Homocysteine, lipoprotein(a), and restenosis after percutaneous transluminal coronary angioplasty: a prospective study.

BACKGROUND: Restenosis complicates 30% to 40% of angioplasty procedures and may be unrelated to traditional coronary risk factors. Homocysteine, lipoprotein(a), and methylenetetrahydrofolate reductase (MTHFR 677T) (a genetic determinant of plasma homocysteine concentrations) are novel risk factors for coronary artery disease. Their roles in restenosis are unclear, and the potential synergism between homocysteine and lipoprotein(a) has not previously been studied. The objective of this study was to determine the relations among homocysteine, lipoprotein (a), MTHFR 677T, and restenosis after percutaneous transluminal coronary angioplasty. METHODS: This prospective study enrolled patients with successful elective percutaneous transluminal coronary angioplasty or stenting of a single, de novo, native coronary lesion. Fasting blood was drawn the morning of the procedure for homocysteine, lipoprotein(a), and MTHFR 677T. Follow-up angiography was performed 6 months after the procedure or earlier if clinically indicated. All cineangiograms were analyzed quantitatively. RESULTS: A total of 144 (92%) of 156 eligible patients underwent follow-up coronary angiography. The overall angiographic restenosis rate (residual stenosis >50%) was 31%. Mean homocysteine concentration was 10.1 +/- 3.7 micromol/L. Plasma homocysteine concentrations were not significantly different in patients with or without angiographic restenosis (9.6 +/- 3.3 vs 10.3 +/- 3.8 micromol/L; P =.31). Mean lipoprotein(a) concentration was 21.2 +/- 20.1 mg/dL. Plasma lipoprotein(a) concentrations were not significantly different in patients with or without restenosis (21.9 +/- 21.8 vs 20.9 +/- 19.5 mg/dL). Homozygosity for MTHFR 677T was present in 6.5% and was not associated with increased restenosis. No interaction between homocysteine and lipoprotein(a) was detected. CONCLUSIONS: Homocysteine, lipoprotein(a), and MTHFR 677T are not associated with restenosis after percutaneous transluminal coronary angioplasty.

Plasma urokinase antigen and plasminogen activator inhibitor-1 antigen levels predict angiographic coronary restenosis.

BACKGROUND: The fibrinolytic system is intimately involved in several processes that contribute to restenosis, including clot dissolution, cell migration, and tissue remodeling. However, the role of the individual activators (urokinase [uPA] and tissue plasminogen [tPA] activators) and inhibitors (plasminogen activator inhibitor [PAI-1]) of the fibrinolytic system in maintaining patency after coronary artery angioplasty and stenting is unclear. METHODS AND RESULTS: We prospectively studied 159 patients with stable angina who underwent successful elective angioplasty (n=110) or stenting (n=49) of de novo native coronary artery lesions. Plasma samples were drawn at baseline (before angioplasty) and serially after angioplasty (immediately afterward and 6 hours, 24 hours, 3 days, 7 days, 1 month, 3 months, and 6 months afterward). Antigen and activity assays were performed for uPA, tPA, and PAI-1. Follow-up quantitative coronary angiography was performed in 92% of eligible patients. The overall angiographic restenosis rate (diameter stenosis >50%) was 31% (37% in PTCA patients, 17% in stented patients). At all time periods, including baseline, uPA antigen levels were significantly higher and PAI-1 antigen levels were significantly lower in patients with restenosis. Restenosis rates for patients in the upper tertile of baseline uPA antigen levels were 2-fold higher than for those in the lower 2 tertiles (46% versus 24% and 22%, respectively; P<0.004). In a stepwise regression multivariate analysis, obstruction diameter after the procedure and uPA antigen were significant predictors of follow-up diameter stenosis. CONCLUSIONS: Plasma uPA antigen levels and PAI-1 antigen levels identify patients at increased risk for restenosis after percutaneous coronary revascularization.

Failed coronary stent deployment.

