Little time, lasting impact: Bereaved caregiver perceptions of legacy in perinatal and infant loss

BACKGROUND

Legacy interventions are standard in most children's hospital, but little is known about how bereaved parents understand and describe the concept of legacy that these interventions are designed to document. The aim of this qualitative study was to understand the legacy experiences and perceptions of parents who have experienced perinatal or early infant (less than three months of age) loss.

METHODS

Grounded in constructionist epistemology and phenomenological qualitative traditions, ten bereaved parents completed an in-depth phenomenological interview regarding their perceptions of and experiences with the legacy of their deceased child. Interviews were transcribed verbatim and analyzed using an open, inductive coding process to illuminate the essence of participants' experiences.

RESULTS

Three themes were identified: 1) legacies are composed of memories and experiences that have a lasting effect on others; 2) healthcare experiences both generate and participate in infants' legacies; and 3) parents' legacy perceptions are shaped by cultural conceptions, spiritual beliefs, and grief experiences. Parents described experiences and interactions with community members and healthcare providers that honored or challenged their perceptions of their child's unique legacy.

CONCLUSIONS

In the context of perinatal or early infant loss, bereaved parents describe legacy as enduring, unique to each child and family, and heavily influenced by healthcare experiences and staff relationships. Parent-led, legacy-oriented interventions are needed in maternal/fetal, labor/delivery, and neonatal intensive care settings to support parent coping with loss.

Aerobic Partial Oxidation of Alkanes Using Photodriven Iron Catalysis

Photodriven oxidations of alkanes in trifluoroacetic acid using commercial and synthesized Fe(III) sources as catalyst precursors and dioxygen (O₂) as the terminal oxidant are reported. The reactions produce alkyl esters and occur at ambient temperature in the presence of air, and catalytic turnover is observed for the oxidation of methane in a pure O₂ atmosphere. Under optimized conditions, approximately 17% conversion of methane to methyl trifluoroacetate at more than 50% selectivity is observed. It is demonstrated that methyl trifluoroacetate is stable under catalytic conditions, and thus overoxidized products are not formed through secondary oxidation of methyl trifluoroacetate.

Co-option of Plasmodium falciparum PP1 for egress from host erythrocytes

Asexual proliferation of the Plasmodium parasites that cause malaria follows a developmental program that alternates non-canonical intraerythrocytic replication with dissemination to new host cells. We carried out a functional analysis of the Plasmodium falciparum homolog of Protein Phosphatase 1 (PfPP1), a universally conserved cell cycle factor in eukaryotes, to investigate regulation of parasite proliferation. PfPP1 is indeed required for efficient replication, but is absolutely essential for egress of parasites from host red blood cells. By phosphoproteomic and chemical-genetic analysis, we isolate two functional targets of PfPP1 for egress: a HECT E3 protein-ubiquitin ligase; and GCα, a fusion protein composed of a guanylyl cyclase and a phospholipid transporter domain. We hypothesize that PfPP1 regulates lipid sensing by GCα and find that phosphatidylcholine stimulates PfPP1-dependent egress. PfPP1 acts as a key regulator that integrates multiple cell-intrinsic pathways with external signals to direct parasite egress from host cells.

Quantitative comparative analysis of human erythrocyte surface proteins between individuals from two genetically distinct populations

Red blood cells (RBCs) play a critical role in oxygen transport, and are the focus of important diseases including malaria and the haemoglobinopathies. Proteins at the RBC surface can determine susceptibility to disease, however previous studies classifying the RBC proteome have not used specific strategies directed at enriching cell surface proteins. Furthermore, there has been no systematic analysis of variation in abundance of RBC surface proteins between genetically disparate human populations. These questions are important to inform not only basic RBC biology but additionally to identify novel candidate receptors for malarial parasites. Here, we use 'plasma membrane profiling' and tandem mass tag-based mass spectrometry to enrich and quantify primary RBC cell surface proteins from two sets of nine donors from the UK or Senegal. We define a RBC surface proteome and identify potential Plasmodium receptors based on either diminished protein abundance, or increased variation in RBCs from West African individuals.

Whole-Genome Analysis Illustrates Global Clonal Population Structure of the Ubiquitous Dermatophyte Pathogen Trichophyton rubrum

Dermatophytes include fungal species that infect humans, as well as those that also infect other animals or only grow in the environment. The dermatophyte species Trichophyton rubrum is a frequent cause of skin infection in immunocompetent individuals. While members of the T. rubrum species complex have been further categorized based on various morphologies, their population structure and ability to undergo sexual reproduction are not well understood. In this study, we analyze a large set of T. rubrum and T. interdigitale isolates to examine mating types, evidence of mating, and genetic variation. We find that nearly all isolates of T. rubrum are of a single mating type, and that incubation with T. rubrum "morphotype" megninii isolates of the other mating type failed to induce sexual development. While the region around the mating type locus is characterized by a higher frequency of SNPs compared to other genomic regions, we find that the population is remarkably clonal, with highly conserved gene content, low levels of variation, and little evidence of recombination. These results support a model of recent transition to asexual growth when this species specialized to growth on human hosts.

