Novel cardiovascular biomarkers in unexplained syncopal attacks: the SYSTEMA cohort.

OBJECTIVES: The aim of the study was to investigate the resting levels of novel cardiovascular biomarkers in common types of noncardiac syncope. DESIGN AND SETTING: An observational study was conducted including 255 patients (mean age 60 years, range 15-93; 45% men) with unexplained syncopal attacks. Subjects underwent an expanded head-up tilt test including carotid sinus massage, and nitroglycerin provocation if indicated. Using logistic regression, we explored the associations between specific diagnoses of syncope and resting levels of circulating biomarkers: C-terminal pro-arginine vasopressin (CT-proAVP), C-terminal endothelin-1 precursor fragment (CT-proET-1), midregional fragments of pro-atrial natriuretic peptide (MR-proANP) and pro-adrenomedullin (MR-proADM). RESULTS: A total of 142 (56%) patients were diagnosed with vasovagal syncope (VVS), 85 (33%) with orthostatic hypotension (OH) and 47 (18%) with carotid sinus hypersensitivity (CSH); in addition, 74 (29%) patients had more than one diagnosis. Thirty-five patients (14%) demonstrated a cardioinhibitory reflex. The probability of VVS was highest in the first quartile of MR-proANP [Q1 vs. Q4: odds ratio (OR) 5.57, 95% confidence interval (CI) 1.86-16.74; P < 0.001] and CT-proET-1 (OR 7.17, 95% CI 2.43-21.13; P < 0.001). By contrast, the probability of OH was highest in the fourth quartile of CT-proET-1 (Q4 vs. Q1: OR 8.66, 95% CI 2.49-30.17; P < 0.001). Furthermore, CSH was most frequently observed in the first quartile of MR-proANP (Q1 vs. Q4: OR 6.57, 95% CI 1.62-26.62; P = 0.008) among those over 60 years of age, whereas the cardioinhibitory reflex was strongly associated with low CT-proET-1 levels (Q1 vs. Q4: OR 69.7, 95% CI 6.97-696.6; P < 0.001). Moreover, in patients with VVS, a high concentration of CT-proET-1 was predictive of OH (OR per 1 SD 2.4, 95% CI 1.15-5.02; P = 0.02), whereas low CT-proET-1 suggested involvement of the cardioinhibitory reflex (OR per 1SD 0.42, 95% CI 0.25-0.70; P = 0.001). CONCLUSIONS: The levels of MR-proANP and CT-proET-1 are markedly changed in common forms of syncope, suggesting the involvement of novel neurohormonal mechanisms in syncopal attacks.

A simple tool for stereological assessment of digital images: the STEPanizer.

STEPanizer is an easy-to-use computer-based software tool for the stereological assessment of digitally captured images from all kinds of microscopical (LM, TEM, LSM) and macroscopical (radiology, tomography) imaging modalities. The program design focuses on providing the user a defined workflow adapted to most basic stereological tasks. The software is compact, that is user friendly without being bulky. STEPanizer comprises the creation of test systems, the appropriate display of digital images with superimposed test systems, a scaling facility, a counting module and an export function for the transfer of results to spreadsheet programs. Here we describe the major workflow of the tool illustrating the application on two examples from transmission electron microscopy and light microscopy, respectively.

Subjects heterozygous for genetic loss of function of the thiazide-sensitive cotransporter have reduced blood pressure.

