Predicting recurrence after unprovoked venous thromboembolism: prospective validation of the updated Vienna Prediction Model.

The updated Vienna Prediction Model for estimating recurrence risk after an unprovoked venous thromboembolism (VTE) has been developed to identify individuals at low risk for VTE recurrence in whom anticoagulation (AC) therapy may be stopped after 3 months. We externally validated the accuracy of the model to predict recurrent VTE in a prospective multicenter cohort of 156 patients aged ≥65 years with acute symptomatic unprovoked VTE who had received 3 to 12 months of AC. Patients with a predicted 12-month risk within the lowest quartile based on the updated Vienna Prediction Model were classified as low risk. The risk of recurrent VTE did not differ between low- vs higher-risk patients at 12 months (13% vs 10%; P = .77) and 24 months (15% vs 17%; P = 1.0). The area under the receiver operating characteristic curve for predicting VTE recurrence was 0.39 (95% confidence interval [CI], 0.25-0.52) at 12 months and 0.43 (95% CI, 0.31-0.54) at 24 months. In conclusion, in elderly patients with unprovoked VTE who have stopped AC, the updated Vienna Prediction Model does not discriminate between patients who develop recurrent VTE and those who do not. This study was registered at www.clinicaltrials.gov as #NCT00973596.

The physiological roles of ICAM-1 and ICAM-2 in neutrophil migration into tissues

PURPOSE OF REVIEW Neutrophil extravasation from the blood into tissues is initiated by tethering and rolling of neutrophils on endothelial cells, followed by neutrophil integrin activation and shear resistant arrest, crawling, diapedesis and breaching the endothelial basement membrane harbouring pericytes. Endothelial intercellular cell adhesion molecule (ICAM)-1 and ICAM-2, in conjunction with ICAM-1 on pericytes, critically contribute to each step. In addition, epithelial ICAM-1 is involved in neutrophil migration to peri-epithelial sites. The most recent findings on the role of ICAM-1 and ICAM-2 for neutrophil migration into tissues will be reviewed here. RECENT FINDINGS Signalling via endothelial ICAM-1 and ICAM-2 contributes to stiffness of the endothelial cells at sites of chronic inflammation and junctional maturation, respectively. Endothelial ICAM-2 contributes to neutrophil crawling and initiation of paracellular diapedesis, which then proceeds independent of ICAM-2. Substantial transcellular neutrophil diapedesis across the blood-brain barrier is strictly dependent on endothelial ICAM-1 and ICAM-2. Endothelial ICAM-1 or ICAM-2 is involved in neutrophil-mediated plasma leakage. ICAM-1 on pericytes assists the final step of neutrophil extravasation. Epithelial ICAM-1 rather indirectly promotes neutrophil migration to peri-epithelial sites. SUMMARY ICAM-1 and ICAM-2 are involved in each step of neutrophil extravasation, and have redundant but also distinct functions. Analysis of the role of endothelial ICAM-1 requires simultaneous consideration of ICAM-2.

Diagnostic value of immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis.

Immunoassays are essential in the workup of patients with suspected heparin-induced thrombocytopenia. However, the diagnostic accuracy is uncertain with regard to different classes of assays, antibody specificities, thresholds, test variations, and manufacturers. We aimed to assess diagnostic accuracy measures of available immunoassays and to explore sources of heterogeneity. We performed comprehensive literature searches and applied strict inclusion criteria. Finally, 49 publications comprising 128 test evaluations in 15 199 patients were included in the analysis. Methodological quality according to the revised tool for quality assessment of diagnostic accuracy studies was moderate. Diagnostic accuracy measures were calculated with the unified model (comprising a bivariate random-effects model and a hierarchical summary receiver operating characteristics model). Important differences were observed between classes of immunoassays, type of antibody specificity, thresholds, application of confirmation step, and manufacturers. Combination of high sensitivity (>95%) and high specificity (>90%) was found in 5 tests only: polyspecific enzyme-linked immunosorbent assay (ELISA) with intermediate threshold (Genetic Testing Institute, Asserachrom), particle gel immunoassay, lateral flow immunoassay, polyspecific chemiluminescent immunoassay (CLIA) with a high threshold, and immunoglobulin G (IgG)-specific CLIA with low threshold. Borderline results (sensitivity, 99.6%; specificity, 89.9%) were observed for IgG-specific Genetic Testing Institute-ELISA with low threshold. Diagnostic accuracy appears to be inadequate in tests with high thresholds (ELISA; IgG-specific CLIA), combination of IgG specificity and intermediate thresholds (ELISA, CLIA), high-dose heparin confirmation step (ELISA), and particle immunofiltration assay. When making treatment decisions, clinicians should be a aware of diagnostic characteristics of the tests used and it is recommended they estimate posttest probabilities according to likelihood ratios as well as pretest probabilities using clinical scoring tools.