Multi-electron reduction of sulfur and carbon disulfide using binuclear uranium(iii) borohydride complexes

The first use of a dinuclear UIII/UIII complex in the activation of small molecules is reported. The octadentate Schiff-base pyrrole, anthracene-hinged 'Pacman' ligand LA combines two strongly reducing UIII centres and three borohydride ligands in [M(THF)4][{U(BH4)}2(μ-BH4)(LA)(THF)2] 1-M, (M = Li, Na, K). The two borohydride ligands bound to uranium outside the macrocyclic cleft are readily substituted by aryloxide ligands, resulting in a single, weakly-bound, encapsulated endo group 1 metal borohydride bridging the two UIII centres in [{U(OAr)}2(μ-MBH4)(LA)(THF)2] 2-M (OAr = OC6H2t Bu3-2,4,6, M = Na, K). X-ray crystallographic analysis shows that, for 2-K, in addition to the endo-BH4 ligand the potassium counter-cation is also incorporated into the cleft through η5-interactions with the pyrrolides instead of extraneous donor solvent. As such, 2-K has a significantly higher solubility in non-polar solvents and a wider U-U separation compared to the 'ate' complex 1. The cooperative reducing capability of the two UIII centres now enforced by the large and relatively flexible macrocycle is compared for the two complexes, recognising that the borohydrides can provide additional reducing capability, and that the aryloxide-capped 2-K is constrained to reactions within the cleft. The reaction between 1-Na and S8 affords an insoluble, presumably polymeric paramagnetic complex with bridging uranium sulfides, while that with CS2 results in oxidation of each UIII to the notably high UV oxidation state, forming the unusual trithiocarbonate (CS3)2- as a ligand in [{U(CS3)}2(μ-κ2:κ2-CS3)(LA)] (4). The reaction between 2-K and S8 results in quantitative substitution of the endo-KBH4 by a bridging persulfido (S2)2- group and oxidation of each UIII to UIV, yielding [{U(OAr)}2(μ-κ2:κ2-S2)(LA)] (5). The reaction of 2-K with CS2 affords a thermally unstable adduct which is tentatively assigned as containing a carbon disulfido (CS2)2- ligand bridging the two U centres (6a), but only the mono-bridged sulfido (S)2- complex [{U(OAr)}2(μ-S)(LA)] (6) is isolated. The persulfido complex (5) can also be synthesised from the mono-bridged sulfido complex (6) by the addition of another equivalent of sulfur.

Plasmodium falciparum CRK4 directs continuous rounds of DNA replication during schizogony

Plasmodium parasites, the causative agents of malaria, have evolved a unique cell division cycle in the clinically relevant asexual blood-stage of infection¹. DNA replication commences approximately halfway through the intracellular development following invasion and parasite growth. The schizont stage is associated with multiple rounds of DNA replication and nuclear division without cytokinesis resulting in a multinucleated cell. Nuclei divide asynchronously through schizogony, with only the final round of DNA replication and segregation being synchronous and coordinated with daughter cell assembly^2,3. However, the control mechanisms for this divergent mode of replication are unknown. Here we show that the Plasmodium-specific kinase PfCRK4 is a key cell cycle regulator that orchestrates the multiple rounds of DNA replication throughout schizogony in P. falciparum. PfCRK4 depletion led to a complete block in nuclear division and profoundly inhibited DNA replication. Quantitative phosphoproteomic profiling identified a set of PfCRK4-regulated phosphoproteins with greatest functional similarity to CDK2 substrates, particularly proteins involved in origin of replication firing. PfCRK4 was required for the initial and subsequent rounds of DNA replication during schizogony, and in addition was essential for development in the mosquito vector. Our results identified an essential S phase promoting factor of the unconventional P. falciparum cell cycle. PfCRK4 is required for both a prolonged period of the intraerythrocytic blood-stage of malaria infection, as well as for transmission, revealing a broad window for PfCRK4-targeted chemotherapeutics.

Ancient human sialic acid variant restricts an emerging zoonotic malaria parasite

Plasmodium knowlesi is a zoonotic parasite transmitted from macaques causing malaria in humans in Southeast Asia. Plasmodium parasites bind to red blood cell (RBC) surface receptors, many of which are sialylated. While macaques synthesize the sialic acid variant N-glycolylneuraminic acid (Neu5Gc), humans cannot because of a mutation in the enzyme CMAH that converts N-acetylneuraminic acid (Neu5Ac) to Neu5Gc. Here we reconstitute CMAH in human RBCs for the reintroduction of Neu5Gc, which results in enhancement of P. knowlesi invasion. We show that two P. knowlesi invasion ligands, PkDBPβ and PkDBPγ, bind specifically to Neu5Gc-containing receptors. A human-adapted P. knowlesi line invades human RBCs independently of Neu5Gc, with duplication of the sialic acid-independent invasion ligand, PkDBPα and loss of PkDBPγ. Our results suggest that absence of Neu5Gc on human RBCs limits P. knowlesi invasion, but that parasites may evolve to invade human RBCs through the use of sialic acid-independent pathways.

Contrasting host-pathogen interactions and genome evolution in two generalist and specialist microsporidian pathogens of mosquitoes

Obligate intracellular pathogens depend on their host for growth yet must also evade detection by host defenses. Here we investigate host adaptation in two Microsporidia, the specialist Edhazardia aedis and the generalist Vavraia culicis, pathogens of disease vector mosquitoes. Genomic analysis and deep RNA-Seq across infection time courses reveal fundamental differences between these pathogens. E. aedis retains enhanced cell surface modification and signalling capacity, upregulating protein trafficking and secretion dynamically during infection. V. culicis is less dependent on its host for basic metabolites and retains a subset of spliceosomal components, with a transcriptome broadly focused on growth and replication. Transcriptional profiling of mosquito immune responses reveals that response to infection by E. aedis differs dramatically depending on the mode of infection, and that antimicrobial defensins may play a general role in mosquito defense against Microsporidia. This analysis illuminates fundamentally different evolutionary paths and host interplay of specialist and generalist pathogens.

