Treatment of resistant hypertension.

AIM: Resistant hypertension (RH) is a common clinical problem. Patients with RH have increased cardiovascular risk. These patients also have high risk for having reversible causes of hypertension and may potentially benefit from special diagnostic or therapeutic considerations. The purpose of this review was to discuss RH, its definition, recognition, evaluation and treatment. METHODS: Authors define RH and the implications of this definition. They present latest data on its prevalence, prognostic implications, genetics, and patient characteristics. Elements of pseudoresistance and possible etiologies of treatment resistance are also identified. Lastly, diagnostic and therapeutic approaches to RH are discussed, focusing on antihypertensive medication classes that have proven benefit in patients with RH, and also on novel therapeutic approaches in these patients. CONCLUSION: RH is a common clinical problem and carries an increased risk for cardiovascular morbidity and mortality, as well as target organ damage. Patients with RH are aat high risk for reversible causes of hypertension and may benefit from special diagnostic or therapeutic considerations. Elements of pseudoresistance, intake of interfering substances and secondary causes of hypertension should be searched for and corrected, if possible. Therapeutic lifestyle modifications should be emphasized. Medical therapy includes optimizing diuretic use and considering the use of mineralocorticoid antagonists as add on antihypertensive agents. Novel approaches include surgical and transcatheter techniques, chronotherapy, and new classes of antihypertensive agents.

Maternal and neonatal demographics of macrosomic infants admitted to the neonatal intensive care unit.

OBJECTIVE: The objective of this study is to determine the incidence, significance, associated demographics and impact of macrosomic infants (⩾4 kg) admitted to the Neonatal Intensive Care Unit (NICU) on NICU census and resources. STUDY DESIGN: A retrospective cohort review was performed from 2010 to 2015. Descriptive statistical analyses were used. RESULTS: Of 19 308 deliveries, 1823 were infants ⩾4000 g and 213 were admitted to the NICU. Cesarean delivery occurred in 70% of the admitted infants, most (74.1%) were Grade 1 macrosomia and male (63%). Preterm birth occurred in 4%. The incidence of maternal diabetes was 25%. Primary admitting diagnoses were respiratory distress, suspected sepsis, hypoglycemia and perinatal depression. The average length of stay was 8±6 days for all macrosomic infants admitted, increased to 22±13 days for infants with Grade 3 macrosomia. CONCLUSION: Macrosomic infants are a growing population, who increase the demand on existing NICU resources. A larger multi-centered study is needed to determine the overall relevance of these findings in other populations.

Effect of spironolactone on diastolic function in hypertensive left ventricular hypertrophy.

We have previously shown rapid reversal of left ventricular hypertrophy (LVH) with 6 months of spironolactone therapy in patients with resistant hypertension (HTN), preserved left ventricular ejection fraction and no history of heart failure. In this substudy, we investigated the effect of mineralocorticoid receptor blockade with spironolactone on pre-clinical diastolic dysfunction. Thirty-four patients (19 with high and 15 with normal aldosterone levels) were treated with spironolactone and followed with cardiac magnetic resonance with tissue tagging at baseline, 3 and 6 months of treatment. Serum markers of collagen turnover (C-propeptide of type-I procollagen and carboxy-terminal telopeptide of type-I collagen) were measured at baseline and at 6 months. At baseline, patients demonstrated reduced E/A ratio (volumetric normalized peak early filling rate/late filling rate, normalized to left ventricular end-diastolic volume), lower peak early-diastolic mitral annular velocity and lower peak early-diastolic circumferential strain rates compared to the reference values obtained from 45 normal controls without HTN or cardiac disease (all comparisons, P<0.01). No significant change occurred in diastolic filling, relaxation parameters or collagen markers with spironolactone therapy at 6 months irrespective of aldosterone status despite significant reduction in left ventricular mass index in both high- and normal-aldosterone groups. In conclusion, resistant HTN patients with LVH demonstrate significant pre-clinical diastolic dysfunction. Short-term spironolactone therapy may not lead to improvement in diastolic function despite rapid reversal of LVH.

