Persistently elevated troponin I in heart failure patients - a suitable prognosticator and a possible boon to public health?

Baseline elevation of troponin I (TnI) has been associated with worse outcomes in heart failure (HF). However, the prevalence of persistent TnI elevation and its association with clinical outcomes has not been well described. HF is a major public health issue due to its wide prevalence and prognosticators of this condition will have a significant impact on public health. Methods: A retrospective study was performed in 510 patients with an initial HF admission between 2002 to 2004, and all subsequent hospital admissions up to May 2009 were recorded in a de-identified database. Persistent TnI elevation was defined as a level ≥0.05 ng/ml on ≥3 HF admissions. Baseline characteristics, hospital readmissions and all cause mortality were compared between patients with persistent TnI elevation (Persistent), patients with no persistence of TnI (Nonpersistent) and patients who had less than three hospital admissions (admission <3) groups. Also the same data was analyzed using the mean method in which the mean value of all recorded troponin values of each patient was used to define persistence i.e. patients who had a mean troponin level ≥0.05 ng/ml were classified as persistent. Results: Mean age of our cohort was 68.4 years out of which 99.6% subjects were male, 62.4% had ischemic HF. 78.2% had NYHA class III to IV HF, mean LVEF was 25.9%. Persistent elevation of TnI was seen in 26% of the cohort and in 66% of patients with more than 3 hospital admissions. Mean TnI level was 0.67 ± 0.15 ng/ml in the 'Persistent' group. Mean TnI using the mean method was 1.11 ± 7.25 ng/ml. LVEF was significantly lower in persistent group. Hypertension, diabetes, chronic renal insufficiency and mean age did not differ between the two groups. 'Persistent' patients had higher mortality (HR = 1.26, 95% CI = 0.89–1.78, p = 0.199 when unadjusted and HR = 1.29, 95% CI = 0.89–1.86, p = 0.176 when adjusted for race, LVEF and ischemic etiology) HR for mortality in persistent patients was 1.99 (95% CI = 1.06–3.73, p = 0.03) using the mean method. The following results were found in those with ischemic cardiomyopathy (HR = 1.44034, 95% CI = 0.92–2.26, p = 0.113) and (HR = 1.89, 95% CI = 1.01–3.55, p = 0.046) by using the mean method. 2 out of three patients with HF who were readmitted three or more times had persistent elevation of troponin I levels. Patients with chronic persistence of troponin I elevation showed a trend towards lesser survival as compared to patients who did not have chronic persistence, however this did not reach statistical significance. This trend was seen more among ischemic patients than non ischemic patients, but did not reach statistical significance. With the mean method, patients with chronic persistence of troponin I elevation had significantly lesser survival than those without it. Also ischemic patients had significantly lesser survival than non ischemic patients. ^

Interferon-gamma release assays for latent tuberculosis infection in child and young adult candidates or recipients of tumor necrosis factor inhibitor therapy

Background. Inhibition of tumor necrosis factor (TNF) is associated with progression of latent tuberculosis infection (LTBI) to active disease. LTBI screening prior to starting TNF inhibitor therapy is recommended. Blood tests, collectively known as interferon-gamma release assays (IGRAs), offer a means other than the tuberculin skin test (TST) of screening for LTBI. However, in the setting of immune compromise, anergy may limit the clinical utility of IGRAs. ^ Methods. A cross-sectional study was conducted in children and young adults ≤ 21 years of age who were cared for at Texas Children's Hospital in Houston, TX, during 2011 and who were candidates for, or were receiving, tumor necrosis factor (TNF)-inhibitor therapy. All subjects answered a risk factor questionnaire and were tested for LTBI by two commercially available IGRAs (QuantiFERON-Gold In-Tube assay and the T-SPOT.TB assay), along with the TST. T-cell phenotypes were evaluated through flow cytometry, both at baseline and after antigen stimulation. ^ Results. Twenty-eight subjects were enrolled. All were TST negative and none were IGRA positive. Results were negative for the 27 subjects who were tested with QuantiFERON-Gold In-Tube. However, 26% of subjects demonstrated anergy in the T-SPOT.T. Patients with T-SPOT. TB anergy had lower quantitative IFN-γ responses to mitogen in the QFT assay—the mean IFN-γ level to mitogen in patients without T-SPOT.TB anergy was 9.84 IU/ml compared to 6.91 IU/ml in patients with T-SPOT.TB anergy (P = 0.046). Age and use of TNF inhibitors, corticosteroids, or methotrexate use were not significantly associated with T-SPOT.TB anergy. Antigen stimulation revealed depressed expression of intracellular IFN-γ in subjects with T-SPOT. TB anergy. ^ Conclusions. The frequency of anergy in this population is higher than would be expected from studies in adults. There appears to be inappropriate IFN-γ responses to antigen in subjects with T-SPOT. TB anergy. This immune defect was detected by the T-SPOT. TB assay but not by the QuantiFERON-Gold In-Tube assay. Further data are needed to clarify the utility of IGRAs in this population.^

Fas ligand and soluble Fas -opposing molecules in melanoma lung metastasis

Deregulation of apoptotic cell death can result in aberrant accumulation of cells and increased tumor incidence. Fas (CD95) and Fas ligand (FasL) are a receptor-ligand pair whose activation induces apoptosis in many cell types. Previously, we demonstrated that low metastatic, Fas+ K1735-P murine melanoma cells spontaneously metastasize to the lung following orthotopic injection into FasL-deficient (gld) mice compared to wild-type (wt) controls. We further demonstrated that the expression of the Fas antagonist soluble Fas (sFas) directly correlates with disease stage in patients with melanoma, breast, and colon cancer. These findings document a role for host-derived FasL, in the control of metastatic disease and suggest a role for tumor-associated sFas in acquiring metastatic potential. To directly test whether FasL expressed on lymphocytes or on lung stromal cells restricts metastasis, bone marrow chimeras were generated between C3H wt and C3H gld mice. Chimeric animals were injected subcutaneously with 5 × 105 K1735-P and the incidence and number of spontaneous lung metastases scored. The data show that wt mice receiving gld marrow had a greater number of lung metastases (median 9.5, range 2–31) than gld mice reconstituted with wt marrow (median 1, range 0–31; p < 0.016). Interestingly, both groups had fewer metastases compared to gld controls (median 18.5, range 0–46) but more than wt controls (median 2, range 0–7). These observations provide the first evidence that both hematopoietic- and nonhematopoietic-host derived FasL, are important in the control of melanoma metastasis to the lung. To directly test whether tumor-associated sFas expression can enhance metastasis, K1735-P cells were transfected with three isoforms of sFas (Exo4Del, Exo6Del, and Exo3, 4, 6Del). RT-PCR and ELISA analysis confirmed the expression of sFas RNA and protein respectively. Following intravenous injection of 5 × 104 cells, sFas transfected cells formed significantly more experimental lung metastases [Exo6Del clone 3 (median 22, range 0–36), Exo6Del clone 7 (median 31, range 4–50), Exo3, 4, 6Del (median 22.5, range 13–48)] compared to vector control cells (median 6.5, range 3–29). Together, these data provide the first evidence that sFas is sufficient to enhance the metastatic potential of Fas+ melanoma cells. ^