Plant size, latitude, and phylogeny explain within-population variability in herbivory

Interactions between plants and herbivores are central in most ecosystems, but their strength is highly variable. The amount of variability within a system is thought to influence most aspects of plant-herbivore biology, from ecological stability to plant defense evolution. Our understanding of what influences variability, however, is limited by sparse data. We collected standardized surveys of herbivory for 503 plant species at 790 sites across 116° of latitude. With these data, we show that within-population variability in herbivory increases with latitude, decreases with plant size, and is phylogenetically structured. Differences in the magnitude of variability are thus central to how plant-herbivore biology varies across macroscale gradients. We argue that increased focus on interaction variability will advance understanding of patterns of life on Earth.

Long-term monitoring of clodronate in equine hair using liquid chromatography-tandem mass spectrometry

Given the potential for long-term inhibition of bone remodeling/healing and detrimental effects to horses in training, bisphosphonates are tightly regulated in horseracing. Hair has proven to be an effective matrix for detection of drug administration to horses and has been particularly effective in detecting drugs for a long period of time post administration. Thus, hair may prove to be a useful matrix for detection of administration of this class of drugs. The objective of the current study was to develop an assay and assess the usefulness of hair as a matrix for long-term detection of clodronate to horses. Seven horses received a single intramuscular administration of 1.8 mg/kg clodronate. Hair samples were collected prior to and up to 6 months post administration. A liquid chromatography-tandem mass spectrometry method was developed and concentrations of clodronate measured in hair samples. The drug was first detected on day 7 in 4/7 horses, and on days 14, 28 and 35 in the remaining three horses. In 4/7 horses, clodronate was still detectable 6 months post administration. Results of this study demonstrate that, although there was significant inter-individual variability in detection times (63 to 180 days) and several intermediate times where the drug could not be detected but was subsequently detected in later timepoints, clodronate administration was detectable in hair for a prolonged period in most of the horses (4/7) studied.

Therapeutic Potential of Cannabidiol (CBD) for Skin Health and Disorders

Though there is limited research confirming the purported topical benefits of cannabinoids, it is certain that cutaneous biology is modulated by the human endocannabinoid system (ECS). Receptors from the ECS have been identified in the skin and systemic abuse of synthetic cannabinoids, and their analogs, have also been associated with the manifestation of dermatological disorders, indicating the effects of the ECS on cutaneous biology. In particular, cannabidiol (CBD), a non-psychoactive compound from the cannabis plant, has garnered significant attention in recent years for its anecdotal therapeutic potential for various pathologies, including skin and cosmetic disorders. Though a body of preclinical evidence suggests topical application of CBD may be efficacious for some skin disorders, such as eczema, psoriasis, pruritis, and inflammatory conditions, confirmed clinical efficacy and elucidation of underlying molecular mechanisms have yet to be fully identified. This article provides an update on the advances in CBD research to date and the potential areas of future exploration.

Recent Advances in Studies of Skin Color and Skin Cancer

The relationship between skin color and skin cancer is well established: the less melanin in one's skin the greater the risk for developing skin cancer. This review is in two parts. First, we summarize the current understanding of the cutaneous pigmentary system and trace melanin from its synthesis in the pigment cell melanosomes through its transfer to keratinocytes. We also present new methods for reducing melanin content in hyper-pigmented areas of skin such as solar lentigenes, melasma, and post-inflammatory hyperpigmentation. Second, we present evidence that at least one mechanism for the development of metastatic melanoma and other solid tumors is fusion and hybridization of leucocytes such as macrophages with primary tumor cells. In this scenario, hybrid cells express both the chemotactic motility of the leucocyte and the de-regulated cell division of the tumor cell, causing the cells to migrate a deadly journey to lymph nodes, distant organs, and tissues.

Chrysanthemum Morifolium Extract And Ascorbic Acid-2-Glucoside (AA2G) Blend Inhibits UVA-Induced Delayed Cyclobutane Pyrimidine Dimer (CPD) Production In Melanocytes

Background

Solar ultraviolet radiation (UV) induces DNA damages in skin via direct absorption of UVB or indirectly by photosensitization mediated through UVA. Recent findings have revealed that UVA induces cyclobutane pyrimidine dimer (CPD) generation via chemiexcitation in melanocytes hours after the exposure. This UVA-induced delayed CPD (dark CPD) constitutes the majority of CPD in melanocytes. These findings indicate that sun light can damage the skin hours after the exposure, suggesting the need for skin care products post sun exposure. The main objective of this study was to investigate whether a blend of Chrysanthemum Morifolium flower extract (Chrys) and vitamin C derivative, Ascorbic Acid-2-Glucoside (AA2G), can provide protective effects against reactive oxygen species, melanin formation and UVA-induced dark CPD.

