Multimodal Biomarkers That Predict the Presence of Gleason Pattern 4: Potential Impact for Active Surveillance.

PURPOSE: Latent grade group ≥2 prostate cancer can impact the performance of active surveillance protocols. To date, molecular biomarkers for active surveillance have relied solely on RNA or protein. We trained and independently validated multimodal (mRNA abundance, DNA methylation, and/or DNA copy number) biomarkers that more accurately separate grade group 1 from grade group ≥2 cancers. MATERIALS AND METHODS: Low- and intermediate-risk prostate cancer patients were assigned to training (n=333) and validation (n=202) cohorts. We profiled the abundance of 342 mRNAs, 100 DNA copy number alteration loci, and 14 hypermethylation sites at 2 locations per tumor. Using the training cohort with cross-validation, we evaluated methods for training classifiers of pathological grade group ≥2 in centrally reviewed radical prostatectomies. We trained 2 distinct classifiers, PRONTO-e and PRONTO-m, and validated them in an independent radical prostatectomy cohort. RESULTS: PRONTO-e comprises 353 mRNA and copy number alteration features. PRONTO-m includes 94 clinical, mRNAs, copy number alterations, and methylation features at 14 and 12 loci, respectively. In independent validation, PRONTO-e and PRONTO-m predicted grade group ≥2 with respective true-positive rates of 0.81 and 0.76, and false-positive rates of 0.43 and 0.26. Both classifiers were resistant to sampling error and identified more upgrading cases than a well-validated presurgical risk calculator, CAPRA (Cancer of the Prostate Risk Assessment; P < .001). CONCLUSIONS: Two grade group classifiers with superior accuracy were developed by incorporating RNA and DNA features and validated in an independent cohort. Upon further validation in biopsy samples, classifiers with these performance characteristics could refine selection of men for active surveillance, extending their treatment-free survival and intervals between surveillance.

The prion protein inhibits monocytic cell migration by stimulating ß1 integrin adhesion and uropod formation.

The broad tissue distribution and evolutionary conservation of the glycosylphosphatidylinositol (GPI)-anchored prion protein (PrP, also known as PRNP) suggests that it plays a role in cellular homeostasis. Given that integrin adhesion determines cell behavior, the proposed role of PrP in cell adhesion might underlie the various in vitro and in vivo effects associated with PrP loss-of-function, including the immune phenotypes described in PrP(-/-) mice. Here, we investigated the role of PrP in the adhesion and (transendothelial) migration of human (pro)monocytes. We found that PrP regulates ß1-integrin-mediated adhesion of monocytes. Additionally, PrP controls the cell morphology and migratory behavior of monocytes: PrP-silenced cells show deficient uropod formation on immobilized VCAM and display bleb-like protrusions on the endothelium. Our data further show that PrP regulates ligand-induced integrin activation. Finally, we found that PrP controls the activation of several proteins involved in cell adhesion and migration, including RhoA and its effector cofilin, as well as proteins of the ERM family. We propose that PrP modulates ß1 integrin adhesion and migration of monocytes through RhoA-induced actin remodeling mediated by cofilin, and through the regulation of ERM-mediated membrane-cytoskeleton linkage.

Textile Aging Characterization on New Generations of Explanted Commercial Endoprostheses: A Preliminary Study.

OBJECTIVE/BACKGROUND: The goal of the present study was to assess the aging phenomena on second-generation textile endoprostheses (EPs) through explant analysis and to establish a preliminary classification of observed defects and material damages. METHODS: From January 2011 to June 2016 110 second- and recent-generation EPs were collected as a part of a European collaborative retrieval program. The analysis focused on the first 41 consecutive commercial EPs collected between 2011 and 2014 and made from polyethylene terephthalate. Explants were submitted to a standardized evaluation protocol, which included data recording, eye-naked evaluation, cleaning of organic remnants, and structural analysis under numerical optical microscopy. Observations were reported using a classification based on 15 features evaluating the fabric, the stitches between the fabric and the stents, and the stents. The total surface area of the holes within the fabric was measured. RESULTS: EPs were implanted for thoracic and abdominal procedures in 12 and 29 cases, respectively. The mean ± SD duration of implantation was 34 ± 26 months (range 2 days-8 years). Sixty-four percent of the samples demonstrated at least one defect caused by compression damage potentially related to the insertion of the EP within the delivery system, which promoted holes and tears. Ninety-five percent of all EPs demonstrated at least one type of abrasion on the stitches. The degradation of the stitches and the number of ruptures increased with duration of implantation. Stent degradation was rare and consisted of corrosion and rupture. Cumulated holed surface area increased with time and was measured up to 13.5 mm2. CONCLUSION: Various aging-related phenomena on commercial textile EPs were identified and classified. Main damaging mechanisms were related to compression and abrasion leading to tears and holes in the fabric and rupture of stitches.

