Requirement for Wnt3 in vertebrate axis formation.

Several studies have implicated Wnt signalling in primary axis formation during vertebrate embryogenesis, yet no Wnt protein has been shown to be essential for this process. In the mouse, primitive streak formation is the first overt morphological sign of the anterior-posterior axis. Here we show that Wnt3 is expressed before gastrulation in the proximal epiblast of the egg cylinder, then is restricted to the posterior proximal epiblast and its associated visceral endoderm and subsequently to the primitive streak and mesoderm. Wnt3-/- mice develop a normal egg cylinder but do not form a primitive streak, mesoderm or node. The epiblast continues to proliferate in an undifferentiated state that lacks anterior-posterior neural patterning, but anterior visceral endoderm markers are expressed and correctly positioned. Our results suggest that regional patterning of the visceral endoderm is independent of primitive streak formation, but the subsequent establishment of anterior-posterior neural pattern in the ectoderm is dependent on derivatives of the primitive streak. These studies provide genetic proof for the requirement of Wnt3 in primary axis formation in the mouse.

Spatial Analysis and Lead-Risk Assessment of Philadelphia, USA.

Childhood lead poisoning is an issue that continues to plague major U.S. cities. Despite efforts by the Philadelphia Department of Public Health to curtail systemic childhood lead poisoning, children continue to be identified with elevated blood lead levels. The persistence of elevated blood lead levels in children is concerning because lead poisoning has been linked to decreases in academic achievement and IQ, with associated repercussions for entire communities. This paper reports the results of an analysis of the spatial distribution of houses with lead paint (i.e., pre-1978), demolitions, and occurrence of historic smelters, in West and North Philadelphia, relative to elevated blood lead level data, to determine which lead sources act as primary lead-risk factors. The presence of lead paint in homes and the number of demolitions of older properties were found to have the highest correlations to elevated blood lead levels for children in Philadelphia. Using lead-risk factors including lead paint, housing code violations, demolitions, and owner-occupied housing units, a lead-risk assessment was performed at the census tract level to identify future soil sampling sites and high-risk neighborhoods in Philadelphia. These sites of high risk for lead exposure, and in particular the census tracts 175 and 172, should be prioritized for lead poisoning prevention initiatives.

Allometry of sexual size dimorphism in dioecious plants: do plants obey Rensch's rule?

Rensch's rule refers to a pattern in sexual size dimorphism (SSD) in which SSD decreases with body size when females are the larger sex and increases with body size when males are the larger sex. Many animal taxa conform to Rensch's rule, but it has yet to be investigated in plants. Using herbarium collections from New Zealand, we characterized the size of leaves and stems of 297 individuals from 38 dioecious plant species belonging to three distantly related phylogenetic lineages. Statistical comparisons of leaf sizes between males and females showed evidence for Rensch's rule in two of the three lineages, indicating SSD decreases with leaf size when females produce larger leaves and increases with leaf size when males produce larger leaves. A similar pattern in SSD was observed for stem sizes. However, in this instance, females of small-stemmed species produced much larger stems than did males, but as stem sizes increased, SSD often disappeared. We hypothesize that sexual dimorphism in stem sizes results from selection for larger stems in females, which must provide mechanical support for seeds, fruits, and dispersal vectors, and that scaling relationships in leaf sizes result from correlated evolution with stem sizes. The overall results suggest that selection for larger female stem sizes to support the weight of offspring can give rise to Rensch's rule in dioecious plants.

Insertion of a telomere repeat sequence into a mammalian gene causes chromosome instability.

