Metabolic Theory of Preeclampsia: Implications for Maternal Cardiovascular Health.

Preeclampsia (PE) is a multisystemic disorder of pregnancy that not only causes perinatal mortality and morbidity but also has a long-term toll on the maternal and fetal cardiovascular system. Women diagnosed with PE are at greater risk for the subsequent development of hypertension, ischemic heart disease, cardiomyopathy, cerebral edema, seizures, and end-stage renal disease. Although PE is considered heterogeneous, inefficient extravillous trophoblast migration leading to deficient spiral artery remodeling and increased uteroplacental vascular resistance is the likely initiation of the disease. The principal pathophysiology is placental hypoxia, causing subsequent oxidative stress, leading to mitochondrial dysfunction, mitophagy, and immunological imbalance. The damage imposed on the placenta in turn results in the 'stress response' categorized by the dysfunctional release of vasoactive components including oxidative stressors, pro-inflammatory factors, and cytokines into the maternal circulation. These bioactive factors have deleterious effects on systemic endothelial cells and coagulation leading to generalized vascular dysfunction and hypercoagulability. A better understanding of these metabolic factors may lead to novel therapeutic approaches to prevent and treat this multisystemic disorder. In this review, we connect the hypoxic-oxidative stress and inflammation involved in the pathophysiology of PE to the resulting persistent cardiovascular complications in preeclamptic patients.

Connecting G protein-coupled estrogen receptor biomolecular mechanisms with the pathophysiology of preeclampsia: a review.

BACKGROUND: Throughout the course of pregnancy, small maternal spiral arteries that are in contact with fetal tissue undergo structural remodeling, lose smooth muscle cells, and become less responsive to vasoconstrictors. Additionally, placental extravillous trophoblasts invade the maternal decidua to establish an interaction between the fetal placental villi with the maternal blood supply. When successful, this process enables the transport of oxygen, nutrients, and signaling molecules but an insufficiency leads to placental ischemia. In response, the placenta releases vasoactive factors that enter the maternal circulation and promote maternal cardiorenal dysfunction, a hallmark of preeclampsia (PE), the leading cause of maternal and fetal death. An underexplored mechanism in the development of PE is the impact of membrane-initiated estrogen signaling via the G protein-coupled estrogen receptor (GPER). Recent evidence indicates that GPER activation is associated with normal trophoblast invasion, placental angiogenesis/hypoxia, and regulation of uteroplacental vasodilation, and these mechanisms could explain part of the estrogen-induced control of uterine remodeling and placental development in pregnancy. CONCLUSION: Although the relevance of GPER in PE remains speculative, this review provides a summary of our current understanding on how GPER stimulation regulates some of the features of normal pregnancy and a potential link between its signaling network and uteroplacental dysfunction in PE. Synthesis of this information will facilitate the development of innovative treatment options.

Secreted Oral Epithelial Cell Membrane Vesicles Induce Epstein-Barr Virus Reactivation in Latently Infected B Cells.

UNLABELLED: In the oral epithelium, peripheral stores of Epstein-Barr virus (EBV) are transmitted from infiltrating B cells to epithelial cells. Once the virus is transmitted to epithelial cells, the highly permissive nature of this cell type for lytic replication allows virus amplification and exchange to other hosts. Since the initial transfer of EBV from B cells to epithelial cells requires transitioning of the B-cell to a state that induces virus reactivation, we hypothesized that there might be epithelium-specific signals that allow the infiltrating B cells to sense the appropriate environment to initiate reactivation and begin this exchange process. We previously found that the epithelium-specific miR-200 family of microRNAs promotes EBV lytic replication. Here we show that there are high levels of miR-200 family members in oral and tonsillar epithelia and in saliva. Analysis of cultured oral epithelial cells (OKF6) showed that they actively secrete membrane vesicles (exosomes) that are enriched with miR-200 family members. Coculturing of EBV-positive B cells with OKF6 cells induced viral reactivation. Further, treatment of EBV-positive B cells with OKF6 cell-derived membrane vesicles promoted reactivation. Using a cell system that does not naturally express miR-200 family members, we found that enforced expression of a miR-200 family member produced membrane vesicles that were able to induce the lytic cascade in EBV-positive B cells. We propose that membrane vesicles secreted by oral and tonsillar epithelial cells may serve as a tissue-specific environmental cue that initiates reactivation in B cells, promoting the transfer of virus from peripheral B-cell stores to the oral epithelium to facilitate virus amplification and exchange to other hosts. IMPORTANCE: Epstein-Barr virus (EBV) is an important human pathogen that is causally associated with several lymphomas and carcinomas. The switch from latency to the lytic cycle is critical for successful host infection and for EBV pathogenesis. Although the EBV lytic cycle can be triggered by certain agents in vitro, the mechanisms that signal reactivation in vivo are poorly understood. We previously reported that endogenously expressed miR-200 family members likely play a role in facilitating the lytic tendencies of EBV in epithelial cells. Here we show that membrane vesicles secreted from oral epithelial cells contain miR-200 family members and that they can be transmitted to proximal EBV-positive B cells, where they trigger reactivation. We propose that this intercellular communication pathway may serve as a sensor mechanism for infiltrating B cells to recognize an appropriate environment to initiate reactivation, thereby allowing the exchange of virus to the oral epithelium.

