DNR Group Research Articles

Reversion of multidrug-resistance by proteasome inhibitor bortezomib in K562/DNR cell line

To observe the reversion of multi-drug resistance by proteasome inhibitor bortezomib in K562/DNR cell line and to analyze the possible mechanism of reversion of multidrug-resistance. MTT method was used to determine the drug resistance of K562/DNR cells and the cellular toxicity of bortezomib. K562/DNR cells were cultured for 12 hours, 24 hours and 36 hours with 100 μg/ml DNR only or plus 4 μg/L bortezomib. The expressions of NF-κB, IκB and P-gp of K562/DNR were detected with Western blot method, the activity of NF-κB was tested by ELISA method and the apoptosis rate was observed in each group respectively. The IC50 of DNR on cells of K562/S and K562/DNR groups were 1.16 μg/ml and 50.43 μg/mL, respectively. The drug-resistant fold was 43.47. The IC10 of PS-341 on Cell strain K562/DNR was 4 μg/L. Therefore, 4 μg/L was selected as the concentration for PS-341 to reverse drug-resistance in this study. DNR induced down-regulation of IκB expression, up-regulation of NF-κB and P-gp expression. After treatment with PS-341, a proteasome inhibitor, the IκB degradation was inhibited, IκB expression increased, NF-κB and P-gp expression decreased in a time dependent manner. Compared to DNR group, the NF-κB p65 activity of DNR+PS-341 group was decreased. Compared to corresponding DNR group, DNR induced apoptosis rate increases after addition of PS-341 in a time dependent manner. Proteasome inhibitor bortezomib can convert the leukemia cell drug resistance. The mechanism may be that bortezomib decreases the degradation of IκB and the expression of NF-κB and P-gp, therefore induces the apoptosis of multi-drug resistant cells.

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia. Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

Baseline Characteristics and Outcomes of Patients Who Do Not Desire Resuscitation: An Analysis of the ESCAPE Trial

Background: Hospitalization represents a sentinel event in the life of a heart failure (HF) patient and often prompts discussion regarding end of life care preferences. The characteristics of patients hospitalized with HF who elect not to be resuscitated (DNR) and their outcomes have not been well described. Methods: The ESCAPE study (n=457) was a randomized trial comparing outcomes of patients randomized to PAC-guided therapy compared to clinical assessment alone. Baseline characteristics of patients who declined (DNR) and desired (CPR) resuscitation at randomization were evaluated as well as outcomes of morbidity, mortality, and quality of life. Results: 388 patients (85%) indicated a resuscitation preference, and 5% established DNR status (DNR=24, CPR=364). DNR patients were older (66 yrs vs. 56 yrs, p=0.001), and of white race (79% vs. 60%, p=0.057). DNR patients more frequently had ischemic cardiomyopathy (70.8% vs. 47.8%, p=0.03) and hypertension (73.9% vs. 45.7%, p=0.009) but there were no differences in frequency of diabetes, presence of an ICD or baseline HF medications. LVEF (20%) and sodium (137) were similar in both groups, but SCr was higher in the DNR group (1.7 mg/dl vs. 1.3 mg/dl, p=0.018). DNR patients performed worse on the 6-minute walk test (43 ft. vs. 361 ft., P=0.003). Quality of life (QOL) score at 3 months (Minnesota Living with Heart Failure) was similar in both groups, but deteriorated in the DNR group at 6 months (73.5 vs. 55.0, p=0.037). There was a similar rate of re-hospitalization (DNR=58.3% vs. CPR=60.2%) but a higher proportion of DNR patients died (37.5% vs. 15.7%, P=0.011). No DNR patients received an LVAD or heart transplant versus 8.5% in the CPR group. Conclusions: HF patients desiring DNR status were more likely to be older and of white race. These patients tended to have more adverse prognostic factors (i.e., ischemic etiology, renal insufficiency) and worse baseline functional status than those desiring CPR. Following HF hospitalization, DNR status patients had greater decrements in HF-related QOL and experienced a 2-fold increase in 6-month mortality compared to individuals desiring CPR. Given the association of DNR status with worsening QOL as well as death, DNR status may be an important identifier of patients who may benefit from palliative care and hospice. Further validation is needed to determine if DNR status is a predictor of HF patient-reported and disease-related outcomes beyond traditional prognostic factors.