Telomere repeat sequences cap the ends of eucaryotic chromosomes and help stabilize them. At interstitial sites, however, they may destabilize chromosomes, as suggested by cytogenetic studies in mammalian cells that correlate interstitial telomere sequence with sites of spontaneous and radiation-induced chromosome rearrangements. In no instance is the length, purity, or orientation of the telomere repeats at these potentially destabilizing interstitial sites known. To determine the effects of a defined interstitial telomere sequence on chromosome instability, as well as other aspects of DNA metabolism, we deposited 800 bp of the functional vertebrate telomere repeat, TTAGGG, in two orientations in the second intron of the adenosine phosphoribosyltransferase (APRT) gene in Chinese hamster ovary cells. In one orientation, the deposited telomere sequence did not interfere with expression of the APRT gene, whereas in the other it reduced mRNA levels slightly. The telomere sequence did not induce chromosome truncation and the seeding of a new telomere at a frequency above the limits of detection. Similarly, the telomere sequence did not alter the rate or distribution of homologous recombination events. The interstitial telomere repeat sequence in both orientations, however, dramatically increased gene rearrangements some 30-fold. Analysis of individual rearrangements confirmed the involvement of the telomere sequence. These studies define the telomere repeat sequence as a destabilizing element in the interior of chromosomes in mammalian cells.

Superoxide dismutase does not cause scar thinning after myocardial infarction.

Previous studies demonstrated that treatment with superoxide dismutase, a scavenger of superoxide anions, limits the extent of myocardial injury in a canine preparation of regional myocardial ischemia and reperfusion. Little is known, however, about the effects of superoxide dismutase on the healing of a myocardial infarct. Therefore, this study was performed to determine whether treatment with superoxide dismutase during myocardial ischemia impairs formation of scar tissue after infarction. Dogs received 2 hour infusions of superoxide dismutase or albumin (controls) by way of the left atrium beginning 15 minutes before and ending 15 minutes after a 90 minute occlusion of the left circumflex coronary artery. Six weeks later the animals were killed. Two-dimensional echocardiography was performed before surgery and before induced death. Wall thickening in the central ischemic zone was decreased at 6 weeks compared with baseline studies (p less than 0.05), but the decrease was similar for both groups. The hydroxyproline concentrations (microgram/mg dry weight) of the scar tissue in the superoxide dismutase and control groups, respectively, were 35.3 +/- 3.8 and 28.7 +/- 5.0 (p less than 0.05). The ratios of the scar thickness to normal wall thickness were superoxide dismutase 0.91 +/- 0.03 and control 0.89 +/- 0.03 (p greater than 0.05). Thus, superoxide dismutase had no adverse effect on wall thickening or scar formation assessed 6 weeks after myocardial infarction, and may be useful to limit oxygen radical-mediated damage during reperfusion of the ischemic myocardium.

Invasive fungal infections in patients with chronic mucocutaneous candidiasis.

Patients with chronic mucocutaneous candidiasis have persistent Candida infection of nails, skin, and mucous membranes, but rarely, if ever, does an invasive fungal infection develop. We describe two patients with chronic mucocutaneous candidiasis who died of fungal infection; one had C albicans meningitis and the second had Cryptococcus neoformans meningitis. The cases of four other patients with chronic mucocutaneous candidiasis and invasive fungal infection, three with crytococcosis and one with histoplasmosis, have been reported previously. Immunological profiles on these six patients revealed no differences from those of other patients with chronic mucocutaneous candidiasis without invasive fungal infection. Three of the four patients who received amphotericin B were cured of their infection; three patients died, including one patient with overwhelming cryptococcosis who had received intensive antifungal therapy and transfer factor.

Bradycardic responses to vagally mediated bedside maneuvers in healthy volunteers.

