Randomized Controlled Trial of a Cohesive Eight-Week Evolution Unit That Incorporates Molecular Genetics and Principles of the Next Generation Science Standards.

In response to calls for curricular materials that integrate molecular genetics and evolution and adhere to the K-12 Next Generation Science Standards (NGSS), the Genetic Science Learning Center (GSLC) at the University of Utah has developed and tested the "Evolution: DNA and the Unity of Life" curricular unit for high school biology. The free, 8-week unit illuminates the underlying role of molecular genetics in evolution while providing scaffolded opportunities to engage in making arguments from evidence and analyzing and interpreting data.  We used a randomized controlled trial design to compare student learning when using the new unit with a condition in which teachers used their typical (NGSS-friendly) units with no molecular genetics. Results from nationwide testing with 38 teachers (19 per condition) and their 2269 students revealed that students who used the GSLC curriculum had significantly greater pre/post gain scores in their understanding of evolution than students in the comparison condition; the effect size was moderate. Further, teacher implementation data suggest that students in the treatment condition had more opportunities to engage in argumentation from evidence and have in-class discussions than students in the comparison classes. We consider study implications for the secondary and postsecondary science education community.

Mapping of pain circuitry in early post-natal development using manganese-enhanced MRI in rats.

Premature or ill full-term infants are subject to a number of noxious procedures as part of their necessary medical care. Although we know that human infants show neural changes in response to such procedures, we know little of the sensory or affective brain circuitry activated by pain. In rodent models, the focus has been on spinal cord and, more recently, midbrain and medulla. The present study assesses activation of brain circuits using manganese-enhanced magnetic resonance imaging (MEMRI). Uptake of manganese, a paramagnetic contrast agent that is transported across active synapses and along axons, was measured in response to a hindpaw injection of dilute formalin in 12-day-old rat pups, the age at which rats begin to show aversion learning and which is roughly the equivalent of full-term human infants. Formalin induced the oft-reported biphasic response at this age and induced a conditioned aversion to cues associated with its injection, thus demonstrating the aversiveness of the stimulation. Morphometric analyses, structural equation modeling and co-expression analysis showed that limbic and sensory paths were activated, the most prominent of which were the prefrontal and anterior cingulate cortices, nucleus accumbens, amygdala, hypothalamus, several brainstem structures, and the cerebellum. Therefore, both sensory and affective circuits, which are activated by pain in the adult, can also be activated by noxious stimulation in 12-day-old rat pups.

Snapshot of Vibrio parahaemolyticus densities in open and closed shellfish beds in Coastal South Carolina and Mississippi.

Vibrio parahaemolyticus is a Gram negative, halophilic bacterium that is ubiquitous in warm, tropical waters throughout the world. It is a major cause of seafood-associated gastroenteritis and is generally associated with consumption of raw or undercooked seafood, especially oysters. This study presents a snapshot of total V. parahaemolyticus densities in surface waters and shellstock American oysters (Crassostrea virginica) from open and closed shellfish harvesting areas, as well as "more rural areas" on two different US coasts, the Atlantic and the Gulf. Sampling was conducted from 2001 to 2003 at five sites near Charleston/Georgetown, SC and at four locations in the Gulfport/Pascagoula, MS area. V. parahaemolyticus numbers were determined by a direct plating method using an alkaline-phosphatase-labeled DNA probe targeting the species-specific thermolabile hemolysin gene (tlh) that was used for identification of bacterial isolates. The greatest difference between the two coasts was salinity; mean salinity in SC surface waters was 32.9 ppt, whereas the mean salinity in MS waters was 19.2 ppt, indicating more freshwater input into MS shellfish harvesting areas during the study period. The mean V. parahaemolyticus numbers in oysters were almost identical between the two states (567.4 vs. 560.1 CFU/g). Bacterial numbers in the majority of surface water samples from both states were at or below the limit of detection (LOD = <10 CFU/mL). The bacterial concentrations determined during this study predict a low public health risk from consumption of oysters in shellfish growing areas on either the Gulf or the Atlantic US coast.

Clinical and diagnostic developments of a gamma interferon release assay for use in bovine tuberculosis control programs.

