Trends in hospice referral and length of stay at a veterans hospital over the past decade.

INTRODUCTION: Hospice decreases the fear of dying alone, reduces the agony of death, and helps in maintaining dignity at the end of life. Physicians are encouraged to offer hospice to terminally ill patients early on in their end-of-life care to maximize these benefits. However, there is limited data on the changes and characteristics of hospice utilization. We performed a study to determine the changes in the hospice utilization over the last decade in our hospital. METHODS: A chart review of all veterans referred to hospice during the years 2001 and 2010 was performed and subsequently analyzed. Analyses were performed with SPSS 19.0 for Windows. RESULTS: Referral to hospice increased significantly but the duration of stay did not change in 2010 in comparison with 2001. Factors associated with increased length of stay were full-code status, receiving hospice at home, hospitalization during enrollment in hospice, referral to hospice by oncologist, and a diagnosis of cancer. CONCLUSION: Hospice referrals need to be considered earlier in their disease process for terminally ill patients. In addition, requirement of a do-not-resuscitate order as a condition for hospice at some agencies needs to be revisited, and patients should not be discouraged to seek treatment for reversible medical conditions even when enrolled in hospice.

Absence of altered autophagy after myocardial ischemia in diabetic compared with nondiabetic mice.

OBJECTIVES: The extent of autophagy in myocardium following persistent ischemia and the effects of insulin resistance and diabetes on cardiac autophagy following myocardial infarction (MI) have not been well elucidated. It is generally thought that autophagy reflects the nutritional status of cells, presumably alterable by diabetes. It has been conjectured that diminution of autophagy early after the onset of MI may preserve jeopardized myocardium thereby improving prognosis. METHODS: Ten-week-old nondiabetic C57BL6 mice, 20-week-old diabetic and nondiabetic C57BL6 mice were subjected to MI for 4 weeks. Hearts from these mice were harvested and assayed for markers of autophagy. RESULT: Hearts of 10-week-old C57BL6 mice subjected to 4 weeks of MI had similar levels of LC3-II, a protein indicator of autophagy, as measured by western blotting compared with hearts from sham operated controls. In 20-week-old C57BL6 mice rendered diabetic by feeding a high-fat diet, the amounts of autophagy were comparable to those in 20-week-old nondiabetic C57BL6 mice on a normal diet. CONCLUSION: The magnitude of autophagy in the heart after infarction is of very modest extent and is not modulated by diabetes. Thus, diminution of autophagy is not likely to reduce infarct size or attenuate late negative remodeling after MI in patients with diabetes.

The angiotensin receptor blocker, azilsartan medoxomil (TAK-491), suppresses vascular wall expression of plasminogen activator inhibitor type-I protein potentially facilitating the stabilization of atherosclerotic plaques.

Increased expression of plasminogen activator inhibitor type-I (PAI-1) in vessel walls seems to accelerate atherosclerosis. Angiotensin II can increase the synthesis of PAI-1. Inhibition of this process may facilitate migration of vascular smooth muscle cells (VSMCs) stabilizing atherosclerotic plaques. To determine whether the inhibition of the angiotensin II type 1 receptor can blunt the expression of PAI-1 protein in the aortic wall, we administered azilsartan medoxomil (AZL-M), a prodrug of an angiotensin II type 1 receptor blocker developed by the Takeda Pharmaceutical Company Limited, for 16 weeks to ApoE knockout mice on a high fat diet rendered overexpressors of PAI-1 in VSMCs. Homogenates of the pooled aortas from each group were assayed for PAI-1 by enzyme-linked immunosorbent assay. Cellularity of atherosclerotic lesions was assessed by 4',6-diamidino-2-phenylindole staining in sections of aortic lesions, and collagen content in the lesions was quantified by immunohistochemistry. Aortic wall PAI-1 was decreased by each of the 3 dosage regimens of AZL-M (0.1-10 mg/kg). Cellularity and collagen were increased in lesions from mice given AZL-M, consistent with the development of more stable plaques. Accordingly, the suppression of PAI-1 expression by AZL-M may attenuate the evolution of atherosclerotic plaques vulnerable to rupture.