Impact of comorbidities on overall survival in patients with chronic myeloid leukemia: results of the randomized CML study IV.

We studied the influence of comorbidities on remission rate and overall survival (OS) in patients with chronic myeloid leukemia (CML). Participants of the CML Study IV, a randomized 5-arm trial designed to optimize imatinib therapy, were analyzed for comorbidities at diagnosis using the Charlson Comorbidity Index (CCI); 511 indexed comorbidities were reported in 1519 CML patients. Age was an additional risk factor in 863 patients. Resulting CCI scores were as follows: CCI 2, n = 589; CCI 3 or 4, n = 599; CCI 5 or 6, n = 229; and CCI ≥ 7, n = 102. No differences in cumulative incidences of accelerated phase, blast crisis, or remission rates were observed between patients in the different CCI groups. Higher CCI was significantly associated with lower OS probabilities. The 8-year OS probabilities were 93.6%, 89.4%, 77.6%, and 46.4% for patients with CCI 2, 3 to 4, 5 to 6, and ≥7, respectively. In multivariate analysis, CCI was the most powerful predictor of OS, which was still valid after removal of its age-related components. Comorbidities have no impact on treatment success but do have a negative effect on OS, indicating that survival of patients with CML is determined more by comorbidities than by CML itself. OS may therefore be inappropriate as an outcome measure for specific CML treatments. The trial was registered at www.clinicaltrials.gov as #NCT00055874.

Targeted therapies for small cell lung cancer: Where do we stand?

Small cell lung cancer (SCLC) accounts for 15% of lung cancer cases and is associated with a dismal prognosis. Standard therapeutic regimens have been improved over the past decades, but without a major impact on patient survival. The development of targeted therapies based on a better understanding of the molecular basis of the disease is urgently needed. At the genetic level, SCLC appears very heterogenous, although somatic mutations targeting classical oncogenes and tumor suppressors have been reported. SCLC also possesses somatic mutations in many other cancer genes, including transcription factors, enzymes involved in chromatin modification, receptor tyrosine kinases and their downstream signaling components. Several avenues have been explored to develop targeted therapies for SCLC. So far, however, there has been limited success with these targeted approaches in clinical trials. Further progress in the optimization of targeted therapies for SCLC will require the development of more personalized approaches for the patients.

Genetic variations in complement factors in patients with congenital thrombotic thrombocytopenic purpura with renal insufficiency.

The congenital form of thrombotic thrombocytopenic purpura (TTP) is caused by genetic mutations in ADAMTS13. Some, but not all, congenital TTP patients manifest renal insufficiency in addition to microangiopathic hemolysis and thrombocytopenia. We included 32 congenital TTP patients in the present study, which was designed to assess whether congenital TTP patients with renal insufficiency have predisposing mutations in complement regulatory genes, as found in many patients with atypical hemolytic uremic syndrome (aHUS). In 13 patients with severe renal insufficiency, six candidate complement or complement regulatory genes were sequenced and 11 missense mutations were identified. One of these missense mutations, C3:p.K155Q mutation, is a rare mutation located in the macroglobulin-like 2 domain of C3, where other mutations predisposing for aHUS cluster. Several of the common missense mutations identified in our study have been reported to increase disease-risk for aHUS, but were not more common in patients with as compared to those without renal insufficiency. Taken together, our results show that the majority of the congenital TTP patients with renal insufficiency studied do not carry rare genetic mutations in complement or complement regulatory genes.