Prospective study of pregnancy and newborn outcomes in mothers with West nile illness during pregnancy.

BACKGROUND: A previous case report of West Nile virus (WNV) illness during pregnancy suggested that WNV could be a cause of congenital defects. We performed a prospective, longitudinal cohort study of pregnant women with WNV illness to increase our knowledge of the effects of WNV illness during pregnancy. METHODS: Participants were enrolled in 2005 to 2008 from pregnant women with serologically confirmed WNV illness reported to the Centers for Disease Control and Prevention. Comparison was made to WNV-uninfected women, matched on maternal age and enrollment month. Pregnancy and newborn data were collected; cord blood WNV serology was obtained. Pediatric exams and the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) were performed. RESULTS: Twenty-eight WNV-infected mothers and 25 WNV-uninfected mothers participated. Maternal demographics were similar except for a higher rate of planned pregnancies, education, and household income in the WNV-uninfected mothers. There were no differences in pregnancy and delivery characteristics except that infected mothers had a higher incidence of febrile illnesses and used more medications. Birth weight, length, head circumference, and rate of congenital malformations were similar in babies born to WNV-infected and -uninfected mothers. Follow-up physical exams were generally normal. The Bayley-III assessments, available for 17 children born to mothers with WNV illness, showed performance at or above age level across domains. CONCLUSION: The risk for adverse pregnancy and newborn outcomes in women experiencing WNV illness in pregnancy appears to be low, but future studies with larger numbers are needed to rule out a small risk. Birth Defects Research (Part A) 106:716-723, 2016. © 2016 Wiley Periodicals, Inc.

Students to Surgeons: Increasing Matriculation in Surgical Specialties.

Introduction Our nation suffers from a shortage in surgeons. This deficiency must be addressed at the medical student level. Increasing faculty and resident interaction with junior students augments surgical interest. Our surgical interest group has recently redefined its role to address these concerns. Methods A multifocal approach has been implemented to increase interest in the surgical specialties. Each academic year, senior students recruit first and second year students to our group to establish early exposure. Members receive didactic presentations from surgical faculty, addressing various topics, on a biweekly basis. In addition, scrubbing, knot-tying, and suturing workshops address technical skills throughout the semester. Membership and match data were collated and analyzed. Results Over the past 5 years, the enrollment in the student interest group increased significantly from 112 to 150. Accordingly, we have observed a parallel increase in the number of students who have successfully matched into surgical residencies. A record number of students (37) from the class of 2013 matched into surgical specialties, representing an 85% increase over the last decade. After creating bylaws and electing societal officers, the group has been recognized by the school's Student Council and given financial support. At present, the group is fiscally solvent with support from the institution, surgery department, and faculty. Conclusion As the demand for surgeons increases so too does the need to increase student interest in surgery. Our school has been successful because of our surgical interest group, and we encourage other schools to adopt a similar approach.

Differences in gastric carcinoma microenvironment stratify according to EBV infection intensity: implications for possible immune adjuvant therapy.

Epstein-Barr virus (EBV) is associated with roughly 10% of gastric carcinomas worldwide (EBVaGC). Although previous investigations provide a strong link between EBV and gastric carcinomas, these studies were performed using selected EBV gene probes. Using a cohort of gastric carcinoma RNA-seq data sets from The Cancer Genome Atlas (TCGA), we performed a quantitative and global assessment of EBV gene expression in gastric carcinomas and assessed EBV associated cellular pathway alterations. EBV transcripts were detected in 17% of samples but these samples varied significantly in EBV coverage depth. In four samples with the highest EBV coverage (hiEBVaGC - high EBV associated gastric carcinoma), transcripts from the BamHI A region comprised the majority of EBV reads. Expression of LMP2, and to a lesser extent, LMP1 were also observed as was evidence of abortive lytic replication. Analysis of cellular gene expression indicated significant immune cell infiltration and a predominant IFNG response in samples expressing high levels of EBV transcripts relative to samples expressing low or no EBV transcripts. Despite the apparent immune cell infiltration, high levels of the cytotoxic T-cell (CTL) and natural killer (NK) cell inhibitor, IDO1, was observed in the hiEBVaGCs samples suggesting an active tolerance inducing pathway in this subgroup. These results were confirmed in a separate cohort of 21 Vietnamese gastric carcinoma samples using qRT-PCR and on tissue samples using in situ hybridization and immunohistochemistry. Lastly, a panel of tumor suppressors and candidate oncogenes were expressed at lower levels in hiEBVaGC versus EBV-low and EBV-negative gastric cancers suggesting the direct regulation of tumor pathways by EBV.