Currently, the Bovigam assay is used as an official supplemental test within bovine tuberculosis control programs. The objectives of the present study were to evaluate two Mycobacterium bovis-specific peptide cocktails and purified protein derivatives (PPDs) from two sources, liquid and lyophilized antigen preparations. PPDs and peptide cocktails were also used for comparison of a second-generation gamma interferon (IFN-γ) release assay kit with the currently licensed first-generation kit (Bovigam; Prionics AG). Three strains of M. bovis were used for experimental challenge: M. bovis 95-1315, M. bovis Ravenel, and M. bovis 10-7428. Additionally, samples from a tuberculosis-affected herd (i.e., naturally infected) were evaluated. Robust responses to both peptide cocktails, HP (PC-HP) and ESAT-6/CFP10 (PC-EC), and the PPDs were elicited as early as 3 weeks after challenge. Only minor differences in responses to Commonwealth Serum Laboratories (CSL) and Lelystad PPDs were detected with samples from experimentally infected animals. For instance, responses to Lelystad M. avium-derived PPD (PPDa) exceeded the respective responses to the CSL PPDa in M. bovis Ravenel-infected and control animals. However, a 1:4 dilution of stimulated plasma demonstrated greater separation of PPDb from PPDa responses (i.e., PPDb minus PPDa) with the use of Lelystad PPDs, suggesting that Lelystad PPDs provide greater diagnostic sensitivity than CSL PPDs. The responses to lyophilized and liquid antigen preparations did not differ. Responses detected with first- and second-generation IFN-γ release assay kits (Bovigam) did not differ throughout the study. In conclusion, antigens may be stored in a lyophilized state without loss in potency, PC-HP and PC-EC are dependable biomarkers for aiding in the detection of bovine tuberculosis, and second-generation Bovigam kits are comparable to currently used kits.

Altered expression and chromatin structure of the hippocampal IGF1r gene is associated with impaired hippocampal function in the adult IUGR male rat.

Exposure to intrauterine growth restriction (IUGR) is an important risk factor for impaired learning and memory, particularly in males. Although the basis of IUGR-associated learning and memory dysfunction is unknown, potential molecular participants may be insulin-like growth factor 1 (Igf1) and its receptor, IGF1r. We hypothesized that transcript levels and protein abundance of Igf1 and IGF1r in the hippocampus, a brain region critical for learning and memory, would be lower in IUGR male rats than in age-matched male controls at birth (postnatal day 0, P0), at weaning (P21) and adulthood (P120). We also hypothesized that changes in messenger Ribonucleic acid (mRNA) transcript levels and protein abundance would be associated with specific histone marks in IUGR male rats. Lastly, we hypothesized that IUGR male rats would perform poorer on tests of hippocampal function at P120. IUGR was induced by bilateral ligation of the uterine arteries in pregnant dams at embryonic day 19 (term is 21 days). Hippocampal Igf1 mRNA transcript levels and protein abundance were unchanged in IUGR male rats at P0, P21 or P120. At P0 and P120, IGF1r expression was increased in IUGR male rats. At P21, IGF1r expression was decreased in IUGR male rats. Increased IGF1r expression was associated with more histone 3 lysine 4 dimethylation (H3K4Me2) in the promoter region. In addition, IUGR male rats performed poorer on intermediate-term spatial working memory testing at P120. We speculate that altered IGF1r expression in the hippocampus of IUGR male rats may play a role in learning and memory dysfunction later in life.

Exploring fecal indicator bacteria in a constructed stormwater wetland.

Microbial pollution in surface waters is a concern throughout the world, with both public health and economic implications. One contributing source to such pollution is stormwater runoff, often treated using various types of stormwater control measures. However, relatively little is known regarding microbe sequestration in constructed stormwater wetlands (CSWs), one type of commonly installed stormwater control measure. In this study, indicator bacteria concentrations in both the water and sediment of a CSW were evaluated at multiple locations. Results suggested that fecal coliform concentrations in stormwater runoff decrease through the system, with relatively consistent concentrations noted throughout the second half of the wetland. This potentially indicates a baseline concentration of fecal coliform is present due to internal processes such as animal activity and microbial persistence. However, wetland sediments showed little E. coli present during most sampling events, with minimal patterns existing with respect to sediment sampling location. CSW designs should promote optimization of hydraulic retention time and minimization of stormwater velocities to promote sedimentation and degradation of microbes by way of wetland treatment functions.