The further evolution of cooperation.

Axelrod's model of the evolution of cooperation was based on the iterated Prisoner's Dilemma. Empirical work following this approach has helped establish the prevalence of cooperation based on reciprocity. Theoretical work has led to a deeper understanding of the role of other factors in the evolution of cooperation: the number of players, the range of possible choices, variation in the payoff structure, noise, the shadow of the future, population dynamics, and population structure.

Evaluation of c4d deposition and circulating antibody in small bowel transplantation.

Antibody-mediated rejection (AMR) consensus criteria are defined in kidney and heart transplantation by histological changes, circulating donor-specific antibody (DSA), and C4d deposition in affected tissue. AMR consensus criteria are not yet identified in small bowel transplantation (SBTx). We investigated those three criteria in 12 children undergoing SBTx, including one retransplantation and four combined liver-SBTx (SBTx), with a follow-up of 12 days to 2 years. All biopsies (91) were evaluated with a standardized grading scheme for acute rejection (AR), vascular lesions and C4d expression. Sera were obtained at day 0 and during the follow-up. C4d was expressed in 37% of biopsies with or without AR, but in 50% of biopsies with severe vascular lesions. In addition, vascular lesions were always associated with AR and a poor outcome. All children with AR (grade 2 or 3) observed before the third month died or lost the graft. DSA were never found in any studied sera. We found no evidence that C4d deposition was of any clinical relevance to the outcome of SBTx. However, the grading of vascular lesions may constitute a useful marker to identify AR that is potentially resistant to standard treatment, and for which an alternative therapy should be considered.

Painful neuropathic disorders: an analysis of the Régie de l'Assurance Maladie du Québec database.

BACKGROUND/OBJECTIVE: Painful neuropathic disorders (PNDs) refer to neurological disorders involving nerves in which pain is a predominant symptom. In most cases, PNDs involve the peripheral nerves. Treatment of PNDs is likely to use large health care resources. However, little is known about the economic burden of PNDs in Canada. METHOD: The present study was performed using data from a random sample of patients covered by the Régie de l'Assurance Maladie du Quebec drug plan. Subjects with a diagnosis of a peripheral PND were identified. Comorbidities, pain-related medication use and resource utilization were compared between PND patients and control patients without PNDs matched for age and sex in a 1:1 ratio. RESULTS: A total of 4912 patients with PNDs were identified. A higher level of comorbidities was found in the PND group (Von Korff chronic disease score 3.91 versus 2.54; P<0.001). The proportion of users of pain-related medications was significantly higher in the PND cohort than in the control group (chi-squared; P<0.001). The average annual number of physician visits was also significantly higher in the PND group than in the control group (14.7 versus 6.4; P<0.001). From a health ministry perspective, costs of health care resources were significantly higher in the PND group (4,163 dollars versus 1,846 dollars; P<0.001). The proportion of potentially inappropriate medications was 34% among those 65 years of age or older. CONCLUSIONS: PNDs are associated with a higher level of comorbidities, higher medical resources utilization and higher health care costs than non-PND conditions.

Pharmacological management of chronic neuropathic pain - consensus statement and guidelines from the Canadian Pain Society.

Neuropathic pain (NeP), generated by disorders of the peripheral and central nervous system, can be particularly severe and disabling. Prevalence estimates indicate that 2% to 3% of the population in the developed world suffer from NeP, which suggests that up to one million Canadians have this disabling condition. Evidence-based guidelines for the pharmacological management of NeP are therefore urgently needed. Randomized, controlled trials, systematic reviews and existing guidelines focusing on the pharmacological management of NeP were evaluated at a consensus meeting. Medications are recommended in the guidelines if their analgesic efficacy was supported by at least one methodologically sound, randomized, controlled trial showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment are based on degree of evidence of analgesic efficacy, safety, ease of use and cost-effectiveness. Analgesic agents recommended for first-line treatments are certain antidepressants (tricyclics) and anticonvulsants (gabapentin and pregabalin). Second-line treatments recommended are serotonin noradrenaline reuptake inhibitors and topical lidocaine. Tramadol and controlled-release opioid analgesics are recommended as third-line treatments for moderate to severe pain. Recommended fourth-line treatments include cannabinoids, methadone and anticonvulsants with lesser evidence of efficacy, such as lamotrigine, topiramate and valproic acid. Treatment must be individualized for each patient based on efficacy, side-effect profile and drug accessibility, including cost. Further studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics, long-term outcomes, and treatment of pediatric and central NeP.