BACKGROUND: Coronary stent deployment failure may be more common in clinical practice than generally appreciated. The incidence of failed deployment in routine clinical practice and the clinical sequelae have not been described. This study sought to determine the incidence and consequences of failed coronary stent deployment and to identify clinical and angiographic characteristics associated with deployment failure. METHODS AND RESULTS: A series of 1303 consecutive procedures involving attempted coronary stenting were reviewed retrospectively. Failed stent deployment was defined as failure of the stent to be either delivered to or adequately deployed at the target lesion site. Clinical records and angiograms were reviewed and qualitative coronary angiography was performed for all cases of failed deployment. Deployment was unsuccessful in 108 (8.3%) cases involving 134 stents. Stenting was attempted as a primary procedure in 40%, as bailout in 18%, and for suboptimal angioplasty in 43% of cases. In 87% of cases, attempts were made to withdraw the stent from the coronary artery. Stent retrieval was successful in 45%, peripheral embolization occurred in 38% of patients, and in 4% the stent dislodged in the left main artery. In 35% of cases, additional stent(s) were successfully deployed. Deployment failure was associated with an overall in-hospital adverse outcome in 19% of patients, including 16% urgent coronary artery bypass grafting, 5% nonfatal myocardial infarction, and 3 in-hospital deaths. At 6-month follow-up, 39% of patients had had at least 1 adverse clinical outcome of death, myocardial infarction, or repeat target lesion revascularization. CONCLUSIONS: Failure to deploy stents is a serious and relatively common problem that is associated with significant morbidity and mortality rates. Improved deployment strategies, including new stent designs, are required to improve procedural outcomes.

Comparative in vitro activities of trovafloxacin (CP 99,219) and other antimicrobials against clinically significant anaerobes.

A total of 590 strains of clinically important anaerobes were tested to determine their susceptibility to trovafloxacin. Overall, trovafloxacin had a mode MIC of 0.25 micrograms/ml and a MIC at which 90% of the isolates were inhibited of 1 micrograms/ml and had activity comparable to that of metronidazole. Trovafloxacin was 8-, 8-, 16-, 32-, and 64-fold more active than ampicillin-sulbactam, clindamycin, ciprofloxacin, cefoxitin, and cefotetan, respectively. Of the Bacteroides fragilis group, 97% of the isolates were inhibited by trovafloxacin at 21 micrograms/ml, and trovafloxacin was more active than ciprofloxacin, cefoxitin, cefotetan, ampicillin-sulbactam, and clindamycin against Clostridium, Fusobacterium, Porphyromonas, and Prevotella strains.

Utility of micral test strips in screening for microalbuminuria.

OBJECTIVE: To evaluate the clinical utility of Micral strips for detection of microalbuminuria. DESIGN: One hundred three urine samples were tested by Micral strips for the presence of microalbuminuria, and the results were compared with the immunonephelometric method. SETTING: Endocrine diabetes clinic in a university-affiliated outpatient facility and the associated clinical laboratory. PATIENTS: Sixty-seven, 24-hour urine samples were obtained from 64 patients with diabetes. Thirty-six urine samples were obtained from normal controls; 22 of these were 24-hour samples and 14 were overnight samples. MAIN OUTCOME MEASURE: Concordance of results obtained by the two methods for the presence or absence of microalbuminuria. RESULTS: All 36 control subjects and 44 urine samples from diabetic patients had normal albumin excretion (<15 mg/24 h) by the immunonephelometric method. Seventy-eight of these were correctly identified as negative by Micral strips, giving a specificity of 97.5%. There were 23 samples with albumin excretion of more than 16 mg/24 h. Sixteen of these were correctly identified, giving a sensitivity of 69.5%. There were 16 samples with albumin excretion of 30 mg/24 h or more; 14 of these were correctly identified by Micral strips, and two were false negatives, giving a sensitivity of 87.7%. However, when urine samples with albumin concentrations of less than 11 mg/L were excluded, the Micral strips correctly read 21 out of 23 samples, giving a sensitivity of 91.3%. CONCLUSIONS: The specificity of Micral strips for detection of albuminuria in 24-hour urine samples is high (97.5%), but the sensitivity is low, ranging from 69.5% to 87.7%. The sensitivity was greatly improved when urine samples with albumin concentrations of less than 11 mg/L were excluded.