Ether in the developing world: rethinking an abandoned agent.

BACKGROUND: The first true demonstration of ether as an inhalation anesthetic was on October 16, 1846 by William T.G. Morton, a Boston dentist. Ether has been replaced completely by newer inhalation agents and open drop delivery systems have been exchanged for complicated vaporizers and monitoring systems. Anesthesia in the developing world, however, where lack of financial stability has halted the development of the field, still closely resembles primitive anesthetics. DISCUSSION: In areas where resources are scarce, patients are often not given supplemental intraoperative analgesia. While halothane provides little analgesia, ether provides excellent intra-operative pain control that can extend for several hours into the postoperative period. An important barrier to the widespread use of ether is availability. With decreasing demand, production of the inexpensive inhalation agent has fallen. Ether is inexpensive to manufacture, and encouraging increased production at a local level would help developing nations to cut costs and become more self-sufficient.

Kaposi's sarcoma-associated herpesvirus G-protein coupled receptor activates the canonical Wnt/ß-catenin signaling pathway.

BACKGROUND: KSHV is a tumorigenic γ-herpesvirus that has been identified as the etiologic agent of Kaposi's sarcoma (KS), a multifocal highly vascularized neoplasm that is the most common malignancy associated with acquired immunodeficiency syndrome (AIDS). The virus encodes a constitutively active chemokine receptor homologue, vGPCR that possesses potent angiogenic and tumorigenic properties, and is critical for KSHV pathobiology. To date, a number of signaling pathways have been identified as key in mediating vGPCR oncogenic potential. FINDINGS: In this study, we identify a novel pathway, the Wnt/ß-catenin pathway, which is dysregulated by vGPCR expression in endothelial cells. Expression of vGPCR in endothelial cells enhances the nuclear accumulation of ß-catenin, that correlates with an increase in ß-catenin transcriptional activity. Activation of ß-catenin signaling by vGPCR is dependent on the PI3K/Akt pathway, as treatment of vGPCR-expressing cells with a pharmacological inhibitor of PI3K, leads to a decreased activation of a ß-catenin-driven reporter, a significant decrease in expression of ß-catenin target genes, and reduced endothelial tube formation. CONCLUSIONS: Given the critical role of Wnt/ß-catenin signaling in angiogenesis and tumorigenesis, the findings from this study suggest a novel mechanism in KSHV-induced malignancies.

Developmental outcomes in young children born to mothers with West Nile illness during pregnancy.

BACKGROUND: West Nile virus (WNV) infection is associated with acute morbidity and mortality in adults and children. Information on the effects of maternal WNV illness during pregnancy on early childhood development is limited. This study was designed to examine the relationship between maternal WNV illness during pregnancy and birth and developmental outcomes at age 3 years. METHODS: Mother-child participants were identified using a national surveillance registry for women with WNV illness during pregnancy. Maternal and infant health data and relevant family characteristics were obtained through medical record reviews and maternal questionnaires. All infants received ophthalmologic examinations. Child development was evaluated at age 3 years using the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III). RESULTS: As a group, the children's (N = 11) birth weight, head circumference, and infant ophthalmologic examination results were within age expectations; one child was born preterm (gestational age 36 weeks). Mean (SD) age at the time of Bayley-III testing was 36.7 (3.8) months. The group's mean performance on the Bayley-III was at or above age level in all domains, but one child showed a mild delay in the Adaptive domain. The variability observed in this sample (1/53 [1.9%] Domain scores < -2.0 SDs) was consistent with expectations based upon the distribution of Bayley-III Domain scores in the general population. CONCLUSION: Maternal WNV infection does not appear to be associated with global developmental delays in young children. These results are preliminary, however, and require confirmation in future research.

