Determinants of variations in initial treatment strategies for stable ischemic heart disease

Background:

The ratio of revascularization to medical therapy (referred to herein as the revascularization ratio) for the initial treatment of stable ischemic heart disease varies considerably across hospitals. We conducted a comprehensive study to identify patient, physician and hospital factors associated with variations in the revascularization ratio across 18 cardiac centres in the province of Ontario. We also explored whether clinical outcomes differed between hospitals with high, medium and low ratios.

Methods:

We identified all patients in Ontario who had stable ischemic heart disease documented by index angiography performed between Oct. 1, 2008, and Sept. 30, 2011, at any of the 18 cardiac centres in the province. We classified patients by initial treatment strategy (medical therapy or revascularization). Hospitals were classified into equal tertiles based on their revascularization ratio. The primary outcome was all-cause mortality. Patient follow-up was until Dec. 31, 2012. Hierarchical logistic regression models identified predictors of revascularization. Multivariable Cox proportional hazards models, with a time-varying covariate for actual treatment received, were used to evaluate the impact of the revascularization ratio on clinical outcomes.

Results:

Variation in revascularization ratios was twofold across the hospitals. Patient factors accounted for 67.4% of the variation in revascularization ratios. Physician and hospital factors were not significantly associated with the variation. Significant patient-level predictors of revascularization were history of smoking, multivessel disease, high-risk findings on noninvasive stress testing and more severe symptoms of angina (v. no symptoms). Treatment at hospitals with a high revascularization ratio was associated with increased mortality compared with treatment at hospitals with a low ratio (hazard ratio 1.12, 95% confidence interval 1.03–1.21).

Interpretation:

Most of the variation in revascularization ratios across hospitals was warranted, in that it was driven by patient factors. Nonetheless, the variation was associated with potentially important differences in mortality.Stable ischemic heart disease is a common manifestation of cardiovascular disease, the leading cause of death in the world.^1,2 The treatment strategies for stable ischemic heart disease include medical therapy alone or in combination with revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).A tremendous amount of research has examined the best initial treatment strategy for stable ischemic heart disease.^3–5 Randomized controlled trials have not shown a difference in major adverse events between optimal medical therapy and revascularization.⁶ Some argue that revascularization should be reserved only for symptom relief.^5,7,8 Criteria for the appropriate use of revascularization have been developed to aid in clinical decision-making; however, a substantial proportion of revascularization procedures for stable ischemic heart disease are performed under clinical circumstances deemed as “uncertain.”^9,10 Reflecting this uncertainty, there is wide regional variation in the rate of coronary revascularization,^11–13 which suggests different thresholds for invasive therapy for stable ischemic heart disease.Studies have predominantly examined the determinants of variations in the type of revascularization modality used.^13,14 There is a paucity of data exploring the determinants of variations in the earlier decision to treat with medical therapy alone or with revascularization. A study published nearly a decade ago did not examine outcomes.⁷ Accordingly, our primary research objective was to determine whether the variations in initial treatment strategies for stable ischemic heart disease are warranted. We conducted a comprehensive population-based study to identify patient, physician and hospital factors associated with variations in treatment strategies within 90 days after angiography. We also explored whether clinical outcomes differed between hospitals with high, medium and low ratios of revascularization to medical therapy (hereafter referred to as the revascularization ratio).     

Changes in the Gallus gallus proteome induced by Marek's disease virus

Marek's disease virus (MDV) is a highly oncogenic avian herpesvirus. We have used a modified MudPIT analysis to examine the effect of MDV infection on the chicken proteome. We identified 3561 unique nonphosphorylated peptides, representing 1460 chicken proteins, in a mock-infected sample versus 4240 unique nonphosphorylated peptides, representing 1676 proteins, in an MDV-infected sample. Of these unique peptides, 59.1% from the mock- and 49.6% from the MDV-infected samples were detected in both samples, and for the represented proteins, 69.1% from the mock- and 60.2% from the MDV-infected samples were common to both samples. In terms of phosphorylation, 357 and 506 phosphopeptides, representing 342 and 483 proteins, were detected in the mock- and MDV-infected samples, respectively. At the phosphopeptide level, 10.1% from the mock- and 7.1% from the MDV-infected samples overlapped, and for the represented phosphoproteins, 12.0% from the mock- and 8.5% from the MDV-infected samples were common to both samples. There were no significant differences in the hydropathicity values and number of transmembrane domains of the identified protein sets. Subtle differences were observed for subcellular localizations of the identified proteins. These results suggest that MDV infection may alter host cell biochemistry by perturbing the host's proteomic composition.     

Closing gaps in the human genome using sequencing by synthesis

The most recent release of the finished human genome contains 260 euchromatic gaps (excluding chromosome Y). Recent work has helped explain a large number of these unresolved regions as 'structural' in nature. Another class of gaps is likely to be refractory to clone-based approaches, and cannot be approached in ways previously described. We present an approach for closing these gaps using 454 sequencing. As a proof of principle, we closed all three remaining non-structural gaps in chromosome 15.     

SNP discovery from next-generation transcriptome sequencing data and their validation using KASP assay in wheat (<Emphasis Type="Italic">Triticum aestivum</Emphasis> L.)