Early postnatal growth of low birthweight infants in the WIC program.

Patterns of early postnatal growth were analyzed among low birthweight infants enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Infants were divided into four groups according to their neonatal status: (1) term, normal birthweight (NBW); (2) term, low birthweight (LBW); (3) moderately preterm LBW; and (4) very preterm LBW. Comparison of mean weight and length z-scores indicated that term NBW and very preterm LBW infants were at or near the national reference averages at 8, 12, and 18 months. Term LBW and moderately preterm infants were lighter and shorter than the other two study groups at each visit. Term LBW and moderately preterm infants displayed evidence of catch-up growth during the study period. Catch-up growth was defined as a decrease in the percentage of infants below the 10th percentile for weight. The effect of neonatal body proportions on postnatal growth was investigated in term LBW infants. The infants were divided into two groups based on their ponderal index (PI) at birth (low PI and proportionate PI). Comparison of weight and length z-scores indicated that both groups of term LBW infants improved in z-scores between birth and the first visit (approximately 8 months). However, infants with evidence of asymmetric intrauterine growth restriction (low PI) continued to improve in weight and length z-scores, whereas those with symmetric growth restriction (proportionate PI) remained lighter and shorter.

The positive predictive value of cervical smears in previously screened postmenopausal women: the Heart and Estrogen/progestin Replacement Study (HERS).

BACKGROUND: The benefits and risks of performing annual cervical smears on postmenopausal women are not well defined. The independent effect of hormone replacement therapy on development of cytologic abnormalities is unknown. OBJECTIVE: To determine the positive predictive value of cervical smears in previously screened postmenopausal women and to determine the effect of oral estrogen plus progestin on incident cervical cytologic abnormalities. DESIGN: Prospective cohort study (incidence) and randomized, double-blind, placebo-controlled trial (hormone therapy). SETTING: 20 U.S. outpatient and community clinical centers. PARTICIPANTS: 2561 women with a uterus and normal cytologic characteristics at baseline. INTERVENTIONS: Annual smears; oral conjugated equine estrogens, 0. 625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, or identical placebo. MEASUREMENTS: Incident cytologic abnormalities (atypical squamous cells of undetermined significance, atypical glandular cells of undetermined significance, low-grade squamous epithelial lesion, and high-grade squamous epithelial lesion) and final histologic diagnoses. RESULTS: The incidence of new cytologic abnormalities in the 2 years following a normal smear was 110 per 4895 person-years (23 per 1000 person-years [95% CI, 18 to 27 per 1000 person-years]). Among the 103 women with known histologic diagnoses, one had mild to moderate dysplasia. The positive predictive value of any smear abnormality identified 1 year after a normal smear, therefore, was 0% (CI, 0% to 5.0%) (0 of 78 women); the positive predictive value of abnormalities found within 2 years was 0.9% (CI, 0.0% to 3.0%) (1 of 110 women). In hormone-treated compared with non-hormone-treated women, the incidence of cytologic abnormalities was nonsignificantly higher (relative hazard, 1.36 [CI, 0.93 to 1.99]), largely because of a nonsignificant 58% greater incidence of atypical squamous cells of undetermined significance (relative hazard, 1.58 [CI, 0.99 to 2.52]). CONCLUSIONS: Because of a poor positive predictive value, cervical smears should not be performed within 2 years of normal cytologic results in postmenopausal women. Therapy with oral estrogen plus progestin does not significantly affect the incidence of cytologic abnormalities.

Health care social workers' views of ethical issues, practice, and policy in end-of-life care.

End-of-life care decision making is perhaps the most difficult practice situation faced by health care social workers. Complex ethical issues arise from decisions regarding use of advancing medical technologies and/or other artificial treatments that may prolong life and/or compromise its quality. NASW has set forth a policy to help guide social workers dealing with end-of-life care decisions and the preservation of client self-determination in these situations. However, the present study (N = 63) revealed that a majority (57%) of social workers were not aware of the existence of, or were only somewhat familiar with the policy. Ethical dilemmas most often faced in end-of-life care situations related primarily to issues of communication between and among patients, families, and professionals. Practitioners indicated that more specific practice guidelines and increased education regarding bioethics and issues of end-of-life care are needed to be effective in assisting patients and families in end-of-life decision making.

