Association of White Blood Cell Count and Differential with the Incidence of Atrial Fibrillation: The Atherosclerosis Risk in Communities (ARIC) Study

Background

Although inflammation is involved in the development of atrial fibrillation (AF), the association of white blood cell (WBC) count and differential with AF has not been thoroughly examined in large cohorts with extended follow-up.

Methods

We studied 14,500 men and women (25% blacks, 55% women, mean age 54) free of AF at baseline (1987–89) from the Atherosclerosis Risk in Communities (ARIC) study, a community-based cohort in the United States. Incident AF cases through 2010 were identified from study electrocardiograms, hospital discharge records and death certificates. Multivariable Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for AF associated with WBC count and differential.

Results

Over a median follow-up time of 21.5 years for the entire cohort, 1928 participants had incident AF. Higher total WBC count was associated with higher AF risk independent of AF risk factors and potential confounders (HR 1.09, 95% CI 1.04–1.15 per 1-standard deviation [SD] increase). Higher neutrophil and monocyte counts were positively associated with AF risk, while an inverse association was identified between lymphocyte count and AF (multivariable adjusted HRs 1.16, 95% CI 1.09–1.23; 1.05, 95% CI 1.00–1.11; 0.91, 95% CI 0.86–0.97 per 1-SD, respectively). No significant association was identified between eosinophils or basophils and AF.

Conclusions

High total WBC, neutrophil, and monocyte counts were each associated with higher AF risk while lymphocyte count was inversely associated with AF risk. Systemic inflammation may underlie this association and requires further investigation for strategies to prevent AF.     

Changes in cellular levels of inositol polyphosphates during apoptosis

Accumulations of higher inositol polyphosphates, diphosphoinositol polyphosphates or pyrophosphates, have been implicated to mediate cellular apoptosis. Whether cellular levels of lower inositol phosphates (lower than inositol hexakisphosphates) change during apoptosis is not known, although these inositol phosphates are known to play crucial roles in a number of cellular signaling processes including calcium mobilization. Therefore, in this study, we have examined changes in cellular levels of inositol phosphates following metabolic labeling of these compounds by [³H]myo-inositol and induction of apoptosis. The levels of inositol mono- and bis-phosphates were increased, whereas the levels of inositol tris- and tetrakis-phosphates decreased significantly with an increasing rate of apoptosis induced by etoposide in a dose-dependent manner. NaF treatment, which increased the rate of apoptosis in a time- and dose-dependent manner, also increased the levels of inositol mono- and bis-phosphates and drastically reduced the levels of inositol tris- and tetrakis-phosphates. Prior treatment with antimycin A, a strategy used to reverse the NaF-induced accumulations of higher InsPs, partially reduced the effects of NaF on apoptosis as well as the levels of lower InsPs. Taken together, our results suggest that cellular levels of lower InsPs are altered during apoptosis.     

Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis

Background

The Thrombolysis in Myocardial Infarction (TIMI) risk score uses clinical data to predict the short-term risk of acute myocardial infarction, coronary revascularization or death from any cause. It was originally developed for use in patients with unstable angina or non–ST-elevation myocardial infarction. We sought to expand the clinical application of the TIMI risk score by assessing its prognostic accuracy in patients in the emergency department with potential acute coronary syndromes.

Methods

We searched five electronic databases, hand-searched reference lists of included studies and contacted content experts to identify articles for review. We included prospective cohort studies that validated the TIMI risk score in emergency department patients. We performed a meta-regression to determine whether a linear relation exists between TIMI risk score and the cumulative incidence of cardiac events.

Results

We included 10 prospective cohort studies (with a total of 17 265 patients) in our systematic review. Data were available for meta-analysis in 8 of the 10 studies. Of patients with a score of zero, 1.8% had a cardiac event within 30 days (sensitivity 97.2%, 95% CI 96.4–97.8; specificity 25.0%, 95% CI 24.3–25.7; positive likelihood ratio 1.30, 95% CI 1.28–1.31; negative likelihood ratio 0.11, 95% CI 0.09–0.15). Meta-regression analysis revealed a strong linear relation between TIMI risk score (p < 0.001) and the cumulative incidence of cardiac events.

Interpretation

Although the TIMI risk score is an effective risk stratification tool for patients in the emergency department with potential acute coronary syndromes, it should not be used as the sole means of determining patient disposition.Chest pain is a common presenting complaint in the emergency department that requires efficient risk stratification, timely initiation of treatment in high-risk patients and safe determination of patient disposition. Several studies have been published that stratify the risk of patients in the emergency department with chest pain.^1–5 However, only the Thrombolysis in Myocardial Infarction (TIMI) risk score, which was initially developed for use in patients with unstable angina or non–ST-segment elevation myocardial infarction or both,⁶ has been broadly validated in several independent emergency department populations with chest pain and thus constitutes the highest level of evidence available.The TIMI risk score assigns each of seven predictors a value of one point, allowing stratification of patients into one of eight prognostic categories (Box 1).⁶ The clinical end points are acute myocardial infarction, coronary revascularization and death from any cause.

