Cellular proliferation in the placenta in normal human pregnancy and pregnancy complicated by intrauterine growth restriction

OBJECTIVE

To determine the incidence of cellular proliferation in the placenta throughout the three trimesters of normal pregnancy, and in the third trimester of pregnancy complicated by intrauterine growth restriction (IUGR).

METHODS

Placental samples were obtained from 17 first-trimester pregnancies, 9 second-trimester pregnancies, 33 uncomplicated third-trimester pregnancies, and 21 third-trimester pregnancies complicated by IUGR. These samples were then stained by immunohistochemical technique, using the monoclonal antibody MIB-1.

RESULTS

The incidences of cellular proliferation in the four groups were as follows: first trimester (n = 17): 11.8% of cells (8.51-17.04); second trimester (n = 9): 9.88% of cells (5.04-10.99); normal third trimester (n = 33): 3.15% of cells (2.07-3.7); IUGR third trimester (n = 21): 3.7% of cells (3.02-4.85). The decline in cellular proliferation throughout the three trimesters of pregnancy was statistically significant (P < .0001 Kruskall-Wallis test). The Spearman rank correlation for proliferative index against gestational age had a P value less than .0001 (Rho corrected for ties = -0.81). There was no statistically significant difference in the incidence of cellular proliferation between normal third-trimester and IUGR third-trimester samples.

CONCLUSION

The incidence of cellular proliferation in the placenta declines as pregnancy progresses, a finding that agrees with previous work by others. The incidence of cellular proliferation was not altered in cases of IUGR.

What is happening in the real world in lipid therapy and is it appropriate? The need for a paradigm shift

Cardiovascular disease is now the leading cause of death and disability in our society. Current strategies in the United States have been very effective in treating the symptomatic manifestations of severe obstructions but have done little to alter the long-term outcome of cardiovascular disease. Although lipid-lowering therapies have proven beneficial in secondary prevention for patients with cardiovascular disease, they are not as widely employed in contemporary practice as they should be. Better implementation of lipid-lowering therapies, including such major issues as clear treatment guidelines, physician and patient compliance, and delivery of healthcare and quality of care, must be addressed to shift thinking about the treatment of cardiovascular disease as we advance into the next century.

Subacute ventricular free-wall rupture presenting as tamponade without frank hemopericardium

Ventricular free-wall rupture is a well-known catastrophic complication of acute myocardial infarction. A significant number of patients present in a subacute fashion and can be successfully treated with surgery if diagnosed promptly. We present a case of subacute free-wall rupture that occurred after an undiagnosed myocardial infarction. The findings at pericardiocentesis were unusual in that the fluid was sanguinous but not frank hemopericardium. This patient represents the first known reported case to present without frank hemopericardium who survived and was successfully treated surgically. The absence of frank hemopericardium should not exclude the diagnosis of free-wall rupture.

Lessons from cholesterol-lowering trials

More than 13 million individuals have coronary artery disease (CAD), and in approximately 2 million patients with congestive heart failure, CAD is the underlying cause. The cost of treating cardiovascular disease has spiraled, yet only a small percentage of the total cost is spent on preventive medical therapies and lifestyle changes that can reduce the morbidity, mortality, and disability caused by heart disease. Recent trials of cholesterol-lowering therapies have clearly shown that this treatment approach, particularly the use of the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, can significantly reduce mortality from cardiovascular events and the need for expensive hospitalization and revascularization procedures. The challenge for clinicians is to apply the important lessons learned from these clinical trials to patient care. Recent data indicate that less than half of patients with CAD receive cholesterol-lowering therapy, and few meet the low-density lipoprotein (LDL) cholesterol goal. Clinicians treating CAD need to emphasize primary and secondary prevention and recognize the key role of cholesterol-lowering therapy.

Aging, physiology, and vision

This article provides an overview of the normal, physiologic changes in vision that are a part of the aging process. Associated symptoms noted by and worrisome to many patients also are discussed. Clear explanations of the rationale and cause of these concerning complaints reduces anxiety and enables people to function more safely in environments in which visual loss is likely to have a deleterious effect. Likewise, accurate understanding of normal versus pathological vision symptoms assists health care providers, such as nurse practitioners, to better triage, assess, and treat ophthalmic-related problems.

Improvement scaling (rehabilitation version). A new approach to measuring progress of patients in achieving their individual rehabilitation goals

OBJECTIVES

Accurate measurement of clinically relevant change in individual patients undergoing rehabilitation has been an elusive goal. Simple, clinically meaningful, patient-centered measures of individual patient change are urgently needed. The purpose of this research was the development and testing of Improvement Scaling (Rehabilitation Version)(IMS), a new approach to measuring the progress that rehabilitation patients make during treatment.

METHODS

Research and clinical staff developed the 65 IMS scales and applied them to all admissions to an an inpatient rehabilitation unit. Date were collected on 292 consecutively admitted rehabilitation patients who were aged 50 or older. An Improvement Score indicates the degree to which each patient achieves the expected level of outcome on his or her unique set of IMS goals. Improvement scores were compared to Goal Attainment Scores and to scores from more traditional measures. Interrater reliability was assessed.

