Risk stratification in non-ST elevation acute coronary syndromes: risk scores, biomarkers and clinical judgment

Undifferentiated chest pain is one of the most common reasons for emergency department attendance and admission to hospitals. Non-ST elevation acute coronary syndrome (NSTE-ACS) is an important cause of chest pain, and accurate diagnosis and risk stratification in the emergency department must be a clinical priority. In the future, the incidence of NSTE-ACS will rise further as higher sensitivity troponin assays are implemented in clinical practice. In this article, we review contemporary approaches for the diagnosis and risk stratification of NSTE-ACS during emergency care. We consider the limitations of current practices and potential improvements. Clinical guidelines recommend an early invasive strategy in higher risk NSTE-ACS. The Global Registry of Acute Coronary Events (GRACE) risk score is a validated risk stratification tool which has incremental prognostic value for risk stratification compared with clinical assessment or troponin testing alone. In emergency medicine, there has been a limited adoption of the GRACE score in some countries (e.g. United Kingdom), in part related to a delay in obtaining timely blood biochemistry results. Age makes an exponential contribution to the GRACE score, and on an individual patient basis, the risk of younger patients with a flow-limiting culprit coronary artery lesion may be underestimated. The future incorporation of novel cardiac biomarkers into this diagnostic pathway may allow for earlier treatment stratification. The cost-effectiveness of the new diagnostic pathways based on high-sensitivity troponin and copeptin must also be established. Finally, diagnostic tests and risk scores may optimize patient care but they cannot replace patient-focused good clinical judgment

Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need

The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment options that include medical therapy and myocardial revascularisation. This clinical paradigm fails to account for the considerable proportion (approximately one-third) of patients with angina in whom obstructive CAD is excluded. This common scenario presents a diagnostic conundrum whereby angina occurs but there is no obstructive CAD (ischaemia and no obstructive coronary artery disease—INOCA). We review new insights into the pathophysiology of angina whereby myocardial ischaemia results from a deficient supply of oxygenated blood to the myocardium, due to various combinations of focal or diffuse epicardial disease (macrovascular), microvascular dysfunction or both. Macrovascular disease may be due to the presence of obstructive CAD secondary to atherosclerosis, or may be dynamic due to a functional disorder (eg, coronary artery spasm, myocardial bridging). Pathophysiology of coronary microvascular disease may involve anatomical abnormalities resulting in increased coronary resistance, or functional abnormalities resulting in abnormal vasomotor tone. We consider novel clinical diagnostic techniques enabling new insights into the causes of angina and appraise the need for improved therapeutic options for patients with INOCA. We conclude that the taxonomy of stable CAD could improve to better reflect the heterogeneous pathophysiology of the coronary circulation. We propose the term ‘stable coronary syndromes’ (SCS), which aligns with the well-established terminology for ‘acute coronary syndromes’. SCS subtends a clinically relevant classification that more fully encompasses the different diseases of the epicardial and microvascular coronary circulation

Virus-transformed pre-B cells show ordered activation but not inactivation of immunoglobulin gene rearrangement and transcription

Virus-transformed pre-B cells undergo ordered immunoglobulin (Ig) gene rearrangements during culture. We devised a series of highly sensitive polymerase chain reaction assays for Ig gene rearrangement and unrearranged Ig gene segment transcription to study both the possible relationship between these processes in cultured pre-B cells and the role played by heavy (H) chain (mu) protein in regulating gene rearrangement. Our analysis of pre-B cell cultures representing various stages of maturity revealed that transcription of each germline Ig locus precedes or is coincident with its rearrangement. Cell lines containing one functional rearranged H chain allele, however, continue to transcribe and to rearrange the allelic, unrearranged H chain locus. These cell lines appear to initiate but not terminate rearrangement events and therefore provide information about the requirements for activating rearrangement but not about allelic exclusion mechanisms

Transcriptional Regulation Of MicroRNA Genes And The Regulatory Networks In Which They Participate