Surgical Management of a Torn ACL and Bucket-Handle Meniscal Tear in the Pregnant Patient: A Case Report.

CASE: A 36-year-old, 7-month pregnant woman presented to the office with a locked knee and a displaced bucket-handle medial meniscus tear, in the setting of chronic anterior cruciate ligament (ACL) insufficiency. After thorough discussion with the patient and her husband, the obstetrician, and the anesthesiologist, the patient was treated with left knee ACL reconstruction and medial meniscus repair. CONCLUSION: With sufficient preoperative planning and coordinated multidisciplinary care among orthopaedic, anesthesiologist, and obstetric specialists, elective knee surgery can be performed safely in time-sensitive situations during pregnancy.

Richard Schatzki: a familiar ring.

OBJECTIVE: The Schatzki ring was named for Richard Schatzki, a renowned radiologist who described the entity with his colleague, John E. Gary. The purpose of this article is to shed more light on a man who made such a significant contribution and to chronicle developments concerning this important radiologic finding. CONCLUSION: The Schatzki ring was described long ago, but its cause is poorly understood even today.

Increasing educational indebtedness influences medical students to pursue specialization: a military recruitment potential?

BACKGROUND: Cost of medical education and student indebtedness has increased dramatically. This study surveyed medical students on educational debt, educational costs, and whether indebtedness influenced career choice. Responses should impact (1) Department of Defense (DoD) recruitment of physicians and (2) future of primary care. METHOD: The authors surveyed 188 incoming medical students (University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Class of 2012) concerning educational indebtedness, perceptions about educational costs, and plans regarding loan repayment. Data were analyzed and expressed as mean +/- standard error. RESULTS: Students with loans anticipated their medical educational costs to be $155,993. 62% felt costs were "exorbitant," and 28% "appropriate." 64% planned to specialize, whereas only 9% chose primary care. 28% of students planning specialization said income potential influenced their decision. 70% of students said cost was a factor in choosing New Jersey Medical School over a more expensive school. Students anticipated taking about 10 years to repay loans. CONCLUSIONS: As medical educational costs and student indebtedness rise, students are choosing less costly education and career paths with higher potential future earnings. These trends will negatively impact health care availability, accessibility, and cost. DoD programs to provide financial assistance in exchange for military service are not well publicized. These findings should increase DoD recruitment opportunities.

George Ryerson Fowler: Brooklyn's surgical pioneer: a biographical sketch based on historical documents.

The Fowler position, widely used in surgery and obstetrics for patient placement, marks a fraction of 19th-century Brooklyn surgeon George Ryerson Fowler's prodigious accomplishments. Fowler was a pioneer who refined the appendectomy, performed the first lung decortication, advocated for sterile techniques, introduced first aid in the US Army, and helped start a precursor to Annals of Surgery. His publications include the first US textbook on appendicitis--ironically, the disease that killed him.

Marjolin's warty ulcer.

Marjolin's ulcer refers to malignant change within burn scar. The French surgeon Jean-Nicolas Marjolin is honored with the eponym. Marjolin described the "warty ulcer" in the first edition of Dictionnaire de Medécine. In his description, Marjolin did not actually state that this ulcer represented malignant transformation. Credit for noting the specific association involved in Marjolin's ulcer belongs to Caesar Hawkins, an English Surgeon, who described skin cancer arising in burn and flogging scars.

Bilateral Knee Dislocations Treated with Acute, Single-Stage Multiligament Reconstructions.

Bilateral knee dislocations are exceedingly rare in orthopaedics. Managing these injuries presents a difficult task given their high complication rate and guarded prognosis. We report the case of a 21-year-old male who presented to our institution with bilateral knee dislocations sustained in a motor vehicle collision. The patient subsequently underwent multiligament knee reconstruction surgeries for each knee at one and three weeks following the initial injury. At one-year follow-up, the patient has achieved a successful outcome and has returned to regular activities which include hiking and exercising at the gym.

Towards Transabdominal Functional Photoacoustic Imaging of the Placenta: Improvement in Imaging Depth Through Optimization of Light Delivery.