High NaCl diet enhances arterial baroreceptor reflex in NaCl-sensitive spontaneously hypertensive rats.

Previous studies from our laboratory have shown that arterial baroreceptor reflex control of lumbar sympathetic nerve activity is blunted in the NaCl-sensitive spontaneously hypertensive rat (SHR-S) compared with either the NaCl-resistant spontaneously hypertensive rat (SHR-R) or the normotensive Wistar-Kyoto (WKY) rat. In the current study, the effect of dietary NaCl supplementation on arterial baroreceptor reflex control of lumbar sympathetic nerve activity and heart rate was assessed in SHR-S and control SHR-R and WKY rats. Male SHR-S, SHR-R, and WKY rats were fed diets containing either 1% or 8% NaCl beginning at 7 weeks of age and were studied at age 9-10 weeks. Arterial baroreceptor reflex-mediated changes in lumbar sympathetic nerve activity and heart rate were recorded in conscious, unrestrained rats during phenylephrine-induced (15-40 micrograms/kg/min) and nitroprusside-induced (15-300 micrograms/kg/min) changes in mean arterial pressure. SHR-S maintained on a 1% NaCl diet had blunted baroreceptor reflex control of lumbar sympathetic nerve activity during acute increases in MAP compared with SHR-R and WKY rats (p less than 0.05). After ingestion of the 8% NaCl diet, this blunting was absent, indicating enhancement of baroreceptor reflex control of lumbar sympathetic nerve activity. SHR-S maintained on a 1% NaCl diet also had blunted arterial baroreceptor control of lumbar sympathetic nerve activity during nitroprusside-induced decreases in mean arterial pressure compared with WKY rats, but this was not significantly altered during ingestion of the 8% NaCl diet.(ABSTRACT TRUNCATED AT 250 WORDS)

Gender and dietary NaCl in spontaneously hypertensive and Wistar-Kyoto rats.

We recently reported that high dietary NaCl exposure significantly increases both daytime and nighttime mean arterial pressure in male spontaneously hypertensive rats (SHR) but only nighttime values in male normotensive Wistar-Kyoto rats (WKY). In the present study we used a telemetry monitoring system to evaluate the effects of high dietary NaCl exposure on diurnal variation of mean arterial pressure and heart rate in male and female SHR and WKY. After implantation of a radio-frequency transducer, rats were fed either high (8%) or basal (1%) NaCl diets for 2 weeks. High dietary NaCl ingestion significantly increased both daytime and nighttime mean arterial pressure in male SHR compared with males receiving a basal NaCl diet, resulting in greater 24-hour values (163 +/- versus 154 +/- 1 mm Hg, high versus basal NaCl diet; P < .05). High dietary NaCl ingestion significantly increased only nighttime blood pressure in male WKY, with no significant effect on 24-hour mean arterial pressure (102 +/- 2 versus 101 +/- 3 mm Hg, high versus basal). High dietary NaCl exposure did not affect daytime or nighttime mean arterial pressure in female SHR (24-hour mean arterial pressure, 144 +/- 2 versus 141 +/- 2 mm Hg, high versus basal NaCl diet). Twenty-four-hour mean arterial pressure tended to be lower in female WKY receiving a high NaCl diet than females ingesting a basal diet (101 +/- 3 versus 106 +/- 1 mm Hg), but the difference was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Physical training and baroreceptor control of sympathetic nerve activity in humans.