Methods

Intracellular ROS levels were measured in epidermal keratinocytes using DHR123 dye. Melanogenesis inhibition efficacy was determined using B16 cells. As for the dark CPD measurement, Melan-a cells were treated with or without actives for 6 days, then irradiated with UVA at various doses. Cells were exposed with anti-CPD mAb followed by secondary Ab. CPD levels were determined by measuring fluorescent intensity using a high content imaging analysis.

Results

Chrys, AA2G and their blend at various concentrations demonstrated ROS scavenging activity. Though Chrys alone did not show significant melanogenesis inhibition in B16 assay, the blend of Chrys with AA2G demonstrated additive effects in comparison with AA2G alone. The blend of AA2G and Chrys at various concentrations exhibited enhanced efficacy for inhibiting dark CPD compared to AA2G alone.

Conclusion

The results from this study indicate that the use of natural antioxidant, Chrys in combination with AA2G, provides protection against UVA-induced delayed CPD formation by enhancing ROS scavenging activity and melanogenesis inhibition. These findings could potentially be applied for formulating post-sun exposure skin care products, possibly extending to evening-after care products.

Animatronic soft robots by additive folding

This paper presents a new class of animatronic soft robots created by a desktop fabrication mechanism called additive folding. In this method, two-dimensional (2D) slices are threaded by multiple strings, accordion-folded by flexure hinges and finally stacked into a predefined three-dimensional (3D) structure. As the 3D assembly of the slices is controlled by embedded strings, it becomes an animatronic soft robot that moves like a biological creature and that shows life-like movements. We create a computational design algorithm that takes as input a desired 3D geometry of the robot, and that produces a 2D surface with built-in folds and string-based actuators. This paper describes the entire robot design process and demonstrates various animatronic motions, highlighting the vision of desktop fabrication technology and its potential applications in animatronics and robotic art.

Assessment and reporting of the clinical immunogenicity of therapeutic proteins and peptides-harmonized terminology and tactical recommendations

Immunogenicity is a significant concern for biologic drugs as it can affect both safety and efficacy. To date, the descriptions of product immunogenicity have varied not only due to different degrees of understanding of product immunogenicity at the time of licensing but also due to an evolving lexicon that has generated some confusion in the field. In recent years, there has been growing consensus regarding the data needed to assess product immunogenicity. Harmonization of the strategy for the elucidation of product immunogenicity by drug developers, as well as the use of defined common terminology, can benefit medical practitioners, health regulatory agencies, and ultimately the patients. Clearly, understanding the incidence, kinetics and magnitude of anti-drug antibody (ADA), its neutralizing ability, cross-reactivity with endogenous molecules or other marketed biologic drugs, and related clinical impact may enhance clinical management of patients treated with biologic drugs. To that end, the authors present terms and definitions for describing and analyzing clinical immunogenicity data and suggest approaches to data presentation, emphasizing associations of ADA development with pharmacokinetics, efficacy, and safety that are necessary to assess the clinical relevance of immunogenicity.

Coordinated influence of β-defensins on innate immunity against bacterial infection of the airway (112.12)

β-defensins act as antimicrobial agents and as immunomodulators. Human β-defensin (BD) peptides 1, 2 and 3 are differentially modulated in primary tracheal epithelial cells (TEC) by viruses, bacteria, and proinflammatory cytokines. We hypothesized that hBD-1 and virulence factors would influence induction of hBD-2 and hBD-3 during lung bacterial infections. Since BD genes exist in close proximity on chromosome 8, making it impossible to delete more than one BD gene, a model was devised to study their coordination. Since mouse orthologs exist, (hBD-1=mBD-1; hBD-2=mBD-3; hBD-3=mBD14), we used mBD-1(-/-) (KO) mice and the inhibitory capability of the type III secretion system of Bordetella bronchiseptica on NF-κB to study effects of mBD-1 deletion on mBD-3 gene expression using wild-type RB50 and mutant WD3 strains lacking this system. In C57BL/6 wild-type (WT) mice, mBD-3, mBD-14 and kerotinocyte-derived chemokine (KC) mRNA levels were suppressed by RB50 compared with WD3 induction in lung 24 hr after infection, whereas mBD-1 levels were unaffected. Deletion of mBD-1 significantly blunted WD3 induction of mBD-3 and mBD-14, but not KC. Bacteria numbers increased, along with decreased neutrophils in the trachea, when KO mice were infected with RB50 compared with WT mice. In TEC, WD3 induced mBD-3 in WT but not in KO mice, yet with cultured KO TEC, mBD-14 and KC were unaffected. The results illustrate the coordination of BD in TEC and in lung to influence bacterial infection.