Changes in women's fear of success and fear of appearing incompetent in business.

The primary purpose of this research was to examine whether fear of success and of appearing incompetent among women have changed recently. Another purpose was to examine whether such fears differed among women who hold Traditional views and those who hold Progressive views about the roles of women in the workplace. The Fear of Success Scale, the Fear of Appearing Incompetent Scale, and the Attitude Toward Women Scale were completed by 61 male and 52 female graduating seniors. Significant differences were found between the groups for scores on the Attitude Toward Women Scale, but none between the sexes for scores on the Fear of Success Scale or the Fear of Appearing Incompetent Scale. Significant differences were found, however, on the latter two scales when women were separated into Traditional and Progressive groups.

Gastric necrosis after fundoplication: a novel approach for esophageal preservation.

An 11-year-old boy presented moribund, with massive abdominal distension. A Nissen fundoplication and gastrostomy tube had been established at age 2 years. After attempts to pass a nasogastric tube were unsuccessful, the old gastrostomy site was used to gain percutaneous access to the stomach resulting in release of gastric contents and stabilization of blood pressure and perfusion. During operation, massive gastric distention with gastric necrosis was found. Subtotal gastrectomy was performed with stapled closure of the distal intraabdominal esophagus and prepyloric region. Sump suction was placed in the proximal esophagus and the abdomen was drained widely. A distal esophageal perforation was apparent on postoperative day 19 confirmed by imaging and endoscopy. A nasoesophageal tube was passed into the abdomen, tied to a Jackson-Pratt drain, and the composite tube repositioned in the midesophagus allowing controlled proximal and distal drainage. Six months later, a Hunt-Laurence esophagojejunal pouch was created. At age 13, the child is clinically well, and enjoys 50% of his nutritional needs orally, with the remainder delivered overnight via tube feedings. This case describes gastric necrosis after gas bloat syndrome as a late complication of Nissen fundoplication. A novel approach to the management of distal esophageal perforation allowed preservation of a functional, intact native esophagus.

Immunopotentiation with low-dose cyclophosphamide in the active specific immunotherapy of cancer.

This paper reviews the use of low-dose cyclophosphamide (CY) with active specific immunotherapy in patients with advanced melanoma and other metastatic cancers, and outlines the basic scientific research that supports this use. In various animal models, CY augments delayed-type hypersensitivity responses, increases antibody production, abrogates tolerance, and potentiates antitumor immunity. The mechanism of CY immunopotentiation involves inhibition of a suppressor function, as indicated by extensive work in the MOPC-315 plasmacytoma murine model. Human studies of the immunopotentiating effect of CY have yielded both positive and negative results. Toxicity associated with low-dose CY has been mild in these studies. Results of efficacy have been variable for reasons such as small sample sizes, short follow-up periods, and the weaker immunogenicity of human tumor-associated antigens. Although beneficial clinical outcomes have been observed in historically controlled trials, there are few randomized, controlled trials that evaluate outcome in relation to CY immunopotentiation of active specific immunotherapy. Additional randomized, controlled trials should be done to examine the clinical efficacy of CY immunopotentiation of therapeutic cancer vaccines.

Matrix metalloproteinase expression in human retinal microvascular cells.