MicroRNA genes are short, non-coding RNAs that function as post-transcriptional gene regulators. Although they have been implicated in organismal development as well as a variety of human diseases, there is still surprisingly little known about their transcriptional regulation. The understanding of microRNA transcription is very important for determining their regulators as well as the specific role they may play in signaling cascades. This dissertation focused on the comparison of mammalian microRNA promoters and upstream sequences to those of known protein coding genes. This dissertation is also focused on determining potential regulatory networks that microRNA genes may participate in, particularly those networks involved in the TGFβ / SMAD signaling pathway. The comparison of intergenic microRNA upstream sequences to those of protein coding genes revealed that the former are up to twice as conserved as the latter, except in the first 500 base pairs where the conservation is similar. Further investigation of the upstream sequences by RNA Polymerase II ChIP-chip revealed the transcription start site for 35 primary-microRNA transcripts. The identification of features capable of distinguishing core promoter regions from background sequences using a support vector machine approach revealed that the transcription start site of primary-microRNA genes share the same sequence features as protein coding genes. These results suggest that in fact microRNA genes are transcribed by the same mechanism by which protein coding genes are transcribed. This information allowed us to then identify the regulatory elements of microRNA genes in the same manner in which we use for protein coding genes. Identification of a SMAD family transcription factor binding site upstream of the human let-7d microRNA revealed a feed-forward regulatory circuit involved in epithelial mesenchymal transition. This provided the first evidence of a direct link between a growth factor and the expression of a microRNA gene. The understanding of microRNA transcriptional regulation has great public health significance. The ability to understand how these post-transcriptional gene regulators function in cellular networks may provide new molecular targets for cures or therapies to a variety of human diseases

The Infrastructure of Influence: Transnational Collaboration and the Spread of US Cultural Influence in Colombia, 1930s-1960s

This dissertation examines the growth of US cultural influence in Andean and Caribbean Colombia during World War II and the first half the Cold War (1930s-1960s). Exploring Colombian-US collaboration in educational and cultural arenas, the study articulates a mid-century shift in Colombian cultural orientation away from Europe and toward the US. Analyzing the cultural complexities of Colombian-US relations during those decades, it demonstrates why this shift began and how it was sustained. While the study credits US cultural diplomacy with encouraging the shift, it emphasizes the role of Colombians in building the new cultural infrastructure that facilitated it. Intent on moving the nation toward capitalist modernity and minimizing the threat of social and political revolution, the Colombian national government and the Colombian Catholic Church aggressively enlisted US resources toward educational and cultural reforms. In doing so, they followed the lead of the nations emerging middle classes, newly expanding professional groups, and modernist segments within the national elite as they engaged US cultural models to clear their own paths toward modernity. At the intersection of cultural and diplomatic history, this study presents intimate views of transnational cultures and communities as they developed around schools, cultural centers and mass media programs. Using the Colombian case, it demonstrates how new venues for collaboration were redefining Latin American-US cultural relations during the mid-twentieth century. In contrast to studies that frame inter-American encounters as manifestations of empire, this dissertation demonstrates the frequently overlooked yet crucial role of common interests in building cultural relations across national borders

The promoter of the human interleukin-2 gene contains two octamer-binding sites and is partially activated by the expression of Oct-2

The gene encoding interleukin-2 (IL-2) contains a sequence 52 to 326 nucleotides upstream of its transcriptional initiation site that promotes transcription in T cells that have been activated by costimulation with tetradecanoyl phorbol myristyl acetate (TPA) and phytohemagglutinin (PHA). We found that the ubiquitous transcription factor, Oct-1, bound to two previously identified motifs within the human IL-2 enhancer, centered at nucleotides -74 and -251. Each site in the IL-2 enhancer that bound Oct-1 in vitro was also required to achieve a maximal transcriptional response to TPA plus PHA in vivo. Point mutations within either the proximal or distal octamer sequences reduced the response of the enhancer to activation by 54 and 34%, respectively. Because the murine T-cell line EL4 constitutively expresses Oct-2 and requires only TPA to induce transcription of the IL-2 gene, the effect of Oct-2 expression on activation of the IL-2 promoter in Jurkat T cells was determined. Expression of Oct-2 potentiated transcription 13-fold in response to TPA plus PHA and permitted the enhancer to respond to the single stimulus of TPA. Therefore, both the signal requirements and the magnitude of the transcription response of the IL-2 promoter can be modulated by Oct-2