Vascular rhexis in mice subjected to non-sustained myocardial ischemia and its therapeutic implications.

We previously described the death of vascular cells (vascular rhexis) following persistent coronary occlusion. The present study was designed to determine whether non-sustained ischemia can initiate vascular rhexis and if so, whether relatively brief ischemic insults are sufficient. C57BL6 mice were subjected to coronary ligation for 15 min or 3 h followed by reperfusion. Soluble fractions of left ventricular (LV) homogenates were obtained 48 h after the onset of transitory coronary occlusion. They were assayed by Western blotting for quantification of alpha smooth muscle actin (α-SMA) and smooth muscle myosin heavy chain (SM-MHC) that we have shown reflect vascular rhexis delineated immunohistochemically. Non-sustained coronary occlusion for 3 h initiated vascular rhexis evident 45 h after reperfusion, but not earlier, as judged from Western blotting of α-SMA and SM-MHC. The number of small- and medium-sized vessels in the previously ischemic zones was reduced at 45 h after reperfusion as well. Thus, vascular rhexis occurs after ischemia as brief as 3 h but evolves slowly and is not evident for 45 h. The delayed disintegration of the vasculature makes it likely that it can be ameliorated by interventions initiated after non-sustained ischemia, rendering it an attractive target for diminution of phenomena such as late negative LV remodeling, and 'no reflow.'

Autophagy in myocardium of murine hearts subjected to ischemia followed by reperfusion.

Autophagy in myocardium has been thought to be cardioprotective, but its extent after transient or prolonged myocardial ischemia remains unclear. Accordingly, we characterized its magnitude in myocardium of murine hearts subjected to ischemia with or without reperfusion. Ten-week-old transgenic GFP-LC3 mice and C57Bl6 mice were subjected to coronary ligation for 1 or 4 h followed by 24 h of reperfusion (1HTL, 4HTL) or to 24 h of persistent ligation (24HPL). Their hearts were analyzed by fluorescence microscopy, electron microscopy, and by Western blotting. Fluorescent GFP-LC3 dots indicative of autophagy were absent in infarct zones and reduced markedly in the peri-infarct zones compared with dots in sham controls (p ≤ 0.05). The LC3-II/LC3-I ratio indicative of autophagy did not increase in LV homogenates from hearts following ischemia. Phosphorylation of ribosomal protein S6 increased in LV homogenates in hearts from mice subjected to 4HTL and 24HPL (p ≤ 0.05). Virtually no autophagic cells recognizable by electron microscopy were evident in infarct or peri-infarct zones. Autophagy is virtually absent within 24 h in the center of zones of infarction and is decreased significantly in the peri-infarct zones compared with that in normal hearts.

Vascular rhexis: loss of integrity of coronary vasculature in mice subjected to myocardial infarction.