The degree of hyperglycemia correlates with the development of diabetic retinopathy. We investigated the effect of glucose on the expression of matrix metalloproteinase (MMP)-2 and MMP-9 (72-kDa and 92-kDa type IV collagenases, respectively) by human retinal microvascular endothelial cells (HRECs). Cultured HRECs from nondiabetic and diabetic donors were exposed to 5 or 30 mmol/l glucose. Using gelatin zymography, conditioned medium (CM) from all cultures revealed a gelatinolytic band migrating at 65 kDa (representing the proform of MMP-2 that runs at 72 kDa under reducing conditions). This band was unchanged by glucose exposure or the disease state of the donors. CM from nondiabetic HREC cultures demonstrated an additional proteolytic activity migrating at 90 kDa when cells were exposed to 30 mmol/l glucose, but not when they were exposed to 5 mmol/l glucose. This same activity was seen in CM from HREC cultures of diabetic origin in the presence of both 5 and 30 mmol/l glucose. Western analysis confirmed the identity of the 65-kDa band as MMP-2. The anomalous activity at 90 kDa was identified as MMP-2 associated and co-migrating with a fibronectin fragment. Competition-based reverse transcription-polymerase chain reaction revealed that nondiabetic and diabetic HRECs expressed constitutively mRNA for MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP)-1, TIMP-2, and fibronectin. After exposure to 5 or 30 mmol/l glucose, no changes were detected in mRNA levels in MMP-2 or MMP-9, their inhibitors TIMP-1 and TIMP-2, or fibronectin in either nondiabetic or diabetic HREC cultures. These results support the notion that modulation of MMP function by extracellular matrix components occurs in response to glucose and may be relevant to the development of diabetic retinopathy.

Pharmacokinetics of once-daily gentamicin dosing in pediatric patients.

BACKGROUND/PURPOSE: To achieve cost-effective health care in adults, once-daily aminoglycosides administration has been used and judged to be safe and efficacious. A similar strategy in children requires the characterization of pharmacokinetic parameters and the development of a therapeutic monitoring protocol for this antibiotic regimen. METHODS: A prospective, controlled, randomized (2:1) study was undertaken in 50 pediatric patients between June 1995 and September 1997. Children between 6 months and 18 years who required gentamicin therapy based on independent clinical assessment were eligible if they had normal renal function, no aminoglycoside allergies, were not neutropenic, or did not have cystic fibrosis. Measurements included a peak, 4-hour, 8-hour, and trough gentamicin levels to determine volume of distribution (Vd) and elimination constant (Ke). Ototoxicity and nephrotoxicity were monitored by pre- and postaudiology examinations and serial calculated creatinine clearance determinations, respectively. RESULTS: Thirty-three patients received 7.5 mg/kg every 24 hours, and 17 patients received 2.5 mg/kg every 8 hours. Most frequent indications for treatment were ruptured appendicitis (n = 19) followed by wound infections caused by trauma (n = 4), but the spectrum of treatment was broad including enteric, genitourinary, central nervous system, biliary, ophthalmologic, and orthopedic infections. Pharmacokinetic data indicated that 24-hour dosing resulted in higher peak levels compared with 8-hour dosing (20.4 +/- 45.4 v 7.2 +/- 6.2 mg/L, P < .0001) and lower trough levels (0.29 +/- .02 v 0.69 +/- 0.13, P < .0001), whereas rate of elimination constant and volume of distribution were not significantly different. No nephrotoxicity or ototoxicity has been noted in either group. CONCLUSIONS: These data confirm that once-daily dosing of gentamicin is a safe method of treatment that provides equivalent pharmacokinetics compared with traditional dosing and enhances bactericidal effect based on higher peak levels, avoids toxicity, and allows cost savings.

Estrogen replacement reverses endothelial dysfunction in postmenopausal women.

PURPOSE: To measure the effect of long-term clinical hormone replacement therapy on brachial artery vasomotor responses, and to compare these responses in premenopausal and postmenopausal women. PATIENTS AND METHODS: We studied 23 postmenopausal women, including 18 who were evaluated prior to starting clinically indicated oral hormone replacement therapy. Twelve postmenopausal women received estrogen alone, the other 6 were treated with estrogen/medroxyprogesterone combinations. Eleven premenopausal volunteers served as a comparison group. Change in brachial artery diameter in response to postischemic hyperemic flow and sublingual nitroglycerin was measured by ultrasound. RESULTS: The 18 postmenopausal subjects receiving hormone replacement showed a progressive improvement in their postischemic vasodilation. Mean (+/-SD) postischemic vasodilation was 0.4%+/-7.1% prior to estrogen replacement. There were significant increases in postischemic vasodilation of 4.8%+/-6.6% after 1 month and 8.3%+/-3.4% after 6 months of estrogen replacement. The response to nitroglycerin was similar at all time points studied. Women with the most abnormal responses to hyperemic flow at baseline demonstrated the greatest improvement after 6 months of hormone replacement therapy. Premenopausal and postmenopausal subjects differed in their response to hyperemic flow, with premenopausal women showing 5.8% vasodilatation compared with a 0.6% vasodilation in postmenopausal women (P=0.046). CONCLUSIONS: Endothelial function is abnormal in many postmenopausal women compared with premenopausal women, and in some postmenopausal women it can be enhanced by estrogen replacement therapy. This effect may increase with prolonged use.