MS 073 Guide to the William C. Moloney MD papers; 1952-1954

William C. Moloney MD kept a personal journal, with photographs, for much of his two years in Japan with the Atomic Bomb Casualty Commission. In January of 1986, Dr.Moloney donated his journal, correspondence and diary pages to the Harris County Medical Archive. He died in 1998 at the age of 91. His first contribution was a set of ten reprints representing his work with the ABCC from 1952 to 1954. Dr.Moloney's journal is a fine document, one which will be of great use to historians. It is an important record of personal impressions, thoughts and details of events. The journal gives new insights into the work of the ABCC and into the people who participated in that work. Dr. Moloney wrote in his journal from April 1952 to February 1954. The Korean War was on and there was a great deal of military activity in southern Japan. The collection is open for research. The collection consists of a handwritten journal, loose calendar or notebook pages and some reprints. The journal is in generally fair condition. The paper is slightly acidic and the binding is loose. There are numerous photos glued onto the pages. The collection encompasses the years 1952-1954 and is 0.25 cubic feet (1 box).

MS#73 William C. Moloney, M.D., papers; 1952-1954

Dr. Moloney kept a personal journal, with photographs, for much of his two years with the Atomic Bomb Casualty Commission in Japan. Along with other scientists, he studied the biological and medical effects of ionized radiation on the survivors of the Hiroshima and Nagasaki atomic bombings. In January of 1986, Dr. Moloney donated his journal, correspondence and diary pages to the Harris County Medical Archive, whose collections were later incorporated into the Texas Medical Center Library. Dr. Moloney's journal is in relatively good shape containing a mix of handwritten notes and comments, news-clippings, photos, and ephemera. The journal is an important record of personal impressions, thoughts and details of events during a pivotal time in Japan. This 192-pagee journal gives new insights into the work of the ABCC and into the people who participated in that work. The journal covers the period from April 1952 to February 1954. In these documents, Moloney records his struggles with understanding the Japanese culture, his frustration at not being allowed to treat the survivors he studied, and his concerns, fears, hopes and revelations as he dealt with the bombing survivors and their children. The original papers are open for research at the John P. McGovern Historical Collections and Research Center in the TMC Library in Houston.

Circulation of core collection monographs in an academic medical library

Academic medical librarians responsible for monograph acquisition face a challenging task. From the plethora of medical monographs published each year, academic medical librarians must select those most useful to their patrons. Unfortunately, none of the selection tools available to medical librarians are specifically intended to assist academic librarians with medical monograph selection. The few short core collection lists that are available are intended for use in the small hospital or internal medicine department library. As these are the only selection tools available, however, many academic medical librarians spend considerable time reviewing these collection lists and place heavy emphasis on the acquisition of listed books. The study reported here was initiated to determine whether the circulation of listed books in an academic library justified the emphasis placed on the acquisition of these books. Circulation statistics for “listed” and “nonlisted” books in the hematology (WH) section of Indiana University School of Medicine's Ruth Lilly Medical Library were studied. The average circulation figures for listed books were nearly two times as high as the corresponding figures for the WH books in general. These data support the policies of those academic medical libraries that place a high priority on collection of listed books.

Self-renewal of primitive human hematopoietic cells (long-term-culture-initiating cells) in vitro and their expansion in defined medium.

A major goal of experimental and clinical hematology is the identification of mechanisms and conditions that support the expansion of transplantable hematopoietic stem cells. In normal marrow, such cells appear to be identical to (or represent a subset of) a population referred to as long-term-culture-initiating cells (LTC-ICs) so-named because of their ability to produce colony-forming cell (CFC) progeny for > or = 5 weeks when cocultured with stromal fibroblasts. Some expansion of LTC-ICs in vitro has recently been described, but identification of the factors required and whether LTC-IC self-renewal divisions are involved have remained unresolved issues. To address these issues, we examined the maintenance and/or generation of LTC-ICs from single CD34+ CD38- cells cultured for variable periods under different culture conditions. Analysis of the progeny obtained from cultures containing a feeder layer of murine fibroblasts engineered to produce steel factor, interleukin (IL)-3, and granulocyte colony-stimulating factor showed that approximately 20% of the input LTC-ICs (representing approximately 2% of the original CD34+ CD38- cells) executed self-renewal divisions within a 6-week period. Incubation of the same CD34+ CD38- starting populations as single cells in a defined (serum free) liquid medium supplemented with Flt-3 ligand, steel factor, IL-3, IL-6, granulocyte colony-stimulating factor, and nerve growth factor resulted in the proliferation of initial cells to produce clones of from 4 to 1000 cells within 10 days, approximately 40% of which included > or = 1 LTC-IC. In contrast, in similar cultures containing methylcellulose, input LTC-ICs appeared to persist but not divide. Overall the LTC-IC expansion in the liquid cultures was 30-fold in the first 10 days and 50-fold by the end of another 1-3 weeks. Documentation of human LTC-IC self-renewal in vitro and identification of defined conditions that permit their extensive and rapid amplification should facilitate analysis of the molecular mechanisms underlying these processes and their exploitation for a variety of therapeutic applications.