We previously observed gross hemorrhage in plasminogen activator inhibitor type-1 (PAI-1) knockout (PKO) mice with induced myocardial infarction (MI). We hypothesized that it reflected degradation of vessels - a phenomenon we termed vascular rhexis. Accordingly, in the present study we characterized vascular rhexis in C57BL6 mice. MI was induced in 10- to 12-week-old mice by coronary artery ligation for 24, 48, 72 or 96 h. Hemorrhage was quantified by non-cross-reacting enzyme-linked immunosorbent assay of left ventricular (LV) hemoglobin corrected for myoglobin. Degradation of vasculature was quantified by the appearance of alpha smooth muscle actin (alphaSMA) in low salt soluble fractions of LV homogenates (Western blotting) and by immunohistochemistry (residual alphaSMA). Co-staining for CD31 (endothelial cells) and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL) (a marker of cell death) was used to identify capillary rhexis. PKO mice (n = 9) had marked hemorrhage in infarct zones (432 +/- 27 standard error of mean microL blood/g). Hemorrhage was evident in C57BL6 mice as well (n = 6): 51 +/- 8 microL/g LV 96 h after coronary occlusion compared with 10 +/- 5 microL /g, n = 13 in normal LVs. Residual intact vasculature was reduced 48 h after infarction. Thus, an average of 16 +/- 1.6 small- and medium-sized vessels (n = 5 hearts) were seen compared with 84 +/- 4.8 in normal LVs (n = 3, P < or = 0.05). An approximately three-fold increase in soluble alphaSMA 48 h after MI (2.68 +/- 0.28, n = 6) was seen relative to that in normal LVs defined as 1.0 +/- 0.04, n = 10, P < or = 0.05. Capillary degradation was evident as well, as judged from CD31 and TUNEL co-localization. Vascular rhexis occurs within 48 h after the onset of MI. It may contribute to the early no-reflow phenomenon and to late negative LV remodeling.

Failure of erythropoietin to render jeopardized ischemic myocardium amenable to incremental salvage by early reperfusion.

OBJECTIVES: Erythropoietin (EPO) has been thought to be capable of potentiating protection of jeopardized myocardium by reperfusion in evolving myocardial infarction. However, diversity in study design and measurements of infarct size in studies evaluating EPO has led to inconsistent results. We sought to characterize the effect of EPO on infarct size after myocardial ischemia and reperfusion with the use of assessment of left-ventricular (LV) creatine kinase (CK) depletion and echocardiography. METHODS: Acute coronary occlusion was induced in 10-week-old C57BL6 mice by left anterior descending coronary artery ligation for 3 h followed by 72 h of reperfusion. EPO (10,000 U/kg) or an equivalent amount of saline vehicle alone was injected intraperitoneally before ligation or immediately after the onset of reperfusion. Assays of residual LV CK activity and calculation of LV CK depletion were performed on LV homogenates harvested 72 h after onset of reperfusion for measurement of infarct size, and echocardiography was performed immediately before harvest of tissue for measurement of function. RESULTS: Mice administered EPO before ligation had similar infarct size (37.1+/-4.1%) and echo scores (22.9+/-0.4) compared with those in corresponding control mice administered saline (35.29+/-1.9 and 21.3+/-1.1%, respectively). Mice administered EPO after reperfusion had similar infarct size (39.1+/-4.8%) and echo scores (19.5+/-1.0) compared with those in corresponding control mice administered saline (40.3+/-4.9 and 21.5+/-1.9%, respectively). CONCLUSION: EPO does not protect ischemic myocardium such that reperfusion after 3 h can yield additional salvage.

A profibrotic effect of plasminogen activator inhibitor type-1 (PAI-1) in the heart.

Increased expression of PAI-1 is profibrotic in several organs. However, its potentially profibrotic effects in the heart subjected to infarction have not been elucidated. Accordingly, we induced coronary occlusion in 10-week-old mice congenic on a C57BL6 background and in mice overexpressing PAI-1 (PTG) in multiple tissues. Compared with C57BL6 control mice without myocardial infarction (MI), PTG mice exhibited consistently elevated PAI-1 in plasma at 16 weeks of age but virtually identical PAI-1 content in left ventricular (LV) myocardium. However, they exhibited a 2-fold increase in LV PAI-1 content 6 weeks after induction of MI (4.21 +/- 1.0 ng/ml tissue protein) compared with that in C57BL6 mice (2.04 +/- 0.5, P < 0.05). In 16-week-old mice, ultrasonically delineated LV fractional shortening (FS) was comparable in normal PTG and normal C57BL6 controls. However, 6 weeks after MI, PTG (n = 21) compared with C57BL6 (n = 14) mice exhibited markedly thinner LV posterior walls in both diastole (C57BL6 0.79 +/- 0.05 mm, PTG 0.55 +/- 0.06, P < 0.05) and systole (0.97 +/- 0.05 mm, 0.75 +/- 0.06, P < 0.05); increased end systolic LV dimensions (4.54 +/- 0.2 mm, 5.17 +/- 0.2, P < 0.05); and significantly depressed FS, more impaired LV segmental function, and greater mitral E wave amplitude. Compared with fibrosis assessed by Masson staining of sections from apex to base in C57BL6 mice (10.85 +/- 0.43% LV area), PTG mice exhibited 33% more LV fibrosis after MI (P < 0.05). Thus, PAI-1 is profibrotic in the heart subjected to infarction. Accordingly, overexpression of PAI-1 is a promising target for attenuation of heart failure after MI that may be exacerbated by fibrosis.