Kinannote, a computer program to identify and classify members of the eukaryotic protein kinase superfamily

Motivation: Kinases of the eukaryotic protein kinase superfamily are key regulators of most aspects eukaryotic cellular behavior and have provided several drug targets including kinases dysregulated in cancers. The rapid increase in the number of genomic sequences has created an acute need to identify and classify members of this important class of enzymes efficiently and accurately.

Results: Kinannote produces a draft kinome and comparative analyses for a predicted proteome using a single line command, and it is currently the only tool that automatically classifies protein kinases using the controlled vocabulary of Hanks and Hunter [Hanks and Hunter (1995)]. A hidden Markov model in combination with a position-specific scoring matrix is used by Kinannote to identify kinases, which are subsequently classified using a BLAST comparison with a local version of KinBase, the curated protein kinase dataset from www.kinase.com. Kinannote was tested on the predicted proteomes from four divergent species. The average sensitivity and precision for kinome retrieval from the test species are 94.4 and 96.8%. The ability of Kinannote to classify identified kinases was also evaluated, and the average sensitivity and precision for full classification of conserved kinases are 71.5 and 82.5%, respectively. Kinannote has had a significant impact on eukaryotic genome annotation, providing protein kinase annotations for 36 genomes made public by the Broad Institute in the period spanning 2009 to the present.

Availability: Kinannote is freely available at http://sourceforge.net/projects/kinannote.

Contact:jmgold@broadinstitute.org

Supplementary information:Supplementary data are available at Bioinformatics online.

Abstract P4-11-06: Automatic referral to genetic counseling for identification of BRCA1/2 mutations: a pilot program at Norton Cancer Institute, Louisville, KY

BACKGROUND: Identifying a hereditary cancer syndrome has the potential to significantly impact a patient's treatment and long-term management, as well as prevent future malignancies among relatives. Therefore, referral of patients appropriate for genetic counseling and testing is critical. Providers traditionally initiate patient referral; however, this can lead to inconsistent referrals and results in failure to refer more than 50% of appropriate individuals, according to recent studies. In an attempt to address these quality issues, we developed an automatic referral program using the National Comprehensive Cancer Network guidelines, which was approved through our cancer committee and implemented 10/1/10. This pilot was conducted within a genetic counseling program staffed by board certified genetic counselors and associated with a private, multi-disciplinary oncology practice that is part of an American College of Surgeons accredited Network Cancer Center. Our Cancer Center is part of a five-hospital integrated healthcare system and a part of the National Cancer Institute Community Cancer Centers Program network.

METHODS: We conducted weekly reviews of oncology patients scheduled for upcoming appointments to identify individuals diagnosed with breast cancer before age 50 or with ovarian, fallopian, or primary peritoneal cancer at any age. Patients previously referred to our genetic counseling program were excluded. Providers were notified weekly of their patients identified via this program, with the option to decline referral. We undertook a retrospective review of the outcomes of individuals identified from 10/1/10 through 10/1/11, with follow up as of 6/1/12. IRB approval was obtained through the University of Louisville.

RESULTS: We identified 521 patients for referral, 24 (4.6%) of whom were declined by a provider, resulting in 497 referrals. Three hundred forty one (69%) referrals had breast cancer and 156 (31%) had other malignancies. Of referrals, 139 (28%) have been seen, 223 (45%) have declined, and 135 (27%) are in process. Testing was pursued by 108 (78%) of referrals seen, all of whom had BRCA1/2 testing and 5 (4.6%) of whom had additional testing. We identified 11 (10%) individuals with a BRCA1/2 mutation. An additional 17 (16%) individuals who completed testing were counseled to consider enhanced surveillance in the absence of a confirmed hereditary cancer syndrome. The total number of first degree relatives with potential to benefit from this program is 62 among individuals with a BRCA1/2 mutation and 86 among individuals without a confirmed hereditary cancer syndrome.

CONCLUSIONS: Initiation of an automatic genetic counseling referral program in the setting of a large oncology practice is feasible and has the potential to identify individuals with a BRCA1/2 mutation who might otherwise go undetected. Few providers object to referral, and the majority of patients are receptive to referral. The impact of this program extends beyond those identified with a BRCA1/2 mutation. This project was funded in part with federal funds: NCI, NIH Contract No. HHSN261200800001E.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-11-06.

The malaria parasite Plasmodium vivax exhibits greater genetic diversity than Plasmodium falciparum

We sequenced and annotated the genomes of four P. vivax strains collected from disparate geographic locations, tripling the number of genome sequences available for this understudied parasite and providing the first genome-wide perspective of global variability in this species. We observe approximately twice as much SNP diversity among these isolates as we do among a comparable collection of isolates of P. falciparum, a malaria-causing parasite that results in higher mortality. This indicates a distinct history of global colonization and/or a more stable demographic history for P. vivax relative to P. falciparum, which is thought to have undergone a recent population bottleneck. The SNP diversity, as well as additional microsatellite and gene family variability, suggests a capacity for greater functional variation in the global population of P. vivax. These findings warrant a deeper survey of variation in P. vivax to equip disease interventions targeting the distinctive biology of this neglected but major pathogen.