PURPOSE: To determine the relative potency in healthy individuals of the vagally mediated reflexes used clinically to inhibit sinoatrial and atrioventricular node function. SUBJECTS AND METHODS: Twenty healthy volunteers with no history of heart disease performed face immersion in cold water and the Valsalva maneuver twice, to maximum endurance and to the subjective point of first discomfort, and face immersion in warm water and the Müller maneuver to maximum endurance only. Right and left carotid massage and left, right, and bilateral eyeball compression were each performed for 15 seconds. Change in heart rate was taken as baseline minus the rate over the slowest three consecutive QRS cycles elicited by each maneuver. Fisher's least-significant-difference multiple comparison procedure was used to analyze heart rate responses. Significance was defined as p less than or equal to 0.05. RESULTS: Maximum pulse decrements from baseline and 95% confidence intervals in beats/minute were as follows: cold-water face immersion to maximum endurance 15.5 (12.3 to 18.5), cold-water face immersion to first discomfort 10.1 (6.7 to 13.1), Valsalva maneuver to maximum endurance 9.2 (6.3 to 12.4), Valsalva maneuver to first discomfort 8.3 (5.0 to 11.3), right carotid massage 7.3 (4.3 to 10.3), left carotid massage 5.2 (2.3 to 8.4), right eyeball compression 6.0 (3.1 to 9.2), left eyeball compression 6.6 (3.6 to 9.5), bilateral eyeball compression 6.0 (3.1 to 9.2), warm-water face immersion 7.0 (3.2 to 9.8), and Müller maneuver 1.6 (-1.3 to 4.9). Bradycardia was significantly greater for cold-water immersion of the face performed to maximum endurance than for all other maneuvers. CONCLUSION: In healthy subjects, the diving reflex is the most potent of the vagally mediated reflexes utilized in clinical practice. Immersion of the face in cold water may prove effective at the bedside when other maneuvers fail to augment vagal tone adequately.

Clinical evaluation of transient myocardial ischemia during daily life.

Ambulatory ST-segment monitoring has been introduced in an attempt to obtain an objective measure of transient myocardial ischemia during daily life. Serial observations conducted out of the hospital have produced a picture of the nature and activity of ischemic heart disease that differs markedly from that obtained by conventional assessment. Episodes of transient ischemia appear to be more frequent and prolonged than is suggested by the occurrence of chest pain. Furthermore, only a minority of episodes are associated with tachycardia, and most occur at heart rates well below those achieved during exercise testing. This suggests that mechanisms other than an excessive increase in myocardial oxygen demand may be responsible for the many episodes occurring outside the hospital. Accurate interpretation of this new information depends on the reliability of transient ST-segment depression as a marker of ischemia. In 100 normal volunteers, episodes of significant ST-segment depression similar to that observed in patients with angina were rare (2 percent). Positron emission tomography with rubidium-82 was used to study regional myocardial perfusion during transient ST-segment depression with and without pain in patients with angina and coronary disease. All episodes of painless ST-segment depression and 97 percent of episodes with angina were accompanied by tomographic evidence of ischemia. This much broader view of ischemic heart disease, revealed by studies performed out of the hospital during patients' ordinary daily activities, has important implications for the objective assessment of symptoms, the relief of ischemia, and the prevention of myocardial damage.

Silent myocardial ischemia during mastication.

Ambulatory outpatient monitoring of patients with angina suggests a different view of myocardial ischemia than is conventionally obtained from in-hospital tests. Multiple episodes of ST segment depression occur, and the majority of these disturbances are not associated with symptoms. Recently, studies of regional myocardial perfusion using the technique of positron emission tomography with rubidium 82 have confirmed the ischemic nature of these silent ST changes. Furthermore, activities of everyday life such as mental stress or cold exposure seem to provoke both symptomatic and asymptomatic ischemia, as judged by ST depression and reduced cation uptake. This report presents an unusual case of silent myocardial ischemia observed during the chewing of food.

Clinical problems in coronary disease are caused by wide variety of ischemic episodes that affect patients out of hospital.