Box 1.?Predictor variables included in the TIMI risk score^*

• Age of more than 65 years
• Three or more risk factors for atherosclerosis
• Known coronary artery disease
• Two or more episodes of anginal chest pain in the preceding 24 hours
• Acetylsalicylic acid use in the seven days before hospitalization
• ST-segment deviation of 0.05 mV or more
• Elevated cardiac markers

A robust estimate of the performance of the TIMI risk score obtained from a systematic review may prove useful to both clinicians and researchers. Clinicians would have a reliable quantitative estimate of a patient’s short-term risk of a cardiac event. This could be used as an adjunct to clinical acumen and as a tool to communicate risk to patients in a shared decision-making model of care.⁷ Researchers would also have an estimate of the prognostic accuracy of the TIMI risk score derived from different practice settings and patient populations that represent a wide variety of ethnic backgrounds. This estimate may serve as a useful baseline for comparison as emerging clinical prediction rules and imaging modalities continue to refine our approach to diagnosis and risk stratification in patients in the emergency department with potential acute coronary syndromes.We conducted a comprehensive systematic review and meta-analysis to assess the methodological quality and prognostic performance of studies that had prospectively validated the TIMI risk score in patients in the emergency department.     

Fine needle aspiration cytology in HIV‐related lymphadenopathy: experience at a single centre in north India

P. K. Sarma, A. K. Chowhan, V. Agrawal and V. Agarwal
Fine needle aspiration cytology in HIV‐related lymphadenopathy: experience at a single centre in north India Objective: Fine needle aspiration (FNA) is emerging as a rapid and minimally invasive tool in evaluating lymphadenopathy associated with human immunodeficiency virus (HIV). We evaluated the role of FNA in differentiating various causes of lymphadenopathy in patients with HIV and correlated the cytological diagnosis with CD4 counts. Methods: Seventy‐nine HIV‐positive patients (median age 35 years, 68 male) underwent ultrasound‐guided (n = 16) and unguided (n = 63) FNA from 1999 to 2006. Smears were stained with May–Grünwald–Giemsa, haematoxylin & eosin and Papanicolaou stains. Ziehl–Neelsen (ZN) staining for acid‐fast bacilli (AFB) was performed in all cases. Staining for fungus was performed whenever required. Results: The aspirates were adequate in 75 cases (95%). Non‐specific reactive hyperplasia was the most common FNA diagnosis (39, 52%) followed by granulomatous necrotizing lymphadenitis (15, 20%), necrotizing lymphadenitis (13, 17.3%) and granulomatous lymphadenitis (4, 5.2%). Fungal infection and non‐Hodgkin lymphoma (NHL) were seen in two patients each. ZN staining was positive for AFB in 25 (33.3%) cases. One of these was morphologically interpreted as reactive hyperplasia, 12 as necrotizing lymphadenitis and 12 as granulomatous necrotizing lymphadenitis. Both patients with NHL had CD4 counts below 100/dl. Necrotizing lymphadenitis and granulomatous lymphadenitis were significantly associated with CD4 counts below and above 200/dl, respectively (P = 0.0002). Conclusions: FNA is an important tool for assessing the cause of lymphadenopathy in HIV patients. Necrotizing inflammation is more often seen in patients with low CD4 counts. AFB are commonly found in necrotic aspirates with or without granulomas. However, a stain for AFB should be performed in all aspirates from HIV‐related lymphadenopathy including reactive hyperplasia.     

Evaluation of PCR,DNA hybridization and immunomagnetic separation — PCR for detection of <Emphasis Type="Italic">Burkholderia mallei</Emphasis> in artificially inoculated environmental samples

Glanders is highly contagious disease of equines, caused by Burkholderia mallei. The disease though rare, can be transmitted to humans. Here, we report a strategy for rapid detection of B. mallei from environmental samples. Different bacteriological media were evaluated and brain heart infusion broth medium with selective supplements (BHIB-SS) of penicillin (200 U/ml) and crystal violet (1:10,00000) was found to support the maximum growth of B. mallei even in the presence of other bacteria like Escherichia coli and Staphylococcus aureus. A polymerase chain reaction (PCR) and a DNA hybridization method was standardized for 823 bp specific dNA sequence of B. mallei. To enable the quicker and direct enrichment of B. mallei bacteria from environmental samples, an immunomagnetic separation (IMS) method was also standardized. Water, husk, grass and gram samples were artificially contaminated by B. mallei bacteria and after enrichment of B. mallei in BHIB-SS, detection was carried out by PCR and DNA hybridization. PCR was found to be a better method of the two with a detection limit of 10⁴–10⁶ CFU/ml (6 h enrichment in BHIB-SS) in water and other particulate matrices. Detection by PCR in the above samples without enrichment in BHIBSS was carried out following IMS where the detection limit was about 1–2 log higher than PCR following enrichment in BHIB-SS. We recommend PCR for 823 bp for detection of B. mallei from environmental samples either following enrichment in BHIB-SS or IMS. IMS-PCR method may be preferred in situations where numbers of B. mallei bacteria are expected to be high and results are required in short time.     

Revisiting Date and Party Hubs: Novel Approaches to Role Assignment in Protein Interaction Networks

The idea of “date” and “party” hubs has been influential in the study of protein–protein interaction networks. Date hubs display low co-expression with their partners, whilst party hubs have high co-expression. It was proposed that party hubs are local coordinators whereas date hubs are global connectors. Here, we show that the reported importance of date hubs to network connectivity can in fact be attributed to a tiny subset of them. Crucially, these few, extremely central, hubs do not display particularly low expression correlation, undermining the idea of a link between this quantity and hub function. The date/party distinction was originally motivated by an approximately bimodal distribution of hub co-expression; we show that this feature is not always robust to methodological changes. Additionally, topological properties of hubs do not in general correlate with co-expression. However, we find significant correlations between interaction centrality and the functional similarity of the interacting proteins. We suggest that thinking in terms of a date/party dichotomy for hubs in protein interaction networks is not meaningful, and it might be more useful to conceive of roles for protein-protein interactions rather than for individual proteins.