without diabetes yet are at increased risk for atherosclerotic cardiovascular disease (CVD). Human HDL is a complex mixture of particles that can vary in cholesterol content by >2-fold. To investigate if specific HDL subspecies contribute to the increased atherosclerosis associated with T1D, we created mouse models of T1D that exhibit human-like HDL subspecies. We also measured HDL subspecies and their association with incident CVD in a cohort of people with T1D. METHODS: We generated LDL receptor-deficient (Ldlr-/-) mouse models of T1D expressing human APOA1 (apolipoprotein A1). Ldlr-/-APOA1Tg mice exhibited the main human HDL subspecies. We also generated Ldlr-/-APOA1Tg T1D mice expressing CETP (cholesteryl ester transfer protein), which had lower concentrations of large HDL subspecies versus mice not expressing CETP. HDL particle concentrations and sizes and proteins involved in lipoprotein metabolism were measured by calibrated differential ion mobility analysis and targeted mass spectrometry in the mouse models of T1D and in a cohort of individuals with T1D. Endothelial transcytosis was analyzed by total internal reflection fluorescence microscopy. RESULTS: Diabetic Ldlr-/-APOA1Tg mice were severely hyperglycemic and hyperlipidemic and had markedly elevated plasma APOB levels versus nondiabetic littermates but were protected from the proatherogenic effects of diabetes. Diabetic Ldlr-/-APOA1Tg mice expressing CETP lost the atheroprotective effect and had increased lesion necrotic core areas and APOB accumulation, despite having lower plasma APOB levels. The detrimental effects of low concentrations of larger HDL particles in diabetic mice expressing CETP were not explained by reduced cholesterol efflux. Instead, large HDL was more effective than small HDL in preventing endothelial transcytosis of LDL mediated by scavenger receptor class B type 1. Finally, in humans with T1D, increased concentrations of larger HDL particles relative to APOB100 negatively predicted incident CVD independently of HDL-cholesterol levels. CONCLUSIONS: Our results suggest that the balance between APOB lipoproteins and the larger HDL subspecies contributes to atherosclerosis progression and incident CVD in the setting of T1D and that larger HDLs exert atheroprotective effects on endothelial cells rather than by promoting macrophage cholesterol efflux.

Umbilical cord blood transplantation in adult myeloid leukemia.

Allogeneic hematopoietic stem cell (HSC) transplantation is a life-saving procedure for hematopoietic malignancies, marrow failure syndromes and hereditary immunodeficiency disorders. However, wide application of this procedure is limited by availability of suitable human leucocyte antigen (HLA)-matched adult donors. Umbilical cord blood (UCB) has been increasingly used as an alternative HSC source for patients lacking matched-HSC donors. The clinical experience of using UCB transplantation to treat pediatric acute leukemias has already shown that higher-level HLA-mismatched UCB can be equally as good as or even better than matched HSC. Recently, large registries and multiple single institutional studies conclusively demonstrated that UCB is an acceptable source of HSCs for adult acute leukemia patients who lack HLA-matched donors. These studies will impact the future clinical allogeneic stem cell transplantation for acute myeloid leukemia (AML), which is the most common acute leukemia in adults. UCB has unique advantages of easy procurement, absence of risk to donors, low risk of transmitting infections, immediate availability, greater tolerance of HLA disparity and lower-than-expected incidence of severe graft-versus-host disease. These features of UCB permit successful transplantation available to almost every patient who needs it. We anticipate that using UCB as a HSC source for allogeneic transplantation for adult AML will increase dramatically over the next 5 years, by expanding the available allogeneic donor pool. Clinical studies are needed with focus on disease-specific UCB transplantation outcomes, including AML, acute lymphoblastic leukemia, and lymphoma.

Effect of manganese chloride and Verapamil on automaticity of digitalized Purkinje fibers.