Transient ischemia arising from proximal events in epicardial coronary arteries causes important symptoms, such as angina pectoris, and is usually studied in the hospital with provocative tests. However, Holter monitoring of ST-segment disturbances in patients out of the hospital has shown frequent asymptomatic evidence of ischemia that is surprisingly prolonged and that is not associated with the obvious tachycardia of exercise or stress. Positron emission tomography has been developed to measure the regional myocardial uptake of a cation (rubidium-82) in order to assess repeatedly the directional changes in regional coronary blood flow during these events. This method has been used to show that both symptomatic and asymptomatic episodes of ST depression are reliably associated with disturbances in regional myocardial perfusion. The daily activities of patients have been analyzed and reproduced in the hospital to assess the effects of cold stimulation, mental arithmetic, cigarette smoking, and exercise. Physical exercise was associated with angina, ST-segment change, and regional abnormalities of myocardial perfusion, including decreased perfusion in poststenotic segments. The other tests caused the same disturbances in myocardial perfusion; these perfusion disturbances were mostly asymptomatic and surprisingly prolonged, with periods of recovery that were two to five times longer than the ST-segment disturbance and the pain. Current studies using a structured diary indicate that the episodes of transient ischemia occurring out of the hospital are more frequently associated with different levels of mental arousal than with any other activity. Physical exercise is a relatively infrequent cause of transient ischemia. The examination of coronary blood flow using provocative tests derived from the patients' own activities out of the hospital have confirmed that, irrespective of the pattern of angina, patients have frequent episodes of asymptomatic transient ischemia that are surprisingly prolonged and that these episodes occur in response to previously unsuspected ordinary daily activities. The disturbances in coronary blood flow usually include a regional decrease in myocardial perfusion that can only be explained by pathophysiologic events in the proximal epicardial coronary arteries.

Use of short- and long-lived rubidium tracers for the study of transient ischemia.

Positron emission tomography (PET) with rubidium-82 (82Rb) has been developed to measure regional myocardial perfusion and to detect transient ischemia both in the experimental laboratory and in humans. There are known and separate contaminating effects of the 82Rb signal by disturbances in wall motion, wall thinning, and the partial volume effect that occur during transient ischemia. In nine anesthetized greyhounds, PET with 82Rb (T1/2 = 78 sec) was used to determine the regional myocardial uptake of this cation during a control period that consisted of a mild stenosis of the left anterior descending coronary artery in the absence of ischemia (to limit reactive hyperemia), during 10 min of total occlusion and, finally, at 30 and 60 min of recovery with release of the occlusion but not of the stenosis. Separately, rubidium-81 (81Rb); T1/2 = 4.58 hr) was given as a peripheral intravenous injection 2 hr before the study to allow this long-lived tracer to distribute in the potassium space of the myocardium. Observations during control and ischemia revealed marked decreases in 82Rb uptake (0.84 +/- 0.12 to 0.28 +/- 0.12, p = 0.001) in affected regions and were paralleled by similar decreases in microsphere blood flow (0.88 +/- 0.08 to 0.12 +/- 0.10 ml/min/g, p = 0.003), which gradually recovered by 60 min postischemia. Lesser decreases in 81Rb activity (0.84 +/- 0.11 to 0.76 +/- 0.17, p = 0.83) were observed in the same regions during ischemia, but these were immediately reversible. Separate in vitro postmortem experiments in eight rabbits confirmed a linear relationship between plasma and myocardial activities of stable potassium and 81Rb although there was a greater concentration of 81Rb in the myocardium that in the plasma relative to potassium (y = -3.29 +/- 0.79 x, s.e.e. 1.91, r = 0.95). These studies demonstrate that if 81Rb is given intravenously to distribute into the potassium pool, tomograms of the heart may be recorded to measure the potassium-rich mass of myocardium providing information about the acute effects of wall thinning during ischemia. Rubidium-81 used in this way may be helpful in assessing the effects of wall thinning and/or scar when other tracers are being used to assess perfusion or metabolism.

Transient ischemia in angina pectoris: frequent silent events with everyday activities.