Single nucleotide polymorphisms (SNPs) are becoming the most amenable form of DNA-based molecular markers for genetic analysis. In hexaploid bread wheat (Triticum aestivum L.), it is difficult to discern true polymorphic SNPs due to homoeologous and paralogous genes. Two serial analysis of gene expression (SAGE) libraries were developed utilizing leaves from resistant plants carrying leaf rust resistance gene Lr28; one library was derived from leaves that were mock inoculated and the other was derived from leaves inoculated with the urediniospores of the leaf rust pathogen Puccinia triticina. Next-generation sequencing reads, after quality trimming and removal of fungal sequences, were mapped to wheat reference sequences at Ensembl Plants. CLC Genomics Workbench and Freebayes softwares were employed for SNP calling. A total of 611 SNPs were predicted to be common by both softwares, of which 207 varietal SNPs were identified by ConservedPrimer software. A subset of 100 SNPs was used for validation across 47 wheat genotypes using Kompetitive Allele Specific PCR (KASP) assay; 83 SNPs could be successfully validated. These SNPs were positioned on wheat subgenomes and chromosome arms. When functionally annotated, many sequences harboring SNPs showed homology to resistance and resistance-like genes listed in Plant Resistance Gene database (PRGdb) as well as pathogenesis-related (PR) and stress-responsive genes. The results of the present study involving discovery of SNPs associated with resistance to leaf rust, a major threat to wheat production worldwide, will be valuable for molecular breeding for rust resistance.     

QTL mapping for some grain traits in bread wheat (<Emphasis Type="Italic">Triticum aestivum</Emphasis> L.)

Grain traits are important agronomic attributes with the market value as well as milling yield of bread wheat. In the present study, quantitative trait loci (QTL) regulating grain traits in wheat were identified. Data for grain area size (GAS), grain width (GWid), factor form density (FFD), grain length-width ratio (GLWR), thousand grain weight (TGW), grain perimeter length (GPL) and grain length (GL) were recorded on a recombinant inbred line derived from the cross of NW1014?×?HUW468 at Meerut and Varanasi locations. A linkage map of 55 simple sequence repeat markers for 8 wheat chromosomes was used for QTL analysis by Composite interval mapping. Eighteen QTLs distributed on 8 chromosomes were identified for seven grain traits. Of these, five QTLs for GLWR were found on chromosomes 1A, 6A, 2B, and 7B, three QTLs for GPL were located on chromosomes 4A, 5A and 7B and three QTLs for GAS were mapped on 5D and 7D. Two QTLs were identified on chromosomes 4A and 5A for GL and two QTLs for GWid were identified on chromosomes 7D and 6A. Similarly, two QTLs for FFD were found on chromosomes 1A and 5D. A solitary QTL for TGW was identified on chromosome 2B. For several traits, QTLs were also co-localized on chromosomes 2B, 4A, 5A, 6A, 5D, 7B and 7D. The QTLs detected in the present study may be validated for specific crosses and then used for marker-assisted selection to improve grain quality in bread wheat.     

Gene networks in hexaploid wheat: interacting quantitative trait loci for grain protein content

In hexaploid wheat, single-locus and two-locus quantitative trait loci (QTL) analyses for grain protein content (GPC) were conducted using two different mapping populations (PI and PII). Main effect QTLs (M-QTLs), epistatic QTLs (E-QTLs) and QTL x environment interactions (QE, QQE) were detected using two-locus analyses in both the populations. Only a few QTLs were common in both the analyses, and the QTLs and the interactions detected in the two populations differed, suggesting the superiority of two-locus analysis and the need for using several mapping populations for QTL analysis. A sizable proportion of genetic variation for GPC was due to interactions (28.59% and 54.03%), rather than to M-QTL effects (7.24% and 7.22%), which are the only genetic effects often detected in the majority of QTL studies. Even E-QTLs made a marginal contribution to genetic variation (2.68% and 6.04%), thus suggesting that the major part of genetic variation is due to changes in gene networks rather than the presence or absence of specific genes. This is in sharp contrast to the genetic dissection of pre-harvest sprouting tolerance conducted by us earlier, where interaction effects were not substantial, suggesting that the nature of genetic variation also depends on the nature of the trait.     

Population Pharmacokinetics of an Indian F(ab')2 Snake Antivenom in Patients with Russell's Viper (Daboia russelii) Bites

Background

There is limited information on antivenom pharmacokinetics. This study aimed to investigate the pharmacokinetics of an Indian snake antivenom in humans with Russell’s viper bites.

Methods/Principal Findings

Patient data and serial blood samples were collected from patients with Russell’s viper (Daboia russelii) envenoming in Sri Lanka. All patients received Indian F(ab’)₂ snake antivenom manufactured by VINS Bioproducts Ltd. Antivenom concentrations were measured with sandwich enzyme immunoassays. Timed antivenom concentrations were analysed using MONOLIXvs4.2. One, two and three compartment models with zero order input and first order elimination kinetics were assessed. Models were parameterized with clearance(CL), intercompartmental clearance(Q), central compartment volume(V) and peripheral compartment volume(V_P). Between-subject-variability (BSV) on relative bioavailability (F) was included to account for dose variations. Covariates effects (age, sex, weight, antivenom batch, pre-antivenom concentrations) were explored by visual inspection and in model building. There were 75 patients, median age 57 years (40-70y) and 64 (85%) were male. 411 antivenom concentration data points were analysed. A two compartment model with zero order input, linear elimination kinetics and a combined error model best described the data. Inclusion of BSV on F and weight as a covariate on V improved the model. Inclusion of pre-antivenom concentrations or different batches on BSV of F did not. Final model parameter estimates were CL,0.078 Lh^-1, V,2.2L, Q,0.178Lh^-1 and V_P,8.33L. The median half-life of distribution was 4.6h (10-90%iles:2.6-7.1h) and half-life of elimination, 140h (10^th-90^th percentilesx:95-223h).

Conclusion

Indian F(ab’)₂ snake antivenom displayed biexponential disposition pharmacokinetics, with a rapid distribution half-life and more prolonged elimination half-life.