The effects of manganese chloride (MnCl2) and verapamil on automaticity of digitlazied Purkinje fibers were studied using conventional microelectrode techniques. The stduied wer made in isolated, spontaneously beating Purkinje prearations. Quabain alone consistently increased the automatic rate, whereas no such increase was observed when the preparations were superfused with a mixture of ouabain adn MnCl2. MnCl2 was also shown to be effective is suppressing the enhanced automaticity induced by ouabain. Mncl2 alone did not have a significant effect on the spontaneous rate of Purkinje fibers. The effect of verapamil was similar to that of MnCl2 in preventing and suppressing the ouabain-induced increase in automaticity. MnCl2 and verapamil have been shown to inhibt tha slow inward calcium current of cardiac fibers. The results therefore suggest that an inward calcium ion current may play a role in the development of digitalis-induced increase in the stope of phase 4 depolarization in Purkinje fibers.

Stem cell transplantation in follicular lymphoma: progress at last?

Follicular non-Hodgkin's lymphomas usually present in advanced stage and although frequently are chemotherapy-sensitive remain incurable using conventional approaches. Treatment options are evolving rapidly and now include targeted therapies such as monoclonal antibodies. Recent studies, including the EBMTR-sponsored 'CUP Trial' (conventional Chemotherapy, Unpurged autograft, Purged autograft), demonstrate that for patients under age 60 years with recurrent chemotherapy-sensitive disease, autologous stem cell transplantation (ASCT) provides a survival benefit over conventional therapy. Allogeneic stem cell transplantation (alloSCT) has become a more effective option. Although incorporation of TBI into the preparative regimen may increase treatment-related mortality (TRM), relapses appear to be reduced compared to a chemotherapy-alone regimen. Reduced-intensity alloSCT procedures are now being performed at an increasing rate, in part due to a lower risk for TRM. Until more data are available, however, reduced-intensity alloSCT should be considered only in cases where myeloablative conditioning is contra-indicated. There are no clear means for choosing ASCT vs alloSCT, a decision influenced by the amount of residual tumor, disease-responsiveness, degree of marrow involvement and extent of prior chemotherapy. ASCT or alloSCT in first remission remains an investigational procedure. Future considerations include incorporation of novel preparative regimens, in vitro purging techniques, antilymphoma vaccines, post transplant immunotherapy and ex vivo-manipulated donor lymphocyte infusions.

Epidemiology of diabetes mellitus in children in Hong Kong: the Hong Kong childhood diabetes register.

OBJECTIVES: To establish a registry for Chinese children with onset of type 1 (insulin dependent) diabetes mellitus before 15 years of age and to determine the incidence of childhood onset type 1 diabetes mellitus in Chinese children in Hong Kong. RESEARCH DESIGN AND METHODS: A registry was established in 1997 to collect childhood diabetes cases retrospectively from all districts in Hong Kong. The study included all newly diagnosed cases of diabetes with onset < 15 yr of age from 1st January 1984 to 31 December 1996. Primary ascertainment was based on review of medical records at all regional public hospitals in Hong Kong and survey of all the registered practitioners in Hong Kong. The secondary source of validation was made impractical, if not impossible, because of the recent implementation of the Personal Data Privacy Ordinance in Hong Kong. RESULTS: A total of 255 diabetic cases were identified, 227 type 1 diabetes mellitus (218 were Chinese), 18 type 2 diabetes mellitus and 11 secondary diabetes. 246 patients were Chinese and 9 non-Chinese. The age-standardized incidence of type 1 and type 2 diabetes mellitus in southern Chinese children in Hong Kong was 1.4/100,000/yr and 0.1/100,000/yr respectively for children < 15 yr of age during the study period. The incidence rates for type 1 diabetes were 0.9, 1.5 and 1.7 per 100,000/yr for 0-4 years, 5 to 9 years and 10 to 14 years age-groups respectively. The incidence for males was 1.2/100,000/yr and for females 1.7/100,000/yr. A significant increase in the incidence was demonstrated during the study period by simple linear regression (slope 0.14/100,000/year, r2 = 0.73, p = 0.0002) CONCLUSIONS: A diabetic registry is established in Hong Kong. This study documents a very low incidence rate of childhood type 1 diabetes mellitus in southern Chinese children in Hong Kong and we have seen an increasing incidence of the disease in the past 13 years.