In nine sedentary subjects (16.5 +/- 0.4 years, mean +/- SEM) we measured blood pressure (Finapres device), heart rate (electrocardiogram), and postganglionic muscle sympathetic nerve activity (microneurography from the peroneal nerve) at rest and during intravenous infusion of phenylephrine and nitroprusside. These measurements were performed before and after 10 weeks of endurance training (2 h/d, 5 d/wk) that increased maximum oxygen consumption from 34.8 +/- 2.1 to 40.4 +/- 1.8 mL/kg per minute (P < .02). Basal mean blood pressure and muscle sympathetic nerve activity were lower after than before endurance training (86.5 +/- 2.6 versus 97.5 +/- 1.8 mm Hg, P < .05, and 14.0 +/- 1.8 versus 21.2 +/- 2.3 bursts per minute, P < .02), and the changes in these variables were closely related (r = .95, P < .01). Similar mean blood pressure increases induced by phenylephrine caused greater reductions in heart rate and muscle sympathetic nerve activity after than before endurance training (-8.6 +/- 0.8 versus -6.1 +/- 1.1 beats per minute, P = NS, and -78.0 +/- 4.6% versus -53.6 +/- 4.8%, P < .05). Likewise, similar mean blood pressure reductions induced by nitroprusside caused greater increases in heart rate and muscle sympathetic nerve activity after than before endurance training (18.6 +/- 3.0 versus 12.4 +/- 2.4 beats per minute, P < .05, and 128.1 +/- 26% versus 63.2 +/- 11%, P < .02). No alteration in hemodynamics, oxygen consumption, muscle sympathetic nerve activity, and baroreceptor reflex sensitivity occurred in four other age-matched sedentary subjects studied before and after a 10-week observation period without endurance training.(ABSTRACT TRUNCATED AT 250 WORDS)

Diurnal blood pressure variation and dietary salt in spontaneously hypertensive rats.

We have previously reported that high dietary salt exposure significantly increases daytime mean arterial pressure in spontaneously hypertensive rats (SHR) but not in normotensive Wistar-Kyoto (WKY) controls. In the present study, we used a telemetry monitoring system to evaluate the effects of high dietary salt exposure on diurnal variation of mean arterial pressure and heart rate in SHR and WKY rats. After implantation of a radio frequency transducer, SHR and WKY rats were maintained on either high (8%) or basal (1%) salt diets. Hemodynamic values were then analyzed for diurnal variation with the use of a nonlinear data-fitting program. After 2 weeks of dietary exposure, high salt-fed SHR had significantly greater 24-hour mean arterial pressure (156 +/- 3 mmHg) than SHR receiving basal (135 +/- 2 mmHg) and WKY rats receiving high (100 +/- 2 mmHg) or basal (100 +/- 1 mmHg) salt diets. Rhythm analysis indicated significant increases in both daytime and nighttime mean arterial pressure during high salt exposure in SHR. In WKY rats, high salt exposure increased nighttime but not daytime mean arterial pressure, with no net effect on 24-hour mean arterial pressure. High dietary salt exposure significantly decreased heart rate in both SHR and WKY rats, and it did not significantly alter the pattern of diurnal blood pressure or heart rate variation. These results indicate that WKY rats manifest an acute sensitivity to salt ingestion but have compensatory mechanisms sufficient to prevent sustained increases in mean arterial pressure; such mechanisms are lacking in SHR.

Atrial natriuretic peptide modulates baroreceptor reflex in spontaneously hypertensive rat.

Our previous studies have suggested that atrial natriuretic peptide in the caudal nucleus tractus solitarii is involved in the centrally mediated regulation of blood pressure in the salt-sensitive spontaneously hypertensive rat (SHR). The current study tested the hypothesis that endogenous atrial natriuretic peptide in the caudal nucleus tractus solitarii participates in baroreceptor reflex control of heart rate in this hypertensive model. Salt-sensitive SHR and control Wistar-Kyoto (WKY) rats maintained on basal (1%) salt intake were studied. Arterial baroreceptor reflex-mediated changes in heart rate were recorded in conscious unrestrained rats during phenylephrine (5-40 micrograms.kg-1.min-1 infusion; 30 minutes later, atrial natriuretic peptide (50 ng), monoclonal antibody to atrial natriuretic peptide (0.55 micrograms), purified mouse immunoglobulin G (0.55 micrograms), or artificial cerebrospinal fluid vehicle (50 nl) was microinjected into the caudal nucleus tractus solitarii. Phenylephrine infusion was then repeated and mean arterial pressure and heart rate were monitored as before. The slope of the heart rate/mean arterial pressure relation was significantly less (p less than 0.05) in the salt-sensitive SHR than in the WKY control, indicating that baroreceptor reflex control of heart rate was blunted in this hypertensive model. Microinjection of atrial natriuretic peptide into the caudal nucleus tractus solitarii further blunted (p less than 0.05) baroreceptor reflex control of heart rate in salt-sensitive SHR but not in WKY rats. In contrast, microinjection of the monoclonal antibody enhanced the sensitivity of baroreceptor reflex control of heart rate in salt-sensitive SHR but not in WKY rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Excitatory sympathetic reflex in NaCl-sensitive spontaneously hypertensive rats.