To help characterize episodes of transient myocardial ischemia, 80 patients with chronic stable angina and evidence of obstructive coronary disease were studied by ambulatory electrocardiographic (ECG) monitoring outside the hospital to detect both symptomatic and asymptomatic episodes of ST-segment depression. In addition, patients were tested on an outpatient basis by means of positron emission tomography to assess regional coronary blood flow under different conditions. All patients showed ECG evidence of transient ischemia, with or without symptoms, while active outside the hospital. In-hospital testing showed that symptomatic and asymptomatic disturbances in regional coronary blood flow occurred with normal everyday activities and were not caused by physical exertion involving marked increases in heart rate and blood pressure. Most of these provocations were followed by a decrease in coronary blood flow in a poststenotic segment of myocardium and, like the ischemic events monitored out of hospital, the majority were silent. Many of these features characterizing the activity of ischemic heart disease may not be apparent from a patient's anginal history or results of hospital diagnostic testing.

Direct effects of smoking on the heart: silent ischemic disturbances of coronary flow.

Cigarette smoking is strongly associated with ischemic heart disease and acute coronary events. The effect of smoking a single cigarette on regional myocardial perfusion was studied in 13 chronic smokers with typical stable angina pectoris using positron emission tomography and rubidium-82 (82Rb). Findings were compared with the effects of physical exercise. After exercise, 8 patients (61%) had angina, ST depression and abnormal regional myocardial perfusion. Uptake of 82Rb increased from 49 +/- 8 to 60 +/- 7 in remote myocardium, but decreased from 46 +/- 3 to 37 +/- 5 in an ischemic area. The remaining 5 patients (39%) had homogeneous increases in 82Rb uptake without angina or ST depression. After smoking, 6 of the 8 patients with positive exercise test responses had a decrease in 82Rb uptake, from 47 +/- 3 to 35 +/- 6 in the same segment of myocardium affected during exercise. However, in contrast to exercise, the events during smoking were largely silent. The absolute decreases in regional 82Rb uptake after smoking occurred at significantly lower levels of myocardial oxygen demand than after exercise. This suggests that an impairment of coronary blood supply is responsible. Thus, in smokers with coronary artery disease, each cigarette can cause profound silent disturbances of regional myocardial perfusion that are likely to occur frequently during daily life. Such repeated insults may represent an important mechanism linking smoking with coronary events.

Exercise testing three days after onset of acute myocardial infarction.

To determine the feasibility and predictive value of early exercise testing 72 hours after acute myocardial infarction, 109 consecutive patients who received reperfusion therapy were prospectively evaluated. In the group studied, in 87 (80%) the course was uncomplicated 3 days after admission, as defined by a lack of congestive heart failure, arrhythmias and angina, and 53 patients (49%) performed heart rate-limited (140 beats/min) treadmill exercise. These patients exercised for 7.9 +/- 3.4 minutes, achieving a heart rate of 129 +/- 11 beats/min and a systolic blood pressure of 151 +/- 27 mm Hg. The exercise test was not accompanied by any protracted ischemia, infarction or significant arrhythmias. Accompanying tomographic thallium-201 scintigraphy demonstrated a reversible perfusion defect in 14 patients (26%), no evidence for ischemia in 36 patients (69%) and an equivocal result in 3 patients (6%). Of the 14 patients with a positive exercise-thallium test result, 4 had an adverse clinical outcome of either reinfarction, postinfarction angina or ventricular tachycardia during hospital days 4 to 10; an adverse in-hospital outcome was not seen in the 40 patients with a negative exercise-thallium test result (p = 0.009). Thus, early exercise testing after acute myocardial infarction is safe in selected patients with an uncomplicated course and the test is predictive of in-hospital clinical outcomes.

Implications of increased left ventricular mass index on in-hospital outcomes in patients undergoing aortic valve surgery.