Development and Implementation of a Registry of Patients Attending Multidisciplinary Pain Treatment Clinics: The Quebec Pain Registry.

The Quebec Pain Registry (QPR) is a large research database of patients suffering from various chronic pain (CP) syndromes who were referred to one of five tertiary care centres in the province of Quebec (Canada). Patients were monitored using common demographics, identical clinical descriptors, and uniform validated outcomes. This paper describes the development, implementation, and research potential of the QPR. Between 2008 and 2013, 6902 patients were enrolled in the QPR, and data were collected prior to their first visit at the pain clinic and six months later. More than 90% of them (mean age ± SD: 52.76 ± 4.60, females: 59.1%) consented that their QPR data be used for research purposes. The results suggest that, compared to patients with serious chronic medical disorders, CP patients referred to tertiary care clinics are more severely impaired in multiple domains including emotional and physical functioning. The QPR is also a powerful and comprehensive tool for conducting research in a "real-world" context with 27 observational studies and satellite research projects which have been completed or are underway. It contains data on the clinical evolution of thousands of patients and provides the opportunity of answering important research questions on various aspects of CP (or specific pain syndromes) and its management.

Nutritional supplement chromium picolinate generates chromosomal aberrations and impedes progeny development in Drosophila melanogaster.

Chromium picolinate, [Cr(pic)(3)], is a popular nutritional supplement found in a variety of consumer products. Despite its popularity, safety concerns over its use have arisen. The supplement has been shown to generate clastogenic damage, mitochondrial damage, oxidative damage, and mutagenic effects in cultured cells and oxidative DNA damage and lipid peroxidation in rats. Recently [Cr(pic)(3)] has been demonstrated to generate heritable genetic change and delays in progeny development in Drosophila melanogaster. Based on the damage to chromosomes of cultured cells and of animal models, similar chromosome damage appeared to be a likely source of the mutagenic effects of the supplement in Drosophila. The current three-part study examines the effects of several chromium-containing supplements and their components on hatching and eclosion rates and success of development of first generation progeny of adult Drosophila fed food containing these compounds. It further examines the effects of the compounds on longevity of virgin male and female adults. Finally, the chromosomes in the salivary glands of Drosophila late in the third instar larval stage, which were the progeny of Drosophila whose diets were supplemented with nutritional levels of [Cr(pic)(3)], are shown to contain on average over one chromosomal aberration per two identifiable chromosomal arms. No aberrations were observed in chromosomes of progeny of untreated flies. The results suggest that human consumption of the supplement should be a matter of concern and continued investigation to provide insight into the requirements of chromium-containing supplements to give rise to genotoxic effects.

Leukocyte adhesion and polarization: Role of glycosylphosphatidylinositol-anchored proteins.

Leukocyte traffic out of the blood stream is crucial for an adequate immune response. Leukocyte extravasation is critically dependent on the binding of leukocyte integrins to their endothelial counterreceptors. This interaction enables the firm adhesion of leukocytes to the luminal side of the vascular wall and allows for leukocyte polarization, crawling and diapedesis. Leukocyte adhesion, polarization and migration requires the orchestrated regulation of integrin adhesion/de-adhesion dynamics and actin cytoskeleton rearrangements. Adhesion strength depends on conformational changes of integrin molecules (affinity) as well as the number of integrin molecules engaged at adhesion sites (valency). These two processes can be independently regulated and several molecules modulate either one or both processes. Cholesterol-rich membrane domains (lipid rafts) participate in integrin regulation and play an important role in leukocyte adhesion, polarization and motility. In particular, lipid raft-resident glycosyl-phosphatidyl-inositol-anchored proteins (GPI-APs) have been reported to regulate leukocyte adhesion, polarization and motility in both integrin-dependent and independent manners. Here, we present our recent discovery concerning the novel role of the GPI-AP prion protein (PrP) in the regulation of ß1 integrin-mediated monocyte adhesion, migration and shape polarization in the context of existing literature on GPI-AP-dependent regulation of integrins.

