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Background— Little is known about the impact of technological and pharmacological advances on long-term outcome after percutaneous coronary intervention in general clinical practice. Methods and Results— We analyzed in-hospital and long-term outcome of 24 410 percutaneous coronary interventions among 18 575 unique patients who underwent percutaneous coronary intervention at Mayo Clinic over 25 years. The study population was divided into group 1 (n=3708), coronary interventions from 1979 to 1989; group 2 (n=7020), interventions from 1990 to 1996; group 3 (n=10 952), interventions from 1996 to 2003; and group 4 (n=2730), interventions from 2003 to 2004. Despite the fact that patients in groups 3 and 4 were significantly older, sicker, and had greater prevalence of comorbid conditions, heart failure, and previous revascularization than those in groups 1 and 2, procedural success in groups 3 and 4 improved significantly (94%) versus groups 2 (89%) and 1 (78%) ( P <0.001). Significant reduction in in-hospital mortality (groups 4 to 1: 1.8%, 1.7%, 2.6%, 3.0%; P <0.001) and need for emergency bypass surgery (groups 4 to 1: 0.4%, 0.5%, 1.6%, 5%; P <0.001) was noted in groups 3 and 4 compared with groups 1 and 2. Better adherence to currently recommended evidence-based medications for secondary prevention was seen in the recent time periods. After adjustment, significant reduction in follow-up mortality (hazard ratio, 0.81 and 0.74 for groups 3 and 4, respectively); death or myocardial infarction (hazard ratio, 0.80 and 0.75 for groups 3 and 4, respectively); death, myocardial infarction, or revascularization (hazard ratio, 0.76 and 0.58 for groups 3 and 4, respectively) was noted in recent time periods. Conclusions— Despite higher-risk profiles of patients who underwent percutaneous coronary intervention in recent time periods, procedural success as well as in-hospital and long-term outcomes improved significantly over the last 25 years.

OBJECTIVE—To determine the contribution of hepatic insulin resistance to the pathogenesis of impaired fasting glucose (IFG). RESEARCH DESIGN AND METHODS—Endogenous glucose production (EGP) and glucose disposal were measured in 31 subjects with IFG and 28 subjects with normal fasting glucose (NFG) after an overnight fast and during a clamp when endogenous secretion was inhibited with somatostatin and insulin infused at rates that approximated portal insulin concentrations present in IFG subjects after an overnight fast (∼80 pmol/l, “preprandial”) or within 30 min of eating (∼300 pmol/l, “prandial”). RESULTS—Despite higher (P &lt; 0.001) insulin and C-peptide concentrations and visceral fat (P &lt; 0.05), fasting EGP and glucose disposal did not differ between IFG and NFG subjects, implying hepatic and extrahepatic insulin resistance. This was confirmed during preprandial insulin infusion when glucose disposal was lower (P &lt; 0.05) and EGP higher (P &lt; 0.05) in IFG than in NFG subjects. Higher EGP was due to increased (P &lt; 0.05) rates of gluconeogenesis in IFG. EGP was comparably suppressed in IFG and NFG groups during prandial insulin infusion, indicating that hepatic insulin resistance was mild. Glucose disposal remained lower (P &lt; 0.01) in IFG than in NFG subjects. CONCLUSIONS—Hepatic and extrahepatic insulin resistance contribute to fasting hyperglycemia in IFG with the former being due at least in part to impaired insulin-induced suppression of gluconeogenesis. However, since hepatic insulin resistance is mild and near-maximal suppression of EGP occurs at portal insulin concentrations typically present in IFG subjects within 30 min of eating, extrahepatic (but not hepatic) insulin resistance coupled with accompanying defects in insulin secretion is the primary cause of postprandial hyperglycemia.

Suppression of colon carcinogenesis by peroxisome proliferator-activated receptor (PPAR)-γ is likely due to some effect of PPAR-γ on normal colonic epithelial cells. However, our understanding of the effects of PPAR-γ in such cells is limited. We analyzed the abundance, distribution, and function of PPAR-γ in epithelial cells isolated from the murine proximal and distal colon. Marked differences in PPAR-γ abundance and distribution were observed, suggesting tissue-specific responses. Analysis of PPAR-γ effects on DNA synthesis, formation of preneoplastic lesions, and activation of MAPK signaling in proximal and distal colonic epithelial cells in vivo indicates that PPAR-γ regulates both tissue-specific and common responses within the proximal and distal colon. Three major functional cohorts of PPAR-γ target genes were identified by genomic profiling of isolated colonic epithelial cells: genes that are involved in metabolism, in signaling, and in cellular adhesion and motility. Two subsets of PPAR-γ target genes were differentially expressed in the proximal and distal epithelium. Proximal target genes were primarily involved in metabolic activities, whereas signal transduction, adhesion, and motility targets were more pronounced in the distal colon. Remarkably, those target genes that are differentially expressed in the proximal colon were all induced on activation of PPAR-γ, whereas all target genes that are preferentially expressed in the distal colon were repressed. Our data indicate that PPAR-γ exerts both common and tissue-specific effects in the colon and challenge the general conclusions that PPAR-γ is induced on differentiation of colonic epithelial cells and that this receptor stimulates differentiated function in epithelial cells throughout the colon.

Purpose To update the recommendations for the use of bisphosphonates in the prevention and treatment of bone disease in multiple myeloma. The Update Committee expanded the guideline to include a discussion of osteonecrosis of the jaw (ONJ). Methods For the 2007 update, an Update Committee composed of members from the full panel completed a review and analysis of data published since 2002. Searches of Medline and the Cochrane Collaboration Library databases were performed. Recommendations For multiple myeloma patients who have, on plain radiograph(s) or imaging studies, lytic destruction of bone or spine compression fracture from osteopenia, intravenous pamidronate 90 mg delivered over at least 2 hours or zoledronic acid 4 mg delivered over at least 15 minutes every 3 to 4 weeks is recommended. Clodronate is an alternative bisphosphonate approved worldwide, except in the United States, for oral or intravenous administration. New dosing guidelines for patients with pre-existing renal impairment were added to the zoledronic acid package insert. Although no similar dosing guidelines are available for pamidronate, the Update Committee recommends that clinicians consider reducing the initial pamidronate dose in patients with pre-existing renal impairment. Zoledronic acid has not been studied in patients with severe renal impairment and is not recommended in this setting. The Update Committee suggests that bisphosphonate treatment continue for a period of 2 years. At 2 years, physicians should seriously consider discontinuing bisphosphonates in patients with responsive or stable disease, but further use is at the discretion of the treating physician. The Update Committee also discusses measures regarding ONJ.