We have previously demonstrated blunted reflex responses of lumbar sympathetic nerve activity during volume expansion in NaCl-sensitive spontaneously hypertensive rats maintained on basal (1% NaCl) diets compared with NaCl-resistant spontaneously hypertensive rats, Wistar-Kyoto rats, and Sprague-Dawley rats. The current study tested the hypothesis that chronic ingestion of a high (8%) NaCl diet further blunts cardiopulmonary reflex function in the NaCl-sensitive spontaneously hypertensive rat. After 3 weeks of a 1% or 8% NaCl diet, male rats of all four strains were instrumented with femoral arterial and venous cannulas and lumbar nerve recording electrodes at 10 weeks of age. Two days later, conscious rats were infused with whole blood to expand blood volume. NaCl-sensitive spontaneously hypertensive rats maintained on a 1% NaCl diet had blunted responses of nerve activity to acute volume expansion compared with control strains. NaCl-sensitive spontaneously hypertensive rats maintained on an 8% NaCl diet had increases in nerve activity responses to volume expansion. In a second experiment, the volume expansion protocol was repeated in anesthetized NaCl-sensitive spontaneously hypertensive rats that had been subjected to sinoaortic denervation after 3 weeks of a 1% or 8% NaCl diet. After sinoaortic denervation, an increase in nerve activity was again observed during volume expansion in animals fed the 8% NaCl diet. In animals fed the 1% NaCl diet, changes in nerve activity were variable. The excitatory response was significantly reduced after bilateral vagotomy. These studies suggest that blood pressure regulation in NaCl-sensitive spontaneously hypertensive rats is a complex interaction of excitatory and inhibitory sympathetic reflex systems that is altered by high dietary NaCl exposure.

Normotensive blacks have heightened sympathetic response to cold pressor test.

The purpose of this study was to compare sympathetic nerve activity responses to the cold pressor test in black and white normotensive subjects. We recorded muscle sympathetic nerve activity (microneurography of the peroneal nerve), arterial blood pressure, and heart rate in 9 normotensive American blacks (24 +/- 2 years, mean +/- SEM) and 10 normotensive American whites (28 +/- 2 years) at rest and during hand immersion in ice water (cold pressor test). Body weight was not different in the two groups (72.4 +/- 3.7 versus 74.1 +/- 3.8 kg, black versus white subjects). During supine rest, mean arterial pressure (92 +/- 2 versus 93 +/- 3 mm Hg, black versus white), heart rate (66 +/- 4 versus 62 +/- 3 beats per minute, black versus white), and muscle sympathetic nerve burst frequency (12 +/- 2 versus 17 +/- 3 bursts per minute, black versus white) were not different in the two groups. During the cold pressor test, mean arterial pressure, heart rate, and muscle sympathetic nerve activity increased from supine rest in both groups. The magnitudes of increases in mean arterial pressure and total minute muscle sympathetic nerve activity were significantly greater in blacks than whites (33.5 +/- 3 versus 22.4 +/- 3 mm Hg and 416 +/- 24% versus 243 +/- 31% of control, respectively, black versus white, P < .05). The increases in heart rate were most significantly different for the two groups. These data suggest that the enhanced pressor response to cold stress observed in normotensive blacks is attributable to greater increases in peripheral sympathetic nerve activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial natriuretic peptide blunts arterial baroreflex in spontaneously hypertensive rats.