Fractional flow reserve-guided management in stable coronary disease and acute myocardial infarction: recent developments

Coronary artery disease (CAD) is a leading global cause of morbidity and mortality, and improvements in the diagnosis and treatment of CAD can reduce the health and economic burden of this condition. Fractional flow reserve (FFR) is an evidence-based diagnostic test of the physiological significance of a coronary artery stenosis. Fractional flow reserve is a pressure-derived index of the maximal achievable myocardial blood flow in the presence of an epicardial coronary stenosis as a ratio to maximum achievable flow if that artery were normal. When compared with standard angiography-guided management, FFR disclosure is impactful on the decision for revascularization and clinical outcomes. In this article, we review recent developments with FFR in patients with stable CAD and recent myocardial infarction. Specifically, we review novel developments in our understanding of CAD pathophysiology, diagnostic applications, prognostic studies, clinical trials, and clinical guidelines

Cardiovascular health technology assessment: recommendations to improve the quality of evidence

The aim of this article is to review the role of Health Technology Assessment (HTA) organisations in appraising and recommending innovative cardiovascular technologies. We consider how bias impairs the quality of evidence from clinical trials involving cardiovascular healthcare technologies. Finally, we provide recommendations to HTA organisations to take account of bias when making guideline recommendations. Clinical research studies of medical devices, diagnostics and interventions in cardiovascular healthcare are susceptible to impairment through bias. While HTA organisations, such as the National Institute of Health and Care Excellence, may require reviewers to take account of bias, there are uncertainties as to how this is achieved, especially in cardiovascular technology trials. This becomes more relevant given that large trials are few in number; therefore, the quality of evidence from an individual trial may have a large bearing on guideline recommendations and clinical practice. HTA organisations should drive improvements in the design and rigour of randomised trials. The evolving landscape of cardiovascular healthcare technologies and related trials presents a challenge for HTA organisations and healthcare providers. The rapid turnover of evidence is externally relevant because the period from the trial publication to implementation of HTA guideline recommendations by healthcare providers may be prolonged, by which time new evidence may have emerged from subsequent trials. Implementation of a cardiovascular healthcare technology including be it a medical device, diagnostic or intervention may have profound implications for healthcare providers. These technologies may have high absolute costs and access may be influenced by socioeconomic and geographic factors

Individualized Hydration Plans Improve Performance Outcomes for Collegiate Athletes Engaging in In-Season Training

Background: Athletes commonly consume insufficient fluid and electrolytes just prior to, or during training and competition. Unlike non-athletes or athletes who do not engage in frequent rigorous and prolonged training sessions, “hard trainers” may require additional sodium and better benefit from a hydration plan tailored to their individual physiology. The purpose of this randomized cross-over study was to determine whether a hydration plan based off of an athlete’s sweat rate and sodium loss improves anaerobic and neurocognitive performance during a moderate to hard training session as well as heart rate recovery from this session. Methods: Collegiate athletes who were injury free and could exercise at ≥ 75% of their maximum heart rate for a minimum of 45 min were recruited for this randomized, cross-over study. After completing a questionnaire assessing hydration habits, participants were randomized either to a prescription hydration plan (PHP), which considered sweat rate and sodium loss or instructed to follow their normal ad libitum hydration habits (NHP) during training. Attention and awareness, as well as lower body anaerobic power (standing long jump) were assessed immediately before and after a moderate to hard training session of ≥ 45 min. Heart rate recovery was also measured. After a washout period of 7 days, the PHP group repeated the training bout with their normal hydration routine, while the NHP group were provided with a PHP plan and were assessed as previously described. Results: Fifteen athletes from three different sports, aged 20 ± 0.85 years, participated in this study. Most participants reported feeling somewhat or very dehydrated after a typical training session. Compared to their NHP, participants following a PHP jumped 4.53 ± 3.80 in. farther, tracked moving objects 0.36 ± 0.60 m/second faster, and exhibited a faster heart rate recovery following a moderate to hard training session of 45–120 min in duration. Conclusion: A tailored hydration plan, based on an athlete’s fluid and sodium loss has the potential to improve anaerobic power, attention and awareness, and heart rate recovery time