Application of Homoharringtonine in the Treatment of Acute Promyelocytic Leukemia.

Objective Homoharringtonine (HHT) as the cytotoxic alkaloid has been demonstrated effective in the treatment of acute myeloid leukemia (AML), chronic myeloid leukemia (CML) and myelodysplastic syndrome (MDS). To evaluate the efficacy of HHT in newly diagnosed acute promyelocytic leukemia (APL) and compare with anthracycline-based regimen in a randomized trial.Methods From January 2004 to January 2007, 39 new diagnosed acute promyelocytic leukemia patients (diagnosed according to MIC criteria) were randomized classified into two groups. Group A included 17 patients (6 males and 11 females), with a median age 37y. They received ATRA plus homoharringtonine as induction therapy. After achieved complete remission (CR), they received three courses HHT+AraC (HA) as consolidation therapy. Group B included 22 patients (11 males and 11females), with a median age 37y. They received ATRA plus daunorubicin-DNR or mitozantrone-MTZ as induction therapy. After achieved CR, patients in group two received three courses DNR+AraC (DA) or MTZ+AraC (MA) as consolidation therapy. ATRA (25mg/m2) was administered daily orally from day1 to day28, HHT (2.5mg/m2/d) was used from d4 (started from the use of ATRA) for seven days, DNR (40–45mg/m2/d) was used from d4 to d6 (since the use of ATRA). The doses of HHT and DNR used in consolidation were similar to that used in induction. The dose of AraC used in consolidation was 100mg to 150mg/m2/d (for seven days). After finish consolidation, all patients received ATRA and 6-MP (70mg/m2/d)+MTX (20mg/m2, 1 dosage per week) as maintenance therapy routinely. Bone marrow and PML/RARa fusion gene (RT-PCR and/or real time PCR) were analyzed after induction therapy and each consolidation therapy. Disease-free survival (DFS) and overall survival (OS) were estimated.Results In Group A (HHT group), all patients achieved hematological complete remission after induction therapy, CR rate was 100%. The CR rate of Group B (DNR group) was 92.9% (one early death). PML/RARa fusion gene became negative in 68.8% patients after HHT+ATRA induction, and 100% were negative after 1 course HA regimen consolidation therapy. In Group B (DNR group), they were 33.3% and 91.7%, respectively. The median DFS and OS in Group A (HHT group) and Group B (DNR group) are 72 (9∼129) weeks and 70 (7∼111) weeks, 81 (13∼133) weeks and 70.5 (2∼115) weeks, respectively. The two different regimens were both well tolerated.Conclusion HHT is an effective drug in the treatment of APL, HHT+ATRA can achieve a high CR rate and a higher rate of PML/RARa fusion gene negative after induction therapy. HHT containing regimen can shorten the time of PML/RARa fusion gene becoming negative (after one course of HA regimen consolidation, PML/RARa fusion gene becomes negative in all patients). In conclusion, HHT based regimen should be a new choice in treatment of APL that can achieve molecular remission. It can be used in the treatment of APL instead of DNR.

