Tzu-Fang Shiu

Early prediction of acute kidney injury in patients with acute myocardial injury

INTRODUCTION Previous studies have revealed that acute myocardial infarction (AMI) with acute kidney injury (AKI), about 17%, is strongly related to long-term mortality and heart failure. The dynamic changes in renal function during AMI are strongly related to long-term mortality and heart failure. OBJECTIVES Our study used clinical parameters and AKI biomarkers including neutrophil gelatinase-associated lipocalin, interleukin (IL)-6, IL-18, and cystatin C to evaluate prognostic relevance of AKI in the setting of AMI. METHODS This prospective study was conducted from November 2009 to January 2011 and enrolled sequential 96 patients with catheter-proven AMI; it was approved by the institutional review board of Chang Gung Memorial Hospital, Taiwan (institutional review board no. 99-0140B) and conformed to the tenets of the Declaration of Helsinki. The definition of AKI is the elevation of serum creatinine of more than 0.3 mg/dL within 48 hours. RESULTS Our results show that the incidence of AKI after AMI is 17.7% (17 patients). The following could be statistically related to AKI after AMI: age (P = .012), cardiac functions (Killip stage and echocardiogram; P = .003 each), Thrombolysis in Myocardial Infarction (TIMI) flow grade (P < .001), stenting (P < .001), neutrophil gelatinase-associated lipocalin (P = .005), IL-6 (P = .01), IL-18 (P = .002), and cystatin C (P = .002) in serum. The TIMI flow grade and serum cystatin C were shown to be important predictors by using multivariate analysis. Both TIMI flow lower than grade 2 and serum cystatin C of more than 1364 mg/L could be used to predict AKI (both overall correctness, 0.78). Moreover, IL-6 in serum is also associated with the major cardiovascular events after AMI (P = .02), as demonstrated in our study. CONCLUSION In conclusion, the worse TIMI flow and high plasma cystatin C can be used to predict AKI after AMI. Moreover, IL-6 can also be used as a 30-day major cardiovascular event indicator after AMI. A larger prospective and longitudinal study should follow the relationship between AKI predictors after AMI.

Deletion of the FHL2 gene attenuates the formation of atherosclerotic lesions after a cholesterol-enriched diet.

AIMS FHL2, a member of the four and a half LIM domain (FHL) family of proteins, may play an important role in the circulatory system and in particular atherosclerosis. MAIN METHODS To investigate the role of FHL2 in atherogenesis, FHL2-null and wild-type control male mice were fed either a normal chow (NC) or a cholesterol-enriched diet (CED). KEY FINDINGS At 3 months post CED, aortic atherosclerotic plaques were observed in both control and FHL2-null mice. Lesions in control mice increased dramatically by 6 months of CED. In contrast, lesion size did not increase during this time in CED-fed FHL2-null mice. Relative to control mice on a normal chow of diet (NCD), control mice on a CED exhibited lower circulating nitric oxide (NO) levels, and decreased expression of connexin37 (Cx37) and Cx40 in aortic endothelium. In contrast, FHL2-null mice on a CED maintained similar levels of circulating NO as FHL2-null mice fed a NCD. Cxs levels in aortic endothelium of FHL2-null mutants on a NCD were lower relative to control mice on a NCD, and did not decrease with CED. SIGNIFICANCE Our data demonstrate a role for FHL2 in atherogenesis, the regulation of circular NO release, and expression of gap junctions within aortic endothelium.

Deletion of the FHL2 Gene Attenuating Neovascularization after Corneal Injury

PURPOSE The four-and-one-half LIM domain-containing protein2 (FHL2) is a member of the four-and-a-half LIM domain-only (FHL) gene family. Although FHL2 is expressed in the cornea, its role in angiogenesis is unclear. The aim of this study was to investigate the role of the FHL2 gene in corneal angiogenesis after chemical injury. METHODS FHL2-LacZ knock-in mice were used to trace FHL2 gene expression before and after corneal injury. Corneal angiogenesis between FHL2-null mice and wild-type mice that underwent chemical and mechanical denudation of corneal and limbal epithelium were compared. New growth vessel density was assessed by CD31 staining and was analyzed using image analysis software. Levels of vascular endothelial growth factor (VEGF) and cyclooxygenase (COX)-2 proteins were determined by Western blot assay. RESULTS beta-Galactosidase staining of corneal tissue in FHL2-LacZ knock-in mice revealed that FHL2 gene expression is upregulated in the corneal epithelium after corneal injury. Ten days after injury, corneal neovascularization was observed in control and FHL2-null mice. New corneal vessel density was found to be lower in the FHL2-null mice injury group than in the wild-type mice injury group. Western blot analysis showed that VEGF and COX-2 protein levels were higher after chemical injury in FHL2-null mice and wild-type mice. However, the upregulated VEGF protein was significantly lower in the FHL2-null mice than in the wild-type mice. CONCLUSIONS The decreased chemical-induced corneal angiogenesis found in the FHL2-null mice in this study indicated that FHL2 protein plays a role in inhibiting inflammatory angiogenesis.