We and other laboratories have reported that arterial baroreflex-mediated control of heart rate is blunted in spontaneously hypertensive rats (SHR) compared with normotensive controls. Recently, we reported that atrial natriuretic peptide (ANP) microinjected into the caudal nucleus tractus solitarii of SHR further blunts this defect. The present study tested the hypothesis that ANP modulates arterial baroreflex-mediated control of sympathetic nervous system activity. Nine-week-old, male SHR (n = 29) and normotensive Wistar-Kyoto control rats (n = 24) were instrumented for microinjection into the caudal nucleus tractus solitarii and for direct measurement of arterial blood pressure, heart rate, and lumbar sympathetic nervous system activity. After urethane- and alpha-chloralose-induced induced anesthesia, arterial baroreflex-mediated control of heart rate and lumbar sympathetic nerve activity was assessed during phenylephrine- (5 to 40 micrograms.kg-1.min-1) induced increases and sodium nitroprusside- (15 to 300 micrograms.kg-1.min-1) induced decreases in mean blood pressure before and after microinjection of ANP (50 ng) or monoclonal antibody to ANP (0.55 micrograms) into the caudal nucleus tractus solitarii. ANP reduced and the antibody enhanced the sensitivity of baroreflex-mediated control of both heart rate and lumbar sympathetic nerve activity in SHR but not in Wistar-Kyoto controls (P < .05). Arterial baroreflex sensitivity was unchanged with control microinjections of vehicle or mouse IgG in SHR. These data suggest that endogenous ANP in the caudal nucleus tractus solitarii may contribute to the development and/or maintenance of hypertension in SHR by blunting baroreflex-mediated control of sympathetic nervous system activity.

Pretreatment with enalaprilat blunts nicardipine-induced sympathetic activation in spontaneously hypertensive and Wistar-Kyoto rats.

OBJECTIVE: We measured changes in heart rate and lumbar sympathetic nerve activity in conscious, spontaneously hypertensive and Wistar-Kyoto rats during acute blood pressure lowering with nicardipine, enalaprilat and concomitant nicardipine/enalaprilat administration. In a second experiment, we determined the effect of these drugs on arterial baroreflex control of lumbar sympathetic nerve activity. METHODS: Male spontaneously hypertensive and Wistar-Kyoto rats were instrumented for continuous heart rate, blood pressure and lumbar sympathetic nerve activity recordings. Twenty-four hours later in conscious rats, nicardipine, enalaprilat and enalaprilat/nicardipine were infused at sufficient doses to reduce mean arterial pressure by 20 mmHg over 30 min. In a second experiment with the same drugs, baroreflex curves relating lumbar sympathetic nerve activity to mean arterial pressure were analyzed using a logistic curve-fitting program. RESULTS: Blood pressure reductions induced by the three infusion protocols were similar in magnitude and profile. In both spontaneously hypertensive and Wistar-Kyoto rats, nicardipine induced greater reflexive increases in lumbar sympathetic nerve activity than enalaprilat Pretreatment with a reduced dose of enalaprilat blunted subsequent nicardipine-induced sympathetic activation. Nicardipine tended to induce greater increases in the heart rate than enalaprilat, but overall, the difference was not significant Baroreflex sensitivity was similar regardless of drug class. Nicardipine significantly increased minimum nerve activity compared with enalaprilat in spontaneously hypertensive rats (similar trends were observed in Wistar-Kyoto rats). This increase in minimum nerve activity was blunted by enalaprilat CONCLUSIONS: These results indicate that pretreatment with an angiotensin converting enzyme inhibitor minimizes dihydropyridine-induced increases in sympathetic activity. This beneficial effect is attributable to suppression of minimum sympathetic activity. These data suggest that co-administration of an angiotensin converting enzyme inhibitor may improve the long-term cardiovascular benefit of dihydropyridine calcium channel blockers.