Factors Influencing DNR Decision-Making in a Surgical ICU

End-of-life decisions in the surgical ICU can be complicated by the unique characteristics of perioperative illness and the focus on life-extending interventions. We sought to determine whether illness severity correlated with the presence of DNR order in critically ill surgical patients. All surgical ICU patients who were given a DNR order from May 1, 1991 to May 31, 1998 were identified. Demographic data for all patients were collected prospectively. Patients who died without a DNR order were compared with patients with DNR orders. Variables in the analysis included date of DNR order, age, ICU, and hospital lengths of stay, APACHE II and III scores and maximum multiple organ dysfunction scores, past medical history, and mortality. ANOVA, multivariate ANOVA, and chi-square statistical tests were used to analyze the data, with p </= 0.05 used to reject the null hypothesis. Mortality for DNR patients was 84.7%. Multiple organ dysfunction syndrome was ubiquitous in this group of patients. There were no differences between DNR and no-DNR groups on the basis of age or APACHE III score or multiple organ dysfunction score. ICU lengths of stay were substantially higher in the patients made DNR, 1.8 +/- 0.1 versus 1.0 +/- 0.1, p = 0.0001, and 16.9 +/- 0.2 versus 12.1 +/- 1.2, p = 0.011, respectively. Multivariate ANOVA revealed that only past medical history predicted a DNR order. Although acuity of illness and organ dysfunction consistently predicted mortality in critically ill patient populations, only elements of the past medical history were positively associated with a DNR order in critically ill surgical patients. Additional prospective studies need to be performed to determine the relative influences of physiologic, demographic, and sociologic factors on the creation of DNR orders in critically ill surgical patients.

Association of Gly82Ser polymorphism in the RAGE gene with diabetic retinopathy in type II diabetic Asian Indian patients

Aim/hypothesis: The binding of advanced glycation end products (AGE) to the receptor induces cellular oxidative stress and vascular dysfunction and this is implicated in the pathogenesis of diabetic retinopathy (DR). This study aims to investigate the frequency of Gly82Ser polymorphism in exon 3 of the receptor for AGE (RAGE) gene and its association with DR in Asian Indian patients who have type II diabetes. Methods: 200 Asian Indian patients with at least 15-year duration of type II diabetes were identified. This group included (1) 100 patients with retinopathy (DR) and (2) 100 patients without retinopathy (DNR). Fifty unrelated healthy controls (CT) were also included in the study. Genotype frequencies of Gly82Ser polymorphism were studied by polymerase chain reaction (PCR) amplification and restriction fragment length polymorphism analysis using AluI enzyme. Later, the nucleotide change was confirmed by DNA sequencing. Results: The frequency of the Ser82 allele was significantly higher, 18% in the DNR group compared to 7% in the DR group ( P=.03). The same genotype was 2% in the CT group. Conclusion/interpretation: Our result suggests that Ser82 allele in the receptor for AGE gene is a low-risk allele for developing DR in Asian Indian patients who have type II diabetes.

Effect of isometric exercise on choroidal blood flow in type I diabetic patients.

In healthy subjects, choroidal blood flow is regulated when the mean ocular perfusion pressure increases. Since capillary vascular beds are altered in diabetic patients, the regulation of choroidal blood flow could be affected by this pathology. 10 type I diabetic patients without retinopathy (DNR group) and 7 type I diabetic patients with retinopathy (DR group) participated in the study. In NDR and DR groups, choroidal blood flow was measured while patients raised their mean arterial blood pressure by squatting. The results were compared to those of a previous study in normals. Pupillometry was performed at rest on the two diabetic groups and on seven normals during a modification of illumination (white/black screen transition). In the NDR and DR groups, mean ocular perfusion pressure raised by 61 and 50 % during squatting, respectively. Consecutively, choroidal blood flow did not change in NDR as in normals, but increased linearly in DR patients. The white/black screen transition produced an increase of the pupil diameter of 52 and 49 % in normals and NDR patients, respectively, while it increased by only 16 % in the DR patients. As already shown in healthy subjects, choroidal blood flow is regulated in NDR patients when the ocular perfusion pressure increases. In DR patients, the absence of this control could be due to a failure of the autonomic nervous system, as suggested by pupillometry results.

Tumor necrosis factor allelic polymorphism with diabetic retinopathy in India

The association of tumor necrosis factor (TNF) with diabetic retinopathy (DR) has been described previously. A total of 207 Asian Indian patients of 15-year duration of type 2 diabetes were identified. This group included (i) 100 patients with DR and (ii) 107 patients without retinopathy (DNR). In this study, we correlated the length of the (GT) n microsatellite di-nucleotide repeat upstream to the promoter region of TNF gene with susceptibility for the development of retinopathy. The microsatellite was polymerase chain reaction amplified and electrophoresed on polyacrylamide gel and silver stained. In our study population, there were 18 alleles ranging from 97 to 131 base pairs (bp). Allele 4 (103 bp) had a higher prevalence (9.81%) in the DNR group compared to that (2.5%) in the DR group ( P=0.002). Patients with retinopathy and allele 8 (111 bp) had a tendency to develop proliferative diabetic retinopathy (PDR). In this study of Indian subjects, it is suggested that allele 4 is a low risk allele for developing retinopathy and allele 8 (111 bp) shows an association with PDR.