Expression of OCT4 in the primary germ cell tumors and thymoma in the mediastinum.

Primary germ cell tumors (GCTs) and thymoma are both located in the anterior mediastinum. A previous study has postulated that octamer binding transcription factor (OCT4) is a nuclear transcription factor that is expressed in pluripotent embryonic germ cells. This study examined OCT4 expression in GCTs and thymoma originating from the mediastinum. A retrospective study included 46 consecutive patients with GCTs conducted between 1983 and 2005, and 22 consecutive thymoma in the mediastinum whose tumors had been surgically excised. The 46 primary GCTs in mediastinum included teratoma (n=27; 58.7%), seminoma (n=10; 21.7%), yolk sac tumor (n=6; 13%), embryonal carcinoma (n=1; 2.1%), and mixed GCTs (n=2; 4%; one consisted of teratoma and yolk sac tumor, and the other teratoma, yolk sac tumor, and seminoma); and 22 thymoma including World Health Organization type A (n=3, 13.6%), type AB (n=4, 18.2%), type B1 (n=6, 27.3%), type B2 (n=4, 13.6%), and type B3 (n=5, 22.7%). Each tumor was examined with hematoxylin and eosin staining, and with antibodies to OCT4. All 10 seminoma cases, 1 embryonal carcinoma case, and 1 mixed GCT case containing seminoma were immunopositive for OCT4. On the other hand, the 22 thymoma, 6 yolk sac tumor, 27 teratomas, and 1 case with mixed GCT without component of seminoma were immunonegative for OCT4. We conclude that immunostaining with antibodies to OCT4 is a useful diagnostic tool in the identification of seminomas and primary embryonal carcinomas in GCTs originating from the mediastinum.

The Fas-mediated apoptotic pathway in cardiac myxoma.

Cardiac myxoma is the most common primary tumor of the heart. The existence of apoptosis in cardiac myxoma has been demonstrated. The purpose of this investigation was to elucidate the pathway of apoptosis and the cell cycle in cardiac myxomas. This study had 2 parts: investigation of a cultured cardiac myxoma cell line and the analysis of data from 20 patients with cardiac myxoma that was surgically excised. Apoptosis signal transduction was determined by assessing DNA fragmentation, Fas ligand (FasL), Fas, tumor necrosis factor-α (TNF-α), caspase-3, and terminal deoxynucleotidyl transferase nick-end labeling (TUNEL) assay through immunohistochemical stain, quantitative reverse transcriptase— polymerase chain reaction (RT-PCR), and Western blot analysis. The patient population consisted of 12 (60%) women and 8 (40%) men with a mean age of 46 years (range = 32-64 years). All cases of myxoma were sporadic myxomas rather than familial. Clinical presentations included asymptomatic (26%), dyspnea (44%), stroke (9%), chest pain (9%), and fever (11%). All myxomas were located in the left atrium. Pathological scores for inflammation, cellularity, calcification, and thrombosis were not related to myxoma location or clinical events. In cardiac myxoma, apoptosis documented by TUNEL (70.9% ± 17.6%) and the caspase-3 (66.5% ± 32.5%) final common pathway is characterized by the extrinsic Fas/ FasL dependent pathway (positive stained 70.9% ± 19.2%; 26.0% ± 17.2%, respectively), but not the intrinsic pathway. The RT-PCR and Western Blot analysis (Fas/FasL, TNF-α, caspase-3, and apoptosis) of the cardiac myxoma and cultured cardiac myxoma cells confirmed the immunochemical results. The extrinsic Fas/FasL-dependent apoptosis pathways in cardiac myxomas were proved by both RNA and protein levels.

MUC1, MUC2 and MUC5AC expression in hepatocellular carcinoma with cardiac metastasis

Advanced hepatocellular carcinoma is characterized by a poor prognosis, and the choice of therapy is complicated in cases with cardiac metastasis due to the questionable benefits of surgery. Since many studies have indicated that mucin (MUC) expression plays an important role in cancer metastasis and recurrence, we investigated mucin expression in hepatocellular carcinoma patients with cardiac metastasis compared with primary hepatocellular carcinoma to confirm the nature of the malignancy. Over a 6-year period, the expression patterns of MUC1, MUC2 and MUC5AC in tumor samples from hepatocellular carcinoma patients with cardiac metastasis were assessed using immunochemistry. The results were compared with findings from a group characterized by a more favorable prognosis; those with primary hepatocellular carcinoma without recurrence. Pathologic examinations indicated that patients with hepatocellular carcinoma and cardiac metastasis had more vascular invasion (P=0.004) and less section-free zone involvement (P<0.001) than those with primary hepatocellular carcinoma. MUC1 expression was significantly higher in hepatocellular carcinoma with cardiac metastasis (P<0.005). In conclusion, the expression of mucins, especially MUC1, confirms the malignant nature of hepatocellular carcinoma with cardiac metastasis. It is recommended that such patients receive aggressive therapy.