Prospective study of one- vs two-unit umbilical cord blood transplantation following reduced intensity conditioning in adults with hematological malignancies.

As the threshold nucleated cell dose for one-unit umbilical cord blood (UCB) in adults has not to date been firmly established, we prospectively compared one- vs two-unit UCB transplantation after reduced intensity conditioning (RIC) in adult patients with hematological malignancies. Study design specified one-UCB unit if the cryopreserved total nucleated cell (TNC) dose was 2.5 × 10(7)/kg recipient weight, otherwise two units matched at minima of 4/6 HLA loci to the patient and 3/6 to each other were infused. A total of 27 patients received one unit; 23 patients received two units. Median time to ANC >500/µL was 24 days (95% confidence interval 22-28 days), 25 days for one unit and 23 days for two units (P=0.99). At day 100, ANC >500/µL was 88.4 and 91.3% in the one- and two-unit groups (P=0.99), respectively. Three-year EFS was 28.6% and 39.1% in the one- and two-unit groups (P=0.71), respectively. Infusion of two units was associated with a significantly lower relapse risk, 30.4% vs 59.3% (P=0.045). Infused cell doses (TNC, CD3(+), CD34(+) and CD56(+)CD3(neg)) did not impact on engraftment, OS or EFS. Taken together, one-unit UCB transplantation with a threshold cell dose 2.5 × 10(7)/kg recipient weight after RIC is a viable option for adults, although infusion of two units confers a lower relapse incidence.

Transmembrane potentials of canine AV junctional tissues.

The atrioventricular (AV) junction comprises the AV node, His bundle (HB), and specialized tissues proximal to the node called paranodal fibers (PNF). In the present study, an in vitro, dissection-exposed canine right atrial (RA), transitional fiber (TF), AV junctional preparation was used. The TF and PNF formed a pathway running along the base of the septal cusp of the tricuspid valve (SCTV). In the first experiment, impulses elicited at the RA were monitored to propagate sequentially through the TF, PNF, AV node, and then the HB. This functional evidence supports the concept that a conduction pathway connecting the RA and the AV node exists along the base of the SCTV. This internodal pathway is referred to as the septal cusp pathway. In another experiment, transmembrane potentials and Vmax were determined on each of the AV junctional tissues. Results showed that PNF had the lowest Vmax (2.5 V/sec), followed by AV node (7.0 V/sec) and HB (33 V/sec). This finding showed that PNF, and not the AV node, has the lowest Vmax, suggesting that the PNF has the lowest conductivity among the AV junctional tissues, and this study advances our understanding on the mechanism of AV conduction delay in dog hearts.

Suppressive effect of acetylcholine on action potentials of canine paranodal fibers.

The canine atrioventricular (AV) junction comprises three major tissues: paranodal fibers (PNF), AV node (AVN), and His bundle (HB). In the present study, dissection-exposed, in vitro canine AV junctional preparations were used. The object of the study was to determine whether the PNF or AVN was more sensitive to the suppressive effect of acetylcholine (ACh). In five experiments these tissues were stimulated antegradely and retrogradely, and their action potentials were recorded simultaneously under the influence of ACh (0.5 micrograms/ml). Results indicated the PNF were more sensitive to the suppressive effect of ACh than were the AVN. In another group of 13 experiments, the effects of ACh at 0.05-0.3 micrograms/ml on rate of rise of phase 0 of action potentials (Vmax), peak potential, resting membrane potential, and action potential duration of the PNF were determined. Results indicated that ACh exerted a strong suppressive effect on Vmax and amplitude of the action potentials and had little effect on the resting membrane potential and action potential duration of the PNF. In 10 of 13 preparations, ACh also suppressed the response of PNF, resulting in generation of one action potential to every two stimuli. In conclusion, these findings suggest that PNF could be the tissue responsible for vagal-induced AV conduction block.

Effect of epinephrine on automaticity of the canine atrioventricular node.