RESULTS

IMS scores correlated r = .78 with comparable Goal Attainment Scores. IMS and Goal Attainment Scores had the same pattern of correlations with other measures. Interrater reliability of IMS scores was r = .91.

CONCLUSIONS

IMS appears to be a practical, reliable, valid, and clinically useful technique for measuring individual patient change. What is needed now is replication and more information on factors which may influence IMS scores. Versions of IMS are being developed for home health care and mental health. Applications of IMS for quality assurance, quality improvement, and documentation of patient change for third parties is discussed.

Diabetic retinopathy

This article describes and differentiates between the two primary forms of diabetic retinopathy, specifically, background and proliferative retinopathies. Current therapeutic treatment modalities are discussed in detail. Signs and symptoms that might prompt urgent referral by the nurse practitioner are overviewed and appropriate patient education strategies to foster optimal understanding and outcomes are discussed.

An immunocytochemical study of the distribution of proline-4-hydroxylase in normal, osteoarthritic and rheumatoid arthritic synovium at both the light and electron microscopic level

The monoclonal antibody 5B5 reacts with the beta subunit of proline-4-hydroxylase, the enzyme which catalyses the formation of 4-hydroxyl proline in collagen and other proteins with collagen-like amino acid sequences. This study aims to assess the production and tissue distribution of this enzyme in normal and diseased synovia from patients with various joint diseases, on the basis that it is a putative marker of collagen-producing cells and, therefore, in this context, of fibroblasts. Sections from five normal, 10 osteoarthritic (OA) and 26 rheumatoid arthritic (RA) synovia were labelled with a mouse monoclonal antibody to proline-4-hydroxylase. The enzyme was found to be expressed by a proportion of synovial intimal cells and by fibroblasts in the underlying connective tissue in normal, OA and RA synovia. Labelling was more pronounced in OA and RA cases. The intimal cells labelling positively showed type B synoviocyte morphology, which was confirmed by subsequent double immunolabelling with 5B5 and antibody against type IV collagen using immunocytochemistry and immunoelectron microscopy.

Isolation and molecular analysis of colonising and non-colonising strains of Campylobacter jejuni and Campylobacter coli following experimental infection of young chickens

Fourteen-day-old chickens were inoculated with selected Campylobacter coli and C. jejuni strains. C. jejuni strains were of two subgroups based on a polymorphism detected using a DNA probe and represented the profiles typical for the majority of strains of either chicken or human origin. All C. coli strains previously isolated from humans colonised chickens, whereas from 4/7 C. jejuni strains of human origin, failed to colonise. Of 12 Campylobacter strains of chicken origin, 10 established a persistent colonisation in the chickens, and 2 strains colonised poorly or not at all. Four strains that failed to colonise chickens were each inoculated into groups of five birds. Three strains again did not colonise any of the chickens and the fourth strain colonised four out of the five chickens, but was poorly excreted. When infected chickens were placed in the same enclosure to facilitate interchange of strains, C. jejuni strain 331 was found to be dominant and colonised all 12 chickens by 21 days, displacing all other strains. C. jejuni strain 331, was then inoculated into groups of five birds with previously established colonisation by C. jejuni and C. coli strains. Strain 331 was able to replace the C. jejuni strain in all five birds but established co-colonisation with C. coli strain. Naturally occurring co-colonisation by two C. jejuni strains was detected in one chicken out of 200 tested. There was no obvious correlation between the type of DNA polymorphism in strains of chicken origin and their ability to colonise chickens.

Risk reduction therapies for patients with coronary artery disease: a call for increased implementation

Recent decades have witnessed significant advances in the use of interventional procedures and medical therapies for relief of symptoms associated with obstructive coronary artery disease (CAD). At the same time, however, little progress has been made in understanding and implementing preventive therapy and risk reduction. Our traditional focus on treatment of severe coronary obstruction has addressed only part of the problem. We now need to adopt a more comprehensive approach aimed at the entire spectrum of atherosclerotic disease. Numerous clinical trials have demonstrated that risk-reduction strategies can produce marked decreases in the incidence of cardiovascular events as well as in total mortality. Despite this strong body of evidence, risk-reduction therapies continue to be underutilized. Comprehensive changes in healthcare delivery systems are needed to ensure that risk-reduction strategies become a routine part of care for patients with cardiovascular disease.

Increased placental apoptosis in intrauterine growth restriction

OBJECTIVES

Our purpose was to investigate a possible role for apoptosis in the pathophysiologic mechanisms of intrauterine growth restriction.

STUDY DESIGN

Placental samples were obtained from 43 uncomplicated third-trimester pregnancies and from 26 pregnancies complicated by intrauterine growth restriction. The definition used to identify cases of intrauterine growth restriction depended on three criteria: clinical evidence of suboptimal growth, ultrasonographic evidence of deviation from an appropriate growth percentile, and individualized birth weight ratios <10th percentile. Light microscopy was used to quantify the incidence of apoptosis. Electron microscopy and TUNEL (terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling) staining were used to confirm the occurrence of apoptosis.