Muscle sympathetic nervous system activity in black and Caucasian hypertensive subjects.

OBJECTIVE: To compare muscle sympathetic nerve activity (MSNA) in age- and weight-matched African-Americans and American Caucasians with primary hypertension. DESIGN: Using microneurography, we compared MSNA at rest and in response to cold-pressor testing and handgrip exercise in 13 hypertensive African-Americans and 12 hypertensive American Caucasians. METHODS: All subjects were withdrawn from antihypertensive medications for at least 2 weeks before the study. MSNA was recorded from the left peroneal nerve. RESULTS: Resting MSNA was similar in the Blacks and the Caucasians. Increases in muscle efferent activity, mean arterial pressure and heart rate in response to the cold pressure and handgrip exercise were not significantly different in Black and in Caucasian subjects. CONCLUSION: MSNA, either at rest or in response to certain laboratory stressors, is not different in Black and in Caucasian hypertensive subjects with similar resting blood pressures.

Enalaprilat blunts reflexive increases in cardiac interstitial norepinephrine in conscious rats.

OBJECTIVE: We have reported that acute administration of enalaprilat, an angiotensin converting enzyme inhibitor, induces less reflexive increase in lumbar sympathetic nerve activity in spontaneously hypertensive rats (SHRs) than nicardipine, a dihydropyridine calcium-channel blocker. The current study was conducted to determine if angiotensin converting enzyme inhibitors likewise suppress cardiac sympathetic activation. DESIGN: Cardiac interstitial levels of norepinephrine were measured in fully conscious SHRs before and after acute blood pressure lowering with enalaprilat or nicardipine. METHODS: Microdialysis probes were inserted into the left ventricular wall of SHRs. Twenty-four to 48 hours post-implantation, myocardial interstitial fluid was collected in fully conscious rats during a 60-min baseline period. Mean arterial pressure was lowered 20 mmHg with intravenous infusion of enalaprilat or nicardipine. During continuous enalaprilat or nicardipine infusion, myocardial interstitial fluid was again collected. Norepinephrine levels were assayed in the perfusate. CONCLUSIONS: Enalaprilat-induced reduction in mean arterial pressure did not significantly increase cardiac interstitial norepinephrine levels. In contrast, nicardipine-induced reduction in blood pressure was associated with a significant increase in interstitial norepinephrine levels. These results indicate that enalaprilat suppresses reflexive sympathetic activation of the heart during acute blood pressure lowering. These results may be clinically relevant in that reductions in end-organ sympathetic stimulation may enhance the long-term cardiovascular benefit of angiotensin converting enzyme inhibitors.

Interaction between lifetime captopril treatment and NaCI-sensitive hypertension in spontaneously hypertensive rats and Wistar-Kyoto rats.

DESIGN: Previous studies that were based on daytime arterial pressure recordings indicate that lifetime treatment with captopril exacerbates the hypertensive response to a high NaCl diet in spontaneously hypertensive rats (SHR) but has no such effect in normotensive Wistar-Kyoto (WKY) rats. The present study used 24-h recording methods to examine the hypothesis that during the normal waking hours of rats (night-time) the hypertensive response to a high NaCl diet is exacerbated in SHR and induced in WKY rats treated with lifetime captopril. METHODS: SHR and WKY rats were (1) untreated, (2), lifetime captopril treated or (3) lifetime captopril treated but removed from the treatment 2 weeks prior to exposure to a high (8%) NaCl diet RESULTS: Compared to untreated SHR, in SHR that were continuously treated with captopril, the high NaCl diet caused a more rapid and greater rise in arterial pressure. Discontinuation of the captopril treatment did not significantly diminish this NaCl-sensitivity. In untreated WKY rats, the high NaCl diet did not alter mean arterial pressure, but in the lifetime captopril-treated WKY rats the high NaCl diet induced a rapid rise in arterial pressure. In WKY rats, discontinuation of the lifetime captopril treatment did not diminish this NaCl-induced rise in arterial pressure, even though baseline mean arterial pressure in this group is similar to that in untreated WKY rats. CONCLUSIONS: Lifetime captopril treatment accelerates the hypertensive response to a high NaCl diet in SHR, and it induces a similar response in WKY rats. In both strains, the lifetime captopril treatment causes a change in the response that is not dependent on concurrent administration of the drug. This finding further suggests that lifetime captopril treatment causes a long-term resetting of cardiovascular response mechanisms.