Excimer laser angioplasty vs. balloon angioplasty in saphenous vein bypass grafts: quantitative angiographic comparison of matched lesions.

Technologies which ablate or debulk tissue may result in better angiographic outcomes by altering the elastic properties of the vessel wall. Accordingly, the procedural outcomes of 88 vein graft lesions treated by either excimer laser angioplasty with adjunct balloon angioplasty (PELCA + PTCA, n = 44) (Spectranetics CVX-300, 1.4-, 1.7-, or 2.0-MM catheters) or balloon angioplasty alone (PTCA, n = 44) were analyzed by quantitative angiography (Cardiac Measurement System). Lesions were individually matched for vessel position, reference diameter (RD), and minimal luminal diameter (MLD). Matching was deemed adequate as the preprocedure MLD (PELCA + PTCA, 1.14 +/- 0.48 mm; PTCA, 1.20 +/- 0.47 mm) and RD (PELCA + PTCA, 3.23 +/- 0.56 mm; PTCA, 3.25 +/- 0.57 mm) were not significantly different. There were also no significant differences between PELCA + PTCA- and PTCA-treated lesions with respect to patient age, graft age, lesion length, symmetry, and plaque area. Balloon diameter at maximal inflation was 2.77 +/- 0.55 mm (PELCA + PTCA group) and 2.84 +/- 0.59 mm (PTCA group), P = NS. Final MLD postprocedure was 2.17 +/- 0.54 mm and 2.19 +/- 0.55 mm for PELCA + PTCA- and PTCA-treated lesions (P = NS), respectively. Vessel stretch [(balloon diameter - MLD pre)/RD], elastic recoil [(balloon diameter - MLD post)/RD], and acute gain [(MLD post - MLD pre)/RD] were calculated and normalized for vessel size (RD). Vessel stretch (PELCA + PTCA, 0.60 +/- 0.22; PTCA, 0.59 +/- 0.24; P = NS), elastic recoil (PELCA + PTCA, 0.28 +/- 0.18; PTCA, 0.26 +/- 0.16), and acute gain (PELCA + PTCA, 0.34 +/- 0.24; PTCA, 0.31 +/- 0.23; P = NS) were not significantly different between the two treatment groups. In a matched population of successfully treated vein graft lesions, PELCA + PTCA did not reduce elastic recoil or improve immediate angiographic outcome, as compared with PTCA alone.

Effect of intracoronary saline infusion on dissection during excimer laser coronary angioplasty: a randomized trial. The Percutaneous Excimer Laser Coronary Angioplasty (PELCA) Investigators.

OBJECTIVES: We sought to evaluate whether intracoronary saline infusion during excimer laser coronary angioplasty decreases the incidence of significant laser-induced coronary artery dissections. BACKGROUND: Despite procedural success rates > 90%, coronary artery dissections occur in 17% to 27% of excimer laser coronary angioplasty procedures. Excimer laser irradiation of blood results in vapor bubble formation and acoustomechanical trauma to the vessel wall. Saline infusion into a coronary artery may minimize blood irradiation and consequent arterial wall damage. METHODS: In this prospective, randomized, controlled study, consecutive patients undergoing excimer laser coronary angioplasty were randomly assigned to conventional laser irradiation in a blood medium or to laser irradiation with blood displacement by intracoronary saline infusion. In the patients randomized to intracoronary saline infusion, prewarmed normal saline was injected through the coronary artery guide catheter at a rate of 1 to 2 ml/s using a power injector. The incidence and severity of dissection after excimer laser ablation were evaluated in a core laboratory by angiographers with no knowledge of treatment assignment. The severity of coronary artery dissection was rated on an ordinal scale of 1 to 5. Dissections of grade 2 or higher were considered significant. RESULTS: The mean (+/- SE) dissection grade after laser angioplasty in patients treated with intracoronary saline infusion was 0.43 +/- 0.13 compared with 0.91 +/- 0.26 in patients undergoing laser angioplasty in a blood medium. The incidence of significant dissection was 7% in saline-treated patients compared with 24% in conventionally treated patients (p < 0.05). No significant complications were associated with saline infusion. CONCLUSIONS: Intracoronary saline infusion should be incorporated into all excimer laser coronary angioplasty procedures.