RESULTS

Quantification of apoptosis (medians and interquartile ranges) resulted in the following values: normal third trimester (n = 43) 0.14% of cells (0.08% to 0.20%) and intrauterine growth restriction third trimester (n = 26) 0.24% of cells (0.16% to 0.29%). The incidence of apoptosis was significantly higher in placentas from pregnancies with intrauterine growth restriction compared with normal third-trimester placentas (p < 0.01, Mann Whitney U test).

CONCLUSIONS

These results suggest that apoptosis may play a role in the pathophysiologic mechanisms of intrauterine growth restriction.

Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-Y gastric bypass

BACKGROUND

Patients who suffer with gastroesophageal reflux Disease (GERD) endure a worsening of symptoms as their weight increases. When medical treatment of this condition in the morbidly obese patients fails, surgical intervention may be indicated. Choosing a procedure which not only helps achieve weight control but which also relieves symptoms and complications of GERD is the goal. We present a review of patients who have undergone Roux-en-Y Gastric Bypass (RYGBP) and related procedures for this disease.

METHODS

One hundred eighty-eight patients undergoing surgery for morbid obesity and for GERD in 1992-1996 were contacted by mail or phone. All of these patients had undergone preoperative esophagogastroduodenoscopy to grade the severity of their disease. Their preoperative symptoms were compared to those experienced postoperatively.

RESULTS

One hundred thirty patients underwent a RYGBP with modified Hill fundopexy, 22 patients underwent a distal gastrectomy with modified Hill fundopexy, 8 patients underwent distal gastrectomy alone and 28 patients underwent RYGBP alone. There have been no deaths. There were nine surgical complications, eight early and one at 2.5 years postoperation. Follow-up is 4-48 months. The average BMI dropped from 43 to 30.2 kg/m2. Whereas all patients were on some form of medical therapy before surgery, only 14 reported the need for medication postoperatively.

CONCLUSIONS

Surgical intervention for weight control and treatment of GERD has been highly successful in our experience both with respect to weight control and to the reduction of reflux symptoms. Depending upon endoscopic and operative findings a RYGBP with or without an antireflux procedure can provide dramatic improvement. Gastrectomy with antireflux modifications is appropriate in selected cases.

Review of recent clinical trials of lipid lowering in coronary artery disease

Early trials with lipid-lowering therapy in patients with established coronary artery disease revealed favorable trends in cardiovascular events but did not yield significant reductions in total mortality. Recent clinical trials using hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor ("statin") therapy have shown significant decreases in total mortality, cardiovascular events, hospitalizations, and the need for revascularization procedures, with its usage (1) to lower low-density lipoprotein (LDL) cholesterol after myocardial infarction (secondary prevention); and (2) in high-risk patients without evidence for coronary artery disease (primary prevention). Secondary prevention benefits have been seen for both men and women, in the young and elderly, and among diabetic and nondiabetic patients. The beneficial effects of LDL-cholesterol reduction occur early and are additive to other risk-reduction therapies. Lipid-lowering therapy should be part of the comprehensive treatment of all patients with atherosclerotic vascular disease and patients at high risk.

Performance assessment model for guideline-recommended pharmacotherapy in the secondary prevention of coronary artery disease and treatment of left ventricular dysfunction

The Agency for Health Care Policy and Research, the National Heart Lung and Blood Institute of the National Institutes of Health, the American Heart Association, and the American College of Cardiology have all developed guidelines for improving the care of patients with cardiovascular disease. The guidelines include recommendations for intensive lipid-lowering therapy in patients with coronary artery disease (CAD) and angiotensin-converting enzyme (ACE) inhibitors in those patients with symptomatic heart failure and asymptomatic left ventricular dysfunction. Despite clinical trial evidence and consensus that these therapies improve survival in high-risk patients, data suggest that there is wide variation in the delivery of guideline-based care. To investigate whether evidence-based assessment of provider practice patterns can impact the delivery of quality cost-effective care, Merck and Company, in conjunction with leading cardiology group practices, the University of North Carolina at Chapel Hill, and Medical Review of North Carolina developed an ambulatory medical record abstraction study. This quality assurance initiative was conducted at practices beginning in the spring of 1996 and continues. Medical records and administrative claims of patients with ischemic heart disease or heart failure were abstracted by a healthcare consulting organization to maintain patient and physician confidentiality. As of mid-July 1997, 626 group practices had completed the medical record abstraction process, with > 1,136 practices participating at some stage of the project; >6,000 physicians participated in the project and >270,000 patients charts were abstracted. Analysis of these data will provide insight and benchmark patterns of care in the pharmacologic management of heart failure and CAD. This project represents a unique collaboration between a pharmaceutical company, an academic institution, a Peer Review Organization, and practicing physicians, to support evidence-based best medical practices.

Acute myocardial infarction caused by a myocardial bridge treated with intracoronary stenting

The clinical significance of myocardial bridges (MBs) is variable, and most patients are asymptomatic. However, angina, myocardial infarction, and sudden death have been reported in association with MBs. Here we describe the use of intracoronary stenting for the treatment of a patient with an anterior myocardial infarction due to an MB.