Functional photoacoustic imaging of the placenta could provide an innovative tool to diagnose preeclampsia, monitor fetal growth restriction, and determine the developmental impacts of gestational diabetes. However, transabdominal photoacoustic imaging is limited in imaging depth due to the tissue's scattering and absorption of light. The aim of this paper was to investigate the impact of geometry and wavelength on transabdominal light delivery. Our methods included the development of a multilayer model of the abdominal tissue and simulation of the light propagation using Monte Carlo methods. A bifurcated light source with varying incident angle of light, distance between light beams, and beam area was simulated to analyze the effect of light delivery geometry on the fluence distribution at depth. The impact of wavelength and the effects of variable thicknesses of adipose tissue and muscle were also studied. Our results showed that the beam area plays a major role in improving the delivery of light to deep tissue, in comparison to light incidence angle or distance between the bifurcated fibers. Longer wavelengths, with incident fluence at the maximum permissible exposure limit, also increases fluence within deeper tissue. We validated our simulations using a commercially available light delivery system and ex vivo human placental tissue. Additionally, we compared our optimized light delivery to a commercially available light delivery system, and conclude that our optimized geometry could improve imaging depth more than 1.6×, bringing the imaging depth to within the needed range for transabdominal imaging of the human placenta.

Open gastrostomy under local anesthesia for patients with neuromuscular disorders.

Patients with neuromuscular disease often require gastrostomy, yet respiratory complications in these patients can preclude the use of general anesthesia, intravenous sedation, or endoscopy. The purpose of this study is to report successful use of open gastrostomy that can be performed under local anesthesia. Fifty-four patients underwent this modified procedure. There were no deaths or complications. They lived an average of 43.4 +/- 6.2 (SE) months postgastrostomy tube placement. Simplified open gastrostomy can be performed safely for patients with neuromuscular disease with resulting improvements in both longevity and quality of life.

Disorders of sexual differentiation: surgical challenges of vaginal reconstruction in complete androgen insensitivity syndrome (CAIS).

Disorders of sexual differentiation have proven difficult to treat not only because of physicians' lack of understanding regarding the determinants of sexual orientation, but also because of the psychological impact associated with sexual dysfunction. Patients with complete androgen insensitivity syndrome not only must undergo gonadectomy after puberty, requiring post-gonadectomy hormonal replacement, but also can suffer from underdeveloped, blind vaginal pouches. As a result, sexual intercourse is compromised. Many attempts have been made throughout medical history to correct the vaginal defect, including surgical and nonsurgical approaches, each with its own technical difficulties and complications. Presently, consensus regarding the optimal time for intervention is when the patient is ready to begin sexual life. However, the optimal surgical approach has not been established. In general, nonsurgical vaginal dilatation, like the Frank and Ingram methods, should be followed by surgical interventions, such as described by McIndoe, Vecchietti, and intestinal transplantation, in case of failure of the more conservative procedures.

Tourniquets revisited.

BACKGROUND: Controversy swirls about optimal control of life-threatening hemorrhage from an injured extremity whether in combat in the Middle East or in trauma care at home. Left unanswered are four critical questions: (1) What is the simplest tourniquet available? (2) Can it be used below the elbow and the knee? (3) Is pain a factor? (4) What data support so called "Pressure Points?" METHODS: To address these questions, we measured the effects of three common tourniquets on arterial pulses (Doppler signals) at wrist and ankle of 10 healthy adult volunteers of either sex. We recorded ease of application (1-3, with 3 easiest) by the applicant and pain experienced by the subject (none, light, moderate, severe). Tourniquets were applied sequentially to arm, forearm, thigh, and leg. Tourniquet success was defined as sustained elimination of distal pulse. Pressure points were brachial artery in arm and cubital fossa, common femoral artery (groin), and popliteal artery (knee). The same criteria defined success. All numerical data were meaned and standard error (SE) computed. Significance of apparent differences was assessed with Student's t test for paired observations. RESULTS: Mean age was 36.5 +/- 6.0 years; blood pressure was 123 +/- 6/72 +/- 4 mm Hg. All three tourniquets (sphygmomanometer, 1/2 inch rubber tubing, cloth and windlass) were successful in all patients in all four locations with two exceptions. Thighs of two subjects were too large for the sphygmomanometer and one person experienced test terminating pain with the rubber tube on arm and thigh and with the cloth and windlass on the thigh. Manual (digital) occlusion of the brachial artery in the arm was possible in all but one subject; however, the Doppler signal at the wrist returned within 40.6 +/-6.5 seconds in all but one of the other nine subjects. Pressure point control of the common femoral artery resulted in identical findings except that the pulse returned within 20.6 +/- 4.7 seconds despite sustained pressure. Attempts at control of the brachial artery at the elbow and the popliteal artery at the knee were less successful. CONCLUSIONS: Our data indicate that all tourniquets can be used successfully below the knee or elbow. The cloth and windlass is the easiest to apply. It is probably the most readily available or simplest to procure/improvise. Pain is irrelevant. "Pressure Point Control" of extremity arterial hemorrhage is a euphemistic misnomer.