Prostaglandin involvement in the responses of the rabbit eye to water-soluble marihuana-derived material.

Both anticoagulants (heparin and streptokinase) and non-steroidal anti-inflammatory compounds (aspirin and indomethacin) were used against a water-soluble derivative of marihuana, MDM. While the anticoagulants had no effect on the ocular effects of MDM, both aspirin and indomethacin altered the time course and effected the MDM-induced reduction of intraocular pressure. The usual initial hypertensive effect of intravenous MDM was eliminated and the later intraocular pressure fall occurred earlier as well as being inhibited by about 35 to 50%. Assay for prostaglandins revealed that intravenous MDM (3.86 micrograms) caused a marked rise in PGE2 concentration of the aqueous humor and iris-ciliary body during the first hour or two after administration of MDM, but normal values occurred at 4, 6, and 8 hours when the intraocular pressure is reduced by up to 60%. Following intravitreal MDM (0.002 microgram), however, the PGE2 levels remained unchanged over 24 hours, despite the induction of a fall in intraocular pressure between 14 and 18 hours which lasts for many hours. Prostaglandin appears to be involved in the hypertensive phase of intraocular pressure change after intravenous MDM injection; and, while the fall in intraocular pressure may contain a component partially mediated by prostaglandins, there is no evidence that intravitreal MDM induces any effect on prostaglandin levels. The involvement of prostaglandins, therefore, in the mediation of MDM-induced ocular hypotensive effects is apparently small.

Separation and properties of cellular and scrapie prion proteins.

Purified preparations of scrapie prions contain a sialoglycoprotein of Mr 27,000-30,000, designated PrP 27-30, which is derived from the scrapie prion protein [Mr, 33,000-35,000 (PrP 33-35Sc)] by limited proteolysis. Under these same conditions of proteolysis, a cellular protein of the same size (PrP 33-35C) is completely degraded. Subcellular fractionation of hamster brain showed that both PrP 33-35Sc and PrP 33-35C were found only in membrane fractions. NaCl, EDTA, and osmotic shock failed to release the prion proteins from microsomal membranes. Electron microscopy of these microsomal fractions showed membrane vesicles but not prion amyloid rods. Detergent treatment of scrapie-infected membranes solubilized PrP 33-35C, while PrP 33-35Sc aggregated into amyloid rods; the concentration of PrP 33-35C was similar to that recovered from analogous fractions prepared from uninfected control brains. The apparent amphipathic character of the PrP 33-35Sc may explain the association of scrapie infectivity with both membranes and amyloid filaments.

Replication of scrapie prions in hamster eyes precedes retinal degeneration.

Progressive degeneration of outer retinal structures occurs in hamsters with scrapie. In order to determine the relationship between histopathologic changes and replication of the scrapie agent, hamsters were inoculated intracerebrally with approximately 10(7) ID50 units. Animals sacrificed at 50 days after inoculation showed no signs of neurologic dysfunction, but had high titers of the scrapie agent or prions in both neural and nonneural portions of the eye. Prion titers in retina were greater than 10(7) ID50 units/ml of 10% (w/v) homogenate and equal to those found in optic nerve and brain. No histopathologic changes were seen by light microscopy in any ocular structure. At 70 days after inoculation, neurologic dysfunction was profound. The titers of the scrapie agent in brain, lens, retinal pigment epithelium, cornea, retina, and optic nerve were not significantly changed compared to those found at 50 days; however, retinal degeneration was severe. No morphologic changes were observed in cornea, pigment epithelium or optic nerve. These findings show that scrapie prion replication to maximal levels precedes the onset of degenerative changes in retina. Furthermore, the retina is preferentially susceptible to the degeneration induced by the scrapie agent while the other ocular structures containing significant levels of prions seem to escape injury.

Ocular fluid dynamics response to topical RU486, a steroid blocker.