Venovenous bypass in adult orthotopic liver transplantation: routine or selective use?

BACKGROUND: The role of venovenous bypass (VVB) during orthotopic liver transplantation (OLT) remains controversial. The aims of this study were to evaluate the current role of VVB at all major centers in North America, to examine the results of OLT and complications of VVB between two periods with a strict policy for routine versus selective use of VVB, and to review the literature. STUDY DESIGN: A survey of 50 major liver transplant centers was conducted using mailed questionnaires. A retrospective chart review was performed for 547 OLT patients having transplantation during two distinct periods with a strict policy for routine versus selective use of VVB at the University of Toronto, Canada, and at Duke University Medical Center, Durham, North Carolina. The literature was reviewed with a focus on the benefits and indications for routine versus selective use of VVB. RESULTS: Thirty-eight (76%) of 50 centers responded. Sixteen (42%) of them used VVB routinely, with a reported complication rate of 10-30%. Lymphocele and hematoma were the most common complications, but patients having major vascular injury, air embolism, and death were reported. A recent change to selective use of VVB was reported in 30% of the centers (11 of 38). In the Duke-Toronto series, the complication rates were similar between the two periods, at 13.4% and 18.8%, respectively. The outcome of OLT was not influenced by the policy of routine or selective use of VVB. CONCLUSIONS: There is a trend away from the routine use of VVB during OLT. Intraoperative hemodynamic instability during the hepatectomy and a failed trial of hepatic venous occlusion were the most important criteria for using VVB. We conclude that VVB should be used selectively to avoid associated complications and to decrease operative time and costs.

Laparoscopic Ladd's procedure in infants with malrotation.

PURPOSE: This clinical study was undertaken to examine the feasibility of a laparoscopic approach for the treatment of documented malrotation. METHODS: From May 1994 through January of 1997, 12 patients, aged 5 days to 4 months, weighing 3 to 7 kg, underwent laparoscopic Ladd's procedure for malrotation. All patients had symptoms of intermittent upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study. None of the patients had acute volvulus or compromised bowel. The procedure was performed using 3 trocars of 3.5 mm diameter. Ports were placed in the infraumbilical ring, and the right and left mid to lower quadrants. A standard Ladd's procedure with appendectomy was performed in all cases. RESULTS: All procedures were completed successfully through the laparoscope. Operative times averaged 58 minutes (35 to 120 minutes). One patient with Pierre-Robin underwent a laparoscopic Nissen fundoplication and gastrostomy tube placement at the same time requiring 120 minutes. Feedings were started on postoperative day (POD) 1 in 10 cases and POD 2 in two cases. Hospital stay ranged from 2 to 4 days (average, 2.2) in the patients with isolated malrotation. The patient with Pierre-Robin had a prolonged hospitalization because of chronic respiratory problems not associated with surgery. There were no complications. All patients had resolution of their symptoms. CONCLUSIONS: Laparoscopic Ladd's procedure is a safe and effective technique. It can be performed in neonates in times equivalent to standard open techniques, and it appears to allow for earlier feeds and decreased hospital stays.

[Diagnosis and therapy of acute rejection in patients after orthotopic heart transplantation]. / Diagnostika a liecba akútnej rejekcie u pacientov po ortotopickej transplantácii srdca.