Effects of epinephrine on the automaticity of canine AV nodal fibers were studied on spontaneously beating AV node-His bundle preparations. Transmembrane potentials of single fibers of the AV node or His bundle were recorded with microelectrode techniques. Action potentials of most AV nodal fibers were characterized by steep phase-4 depolarization and smooth transition from phases 4 to 0. Epinephrine (0.1-0.2 mug/ml) increased the spontaneous rate of the AV nodal fibers. The slope of phase 4 depolarization was increased and the threshold shifted to a more negative level. These changes probably accounted for the increase in the automaticity of the node. Also, in the presence of epinephrine, the pacemaker of the preparation was consistently located at the AV node had a higher degree of automaticity than the His bundle. The findings of the present experiment, therefore, further support the view that the AV node is automatic.

Suppressive effect of acetylcholine on automaticity of canine atrioventricular node.

The effects of acetylcholine on the spontaneous activity of the AV node of dog hearts were studied by recording transmembrane potentials of its fibers. Action potentials of most nodal fibers were characterized by prominent phase 4 depolarization and a smooth transition from phases 4 to 0. On the isolated AV nodes, acetylcholine at 1.0 microgram/m1 suppressed the rate of phase 4 depolarization and increased the amplitude of the maximum diastolic potential, resulting in a slowing of spontaneous activity. At 2.0 micrograms/m1, spontaneous activity was completely suppressed. In comparison, spontaneous activity of the isolated His bundle was relatively insensitive to the suppressive effect of acetylcholine at the same concentrations. In the AV node-His bundle preparations in which the AV node was the pacemaker, acetylcholine decreased spontaneous activity by suppressing the phase 4 depolarization of the nodal fibers and shifted the pacemaker of the preparation to the His bundle. The findings provide a basis for predicting that under strong vagal influence, the automaticity of the AV node will be suppressed and the pacemaker of the junctional rhythm will be located at the His bundle.

Adrenergic potentiation on spontaneous activity of canine paranodal fibers.

The present study, using in vitro preparations, was designed to determine the anatomic, histological, and automatic properties of canine paranodal fibers. This tissue, together with the atrioventricular (AV) node and His bundle, constituted the three major tissues in the AV junction. The fascicles of the paranodal fibers ran parallel and adjacent to the base of the septal cusp of the tricuspid valve. The distal end of the paranodal fibers joined the lower half of the compact AV node on its convex side. Paranodal fibers when isolated were able to initiate spontaneous activity. Action potentials of many of these fibers showed primary pacemaker characteristics, i.e., a prominent phase 4 depolarization and smooth transition from phases 4 to 0. In 14 preparations, epinephrine (2.0 micrograms injected into the tissue bath) potentiated spontaneous rates to 144 +/- 6.0 beats/min from 61 +/- 5.0, an increase of 136%. Also, under the influence of epinephrine, paranodal fibers consistently generated a spontaneous rate higher than that of the AV node or His bundle, whether they were functionally connected or separated. These findings provide a basis for explaining the junctional tachycardia that occurs under adrenergic influence and demonstrate the presence of three major automatic tissues: the paranodal fibers, AV node, and His bundle in the canine AV junction.

Effects of atropine on the cardiac arrest induced by propranolol and digitoxin in dogs.

The present study examines the hypothesis that vagal activity can accelerate the onset of cardiac arrest produced by administering a beta-adrenergic blocking dose of propranolol to digitoxin-intoxicated dogs. In 11 experiments, intravenous injection of 0.75 mg/kg propranolol into digitoxin intoxicated dogs induced a sustained ventricular asystole (early-phase cardiac arrest). In six of these eleven experiments, intermittent pacing of the ventricles for as long as 150 min to maintain blood pressure after the onset of asystole, led to the resumption of spontaneous heart beats in only one dog. In five other experiments, injection of atropine (1 mg/kg) three min after the onset of early-phase cardiac arrest elicited sustained spontaneous junctional rhythms. In another four experiments the injection of atropine prior to or simultaneously with propranolol prevented the occurrence of asystole and caused the emergence of a junctional pacemaker. In eight experiments in which the cardiac arrest was reversed or prevented, injection of maintenance doses of atropine and propranolol caused eventual failure of the junctional pacemaker (late-phase cardiac arrest). This failure could not be prevented or reversed by atropine. The results suggest that early-phase cardiac arrest is due to vagal suppression of cardiac pacemakers and therefore supports the above hypothesis.

