Establishing a diagnostic reference level of radiation dose in coronary angiography and intervention: A prospective evaluation.

INTRODUCTION: Invasive Coronary Angiography (CAG) leads to significant radiation exposure to the patients. Guidelines suggest that a local landmark or Diagnostic Reference Level (DRL) for these procedures should be established for every region and country. This study attempts to create a DRL for a tertiary care hospital, acting as an interim DRL for the country/region. METHODS: Radiation exposure data for all coronary procedures done at a tertiary care hospital between October 2016 to September 2018 were collected. Data was segregated into diagnostic Coronary Angiography (CAG) and single-vessel Percutaneous Intervention (PCI). The parameters collected include dose surface product (PKA), skin surface entry dose (KAR), and fluoroscopy time (FT). The 75th percentile of the PKA was used to define the DRL. RESULTS: 500 Patients were included in the CAG group, in which the Median KAR was 412.05 mGy, Median PKA was 2635.7 µGysqm, and median FT was 2.25 min. The DRL for coronary angiography was calculated as 3695.1 µGysqm. Two hundred fifty patients were in the PCI group, the Median KAR was 1649 mGy, Median PKA was 8822.1 µGysqm, the median FT being 8.2 min. The DRL for single-vessel coronary intervention was calculated as 11038 µGysqm. CONCLUSION: This study establishes a benchmark for radiation dose for diagnostic coronary angiography and single-vessel coronary intervention at a tertiary care hospital in NCR. It establishes an interim DRL that can be used for future studies in other institutions in the region and country and to compare with other countries.

First in man: percutaneous coronary angioplasty using non-fluoroscopic electro-anatomic mapping.

Reduction of radiography exposure and contrast use continue to be challenging goals for interventional cardiology. We present a case where percutaneous coronary intervention was done successfully using an electroanatomic mapping system (NavX™; Abbot Inc. USA); with near zero use of fluoroscopy or contrast agent.

Dexamethasone-Mediated Upregulation of Calreticulin Inhibits Primary Human Glioblastoma Dispersal Ex Vivo.

Dispersal of Glioblastoma (GBM) renders localized therapy ineffective and is a major cause of recurrence. Previous studies have demonstrated that Dexamethasone (Dex), a drug currently used to treat brain tumor-related edema, can also significantly reduce dispersal of human primary GBM cells from neurospheres. It does so by triggering α5 integrin activity, leading to restoration of fibronectin matrix assembly (FNMA), increased neurosphere cohesion, and reduction of neurosphere dispersal velocity (DV). How Dex specifically activates α5 integrin in these GBM lines is unknown. Several chaperone proteins are known to activate integrins, including calreticulin (CALR). We explore the role of CALR as a potential mediator of Dex-dependent induction of α5 integrin activity in primary human GBM cells. We use CALR knock-down and knock-in strategies to explore the effects on FNMA, aggregate compaction, and dispersal velocity in vitro, as well as dispersal ex vivo on extirpated mouse retina and brain slices. We show that Dex increases CALR expression and that siRNA knockdown suppresses Dex-mediated FNMA. Overexpression of CALR in GBM cells activates FNMA, increases compaction, and decreases DV in vitro and on explants of mouse retina and brain slices. Our results define a novel interaction between Dex, CALR, and FNMA as inhibitors of GBM dispersal.

Dexamethasone-Mediated Activation of Fibronectin Matrix Assembly Reduces Dispersal of Primary Human Glioblastoma Cells.

Despite resection and adjuvant therapy, the 5-year survival for patients with Glioblastoma multiforme (GBM) is less than 10%. This poor outcome is largely attributed to rapid tumor growth and early dispersal of cells, factors that contribute to a high recurrence rate and poor prognosis. An understanding of the cellular and molecular machinery that drive growth and dispersal is essential if we are to impact long-term survival. Our previous studies utilizing a series of immortalized GBM cell lines established a functional causation between activation of fibronectin matrix assembly (FNMA), increased tumor cohesion, and decreased dispersal. Activation of FNMA was accomplished by treatment with Dexamethasone (Dex), a drug routinely used to treat brain tumor related edema. Here, we utilize a broad range of qualitative and quantitative assays and the use of a human GBM tissue microarray and freshly-isolated primary human GBM cells grown both as conventional 2D cultures and as 3D spheroids to explore the role of Dex and FNMA in modulating various parameters that can significantly influence tumor cell dispersal. We show that the expression and processing of fibronectin in a human GBM tissue-microarray is variable, with 90% of tumors displaying some abnormality or lack in capacity to secrete fibronectin or assemble it into a matrix. We also show that low-passage primary GBM cells vary in their capacity for FNMA and that Dex treatment reactivates this process. Activation of FNMA effectively "glues" cells together and prevents cells from detaching from the primary mass. Dex treatment also significantly increases the strength of cell-ECM adhesion and decreases motility. The combination of increased cohesion and decreased motility discourages in vitro and ex vivo dispersal. By increasing cell-cell cohesion, Dex also decreases growth rate of 3D spheroids. These effects could all be reversed by an inhibitor of FNMA and by the glucocorticoid receptor antagonist, RU-486. Our results describe a new role for Dex as a suppressor of GBM dispersal and growth.