The magnitude and temporal dependence of apoptosis early after myocardial ischemia with or without reperfusion.

In view of the conventional wisdom in the cardiology literature that apoptosis is extensive early after myocardial ischemia, predicated largely from results with the TUNEL assay known to be nonspecific, this study was performed to delineate its extent with multiple assays and at multiple intervals. Coronary occlusion with and without subsequent revascularization was induced in 10-wk-old C57BL6 mice subjected to 1 or 4 h of transient ligation followed by 24 h of reperfusion, or 24 h persistent ligation. Apoptosis was quantified throughout the left ventricle immunohistochemically by assay of TUNEL, single-stranded DNA (ssDNA), and cleaved caspase 3; electron microscopy (EM); and activity assays of caspase 3 and 8. TUNEL staining was marked, but ssDNA and cleaved caspase 3 staining were significantly less (P<0.001 compared with TUNEL), and apoptosis defined by EM was virtually absent in all groups. Caspase 3 and caspase 8 activities per milligram protein were not significantly different from those in normal hearts. Only rare, potentially apoptotic cells were seen by EM in hearts from any group. Thus, the results with TUNEL were not specific, and the extent of apoptosis was markedly less than that predicated on the results with the TUNEL procedure. Apoptosis is de minimus early after transitory or persistent ischemia, though it is overestimated by TUNEL assays. Thus, antiapoptotic interventions per se are not likely to preserve substantial amounts of myocardium early after ischemic insults.

Woody biomass phytoremediation of contaminated brownfield land.

Economic and environmental regeneration of post-industrial landscapes frequently involves some element of re-afforestation or tree planting. We report field trials that evaluate whether woody biomass production is compatible with managing residual trace element contamination in brownfield soils. Large-scale mapping of contamination showed a heterogenous dispersion of metals and arsenic, and highly localised within-site hotspots. Yields of Salix, Populus and Alnus were economically viable, showing that short-rotation coppice has a potentially valuable role in community forestry. Mass balance modelling demonstrated that phytoextraction potentially could reduce contamination hotspots of more mobile elements (Cd and Zn) within a 25-30-year life cycle of the crops. Cd and Zn in stems and foliage of Salix were 4-13 times higher than EDTA-extractable soil concentrations. Lability of other trace elements (As, Pb, Cu, Ni) was not increased 3 years after planting the coppice; woody biomass may provide an effective reduction of exposure (phyto-stabilization) to these less mobile contaminants.

Bioactive constituents from Iryanthera megistophylla.

Activity-guided fractionation of the 95% ethanol extract from the stem bark of Iryanthera megistophylla led to the isolation of two new compounds, named megislignan [2,3-dimethyl-4-(4-methoxyphenyl)-6-hydroxynaphthalene] (1) and megislactone [(2R,3R,4R)-3-hydroxy-4-methyl-2-(hexacos-17-enyl)butanolide] (2), along with seven known compounds, grandinolide (3), iryantherin K (4), iryantherin L (5), cinchonain I b (6), cinchonain I a (7), procyanidin B-2 (8), and cinchonain IIa (9). The structures of the new compounds were elucidated by spectral data interpretation. Isolates were evaluated for their antibacterial, antifungal, antiviral, and antiacetylcholinesterase activities.