Efeito da desnutrição proteica sobre aspectos da mobilização, migração e sinalização celular. Papel da glutamina na modulação desses processos

A desnutrição é uma condição nutricional que pode afetar muitos aspectos da resposta imunológica, como alterações na migração celular, na fagocitose, na resposta bactericida, mudanças na produção de radicais livres e espécies de nitrogênio e na produção de citocinas pró-inflamatórias. Logo, indivíduos desnutridos apresentam maior susceptibilidade a infecções. Visto que a glutamina é um aminoácido de extrema importância para a funcionalidade de diversas células do sistema imune e que as mesmas apresentam aumento da utilização desse aminoácido durante processos infecciosos, investigou-se, neste trabalho, quais os efeitos da glutamina sobre alguns aspectos da mobilização, migração e sinalização celular em um modelo experimental de desnutrição proteica. Para tanto, utilizou-se camundongos da linhagem BALB/c machos, os quais foram divididos em dois grupos, Controle e Desnutrido, que passaram a receber dietas isocalóricas contendo 12% (normoproteica) e 2% de caseína (hipoproteica), respectivamente, durante 5 semanas. Para as avaliações in vivo, animais de ambos os grupos receberam por via endovenosa 100µL de solução contendo 1,25µg de LPS e após 1 hora 0,75mg/Kg de L-glutamina (GLUT). Após o período de desnutrição ou de indução ao processo inflamatório, os animais foram eutanasiados e as amostras biológicas coletas. Foram avaliados nos animais estimulados in vivo hemograma, mielograma, as citocinas IL-10 e TNF-α circulantes e a expressão de CD11b/CD18 nos granulócitos do sangue periférico. Foi avaliado, in vitro, a capacidade migratória, a expressão de CD11b/CD18 de polimorfonucleados da medula óssea e do sangue periférico, bem como a síntese de citocinas IL-1α, IL-6, IL-10, IL-12 e TNF-α e a expressão de NF-κB e IκBα em células cultivadas em meio com 0; 0,6; 2 e 10 mM de GLUT. Os animais desnutridos apresentaram anemia, leucopenia, hipoplasia medular e diminuição na concentração sérica de proteínas, albumina e pré-albumina. A GLUT, in vitro, apresentou capacidade de reduzir a produção de IL-1α e IL-6, bem como a ativação da via do NF-κB. No modelo in vivo a GLUT, em animais estimulados com LPS, alterou a cinética de migração neutrofílica e reduziu a expressão de CD18, bem como diminuiu os níveis de TNFα circulantes.

Determinação de biomarcadores de aflatoxina B1 e aplicabilidade na avaliação da eficiência de adsorventes em frangos de corte