Comparative functional genomics of the fission yeasts

The fission yeast clade--comprising Schizosaccharomyces pombe, S. octosporus, S. cryophilus, and S. japonicus--occupies the basal branch of Ascomycete fungi and is an important model of eukaryote biology. A comparative annotation of these genomes identified a near extinction of transposons and the associated innovation of transposon-free centromeres. Expression analysis established that meiotic genes are subject to antisense transcription during vegetative growth, which suggests a mechanism for their tight regulation. In addition, trans-acting regulators control new genes within the context of expanded functional modules for meiosis and stress response. Differences in gene content and regulation also explain why, unlike the budding yeast of Saccharomycotina, fission yeasts cannot use ethanol as a primary carbon source. These analyses elucidate the genome structure and gene regulation of fission yeast and provide tools for investigation across the Schizosaccharomyces clade.

A stochastic model of the repetitive activity of neurons

A recurrent model of the repetitive firing of neurons responding to stimuli of long duration is given. The model assumes a deterministic threshold potential and a membrane potential which is composed of both deterministic and random components. The model accurately reproduces interval statistics obtained from different neurons discharging repetitively over a wide range of discharge rates. It is shown that the model has three important parameters; the time course of threshold recovery following a discharge, the variance of the random component, and the level of excitatory drive. The model is extended, by the use of hyperpolarizing afterpotentials, to include negative correlation between successive interspike intervals.

The dictyostelium kinome--analysis of the protein kinases from a simple model organism

Dictyostelium discoideum is a widely studied model organism with both unicellular and multicellular forms in its developmental cycle. The Dictyostelium genome encodes 285 predicted protein kinases, similar to the count of the much more advanced Drosophila. It contains members of most kinase classes shared by fungi and metazoans, as well as many previously thought to be metazoan specific, indicating that they have been secondarily lost from the fungal lineage. This includes the entire tyrosine kinase–like (TKL) group, which is expanded in Dictyostelium and includes several novel receptor kinases. Dictyostelium lacks tyrosine kinase group kinases, and most tyrosine phosphorylation appears to be mediated by TKL kinases. About half of Dictyostelium kinases occur in subfamilies not present in yeast or metazoa, suggesting that protein kinases have played key roles in the adaptation of Dictyostelium to its habitat. This study offers insights into kinase evolution and provides a focus for signaling analysis in this system.

Protein kinases are eukaryotic enzymes involved in cell communication pathways, and transmit information from outside the cell or between subcellular components within the cell. About 2.5% of genes code for protein kinases, and mutations in many of these cause human disease. The authors characterize the complete set of protein kinases (kinome) from Dictyostelium discoideum, a social amoeba that responds to starvation by forming aggregates of cells, which then differentiate into multicellular fruiting bodies. Dictyostelium branched from the vertebrate lineage after plants but before fungi, and thus illuminates an interesting period in evolutionary history. By comparing the Dictyostelium kinome to those of other organisms, the authors find 46 types of kinases that appear to be conserved in all organisms, and are likely to be involved in fundamental cellular processes. Dictyostelium is an established model organism for studying many aspects of cell biology that are conserved in humans, and this exposition of conserved kinases will help to guide future studies. The Dictyostelium kinome also contains an impressive degree of creativity—almost half of the kinases are unique to Dictyostelium. Many of these Dictyostelium-specific kinases may be related to this organism's distinctive mechanism for coping with starvation.

Myosin light chain kinase A is activated by cGMP-dependent and cGMP-independent pathways

Stimulation of Dictyostelium cells with the chemoattractant cAMP results in transient phosphorylation of the myosin regulatory light chain (RLC). We show that myosin light chain kinase A (MLCK-A) is responsible for RLC phosphorylation during chemotaxis, and that MLCK-A itself is transiently phosphorylated on threonine-166, dramatically increasing its catalytic activity. MLCK-A activation during chemotaxis is highly responsive to cellular cGMP levels and the cGMP-binding protein GbpC. MLCK-A- cells have a partial cytokinesis defect, and do not phosphorylate RLC in response to concanavalin A (conA), but cells lacking cGMP or GbpC divide normally and phosphorylate in response to conA. Thus MLCK-A is activated by a cGMP/GbpC-independent mechanism activated during cytokinesis or by conA, and a cGMP/GbpC-dependent pathway during chemotaxis.

The PrP-like protein Doppel binds copper

Doppel (Dpl) is a glycosylphosphatidylinositol-anchored protein expressed in the testis. It exhibits 26% sequence identity with the prion protein (PrP) but lacks the octarepeat region implicated as the major copper-binding domain. Contrary to expectations, Cu(II) induced a 26% reduction in the intrinsic fluorescence of Dpl(27-154) and a calculated K(d) for a single-site model of 0.16 +/- 0.08 microm. Other metals had minimal effects on fluorescence quenching. Matrix-assisted laser desorption ionization mass spectrometry of a Dpl peptide revealed binding of copper (but not other metals) to the helical alphaB/B'-loop-alphaC subregion of Dpl. Fluorescence quenching and equilibrium dialysis analyses of this Dpl(101-145) peptide were compatible with a binding site of K(d) = 0.4 microm. Diethylpyrocarbonate footprinting (Qin, K., Yang, Y., Mastrangelo, P., and Westaway, D. (2002) J. Biol. Chem. 277, 1981-1990) of Dpl(27-154) defined one residue/molecule was protected by copper from diethylpyrocarbonate adduct formation, and reiteration of this analysis with Dpl(101-145) suggested that His(131) may contribute to Cu(II) binding. Taken together, our data indicate that the alpha-helical region of mouse Dpl possesses a selective copper-binding site with a submicromolar K(d) and perhaps one or more lower affinity sites. Although metallated forms of Dpl might exist in vivo, analyses of Tg(Dpl)10329 mice were inconsistent with reports that Dpl expression is associated with increased carbonylation and nitrosylation of brain proteins. Thus, rather than comprising an important source of free radical damage, copper binding may serve to modulate the activity, stability, or localization of the Dpl protein.