Gitelmans syndrome (GS) is an inherited recessive disorder caused by homozygous or compound heterozygous loss of function mutations of the NaCl cotransporter (NCCT) gene encoding the kidney-expressed NCCT, the pharmacological target of thiazide diuretics. An observational study estimated the prevalence of GS to 19/1,000,000, in Sweden, suggesting that approximately 1% of the population carries one mutant NCCT allele. As the phenotype of GS patients, who always carry two mutant alleles, is indistinguishable from that seen in patients treated with high-dose thiazide diuretics, we aimed at investigating whether subjects carrying one mutated NCCT allele have a phenotype resembling that of treatment with low-dose thiazide diuretics. We screened first-degree relatives of 18 of our patients with an established clinical end genetic diagnosis of GS for NCCT loss of function mutations and identified 35 healthy subjects carrying one mutant allele (GS-heterozygotes). Each GS-heterozygote was assigned a healthy control subject matched for age, BMI and sex. GS-heterozygotes had markedly lower blood pressure (systolic 103.3 +/- 16.4 versus 123.2 +/- 19.4 mmHg; diastolic 62.5 +/- 10.5 versus 73.1 +/- 9.4 mmHg; P < 0.001) than controls. There was no significant difference between the groups either in plasma concentration or urinary excretion rate of electrolytes, however, GS-heterozygotes had higher fasting plasma glucose concentration. Similar to patients being treated with low-dose thiazide diuretics, GS-heterozygotes have markedly lower blood pressure and slightly higher fasting plasma glucose compared with control subjects. Our findings suggest that GS-heterozygotes, the prevalence of which can be estimated to 1%, are partially protected from hypertension through partial genetic loss of function of the NCCT. However, as our study had a case-control design, it is important to underline that any potential effects on population blood pressure and risk of future cardiovascular disease need to be examined in prospective and population-based studies.

Overexpression of Mos, Ras, Src, and Fos inhibits mouse mammary epithelial cell differentiation.

Mammary epithelial cells terminally differentiate in response to lactogenic hormones. We present evidence that oncoprotein overexpression is incompatible with this hormone-inducible differentiation and results in striking cellular morphological changes. In mammary epithelial cells in culture, lactogenic hormones (glucocorticoid and prolactin) activated a transfected beta-casein promoter and endogenous beta-casein gene expression. This response to lactogenic hormone treatment was paralleled by a decrease in cellular AP-1 DNA-binding activity. Expression of the mos, ras, or src (but not myc) oncogene blocked the activation of the beta-casein promoter induced by the lactogenic hormones and was associated with the maintenance of high levels of AP-1. Mos expression also increased c-fos and c-jun mRNA levels. Overexpression of Fos and Jun from transiently transfected constructs resulted in a functional inhibition of the glucocorticoid receptor in these mouse mammary epithelial cells. This finding clearly suggests that glucocorticoid receptor inhibition arising from oncogene expression will contribute to the block in hormonally induced mammary epithelial cell differentiation. Expression of Src resulted in the loss of the normal organization and morphological phenotype of mammary epithelial cells in the epithelial/fibroblastic line IM-2. Activation of a conditional c-fos/estrogen receptor gene encoding an estrogen-dependent Fos/estrogen receptor fusion protein also morphologically transformed mammary epithelial cells and inhibited initiation of mammary epithelial differentiation-associated expression of the beta-casein and WDNM 1 genes. In response to estrogen treatment, the cells displayed a high level of AP-1 DNA-binding activity. Our results demonstrate that high cellular AP-1 levels contribute to blocking the ability of mammary epithelial cells in culture to respond to lactogenic hormones. This and other studies indicate that the oncogene products Mos, Ras, and Src exert their effects, at least in part, by stimulating cellular Fos and probably cellular Jun activity.

Intussusceptive angiogenesis: its role in embryonic vascular network formation.