OBJECTIVE: In organ allotransplantation represents a serious problem acute rejection, which is the reaction of recipient organism aimed to reject the transplanted organ. AIM: To obtain experience in the field of routine long term are of patients after heart transplantation living in Slovakia. METHOD: 33 patients after orthotopic heart transplantation (HTx) were included in our long term care by the 1. June 1996. According to the accepted protocol we make the whole set of examinations is performed. This includes endomyocardial biopsy which is the only reliable method for the detection of rejection and also the criterion of sufficiency of immunosuppressive therapy. RESULTS: Acute rejection was revealed in 14 (43%) patients. CONCLUSIONS: Tactics of therapy and the length of the interval to subsequent biopsy were determined according to the histological findings of preceding biopsy, the clinical status and the combination of immunosuppression therapy. (Tab. 2, Ref. 13.)

Human cytotrophoblast differentiation/invasion is abnormal in pre-eclampsia.

During human placental development, cytotrophoblast stem cells differentiate and invade the uterus. Simultaneously, the cells modulate their expression of several classes of stage-specific antigens that mark transitions in the differentiation process and play a role in either uterine invasion (integrin cell-extracellular matrix receptors and matrix metalloproteinase-9) or immune interactions (HLA-G). The pregnancy disease pre-eclampsia is associated with shallow cytotrophoblast invasion. Previously we showed, by immunofluorescence localization on placental tissue, that in pre-eclampsia invasive cytotrophoblasts fail to properly modulate their integrin repertoire. This finding suggests possible abnormalities in the differentiation pathway that leads to uterine invasion. Here we used a culture system that supports this differentiation process to compare the differentiative and invasive potential of cytotrophoblasts obtained from control (n = 8, 22 to 38 weeks) and pre-eclamptic (n = 9, 24 to 38 weeks) placentas. In culture, the cells from pre-eclamptic placentas failed to properly modulate alpha1 integrin and matrix metalloproteinase-9 expression at the protein and mRNA levels. Their invasive potential was also greatly reduced. Likewise, the cells failed to up-regulate HLA-G protein and mRNA expression. These results suggest that defective cytotrophoblast differentiation/invasion can have significant consequences to the outcome of human pregnancy (ie, development of pre-eclampsia) and that, by the time delivery becomes necessary, the defect is not reversed by removing the cells from the maternal environment.

Extended cervicomediastinal thymectomy in the integrated management of myasthenia gravis.

OBJECTIVE: The authors evaluated the response to extended cervicomediastinal thymectomy as a component of the integrated management of patients with myasthenia gravis in a large series of patients from a single institution. The authors evaluated the response to therapy with respect to a graded, multivariate, ordinal scale chosen to reflect the full range of the disease's manifestations. SUMMARY BACKGROUND DATA: A number of series, of varying sizes, describe the response of patients with myasthenia gravis to thymectomy primarily with respect to the bivariate endpoint of the presence or absence of "remission." These studies fail to describe the full spectrum of postoperative disease severity and have been unable to quantify definitively the influence of putative prognostic variables, nor to assess definitively the statistical significance of apparent improvements over time. METHODS: The authors evaluated 202 consecutive patients who underwent trans-sternal thymectomy for symptomatic myasthenia gravis from 1969 through 1996 at the Johns Hopkins Hospital. The response to surgery, combined with postoperative medical therapy, was evaluated by a standardized scale reflecting the full spectrum of the disease. These data were analyzed by a novel mean multivariate regression analysis, which allowed the quantification of the statistical significance of apparent responses over time and the evaluation of the independent influence of each of nine putative prognostic indicators. RESULTS: There was no perioperative mortality and a 33% perioperative morbidity. There was a marked clinical response at 6 months to 1 year after surgery that was sustained for at least 10 years thereafter. The median increment of improvement was two (of five) classes. Eighty-six percent and 83% of the patients had improved by at least one class at 5 and 10 years, respectively. These changes were statistically significant (p < 0.001). Whereas the use of extended cervicomediastinal thymectomy was associated with a greater than twofold chance of improvement, compared to conventional trans-sternal thymectomy, neither the pathologic diagnosis (presence of thymoma) nor the age at surgery proved to be negative predictors of postoperative response. CONCLUSIONS: Extended cervicomediastinal thymectomy is the procedure of choice as a component of the integrated management of myasthenia gravis, with significant improvement seen in the group as a whole, as well as in subgroups of patients with thymoma and those older than 40 years of age.