Antihypertensive effect of isradipine administered once or twice daily on ambulatory blood pressure.

The antihypertensive efficacy of sustained-release isradipine administered once daily compared to the immediate-release formulation administered twice daily was assessed by ambulatory blood pressure (BP) monitoring in a double-blind randomized crossover study in 76 mild-to-moderate hypertensive patients. Conventional BP and heart rate parameters were evaluated after a 4-week placebo period and patients qualified for entry if sitting diastolic BP was between 95 and 114 mm Hg. Ambulatory BP monitoring was measured at baseline and after active treatment with both formulations. The 2 regimens induced a significant and almost identical reduction (p less than 0.001) in the mean 24-hour BP without affecting heart rate. Isradipine was more effective in patients whose clinical hypertension was confirmed by ambulatory BP monitoring (35) than in patients who remained normotensive by ambulatory BP monitoring criteria (41). The isradipine-treated ambulatory hypertensive group experienced significantly greater decreases in BP during 24-hour, work, awake and sleep periods than did the ambulatory normotensive group. These data suggest that sustained-release isradipine has a sustained antihypertensive effect throughout 24 hours comparable to that of isradipine given twice daily and may improve compliance with long-term treatment. In addition, the results confirm the usefulness of ambulatory BP monitoring in determining truly hypertensive patients likely to respond to drug administration.

Taking to bed. Rapid functional decline in an independently mobile older population living in an intermediate-care facility.

The objective of this study was to determine the incidence and selected clinical outcomes of taking to bed among a population of independently ambulating older individuals. It was designed as a retrospective case series and was conducted in the intermediate-care facility of a not-for-profit, teaching nursing home. Our study group was composed of individuals over 65 years of age who became bed bound. Thirty-six taking-to-bed episodes occurred in 36 individuals during one calendar year, giving an incidence of 13 per 1,000 resident-months (95% CI, 4 to 23 per 1,000). Twelve of the 36 died within 3 months, and 17 within 6 months, but almost all who survived regained ambulation. Survival was significantly shorter for the five without localizing symptoms (P less than .05). Orthopedic, neurologic, psychiatric, and iatrogenic conditions were most commonly identified as concurrent medical events. Almost half who took to bed had multiple concurrent medical events, and these residents were more likely to present without localizing symptoms (P less than .05). Twenty-one (58%) of the episodes occurred after a fall. The incidence of taking to bed in this population indicates that clinicians caring for older persons should be alert to its occurrence. The dramatic decline in mobility deserves careful assessment because it initiated a period of relatively rapid change in the health careers of the individuals we studied: almost half died within 6 months, but nearly all who survived regained ambulation. Those without localizing symptoms may have more complex interacting medical problems and a worse prognosis.

Beneficial effects of the calcium antagonist isradipine on apolipoproteins in hypertensive patients.

The objective of the study was to assess the effects of the calcium antagonist isradipine on plasma lipids, lipoproteins, and apolipoproteins in patients with essential hypertension. After a four-week placebo wash-out period, 73 patients (41 men, 32 women) were studied in a double-blind, randomized, crossover study comparing sustained-release isradipine (isradipine SR) with the standard isradipine formulation. Nineteen patients received 5 mg/day and 54 patients 10 mg/day. Lipids were evaluated at the end of the placebo period and after 12 weeks of treatment with isradipine. In both treatment groups, lipid and lipoproteins were not modified. However, apolipoprotein A-I levels increased significantly (P less than .001) and the ratio of apolipoprotein B to apolipoprotein A-I concentration decreased significantly (P less than .01) irrespective of gender. These data show that the levels of plasma apolipoprotein A-I, a strong predictor of coronary heart disease, are favorably affected by isradipine of either formulation. The mechanisms of this effect remain to be elucidated.

Tissue and subcellular distribution of chromium picolinate with time after entering the bloodstream.

Chromium picolinate, [Cr(pic)(3)], is a popular nutritional supplement; however, the fate of the complex in vivo has not previously been established. Consequently, rats were administered [51Cr(pic)(3)] intravenously and the fate of the radiolabel in the urine, blood plasma, tissues, and subcellular components of hepatocytes was followed for the first 24 h after injection. The supplement leaves the blood stream rapidly appearing in the urine and entering tissue cells intact. Kidney, muscle, and liver possess most of the absorbed radiolabel. In hepatocytes, the radiolabel appears most rapidly in the nucleus and mitochondria, then in the cytosol, and finally in the lysosomes and microsomes. Thus, while the lifetime of the supplement in vivo is brief, it enters cells rapidly intact. The significance of the lifetime and distribution of [Cr(pic)(3)] in relationship to recent reported potential DNA damage from the supplement is discussed.