Intussusceptive angiogenesis is a novel mode of blood vessel formation and remodeling, which occurs by internal division of the preexisting capillary plexus without sprouting. In this study, the process is demonstrated in developing chicken eye vasculature and in the chorioallantoic membrane by methylmethacrylate (Mercox) casting, transmission electron microscopy, and in vivo observation. In a first step of intussusceptive angiogenesis, the capillary plexus expands by insertion of numerous transcapillary tissue pillars, ie, by intussusceptive microvascular growth. In a subsequent step, a vascular tree arises from the primitive capillary plexus as a result of intussusceptive pillar formation and pillar fusions, a process we termed "intussusceptive arborization." On the basis of the morphological observations, a 4-step model for intussusceptive arborization is proposed, as follows: phase I, numerous circular pillars are formed in rows, thus demarcating future vessels; phase II, formation of narrow tissue septa by pillar reshaping and pillar fusions; phase III, delineation, segregation, growth, and extraction of the new vascular entity by merging of septa; and phase IV, formation of new branching generations by successively repeating the process, complemented by growth and maturation of all components. In contrast to sprouting, intussusceptive angiogenesis does not require intense local endothelial cell proliferation; it is implemented primarily by rearrangement and attenuation of the endothelial cell plates. In summary, transcapillary pillar formation, ie, intussusception, is a central and probably widespread process, which plays a role not only in capillary network growth and expansion (intussusceptive microvascular growth), but also in vascular plexus remodeling and tree formation (intussusceptive arborization).

Expression of hypoxia-inducible factor-1alpha: a novel predictive and prognostic parameter in the radiotherapy of oropharyngeal cancer.

Hypoxia has long been recognized as detrimental to the successful treatment of malignant tumors with ionizing radiation. Because hypoxia-inducible factor (HIF)-1alpha plays an essential role in oxygen homeostasis in vitro, we explored the predictive potential of this factor in a cohort of 98 patients with squamous cell cancer of the oropharynx, who were treated by curative radiation therapy. Ninety-four % of the primary tumors showed overexpression of HIF-1alpha, relative to the surrounding tissue, as determined by immunohistochemistry. The degree of HIF-1alpha immunoreactivity correlated inversely with both the rate of complete remission of the primary tumor (odds ratio, 0.33; P = 0.03) and lymph node metastases (odds ratio, 0.34; P = 0.02) as well as with local failure-free survival (risk ratio, 2.15; P = 0.006), disease-free survival (risk ratio, 2.01; P = 0.008), and overall survival (risk ratio, 2.17; P = 0.002). The multivariate analysis revealed the predictive power of HIF-1alpha to be independent of other covariables. We conclude that HIF-1alpha is overexpressed in the vast majority of patients with squamous cell cancer of the oropharynx and that the degree of expression has predictive and prognostic significance in individuals undergoing curative radiation therapy.

Intussusceptive microvascular growth, a new mechanism of capillary network formation.

Growth by intussusception is defined as growth by deposition of new particles or pieces of formative material among those already embodied in a tissue or structure. In the context of capillary growth the term stands for the extension of the capillary system by the insertion of new capillary meshes within the existing network. New meshes arise as slender transcapillary tissue pillars. These are formed initially by a circumscribed fusion of opposite endothelial leaflets. Following reorganization of the junctional complexes, the pillar is invaded by interstitial tissue. This means that for the formation of new capillaries no sprouting of endothelial cords or tubules is required. The mechanism is described in the growing lung, but may occur in other tissues too. There may be a chance for in vivo observation of the process in the capillaries of the chorio-allantoic membrane of the chicken.

Do mature pulmonary lobes grow after transplantation into an immature recipient?

BACKGROUND: The use of reduced-size adult lung transplants could help solve the profound pediatric donor lung shortage. However, adequate long-term function of the mature grafts requires growth in proportion to the recipient's development. METHODS: Mature left lower lobes from adult mini-pigs (age: 7 months; mean body weight: 30 kg) were transplanted into 14-week-old piglets (mean body weight: 15 kg). By the end of the 14-week holding period, lungs of the recipients (n = 4) were harvested. After volumetric measurements, the lung morphology was studied using light microscopy, scanning, and transmission electron microscopy. Changes of alveolar airspace volume were determined using a computer aided image analysis system. Comparisons were made to age- and weight-matched controls. RESULTS: Volumetric studies showed no significant differences (p = 0.49) between the specific volume (mL/kg body weight) of lobar grafts and left lower lobes of adult controls. Morphologic studies showed marked structural differences between the grafts and the right native lungs of the recipients, with increased average alveolar diameter of the grafts. On light microscopy and scanning electron microscopy, alveoli appeared dilated and rounded compared to the normal polygonal shape in the controls. The computer generated semi-quantitative data of relative alveolar airspace volume tended to be higher in transplanted lobes. CONCLUSIONS: The mature pulmonary lobar grafts have filled the growing left hemithorax of the developing recipient. Emphysema-like alterations of the grafts were observed without evidence of alveolar growth in the mature lobar transplants. Thus, it can be questioned whether mature pulmonary grafts can guarantee sufficient long-term gas exchange in growing recipients.