Identification of four candidate cGMP targets in Dictyostelium

In Dictyostelium, a transient increase in intracellular cGMP is important for cytoskeletal rearrangements during chemotaxis. There must be cGMP-binding proteins in Dictyostelium that regulate key cytoskeletal components after treatment with chemoattractants, but to date, no such proteins have been identified. Using a bioinformatics approach, we have found four candidate cGMP-binding proteins (GbpA-D). GbpA and -B have two tandem cGMP-binding sites downstream of a metallo beta-lactamase domain, a superfamily that includes cAMP phosphodiesterases. GbpC contains the following nine domains (in order): leucine-rich repeats, Ras, MEK kinase, Ras guanine nucleotide exchange factor N-terminal (RasGEF-N), DEP, RasGEF, cGMP-binding, GRAM, and a second cGMP-binding domain. GbpD is related to GbpC, but is much shorter; it begins with the RasGEF-N domain, and lacks the DEP domain. Disruption of the gbpC gene results in loss of all high-affinity cGMP-binding activity present in the soluble cellular fraction. GbpC mRNA levels increase dramatically 8 h after starvation is initiated. GbpA, -B, and -D mRNA levels show less dramatic changes, with gbpA mRNA levels highest 4 h into starvation, gbpB mRNA levels highest in vegetative cells, and gbpD levels highest at 8 h. The identification of these genes is the first step in a molecular approach to studying downstream effects of cGMP signaling in Dictyostelium.

Prediction of endometriosis with serum and peritoneal fluid markers: a prospective controlled trial

BACKGROUND

The objective of this prospective controlled trial was to investigate the ability of a group of serum and peritoneal fluid (PF) markers to predict, non-surgically, endometriosis.

METHODS AND RESULTS

Serum and PF samples were obtained from 130 women while undergoing laparoscopy for pain, infertility, tubal ligation or sterilization reversal. Concentrations of six cytokines [interleukin (IL)-1beta, IL-6, IL-8, IL-12, IL-13 and tumour necrosis factor (TNF)-alpha] were measured in serum and PF, and reactive oxygen species (ROS) in PF, and levels were compared among women who were allocated to groups according to their post-surgical diagnosis. Fifty-six patients were diagnosed with endometriosis, eight with idiopathic infertility, 27 underwent tubal ligation or reanastomosis (control group) and 39 were excluded due to bloody PF. Only serum IL-6 and PF TNF-alpha could be used to discriminate between patients with and without endometriosis with a high degree of sensitivity and specificity (P < 0.001). A threshold of 15 pg/ml PF TNF-alpha provided 100% sensitivity and 89% specificity (positive likelihood ratio of 9.1 and negative likelihood ratio of 0). A threshold of 2 pg/ml for serum IL-6 provided a sensitivity of 90% and specificity of 67% (positive likelihood ratio of 2.7 and negative likelihood ratio of 0.14).

CONCLUSIONS

By measuring serum IL-6 and PF TNF-alpha, it was possible to discriminate between patients with endometriosis and those without. Before these markers can be used as a non-surgical diagnostic tool, these data should be verified in a larger study.

A 4-year follow-up study of women with Norplant-2 contraceptive implants

One-hundred-thirty of 178 women who received Norplant-2 implants were followed prospectively for 4 years. Menstrual disorders were the most common reason for discontinuation. Only one patient conceived, for a failure rate of 0.6%.

Recurrent osseous metaplasia of the cervix after loop electrosurgical excision

BACKGROUND

Osseous metaplasia of the uterus is a rare pathologic entity usually affecting the endometrial cavity without cervical extension. It has been reported after abortion, in cases of chronic endometritis, and as a result of metabolic disorders as hypervitaminosis D, hyperparathyroidism, hypercalcemia, and hyperphosphatemia.

CASE

A woman developed osseous metaplasia of the cervix shortly after loop electrosurgical excision procedure (LEEP) for severe cervical dysplasia. Normal transvaginal ultrasonograms before the LEEP, and failure to detect osseous metaplasia after histologic review of the tissue obtained from that procedure indicate that the osseous metaplasia had been induced by the LEEP. The heterotopic bone formation rapidly recurred after initial removal. Her serum calcium, phosphorus, and vitamin D levels were normal.

CONCLUSION

LEEP may result in healing with metaplastic bone formation.

Molecular characterization of calmodulin trapping by calcium/calmodulin-dependent protein kinase II

Autophosphorylation of alpha-Ca(2+)/calmodulin-dependent protein kinase II (CaM kinase II) at Thr(286) results in calmodulin (CaM) trapping, a >10,000-fold decrease in the dissociation rate of CaM from the enzyme. Here we present the first site-directed mutagenesis study on the dissociation of the high affinity complex between CaM and full-length CaM kinase II. We measured dissociation kinetics of CaM and CaM kinase II proteins by using a fluorescently modified CaM that is sensitive to binding to target proteins. In low [Ca(2+)], the phosphorylated mutant kinase F293A and the CaM mutant E120A/M124A exhibited deficient trapping compared with wild-type. In high [Ca(2+)], the CaM mutations E120A, M124A, and E120A/M124A and the CaM kinase II mutations F293A, F293E, N294A, N294P, and R297E increased dissociation rate constants by factors ranging from 2.3 to 116. We have also identified residues in CaM and CaM kinase II that interact in the trapped state by mutant cycle-based analysis, which suggests that interactions between Phe(293) in the kinase and Glu(120) and Met(124) in CaM specifically stabilize the trapped CaM-CaM kinase II complex. Our studies further show that Phe(293) and Asn(294) in CaM kinase II play dual roles, because they likely destabilize the low affinity state of CaM complexed to unphosphorylated kinase but stabilize the trapped state of CaM bound to phosphorylated kinase.