As aflatoxinas são metabólitos secundários produzidos por fungos toxigênicos das espécies Aspergillus flavus, A. parasiticus e A. nomius. São amplamente encontradas em matérias-primas de rações animais, em especial o milho, e têm a capacidade de levar a quadros clínicos agudos ou crônicos de aflatoxicose, caracterizados por, desde a morte por hepatite aguda até a diminuição do desempenho zootécnico por diminuição de peso ou consumo de ração. A aflatoxina B1 tem sido considerada o metabólito mais perigoso, uma vez que possui alto poder hepatotóxico, além de ser mutagênica e carcinogênica. Atualmente a ciência trabalha rumo à descoberta de substâncias que sejam indicadoras confiáveis de contaminação por componentes tóxicos em homens e em animais, os chamados biomarcadores, que medem uma mudança celular, biológica ou molecular em um meio biológico (tecidos humanos, células ou fluídos) que fornecem informação a respeito de uma doença ou exposição a uma determinada substância. Sua detecção pode auxiliar na identificação, no diagnóstico e no tratamento de indivíduos afetados que podem estar sob risco, mas ainda não exibem os sintomas. Sendo assim, com o auxílio de análises que confirmem a patogenicidade da aflatoxina B1 (determinação da atividade de enzimas hepáticas, da avaliação da função renal, de hematologia, da dosagem de minerais séricos e da avaliação de desempenho zootécnico), o objetivo deste trabalho foi avaliar a aplicabilidade da determinação de resíduos hepáticos de aflatoxinas e do aduto sérico AFB1-lisina na avaliação da eficiência de adsorventes em frangos de corte. Utilizou-se 240 pintos de 1 dia, machos, de linhagem Cobb 500®, distribuídos aleatoriamente em 4 dietas experimentais: Controle Negativo: Ração Basal (RB); RB + 0,5% de adsorvente ((aluminosilicato de cálcio e sódio hidratado/HSCAS); RB + 0,5% de adsorvente + 500 µg de AFB1/kg de ração e; RB + 500 µg de AFB1/kg de ração.Os resultados experimentais mostram que o efeito deletério da AFB1, na concentração utilizada, é mais pronunciado que os efeitos protetores do HSCAS sobre os parâmetros de saúde dos animais. Não houve ação efetiva do adsorvente utilizado sobre quase nenhuma variável estudada, apenas para a redução das lesões histopatológicas em fígado, na redução da concentração de gama-glutamiltransferase (GGT), fósforo e aumento da contagem de hemáceas aos 21 dias de idade. Porém, influenciou positivamente a redução de resíduos hepáticos de aflatoxina G1 aos 21 dias e as concentrações de AFB1-lisina sérica aos 21 e aos 42 dias de idade. Estes dados são importantes porque permite concluir que, embora sintomatologicamente o HSCAS não tenha exercido função efetiva, molecularmente foi capaz de mostrar de eficácia sobre os alguns biomarcadores de aflatoxinas no organismo das aves

Estado sanitário do jacaré-de-papo-amarelo (Caiman latirostris) em paisagens antropizadas no Estado de São Paulo

O jacaré-de-papo (Caiman latirostris) é considerado um crocodiliano de médio porte que apresenta uma ampla distribuição latitudinal na América do Sul. Possivelmente a espécie possui a situação mais complexa entre os crocodilianos brasileiros quanto ao aspecto da conservação, basicamente porque suas populações encontram-se fragmentadas em grande parte de sua área de distribuição original e por utilizarem áreas com fortes atividades antrópicas. Embora a espécie possua aparentemente um processo adaptativo frente a estas pressões, um aspecto fisiológico pode ainda sofrer rápida alteração quando submetido a elas: o estado sanitário. Desta maneira, este estudo objetivou determinar o estado sanitário do maior predador aquático, utilizando duas áreas distintas no Estado de São Paulo, através da determinação dos perfis hematológicos e bioquímicos do sangue, além da caracterização da microbiota oral, servindo de modelo à conservação da espécie em ambientes alterados. No primeiro capítulo foram determinados o perfil hematológico e bioquímico do sangue utilizando-se 29 indivíduos (19 machos e 10 fêmeas) capturados em Angatuba e 11 indivíduos (2 machos, 4 fêmeas e 5 filhotes) capturados em Cubatão. Diferenças estatísticas significativas foram encontradas nos valores de creatinina na comparação entre fêmeas de ambas as áreas de estudo (p = 0,033) e nos valores de alanina aminotransferase (p = 0,003), hemácias (p = 0,034), hemoglobina (p = 0,049) e volume corpuscular médio (p = 0,027) quando da comparação entre sexos. No segundo capítulo determinou-se a microbiota oral destes animais através do isolamento, identificação e caracterização bacteriana, em conjunto com o teste de perfil de susceptibilidade aos antimicrobianos. Foram determinados 14 diferentes tipos de bactérias na área de Angatuba, sendo uma classificada como baciliforme aeróbio Gram-positivo, uma como bacilo Gram-negativo e 12 classificadas como Enterobactérias Gram-negativas. Na área de Cubatão foram isolados cinco tipos de bactérias, sendo quatro classificadas como Enterobactérias Gram-negativas e uma como baciliforme aeróbio Gram-positivo. Considerando que o uso de antimicrobianos é um processo primário no tratamento de animais e pessoas, principalmente nos casos que envolvam infecções provocadas pela interação homem x animais, para ambas as áreas de estudo, as quinolonas Enrofloxacina e Norfloxacina, além do aminoglicosídeo Gentamicina, foram os antimicrobianos que apresentaram os menores índices de resistência frente aos isolados testados.