Morphometry and allometry of the postnatal lung development in the quokka wallaby (Setonix brachyurus): a light microscopic study.

The postnatally developing lungs of the quokka wallaby, Setonix brachyurus, were investigated macroscopically and by light microscopic morphometry. Lung, parenchymal and non-parenchymal volumes as well as the components of the latter two were analysed by regression analysis. The lungs comprised a single undivided left lung and a right lung with an adherent accessory lobe. Septal tissue growth was most remarkable in the canalicular and saccular stages. Between mid-canalicular stage and the saccular stage, the lung volume increased 2-fold, mainly due to airspace expansion, coupled with septal tissue thinning. The non-parenchymal vascular volume increase accelerated in the successive developmental stages while the airway and connective tissue volumes progressed in a decreasing order, being highest in the canalicular and saccular stages and lowest in the alveolar stage. Growth and remodelling of the alveolar septa occurred simultaneously with airspace subdivision. Airspace expansion accelerated during the stage of microvascular maturation, when most other parameters showed the least rate of increase.

Morphometry and allometry of the postnatal marsupial lung development: an ultrastructural study.

An utrastructural morphometric study of the postnatally remodelling lungs of the quokka wallaby (Setonix brachyurus) was undertaken. Allometric scaling of the volumes of the parenchymal components against body mass was performed. Most parameters showed a positive correlation with body mass in all the developmental stages, except the volume of type II pneumocytes during the alveolar stage. The interstitial tissue and type II cell volumes increased slightly faster than body mass in the saccular stage, their growth rates declining in the alveolar stage. Conversely, type I pneumocyte volumes increased markedly in both the saccular and alveolar stages. Both capillary and endothelial volumes as well as the capillary and airspace surface areas showed highest rates of increase during the alveolar stage, at which time the rate was notably higher than that of the body mass. The pulmonary diffusion capacity increased gradually, the rate being highest in the alveolar stage and the adult values attained were comparable to those of eutherians.

Influence of bilirubin on surface tension properties of lung surfactant.

AIM: To investigate the influence of bilirubin on the surface tension activity of a porcine derived (Curosurf) and synthetic (Exosurf) surfactant. METHODS: The captive bubble surfactometer at phospholipid doses of 0.5 mg/ml (low dose) and 1 mg/ml (high dose) in solutions of increasing bilirubin concentrations (0.25, 0.5, and 1.0 mg/ml) was used. RESULTS: Curosurf (without bilirubin) showed a higher surface f1p4ion activity than Exosurf, as shown by area compression of 30 (SD 0.6)% compared with 76(1.4)% at low surfactant dose and 25 (0.9)% compared with 85 (0.5)% at high dose (P < 0.01). Bilirubin showed negligible surface activity at the concentrations studied. At low phospholipid dose (0.5 mg/ml Curosurf), bilirubin increased film area compression of lipid extract surfactant from 30 (0.6)% to 55 (1.6)%, 59 (0.1)%, and 68 (0.5)% at the three studied bilirubin concentrations, respectively (P < 0.01). At high phospholipid dose (1 mg/ml Curosurf), bilirubin had the same adverse, although less pronounced, effect on film area compression of porcine lipid extract surfactant (25 (0.9)% vs 26 (0.9)%, 39 (1.3)%, and 44 (1.1)%, respectively) (P < 0.01). Using synthetic surfactant (Exosurf), with a much lower original surface activity, bilirubin did not further inhibit its surface tension properties at any of the phospholipid doses studied. CONCLUSION: These results indicate that in vitro bilirubin impairs the surface tension activity of porcine lipid extract surfactant, but does not affect synthetic surfactant activity.