Hysterectomy in Veterans Affairs Medical Centers

OBJECTIVE

To examine the indications and surgical morbidity for women veterans who underwent hysterectomies in Department of Veterans Affairs Medical Centers (VAs).

METHODS

Data on hysterectomies performed in VAs from 1991 to 1997 were abstracted from a surgical quality improvement program.

RESULTS

Records of 1722 women who had hysterectomies in VAs over 6 years were examined. Women were predominately white (62%) and their average age was 42.5 years. Operations included abdominal (74%), vaginal (22%), and laparoscopic-assisted (4%) methods. The most common indications for surgery included uterine leiomyomas (31%), abnormal uterine bleeding (14%), and endometriosis (11%). Indications differed by race (P <.01); nonwhite women were most likely to have surgery for leiomyoma (51%), whereas white women had hysterectomies for leiomyomas (19%), abnormal bleeding (15%), endometriosis (13%), and genital prolapse (11%). The mean postoperative stay was significantly longer for abdominal hysterectomies (4.51 days) than either vaginal or laparoscopic-assisted hysterectomies (2.92 and 2.21 days, respectively; P <.001). The overall complication rate within 30 days was 9%, and the most frequent complication was urinary tract infection (3.3%).

CONCLUSION

Women who underwent hysterectomies in VAs had low complication rates, comparable to hysterectomy complication rates in the United States generally.

Prolapsed cervical myoma after uterine artery embolization. A case report

BACKGROUND

Cervical prolapse of myomas following uterine artery embolization is an infrequently reported occurrence.

CASE

A 40-year-old woman with a history of three prior abdominal myomectomies underwent uterine artery embolization for severe menorrhagia due to myomas. Two weeks later a large cervical myoma prolapsed, requiring an abdominal hysterectomy.

CONCLUSION

Cervical myomas should be considered a relative contraindication to uterine artery embolization.

The effect of follicular fluid reactive oxygen species on the outcome of in vitro fertilization

OBJECTIVE

To examine the presence of reactive oxygen species (ROS) in the follicular fluid of women undergoing in vitro fertilization (IVF) and identify its role in pregnancy outcome.

STUDY DESIGN

In this prospective study, ROS and total antioxidant capacity (TAC) levels were measured by the chemiluminescence method in the follicular fluid of 53 women. Age, number of oocytes recovered, percentage of oocytes fertilized, ROS and TAC levels were compared in women who did and did not become pregnant.

RESULTS

Patients who become pregnant had significantly higher log-transformed ROS levels (1.01 +/- 0.14, P = 0.031 than those who did not (0.69 +/- 0.08). Women with endometriosis or male factor infertility who became pregnant had significantly higher ROS levels (1.44 +/- 0.23 and 1.31 +/- 0.19) than those who did not (0.60 +/- 0.17 and 0.67 +/- 0.16; P < .006 and P < .01).

CONCLUSION

Follicular fluid ROS, at low concentrations, may be a potential marker for predicting success in IVF patients.

Case-control study of laparoscopic versus abdominal myomectomy

PURPOSE

To compare laparoscopic with abdominal approaches to myomectomy.

PATIENTS AND METHOD

Frequency matching was used to ensure similar fibroid weights among the laparoscopic and abdominal groups in this case-control study. The study group consisted of prospectively recruited patients undergoing laparoscopic (N = 5) or laparoscopically assisted (N = 20) myomectomy (lap). The control group represented both prospectively (N = 14) and retrospectively (N = 37) identified abdominal myomectomy patients (abd). Analysis of the variables was performed using a t-test, Wilcoxon rank-sum test, chi-square test, or analysis of covariance at the 0.01 significance level.

RESULTS

All results are reported after matching for fibroid weight, with the median (quartiles) aggregate weight measuring 151 g (31.0, 262.0) and 170.0 g (81.0, 285.0) for the lap and abd patients, respectively (P = 0.15). Median (quartiles) length of hospital stay (30.5 hours [25.0, 52.5] v 65.0 hours [45.0, 76.0]; P < 0.001) and duration of postoperative intravenous narcotic use (14.8 hours [3.0, 18.5] v 24.0 hours [18.0, 40.0]; P = 0.001) were significantly shorter for the lap patients. The laparoscopic cases required a longer median operative time (222.5 minutes [192.5, 270.0]) than the abdominal cases (180.0 minutes [160.0, 220.0]; P = 0.001). No difference was detected in estimated blood loss from surgery (P = 0.57).

CONCLUSIONS

A laparoscopic approach to myomectomy may be safely chosen for patients with fibroids and offers the benefits of less postoperative intravenous narcotic use, a shorter hospital stay, and no greater intraoperative blood loss than abdominal myomectomy.

Laparoscopic repair of ureteral transection

Injury to the ureter is a possible complication of laparoscopic surgery. Traditionally, it is repaired by laparotomy. During laparoscopic surgery for bilateral ovarian remnants in a 29-year-old woman, the left ureter was transected. The ureter was repaired by primary end-to-end anastomosis by laparoscopy. The patient recovered uneventfully, and postoperative intravenous puelogram confirmed the repair to be intact.