In situ right ventricular thrombus secondary to heparin induced thrombocytopenia.

Heparin induced thrombocytopenia (HIT) is a relatively common complication of heparin therapy, occurring in approximately 5% of patients treated with this drug. HIT may be associated with diffuse arterial and venous thrombosis. The case of a patient without underlying heart disease who developed a right ventricular thrombus and recurrent pulmonary emboli in association with and possibly as a complication of HIT is reported. Ancrod was used as an alternative to heparin for the time required to obtain an effective oral anticoagulant effect. The patient recovered completely and has no residual right ventricular thrombus.

A new, simple and accurate method for determining ejection fraction by Doppler echocardiography.

OBJECTIVE: To evaluate the feasibility, accuracy and reproducibility of a new and simple method for determining ejection fraction by Doppler echocardiography. This method should theoretically be less influenced by the distortions of left ventricular geometry caused by prior myocardial infarction. DESIGN: Two groups of patients (total 114) were evaluated independently at the Quebec and Ottawa Heart Institutes (60 and 54 patients, respectively). All were referred for radionuclide angiography performed within 24 h of the echocardiogram. Regional asynergy was present in 59% of Quebec patients and 37% of Ottawa patients. The new method for calculating ejection fraction consisted of dividing Doppler derived stroke volume in the left ventricular outflow tract by left ventricular end-diastolic volume calculated by Teichholz's formula; for comparison, ejection fraction was also measured by single plane area length or multiple disc planimetry as well as by the Quinones method at the Quebec Heart Institute. RESULTS: Feasibility of the new method was 97% in Quebec and 100% in Ottawa. Compared with radionuclide angiography, the correlation coefficient for the new method was 0.92 (standard error of estimate [SEE] = 7.3) in Quebec compared with 0.88 (SEE = 8.5 and 8.1) for both the Quinones and single plane area length methods, and 0.84 (SEE = 12.0) in Ottawa compared with 0.77 (SEE = 10.9) for the single plane multiple disc method. Correlations in patients with regional asynergy were 0.90 in Quebec and 0.75 in Ottawa compared with 0.81 and 0.54 with planimetry. Correlation coefficients for interobserver variability in 12 patients were 0.97 with the new method compared with 0.83 with the Quinones method and 0.85 with single plane planimetry. CONCLUSION: This new and simple method is feasible, accurate and reproducible even in patients with regional asynergy. Provided there is no significant mitral regurgitation, it is a time-saving alternative for the routine evaluation of ejection fraction by Doppler echocardiography.

Successful use of methadone in the treatment of chronic neuropathic pain arising from burn injuries: a case-study.

Methadone is used increasingly as a second-line opioid in the management of cancer pain refractory to conventional opioids. Recent case studies suggest that its use as an analgesic could be extended to non-cancer pain, especially neuropathic pain. The present case study reports, for the first time, the efficacy of methadone in a burn patient experiencing neuropathic pain in his healed wounds. The patient sustained extensive (55% total body surface area) chemical burns and developed chronic burning sensations, particularly in the lower limbs where skin grafting had been performed. Conventional pharmacotherapies against neuropathic pain were attempted to control pain for over 5 years. The agents used included long- and short-acting opioids, amitriptyline, clonazepam, and gabapentin, but they all failed to relieve the pain. When methadone (5 mg every 12 h) was introduced, it significantly alleviated the patient's pain within a few days of administration. The patient has now been taking methadone (15 mg every 12 h) for 10 months and reports that the opioid caused 70% pain relief and a 55% amelioration in his quality of life. Although these results are based on a case report, they suggest that a switch to methadone might be useful in some burn patients who have developed chronic neuropathic pain unrelieved by conventional pharmacotherapies. Methadone, however, needs to be titrated with vigilance and thus should be administered by a physician experienced with its use in the treatment of chronic pain.

Traumatic innominate artery aneurysm 26 years after stab injury.

We report the case history of a 46-year-old African man with a false aneurysm of the innominate artery subsequent to a stab wound in the right supraclavicular area 26 years previously, presenting with stridor.