Evidence for intussusceptive capillary growth in the chicken chorio-allantoic membrane (CAM).

The aim of our investigations was to test whether the chicken chorio-allantoic membrane (CAM) could be an adequate in vivo model for a new mode of capillary growth, originally described in the rat lung and termed intussusceptive microvascular growth. According to that concept the capillary system does not grow by sprouting of vessels, but expands by insertion of transcapillary tissue pillars or posts which form new intercapillary meshes. In the present study, we observed slender transcapillary tissue pillars with diameters around 1 microns in the CAM by in vivo microscopy, and analyzed their ultrastructure by transmission electron microscopic investigation of serial sections. The pillars corresponded in size to those previously described in rat lung microvasculature. On day 7, the pillar core contained endothelial-, endothelial-like cells and collagen fibers, and on day 12 additionally chorionic epithelial cells. As a hypothesis we propose that slender cytoplasmic extensions of endothelial cells, heavily interdigitated in the post area and often projecting into the vascular lumen, could initiate the first step of pillar formation, i.e., interconnect opposite capillary walls. During both stages of development endothelial-like cells were observed in close relationship with the pillars. These cells seem to be relevant for tissue post completion and growth, as they were found to invade the core of the pillars. From the localization of the interendothelial junctions in the post region, a certain similarity to the concept proposed for the lung can be found. The observations confirm that the CAM is a very suitable material for the in vivo investigation of intussusceptive capillary growth.

Intussusceptive arborization contributes to vascular tree formation in the chick chorio-allantoic membrane.

Various reports indicate that the process of intussusceptive microvascular growth (IMG) plays a crucial role in capillary network formation of the chorio-allantoic membrane (CAM). In the present study we demonstrate by methylmethacrylate (Mercox) casting and in vivo time-lapse observations that intussusception, i.e. insertion of transcapillary tissue pillars, is also strongly involved in vascular tree formation, a process we refer to as intussusceptive arborization (IAR). From day 7 to day 14 of incubation, several arterial and venous branching generations arise from the capillary plexus. The process is initiated by pillar formation in rows, which are demarcating future large vessels in the capillary meshwork. In a subsequent step the pillars undergo reshaping to form narrow tissue septa that successively merge, which results in the production of new generations of blood vessels. This is followed by growth and maturation of all vascular components. The process of IAR in the CAM is very active at days 10 and 11 of incubation and takes place in preferentially perfused capillary regions determining "dynamic areas". The process of intussusception may be preceded by endothelial division, but the transcapillary pillar formation itself occurs primarily by rearrangement and attenuation of the endothelial cells without local endothelial cell proliferation. We conclude that after the early sprouting phase, the process of intussusception is the basic mechanism of CAM vascularization. It leads to capillary network growth and expansion (IMG) and, at the same time to feed vessel formation with several branching generations (IAR).

[A passive sampler for nitrogen dioxide]. / Passivsammler für Stickstoffdioxid.

Passive samplers run without electric power supply, are easy to handle and thus are suitable for exposure measurements in epidemiological studies, to evaluate indoor air quality, to control ambient concentrations etc. Passive sampler values agree with continuous measuring apparatus within 85 to 105% and the lower detection limit is 4 micrograms/m3 for a one week exposure or longer.

[Automated perimetry in patients with posterior chamber implants]. / La périmétrie automatisée chez les patients porteurs d'un implant de chambre postérieure.

Automated perimetry was performed on 32 eyes of 31 patients with posterior chamber intraocular lens. Visual field and retinal sensibility were studied a week and three months after surgery for each eye. Decreased retinal sensibility in the foveal area was observed in 75% of the eyes. Such a deficiency was also noted in the nasal visual field from 30 to 45 degrees, and within 60 degrees in the temporal area. Further investigation is mandatory to assess our hypothesis about this phenomenon.