Robotic-assisted laparoscopic microsurgical tubal anastomosis: a human pilot study

OBJECTIVE

To evaluate the feasibility and safety of a robotic device to perform a laparoscopic tubal anastomosis.

DESIGN

Prospective pilot study.

SETTING

Tertiary care medical center.

PATIENT(S)

Ten patients with previous tubal ligations underwent laparoscopic tubal ligation reversal using a robotic suturing device.

INTERVENTION(S)

Tubal surgery was performed with a robotic system. A two-layered closure was used for all tubes. Four stitches of 8-0 polygalactin sutures were used for each layer.

MAIN OUTCOME MEASURE(S)

Tubal patency; secondary measures were pregnancy rates, complications, and operative time.

RESULT(S)

The procedure was completed successfully in all 10 patients. No patient required conversion to an open procedure. The mean time (+/-SD) required to complete the anastomosis of both tubes was 159 +/- 33.8 minutes. Chromotubation at the end of the procedure showed patency in all tubes anastomosed. A postoperative hysterosalpingogram 6 weeks after surgery demonstrated patency in 17 of the 19 (89%) tubes anastomosed. There have been five pregnancies so far. There were no complications.

CONCLUSION(S)

Robotic technology can be used safely to create laparoscopic microsurgical anastomoses with adequate patency rates. Robotic technology has the potential to make laparoscopic microsuturing easier.

Morphological identification of physiologically characterized afferents innervating the turtle posterior crista

The turtle posterior crista consists of two hemicristae. Each hemicrista extends from the planum semilunatum to the nonsensory torus and includes a central zone (CZ) surrounded by a peripheral zone (PZ). Type I and type II hair cells are found in the CZ and are innervated by calyx, dimorphic and bouton afferents. Only type II hair cells and bouton fibers are found in the PZ. Units were intraaxonally labeled in a half-head preparation. Bouton (B) units could be near the planum (BP), near the torus (BT), or in midportions of a hemicrista, including the PZ and CZ. Discharge properties of B units vary with longitudinal position in a hemicrista but not with morphological features of their peripheral terminations. BP units are regularly discharging and have small gains and small phase leads re angular head velocity. BT units are irregular and have large gains and large phase leads. BM units have intermediate properties. Calyx (C) and dimorphic (D) units have similar discharge properties and were placed into a single calyx-bearing (CD) category. While having an irregular discharge resembling BT units, CD units have gains and phases similar to those of BM units. Rather than any single discharge property, it is the relation between discharge regularity and either gain or phase that makes CD units distinctive. Multivariate statistical formulas were developed to infer a unit's morphological class (B or CD) and longitudinal position solely from its discharge properties. To verify the use of the formulas, discharge properties were compared for units recorded intraaxonally or extracellularly in the half-head or extracellularly in intact animals. Most B units have background rates of 10-30 spikes/s. The CD category was separated into CD-high and CD-low units with background rates above or below 5 spikes/s, respectively. CD-low units have lower gains and phases and are located nearer the planum than CD-high units. In their response dynamics over a frequency range from 0.01-3 Hz, BP units conform to an overdamped torsion-pendulum model. Other units show departures from the model, including high-frequency gain increases and phase leads. The longitudinal gradient in the physiology of turtle B units resembles a similar gradient in the anamniote crista. In many respects, turtle CD units have discharge properties resembling those of calyx-bearing units in the mammalian central zone.

Responses to efferent activation and excitatory response-intensity relations of turtle posterior-crista afferents

Multivariate statistical formulas were used to infer the morphological type and longitudinal position of extracellularly recorded afferents. Efferent fibers were stimulated electrically in the nerve branch interconnecting the anterior and posterior VIIIth nerves. Responses of bouton (B) units depended on their inferred position: BP units (near the planum semilunatum) showed small excitatory responses; BT units (near the torus) were inhibited; BM units (in an intermediate position) had a mixed response, including an initial inhibition and a delayed excitation. Calyx-bearing (CD-high) units with an appreciable background discharge showed large per-train excitatory responses followed by smaller post-train responses that could outlast the shock train by 100 s. Excitatory responses were smaller in calyx-bearing (CD-low) units having little or no background activity than in CD-high units. Excitatory response-intensity functions, derived from the discharge during 2-s angular-velocity ramps varying in intensity, were fit by empirical functions that gave estimates of the maximal response (r(MAX)), a threshold velocity (v(T)), and the velocity producing a half-maximal response (v(1/2)). Linear gain is equal to r(MAX)/v(S), v(S) = v(1/2) - v(T). v(S) provides a measure of the velocity range over which the response is nearly linear. For B units, r(MAX) declines by as much as twofold over the 2-s ramp, whereas for CD units, r(MAX) increases by 15% during the same time period. At the end of the ramp, r(MAX) is on average twice as high in CD as in B units. Thresholds are negligible in most spontaneously active units, including almost all B and CD-high units. Silent CD-low units typically have thresholds of 10-100 deg/s. BT units have very high linear gains and v(S) < 10 deg/s. Linear gains are considerably lower in BP units and v(S) > 150 deg/s. CD-high units have intermediate gains and near 100 deg/s v(S) values. CD-low units have low gains and v(S) values ranging from 150 to more than 300 deg/s. The results suggest that BT units are designed to measure the small head movements involved in postural control, whereas BP and CD units are more appropriate for monitoring large volitional head movements. The former units are silenced by efferent activation, whereas the latter units are excited. This suggests that the efferent system switches the turtle posterior crista from a "postural" to a "volitional" mode.