The fate of internalized α5 integrin is regulated by matrix-capable fibronectin.

BACKGROUND: Assembly of fibronectin matrices is associated with integrin receptor turnover and is an important determinant of tissue remodeling. Although it is well established that fibronectin is the primary ligand for α5ß1 receptor, the relationship between fibronectin matrix assembly and the fate of internalized α5 integrin remains poorly characterized. MATERIALS AND METHODS: To evaluate the effect of fibronectin matrix on the fate of internalized α5 integrin, fibronectin-null Chinese hamster ovary and mouse embryo fibroblast cells were used to track the fate of α5 after exposure to exogenous fibronectin. RESULTS: In the absence of matrix-capable fibronectin dimer, levels of internalized α5 decreased rapidly over time. This correlated with a decline in total cellular α5 and was associated with the ubiquitination of α5 integrin. In contrast, internalized and total cellular α5 protein levels were maintained when matrix-capable fibronectin was present in the extracellular space. Further, we show that ubiquitination and degradation of internalized α5 integrin in the absence of fibronectin require the presence of two specific lysine residues in the α5 cytoplasmic tail. CONCLUSIONS: Our data demonstrate that α5 integrin turnover is dependent on fibronectin matrix assembly, where the absence of matrix-capable fibronectin in the extracellular space targets the internalized receptor for rapid degradation. These findings have important implications for understanding tissue-remodeling processes found in wound repair and tumor invasion.

The fiber diameter of synthetic bioresorbable extracellular matrix influences human fibroblast morphology and fibronectin matrix assembly.

BACKGROUND: The ideal scaffold material should provide immediate capacity to bear mechanical loads and also permit eventual resorption and replacement with native tissue of similar mechanical integrity. Scaffold characteristics such as fiber diameter provide environmental cues that can influence cell function and differentiation. In this study, the impact of fiber diameter of scaffolds constructed from a tyrosine-based bioresorbable polymer on cellular response was investigated. METHODS: Electrospun bioresorbable poly(desamino tyrosyl-tyrosine ethyl ester carbonate) scaffolds composed of microfibers or nanofibers were constructed and seeded with human dermal fibroblasts. The impact of fiber diameter on actin cytoskeletal morphology, focal adhesion size, fibronectin matrix assembly, and cell proliferation was evaluated using immunofluorescent microscopy and computer-assisted image analysis. RESULTS: Actin stress fibers were more easily observed in cells on microfiber scaffolds compared with those on nanofiber scaffolds. Cells on nanofiber scaffolds developed smaller focal adhesion complexes compared with those on microfiber scaffolds (p < 0.0001). The temporal patterns of fibronectin matrix assembly were affected by scaffold fiber diameter, with cells on microfiber scaffolds showing a delayed response in dense fibril formation compared with nanofiber scaffolds. Cells on nanofiber scaffolds showed higher proliferation compared with microfiber scaffolds at time points under 1 week (p < 0.01), but by 2 weeks significantly higher cell proliferation was observed on microfiber scaffolds (p < 0.01). CONCLUSIONS: The fiber diameter of bioresorbable scaffolds can significantly influence cell response and suggests that the ability of scaffolds to elicit consistent biological responses depends on factors beyond scaffold composition. Such findings have important implications for the design of clinically useful engineered constructs.

Radiofrequency catheter ablation of ventricular tachycardia in arrhythmogenic right ventricular dysplasia/cardiomyopathy using non-contact electroanatomical mapping: single-center experience with follow-up up to median of 30 months.

OBJECTIVE OF STUDY: To evaluate the efficacy of radiofrequency ablation (RFA) of ventricular tachycardia (VT) using non-contact electro-anatomic mapping in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). METHODS: Fifteen consecutive patients (44 ± 15 years) with ARVD/C and symptomatic VTs were studied. Eight patients had syncopal VTs. Two patients had recurrent VT while on AICD; in three patients, RFA was done prior to AICD implantation, and ten patients refused AICD. After obtaining activation maps, first, the clinical VT was targeted, and then, other VTs were sought. RESULTS: Twenty-five inducible VTs were mapped, and 22 of them were successfully ablated. In 13 out of 15 patients, all the clinical and inducible VTs were ablated. In two patients, non-clinical inducible VTs could not be ablated. At 25 ± 16 months (2-52 months), all patients remained asymptomatic. Antiarrhythmic medications were discontinued after 6 months. Two patients had recurrence of non-clinical VT on follow-up. There were no episodes of asymptomatic VT recorded in five patients with AICD. CONCLUSION: A majority of induced VT in patients with ARVD/C can be successfully mapped and ablated using the non-contact Ensite Array Mapping system with good long-term VT-free outcome. Ablation can be a useful adjunct to AICD implantation in such patients.

Brugada pattern in toxic myocarditis due to severe aluminum phosphide poisoning.

Brugada pattern electrocardiogram (ECG) unmasking can occur due to various drugs. There are old reports of the acute infarction pattern in aluminum phosphide (rodenticide)-related toxic myocarditis. The given case illustrates the Brugada pattern and various other ECG abnormalities in a patient with this poisoning. The old reported cases of the acute infarction pattern are also likely the Brugada pattern.