A steroid antagonist applied to one eye of 18 young pigmented rabbits during a 10-week period caused a statistically significant fall in IOP, but no statistically significant nor clinically relevant change in the rate of aqueous humor turnover. The pressure change is therefore ascribed to an alteration in outflow channels. No changes occurred in a parallel group of 5 animals in which one eye was treated with vehicle and the contralateral eye was untreated. The drug effects became evident after two weeks of application, suggesting that a slow turnover pathway is involved.

Interaction between ophthalmic drugs and intraocular lenses.

We evaluated the in vitro interaction between commonly used ophthalmic drugs and a series of intraocular lenses to determine if the lenses could act as a drug reservoir in the eye. Lenses examined included anterior and posterior chamber lenses as well as iris plane lenses. Assessment of lens uptake was made by immersing the lens for nine days in a radioactive drug solution with a concentration equal to that found in the anterior chamber one hour after drug administration. No evidence of drug uptake was found for any lens immersed in epinephrine, norepinephrine, dexamethasone, or chloramphenicol.

Intracellular potential and pH of rabbit corneal endothelial cells.

Rabbit corneal endothelial pH and electrical potential have both been determined using tracer distribution techniques. Intercellular pH was measured using the dimethyloxazolidine-dione method and intracellular potential was measured using tetraphenylphosphonium bromide. Intracellular pH was determined as 7.10 in an ambient solution of pH 7.5. The only solution variations which altered intracellular pH were variations in the external solution pH, bathing in sodium-free or bicarbonate-free solution, incubation for 3 hours with 10(-6) or 10(-4) M ouabain or for 1 hour with 10(-4) M ouabain or in a high (60 mM) bicarbonate solution. The data indicate a close correlation between sodium and bicarbonate needs for the endothelium which corresponds with known effects of these ions on transendothelial ion fluxes. Intracellular potentials were measured of -34 mV, which were stable in the face of all environmental perturbations except 1 mM acetazolamide and 10(-6) M ouabain exposure for 3 hours. These newer techniques may be employed to provide some clues into the mechanism of endothelial transport systems.

Marihuana-derived material: distribution and effects after systemic administration.

Studies have been made in an attempt to elucidate the mode of action of water-soluble marihuana-derived material (MDM). MDM lowers intraocular pressure (IOP) at systemic dose levels greater than 5 micrograms/rabbit by reducing aqueous humor inflow. Blood pressure, body temperature, and PO2 remain constant despite the wide variation in IOP caused by high dose levels of MDM, viz. an initial hypertensive phase followed by a hypotensive phase. Blood PCO2 and pH, however, both decrease with 1 mg MDM/rabbit indicating an acidosis which may partially explain some of the fall in IOP caused by MDM at this high dose level. Low doses of MDM (50 micrograms/animal), however, induce no such changes in systemic chemistry, illustrating the absence of an MDM effect which can explain the greater than 50% fall in IOP. Repeated injections of MDM on a weekly basis indicate a sequentially reduced effect on IOP. MDM, when incubated in vitro for 6 hours with saline, aqueous or vitreous, always induced a fall in IOP; incubation in these media for 24 hours, however, reduced the capacity to induce an IOP decrease. When aqueous or vitreous was removed from animals which had received intravitreal injections of MDM 24 hours previously (thus, at a time when the IOP in these animals was low) and was reinjected intravitreally into fresh recipient rabbits, the IOP fell in the recipients with aqueous, but not vitreous. Only when high doses of MDM (greater than or equal to 2 mg) were given systemically to a donor rabbit was any evidence obtained of a fall in IOP in recipient rabbits at short times after the donor injection (less than 10 min); at greater times after the donor injections whole blood or serum from donor rabbits failed to elicit a fall in IOP in recipient animals. These data indicate that, in vivo, MDM is bound or metabolized rapidly in rabbits when MDM is given systemically.

Scrapie prions aggregate to form amyloid-like birefringent rods.