Caspase-3-dependent apoptosis in cardiac myxoma: not associated with human papillomavirus or Epstein–Barr virus

Cardiac myxoma is the most common tumor of the heart, has a variable clinical presentation and immunohistochemical profile. Viral infections, such as herpes simplex virus, human papillomavirus (HPV), and Epstein–Barr virus (EBV), may play an important role in the causes of cardiac myxoma. This investigation will demonstrate caspase-3-dependent apoptosis in cardiac myxoma without HPV or EBV infection. This study included 15 patients with cardiac myxoma, who were treated with surgical excision of the lesion. Data were collected on detailed clinical parameters. Terminal deoxynucleotidyl transferase nick-end labeling assay, electrophoresis, and caspase-3 immunohistochemical studies were performed to characterize apoptosis. Genechip containing 39 subtypes was used to elucidate HPV; and polymerase chain reaction to detect LMP-1 gene of EBV. The patient population comprised of eight (53%) women and seven (47%) men. The mean age of patient participants was 45 years, with an age range of 30–70 years. All patient cases were sporadic myxomas rather than familial myxomas. The patient presentations included dyspnea (53%), asymptomatic (27%), stroke (7%), chest pain (7%), and fever (7%). All lesions were located in the left atrium. The individual patient cases of myxoma did not differ in location or clinical event in terms of pathological scores, such as vascular proliferation, inflammation, cellularity, hyaline, calcification, or thrombosis. Cardiac myxoma is characterized by apoptosis through caspase-dependent pathway. HPV or EBV was not detected in any of the study patient samples. In conclusion, no viral genomes of HPV or EBV were detected in these 15 patients. This study demonstrates that caspase-3-dependent apoptosis in cardiac myxoma is not dependent on concurrence of previous HPV and/or EBV infection.

Expression of caspase-3-dependent apoptosis in mural thrombi leukocytes

Failure of arteriovenous access is mostly due to graft thrombosis and multifactorial, with medical and surgical etiologies. Apoptosis of blood cells, such as macrophages, lymphocytes and eosinophils, may play an important role in thrombus formation. We also investigated caspase‐3‐dependent apoptosis in thrombi. We recorded clinical parameters in 43 consecutive patients with vascular access failure (13 men, 30 women; mean age±SD, 64.6±14.2 years) who underwent surgical thrombectomy. Major presentations included absent (92%) and/or near near‐absent (16%) flow through the access during hemodialysis. Cardiovascular risk factors were hypertension (70%), hyperlipidemia (47%), diabetes mellitus (47%), chronic obstructive pulmonary disease (12%), heart failure (12%), coronary artery disease (21%), and stroke (16%). Laboratory data included hemoglobin level of 100±17 g/L, total white blood cell count of 7.65±2.14×109/L, and platelet count of 205.6±57.9 1000/ìL. Abnormal biochemistry data included elevated blood urea nitrogen level of 63.5±24.4 mg/dL and creatinine level of 8.6±4.0 mg/dL (normal <1.4 mg/dL). Thrombi were characterized by apoptosis (32%) in a caspase‐dependent pathway in all types of leukocytes. Thrombi in arteriovenous access failure demonstrate apoptosis by means of the caspase‐3 pathway in white blood cells.

Polycythemia vera as a presentation of renal angiomyolipoma: a case report

IntroductionAngiomyolipoma is a common benign renal tumor composed of thick-walled blood vessels, smooth muscle, and adipose tissue. It may be found incidentally during workup for suspected renal disease. Although angiomyolipoma may present as a palpable, tender renal mass with flank pain and gross or microscopic hematuria, many patients are asymptomatic. Erythrocytosis is an unusual presentation, and malignant transformation may be suspected. This report describes a rare case of a woman diagnosed with renal angiomyolipoma and polycythemia vera. The report discusses the differential diagnosis using erythropoietin, erythropoietin-receptor and Janus kinase 2.Case presentationA 79-year-old Chinese woman was diagnosed with erythrocytosis according to World Health Organization criteria. An upper left renal pole angiomyolipoma was successfully ablated after multiple phlebotomy treatments. Red cell count immediately returned to normal, but gradually increased after 4 months. Polycythemia vera was finally diagnosed by positive mutation of Janus kinase 2 and negative erythropoietin protein expression. Her clinical symptoms improved with regular phlebotomy and hydroxyurea treatment.ConclusionConcurrent occurence of angiomyolipoma and polycythemia vera is rare. Polycythemia vera can be easily missed. Polycythemia vera can be confirmed with high specificity and sensitivity by the acquired somatic mutation. Surgical intervention for this renal tumor should be avoided unless malignancy or renal cell carcinoma is suspected or to prevent spontaneous rupture of larger tumors.