Comparison of toxicity and outcome in patients with acute myeloid leukemia treated with high-dose cytosine arabinoside consolidation after induction with a regimen containing idarubicin or daunorubicin

The toxicity and outcome after high-dose ara-C/daunorubicin (HDara-C/DNR) consolidation therapy in de novo AML was compared in 11 patients who received an idarubicin-containing induction therapy (IDA; from June 1995 to March 1997) and 16 patients pretreated with daunorubicin (DNR; from July 1990 to May 1995) for induction. The DNR group consisted of two cohorts, one (n = 6) of patients who had received, as had the IDA group, two induction and one intermediate-dose ara-C consolidation courses, and another (n = 10) of patients who had been pretreated with one induction and one consolidation course prior to HDara-C/DNR. There was no difference in the relative dose between the three cohorts. Following HDara-C/DNR, the IDA-pretreated patients experienced a more prolonged myelosuppression during consolidation therapy compared with the DNR group. Duration of neutropenia (< 500 neutrophils/microl) following HDara-C/DNR was 31.2 +/- 16 days (mean +/- SEM) in the IDA group compared with 18.7 +/- 5 days in the DNR group (p < .001 Mann-Whitney U-test). The duration 'of thrombocytopenia (platelets < 25000/microl) was 34.8 +/- 20 days in the IDA group vs. 18.5 +/- 6 days in the DNR group (p < .005). The more prolonged myelosupression was associated with a longer duration of fever (18.9 +/- 24 vs. 6.9 +/- 5.2 days). A greater incidence, length (11 +/- 8 vs. 1.2 +/- 2 days), and severity of diarrhea were observed in the IDA-pretreated group. Three of 11 IDA patients experienced WHO grade III-IV diarrhea. In the IDA group two patients developed severe enterocolitis with Candida septicemia, and one of these patients died. One patient in the IDA group died during prolonged aplasia. In the DNR group 6/16 patients experienced grade I-II diarrhea. Two patients in each group died during consolidation therapy. The CR rate was 87% in the IDA group and 79% in the DNR group. Relapse-free survival after HDara-C is 50% at a median follow-up of 60 months in the DNR group and 45% after a median follow-up of 17 months in the IDA group. Whether the advantage of the superior response rate in the IDA-treated patients may be lost during HDara-C consolidation treatment due to increased toxicity remains to be proven in larger trials.

Clinical trials with daunorubincin-DNA and adriamycin-DNA in acute lymphoblastic leukemia of childhood, acute nonlymphoblastic leukemia, and bronchogenic carcinoma

Treatment with daunorubicin-DNA (DNR-DNA) or adriamycin-DNA (ADM-DNA) has been evaluated in acute lymphoblastic leukemia of childhood (ALL), acute nonlymphoblastic leukemia (ANLL) and bronchogenic carcinoma (BC). The Five-year survival rate in 69 children with ALL was 73.7% when ADM-DNA was introduced in the treatment and 38% with DNR-DNA (P = 0.03). A randomization between free DNR and DNR-DNA for remission induction in 26 patients with ANLL has shown that the drugs were of equivalent effectiveness. The one-year survival rate was 66% for the DNR group and 64% for the DNR-DNA group. In 59 patients with BC, a randomized trial between ADM-DNA and cyclophosphamide-vinblastine (CTX-VLB) did not show an advantage in favor of one of these treatments. In anaplastic BC (51 patients), there was no difference in survival rate or remission rate between patients treated with ADM or ADM-DNA. No cardiotoxicity was noted among the patients treated with the complexed drugs. ADM-DNA and DNR-DNA are as effective as the free drugs. Cardiotoxicity appears to be reduced.