A large scale purification protocol employing zonal rotor centrifugation has been developed for scrapie prions. The extensively purified fractions derived using this protocol contained only one major protein, designated PrP, and rod-shaped particles. The rods measured 10 to 20 nm in diameter and 100 to 200 nm in length by negative staining; no other particles were consistently observed. SDS denaturation caused the rods to disappear, prion infectivity to diminish, and PrP to become sensitive to protease digestion. Arrays of prion rods ultrastructurally resembled purified amyloid and showed green birefringence by polarization microscopy after staining with Congo red dye. The rods appear to represent a polymeric form of the scrapie prion; each rod may contain as many as 1,000 PrP molecules. Our findings raise the possibility that the amyloid plaques observed in transmissible, degenerative neurological diseases might consist of prions.

Replication of the scrapie agent in hamster brain precedes neuronal vacuolation.

The scrapie agent causes a degenerative neurological disorder in sheep and goats after a prolonged incubation period. Hamsters inoculated intracerebrally with 10(7) ID50 units of the scrapie agent develop clinical signs of neurological dysfunction 60-65 days later. The titers of scrapie agent in selected regions of the central nervous system (CNS) of hamsters were determined prior to the onset of clinical illness. At 48 days after inoculation, the cerebrum, cerebellum, brain stem, and spinal cord contained 9.3, 9.1, 9.3, and 8.6 log ID50 units/g of tissue, respectively. Sections from the cerebrum showed minimal vacuolation without any astrogliosis. The spinal cord and cerebellum revealed no lesions. At 71 days after inoculation, when clinical signs of scrapie were prominent, another group of hamsters was evaluated. The mean titers of the agent in the same CNS regions were virtually unchanged, but severe vacuolation and moderate astrogliosis were present in the cerebral cortex. A moderate degree of vacuolation and astrogliosis were observed in the cerebellum, brain stem, and spinal cord. These studies indicate that replication of the scrapie agent in the hamster is uniform throughout the CNS and precedes the development of pathological changes.

Measurement of the scrapie agent using an incubation time interval assay.

The titer of the scrapie agent was determined by measurements of time intervals from inoculation to onset of illness and from inoculation to death. Both intervals were found to be inversely proportional to the size of the dose injected intracerebrally into random-bred weanling Syrian hamsters. The logarithms of the time intervals minus a time factor were linear functions of the logarithm of the inoculum size. The time factors were determined by regression analysis in order to maximize these linear relationships. An equation relating the titer of the inoculum to the dilution of the sample and the length of the time intervals was developed. This equation facilitates the use of a computerized data base. Validation of these relationships was provided by comparing samples for which the agent was measured both by end-point titration and by time interval assay. Agreement between the two methods was generally within +/-0.5 log10 median infective dose units. No differences between the molecular properties of the agents from hamster and murine sources were observed using primarily the incubation time interval method with the former and end-point titration with the latter. The advantages of this new approach based on time interval measurements are considerable with respect to time and resources.

Pharmacological modification of rabbit corneal endothelial transport and permeability.

Either isolated normal or preswollen rabbit corneas were perfused across their endothelial surface with various drugs in the specular microscope. The deswelling rate of preswollen corneas was uninfluenced by calmodulin (1 and 10 micrograms/ml), phenylephrine (0.1 and 1 mM), DbcAMP (10(-4) M), theophylline (10(-3) and 10(-4) M), isoproterenol (2 x 10(-7) and 2 x 10(-6) M), or cyclic GMP (10(-4) and 10(-6) M). The swelling rate of normal thickness corneas was increased by furosemide (10(-5) and 10(-4) M) and thiocyanate (5 x 10(-2) and 5 x 10(-3) M) but not by SITS (10(-4) M), dipyridamole (5 x 10(-5) M) or NAP-taurine (10(-3) M). The results suggest that alteration of endothelial cyclic AMP or cyclic GMP levels has no influence on transendothelial fluid flow. Modulation of the metabolic processes underlying anion fluxes by furosemide and thiocyanate caused corneal swelling but none of the agents which affect passive anion exchange in other systems influenced transendothelial fluid movement. The furosemide and thiocyanate effects confirm that bicarbonate, or chloride, exchange may be important in part in the regulation of corneal dehydration by the endothelium.