Neonatal alloimmune neutropenia in premature monozygous twins.

Alloimmune neonatal neutropenia (ANN) is an uncommon but potentially life-threatening disorder of the neonate and young infant. Hematologically, the mother's peripheral neutrophil count is normal. However, the passive transfer of maternal immunoglobulin G neutrophil-specific antibodies and the subsequent sensitization of fetal neutrophils can result in severe neutropenia in the neonate. Generally, ANN is a self-limiting condition, but with severe bacterial infection, mortality can be high. We present the clinical features of monozygous twins delivered at 33 weeks' postconception with this condition. This case report is unique in that it occurred in twins born prematurely and was attributable to antibodies against 2 neutrophil-specific antigens, NA1 and NB1. A brief review of the diagnosis, management, and treatment of ANN is presented.

Transfer of recombinant human granulocyte colony stimulating factor (rhG-CSF) from the maternal to the fetal circulation is not dependent upon a functional G-CSF-receptor.

Administration of granulocyte colony stimulating factor (G-CSF), a haematopoietic growth factor, to pregnant rats increases neutrophil production in the pups. The mechanism for the placental transfer is unknown, but it has been speculated to involve the placental G-CSF receptor (G-CSFR). The purpose of this study was to test that hypothesis. Pregnant mice were treated with a single subcutaneous dose of 50 microg/kg recombinant human G-CSF (rhG-CSF). Mice with an intact G-CSFR ("wild type", WT) and those with a homozygous deletion in the G-CSFR gene (G-CSFR deficient, "knock-out", KO) were studied. At intervals after injection, fetuses were delivered and maternal blood, amniotic fluid (AF) and fetal blood collected. G-CSF concentrations were measured using an enzyme linked immunosorbent assay specific for human G-CSF. Thirty minutes after injection, G-CSF was measurable in the AF (167+/-50 versus 445+/-217 pg/ml, mean+/-sem, WT versus KO) and fetal plasma (774+/-673 versus 427+/-121 pg/ml, WT versus KO). Peak concentrations occurred 2 h after injection in WT dams (572 542+/-41 262 pg/ml) and 4 h in KO dams (616 100+/-96 300 pg/ml). Therefore, in mice, a functional G-CSFR is not essential for the transfer of rhG-CSF from pregnant dams to their fetuses.

Production of granulocyte colony-stimulating factor by the human placenta at various stages of development.

The human placenta is capable of producing a variety of haematopoietic growth factors in vitro. It is not clear, however, whether the placenta produces such factors in vivo and if so, whether placental production of haematopoietic growth factors has a physiological role in fetal haematopoietic development. As a step toward making this determination, we assessed whether the onset of placental production of granulocyte colony-stimulating factor (G-CSF), in vivo, coincides with the onset of granulocytopoiesis in the developing fetus. To make this assessment, we obtained human placentae between 10 weeks of gestation and term and studied production of G-CSF in several ways. First, we sought to determine whether the onset of production of G-CSF mRNA in the placenta immediately precedes the appearance of neutrophil development in the fetus. Second, we assessed the effect of gestational age on the capacity of the placenta to generate G-CSF in vitro, by incubating cubes of placenta, with or without including interleukin-1 alpha (IL-1 alpha) in the culture media, and quantifying G-CSF in the cell culture supernatants 24 h later. Third, we assessed the rate of G-CSF production by the placenta, by perfusing two normal, term placentae using a membrane-oxygenator system, and quantifying G-CSF, at intervals, in the perfusates. We found: (1) no evidence that placental production of G-CSF is involved in regulating granulocytopoiesis in the fetus, (2) that the healthy placenta contains little or no G-CSF mRNA in vivo, (3) the placenta at term has a far greater capacity to produce G-CSF, when stimulated, than does the placenta before term, and (4) that although the placenta does not normally produce G-CSF in vivo, it has the capacity of generating very large quantities of G-CSF continuously over at least several days.