Effect of acetylcholine on automaticity of canine Purkinje fibers.

The effect of acetylcholine on automaticity of Purkinje fibers was studied in isolated canine false tendon preparations with conventional microelectrode techniques. Of 15 preparations with the control spontaneous rate of 12-60 beats/min, acetylcholine in a concentration of 0.5 mug/ml decreased the spontaneous rate by 20-87% in 13 preparations. This decrease in automaticity was due to a decrease in the slope of phase 4 depolarization and an increase in the maximum diastolic potential. The inhibitory effect of acetylcholine could be reversed by atropine in a concentration of 3 mug/ml in six preparations and prevented by pretreatment with atropine in another six preparations. Atropine per se did not have any appreciable effect on automaticity of Purkinje fibers. The results indicate that acetylcholine significantly suppresses automaticity of canine Purkinje fibers through its muscarinic action.

Conduction disturbances of the bundle branches produced by lesions in the nonbranching portion of His bundle.

The present experiments were conducted on isolated dog hearts to demonstrate that conduction disturbances can be induced in the bundle branches by transection of about 50 per cent of the cross-sectional area of the His bundle on the right or left side. The His bundle, the posterior and anterior divisions of left bundle, and the right bundle were exposed by careful dissection, and microelectrode techniques were used to record action potentials from the three bundle branches. Pacing stimuli were applied to the nonbranching portion of His bundle proximal and then distal to the site of transection to study the effect of such lesions on impulse conduction to the bundle branches. It was demonstrated that conduction to the bundle branches was not affected by such lesions in the His bundle at pacing rates slower than 100 per minute; however, conduction disturbances were rate-dependent and manifested at faster pacing rates. In nine out of all 16 experiments, partial or complete block occurred in all three bundle branches regardless of the side of the lesion. In the remaining seven experiments, they were observed in the bundle branch on the same side as the lesion. It was assumed that conduction disturbances of the bilateral bundle branches resulted from decremental conduction in the uncut portion of His at the level of lesion, and those of the ipsilateral branch from the functional failure of transverse crossover connections between the longitudinal His bundle fibers. The results indicate that localized lesions in the nonbranching portion of His bundle can indeed produce the pattern of bundle branch block under certain conditions.

Effects of vagal stimulation, atropine, and propranolol on fibrillation threshold of normal and ischemic ventricles.

The effects of electrical stimulation of the vagus nerves and the administration of atropine on ventricular fibrillation threshold (VFT) were studied in open-chest hearts of 15 dogs anesthetized by alpha-chloralose. These studies were made in both normal and ischemic ventricles, i.e., before and during acute coronary occlusion. The ventricles were paces at a constant rate to eliminate rate-dependent changes and the minimal current required to induce ventricular fibrillation (or VFT) was determined by delivering a train of rapid rectanglular pulses (100 per second) to the venticle actoss the vulnerable period. In normal ventricles, VFT's were significantly increased by vagal stimulation (P less than 0.01) and decreased by atropine (P less than 0.05). Coronary occlusion markedly decreased VFT's (P less than 0.01), and vagal stimulation or atropine failed to alter VFT's significantly in these ischemic ventricles (P greater than 0.8). In additional 14 dogs, the effects of vagal stimulation and atropine were studied after the administration of propranolol. Propranolol alone increased VFT's significantly in boetreatment with propranolol, vagal stimulation and atropine failed to change VFT's significantly in both normal and ischemic ventricles (P greater than 0.8). These results indicate that the vagus nerves exert their effect on VFT by modifying the sympathetic nerve activity in normal ventricles, but such an effect is not significant enough to alter VFT in ischemic ventricles.