BACKGROUND: Increased left ventricular mass index has been shown to be associated with higher mortality in epidemiologic studies. However, the effect of increased left ventricular mass index on outcomes in patients undergoing aortic valve replacement is unknown. METHODS: We studied 473 consecutive patients undergoing elective aortic valve replacement to assess the influence of left ventricular mass index on outcomes in patients having this procedure. Echocardiographic left ventricular dimensions were used to calculate left ventricular mass index (considered increased if >134 g/m(2) in male patients and >110 g/m(2) in female patients). RESULTS: Left ventricular mass index was increased in 24% of patients undergoing aortic valve replacement. Postprocedural complications (respiratory failure, renal insufficiency, congestive heart failure, and atrial and ventricular arrhythmias), length of stay in the intensive care unit, and in-hospital mortality were increased in patients with increased left ventricular mass index. Multivariable analysis identified prior valve surgery (odds ratio, 4.3; 95% confidence interval, 1.2-15.7; P =.030), left ventricular ejection fraction (odds ratio, 1.07; 95% confidence interval, 1.01-1.14; P =.020), history of hypertension (odds ratio, 8.2; 95% confidence interval, 2.2-30.4; P =.002), history of liver disease (odds ratio, 50.4; 95% confidence interval, 4.2-609.0; P =.002), and increased left ventricular mass index (odds ratio, 38; 95% confidence interval, 9.3-154.1; P <.001) as independent predictors of in-hospital mortality. Furthermore, low output syndrome was identified as the most common mode of death (36%) after aortic valve replacement in patients with increased left ventricular mass index. CONCLUSIONS: Increased left ventricular mass index is associated with increased adverse in-hospital clinical outcomes in patients undergoing aortic valve replacement. Although this finding warrants special modification in perioperative management, further studies are needed to address whether outcomes in asymptomatic patients with aortic valve disease could be improved by earlier aortic valve replacement before a significant increase in left ventricular mass index.

Haemostatic mechanism in uraemia.

The haemostatic mechanism was investigated in 20 patients with renal failure, of whom nine had evidence of a bleeding tendency. A defect of platelet function was the most common finding. The effect of dialysis on the bleeding state is briefly discussed, and a scheme for the routine investigation of haemostasis in renal failure is put forward.

A new coagulation defect associated with a case of melanomatosis.

A marked abnormality of the intrinsic coagulation system was observed in a patient with melanomatosis and frank melanuria. With successful treatment of the tumour there was a parallel improvement in the clotting abnormality. This defect was shown to be a deficiency of factor XI together with a previously unrecognised factor. This is distinct from either Fletcher or Fitzgerald factors and appears to act between factors XI and X in the coagulation sequence.

Abridged differential leucocyte counts provided by a Coulter Channelyzer in a routine haematology laboratory.

We have used automated differential leucocyte counts by volume analysis for the past six months after initial evaluation had shown several advantages--namely, accuracy, simplicity, speed, and low cost. We describe the operation of the Coulter Channelyzer Model C-1000, which is linked to a Coulter Model S cell counter, analyse the cost, and comment on the clinical and laboratory consequences of adopting this method.

Laboratory control of heparin therapy.

The effect of heparin therapy was followed in 50 patients treated for thrombo-embolic disease. Individual response to a standard dose of 40,000 units of heparin daily showed a considerable variation and the effect was not constant on subsequent days. Five of the 50 patients developed a serious haemorrhage. It is proposed that to ensure the adequacy of treatment detectable levels of heparin should be obtained but because of the high risk of bleeding these levels should not be excessive. The results suggest that control of heparin therapy can be based on the thrombin clotting time. Using this test it is advised that treatment is monitored daily in order to achieve a plasma heparin level of up to 1 mg per 100 ml.

Persistent ST-segment elevation following pericardiocentesis: caution with thrombolytic therapy.

We report a case of persistent electrocardiographic ST-elevation following pericardiocentesis despite lack of evidence for transmural infarction or vasospasm. The electrocardiographic pattern was felt to reflect subepicardial injury due to a small myocardial laceration. The implications of this finding are discussed.