The calcium antagonists in the 1990s. An overview.

The calcium antagonists are effective in the treatment of essential hypertension. This quality, in addition to their ability to inhibit atherosclerotic lesion formation, may make them superior to other classes of antihypertensive agents in preventing vascular complications of mild to moderate hypertension. Preliminary results of clinical trials suggest that the calcium antagonists retard the progression of early atherosclerotic lesions in native coronary arteries and saphenous vein grafts, but have less effect on established lesions. Further study is needed to determine whether these agents have a favorable effect on the overall clinical outcome of patients with coronary artery disease. Clinical trials also suggest that the calcium antagonists retard the progression of renal insufficiency in hypertensive patients by mechanism(s) that do not depend on blood pressure lowering per se. Prospective studies with larger numbers of patients are needed to determine whether these apparent renoprotective effects are sustained for the long term in both diabetic and nondiabetic hypertensive populations. The dihydropyridine calcium antagonists are effective in reducing brain damage and mortality secondary to acute ischemic stroke. It is still unknown whether they are also effective in the primary and secondary prevention of ischemic stroke, and whether other classes of calcium antagonists are useful in the prevention and/or treatment of ischemic stroke. The potential antiatherosclerotic and cardio-, neuro-, and renoprotective effects of the calcium antagonists, coupled with their lack of adverse metabolic effects, have defined an expanding therapeutic role for these agents in the 1990s.

Granulocyte colony-stimulating factor in preterm and term pregnancy, parturition, and intra-amniotic infection.

OBJECTIVE: [corrected] To determine the sources of granulocyte colony-stimulating factor (G-CSF) in amniotic fluid and to examine its relation to labor and clinically diagnosed intra-amniotic infection. METHODS: We assessed G-CSF and G-CSF receptor expression in placentas (n = 50) from 5-40 weeks' gestation, and G-CSF concentrations were measured in amniotic fluid (n = 146), bronchoalveolar lavage fluid (n = 8), and paired maternal serum, cord blood, neonatal serum, and neonatal urine samples (n = 16). RESULTS: Immunohistochemical staining and messenger RNA analysis showed placental expression of G-CSF and G-CSF receptor throughout gestation. The number of decidual stromal cells expressing G-CSF receptor was significantly higher in women with intra-amniotic infection compared with women without infection (27 +/- 2 versus 18 +/- 3 cells per high power field, P =.02). Amniotic fluid concentrations of G-CSF were not significantly different in noninfected preterm compared with term samples (1708 +/- 1673 versus 1612 +/- 2100 pg/mL, P =.9). Labor was not associated with a significant increase in amniotic fluid G-CSF concentrations (1864 +/- 3151 versus 1612 +/- 2100 pg/mL, P =.77, term labor versus no labor; 3335 +/- 5364 versus 1708 +/- 1673 pg/mL, P =.09, preterm). Concentrations of G-CSF in maternal serum, amniotic fluid, bronchoalveolar lavage fluid, and neonatal urine were increased during intra-amniotic infection (all P <.05). CONCLUSION: Amniotic fluid G-CSF concentrations were similar in preterm and term pregnancies and were not significantly influenced by labor. Intra-amniotic infection was associated with an increased number of placental cells expressing the G-CSF receptor and higher concentrations of G-CSF in amniotic fluid, maternal serum, neonatal urine, and neonatal bronchoalveolar lavage samples.