Afferent diversity and the organization of central vestibular pathways

This review considers whether the vestibular system includes separate populations of sensory axons innervating individual organs and giving rise to distinct central pathways. There is a variability in the discharge properties of afferents supplying each organ. Discharge regularity provides a marker for this diversity since fibers which differ in this way also differ in many other properties. Postspike recovery of excitability determines the discharge regularity of an afferent and its sensitivity to depolarizing inputs. Sensitivity is small in regularly discharging afferents and large in irregularly discharging afferents. The enhanced sensitivity of irregular fibers explains their larger responses to sensory inputs, to efferent activation, and to externally applied galvanic currents, but not their distinctive response dynamics. Morphophysiological studies show that regular and irregular afferents innervate overlapping regions of the vestibular nuclei. Intracellular recordings of EPSPs reveal that some secondary vestibular neurons receive a restricted input from regular or irregular afferents, but that most such neurons receive a mixed input from both kinds of afferents. Anodal currents delivered to the labyrinth can result in a selective and reversible silencing of irregular afferents. Such a functional ablation can provide estimates of the relative contributions of regular and irregular inputs to a central neuron's discharge. From such estimates it is concluded that secondary neurons need not resemble their afferent inputs in discharge regularity or response dynamics. Several suggestions are made as to the potentially distinctive contributions made by regular and irregular afferents: (1) Reflecting their response dynamics, regular and irregular afferents could compensate for differences in the dynamic loads of various reflexes or of individual reflexes in different parts of their frequency range; (2) The gating of irregular inputs to secondary VOR neurons could modify the operation of reflexes under varying behavioral circumstances; (3) Two-dimensional sensitivity can arise from the convergence onto secondary neurons of otolith inputs differing in their directional properties and response dynamics; (4) Calyx afferents have relatively low gains when compared with irregular dimorphic afferents. This could serve to expand the stimulus range over which the response of calyx afferents remains linear, while at the same time preserving the other features peculiar to irregular afferents. Among those features are phasic response dynamics and large responses to efferent activation; (5) Because of the convergence of several afferents onto each secondary neuron, information transmission to the latter depends on the gain of individual afferents, but not on their discharge regularity.

Successful management of a viable cervical pregnancy by single-dose methotrexate

Cervical pregnancy is very uncommon and carries a high risk for hysterectomy with surgical treatment. Prior reports of medical treatment included various regimens of high-dose systemic methotrexate (MTX) with citrovorum rescue and local injection. This is the first report of successfully treating a viable cervical pregnancy with single-dose i.m. MTX, followed by a vaginal delivery.

Comparison of intrauterine and intracervical insemination with frozen donor sperm: a meta-analysis

OBJECTIVE

To determine whether artificial insemination with frozen donor sperm yielded a higher pregnancy rate per cycle by intracervical (ICI) or intrauterine (IUI) techniques. A meta-analysis was performed.

DATA IDENTIFICATION

A computerized MEDLINE search of the English-language literature on artificial insemination with donor sperm was performed and augmented by a review of meeting abstract books and references in published papers.

STUDY SELECTION

Only prospective randomized studies that reported monthly fecundity rates for IUI and ICI with frozen donor sperm were included.

DATA ANALYSIS

Seven studies were identified. The odds ratios (OR) and 95% confidence intervals (CI) were determined with use of the general estimating equation method for the three studies for which raw data could be obtained. For the remaining four studies, the OR and CI were assessed with use of the published summary data. A random-effects meta-analysis was then performed.

RESULT

Intrauterine insemination resulted in a significantly higher monthly fecundity rate with a common OR of 2.4 (CI 1.5-3.8).

CONCLUSION

On the basis of this meta-analysis of the seven prospective studies, IUI results in higher pregnancy rates than ICI for frozen donor insemination.

Evaluation of Langerhans' cells in the cervical epithelium of women with cervical intraepithelial neoplasia

OBJECTIVE

Cervical infection with human papillomavirus (HPV) results in a more permissive environment for malignant transformation. In squamous epithelia the Langerhans' cell (LC) is responsible for antigen presentation. Studies that use S-100 immunostaining demonstrate low LCs in cervical intraepithelial neoplasia (CIN) while those that use other methods have shown normal numbers of LCs. This observation led us to postulate that a defect in S-100 proteins, not a simple decrease in LC number, may be the cause of immune suppression. To evaluate this we identified LCs in the cervix of women with HPV/CIN in a prospective fashion using two antibodies, S-100 and CD1, each targeting a different element of the LC.

METHODS

Paired biopsies of the cervix were taken, one paraffin embedded for S-100 and the other snap frozen for CD1 staining. LCs were counted and expressed as the number of cells per millimeter of epithelium. Analysis of variance was used to assess differences between counts in normal, low-grade, and high-grade lesions. HPV was tested by hybrid capture.

RESULTS

S-100 LCs were significantly reduced in dysplasia, LG 8.6 and HG 6.0, compared to normal at 16.7 cells/mm (P = 0.04). S-100 LCs were reduced in HPV-infected cases at 5.9 vs 12.8 cells/mm in HPV negatives (P = 0.02). Acute inflammatory infiltrates were associated with increased S-100 LCs independent of pathology. CD1 LCs were not significantly altered by any parameters tested.

CONCLUSIONS

HPV/CIN may exert an immunosuppressive effect by decreasing the S-100 LCs. The association of S-100-positive LCs coupled with cervical inflammatory changes suggests an important function of the S-100 proteins in the development of an anti-HPV response.