Induction of triggering receptor expressed on myeloid cells (TREM-1) in airway epithelial cells by 1,25(OH)₂ vitamin D₃

The airway epithelium plays a role in host defense through the binding of innate immune receptors, which leads to the activation of inflammatory mediators, including antimicrobial peptides. The active form of vitamin D, 1,25(OH)(2)D(3), induces the expression of the antimicrobial peptide LL-37 in both myeloid cells and airway epithelial cells (AEC). Here, we demonstrate that mRNA encoding triggering receptor expressed on myeloid cells (TREM)-1 was induced up to 12-fold by 1,25(OH)(2)D(3) in normal human bronchial epithelial (NHBE) cells and in well-differentiated cultures of six airway epithelial cell lines from patients with cystic fibrosis and healthy individuals. TREM-2 and DAP12 were also expressed in airway cultures, but not induced by vitamin D. Induction occurs through a vitamin D response element identified in its proximal promoter region, and was regulated by PU.1 expressed in the AEC. Activation of TREM-1 by a cross-linking antibody led to an induction of both human β-defensin-2 and TNF-α mRNA, demonstrating its functionality in these cells. Our results expand on the role played by the airway epithelium in innate immunity and suggest that vitamin D can modulate the innate immune defense of the airway epithelium, and could potentially be developed as an adjunctive therapy for airway infections.

Modulation of human beta-defensin-1 (hBD-1) in plasmacytoid dendritic cells (PDC), monocytes, and epithelial cells by influenza virus, Herpes simplex virus, and Sendai virus and its possible role in innate immunity

hBD comprise a family of antimicrobial peptides that plays a role in bridging the innate and adaptive immune responses to infection. The expression of hBD-2 increases upon stimulation of numerous cell types with LPS and proinflammatory cytokines. In contrast, hBD-1 remains constitutively expressed in most cells in spite of cytokine or LPS stimulation; however, its presence in human PDC suggests it plays a role in viral host defense. To examine this, we characterized the expression of hBD-1 in innate immune cells in response to viral challenge. PDC and monocytes increased production of hBD-1 peptide and mRNA as early as 2 h following infection of purified cells and PBMCs with PR8, HSV-1, and Sendai virus. However, treatment of primary NHBE cells with influenza resulted in a 50% decrease in hBD-1 mRNA levels, as measured by qRT-PCR at 3 h following infection. A similar inhibition occurred with HSV-1 challenge of human gingival epithelial cells. Studies with HSV-1 showed that replication occurred in epithelial cells but not in PDC. Together, these results suggest that hBD-1 may play a role in preventing viral replication in immune cells. To test this, we infected C57BL/6 WT mice and mBD-1((-/-)) mice with mouse-adapted HK18 (300 PFU/mouse). mBD-1((-/-)) mice lost weight earlier and died sooner than WT mice (P=0.0276), suggesting that BD-1 plays a role in early innate immune responses against influenza in vivo. However, lung virus titers were equal between the two mouse strains. Histopathology showed a greater inflammatory influx in the lungs of mBD-1((-/-)) mice at Day 3 postinfection compared with WT C57BL/6 mice. The results suggest that BD-1 protects mice from influenza pathogenesis with a mechanism other than inhibition of viral replication.

Induction of cathelicidin in normal and CF bronchial epithelial cells by 1,25-dihydroxyvitamin D(3)

BACKGROUND

Antimicrobial peptides (AMPs) such as cathelicidins contribute to initial defense of the airway against inhaled pathogens. Recent studies have shown that the hormonally active form of vitamin D(3), 1,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) up-regulates AMP gene expression in several established cell lines. Furthermore, serum levels of vitamin D are often deficient in cystic fibrosis (CF) patients.

METHODS

We investigated the effect of 1,25(OH)(2)D(3) on AMP mRNA levels in primary cultures of normal human bronchial epithelial (NHBE) cells by real-time PCR, and protein levels by Western blot. Antimicrobial activity of airway surface fluid from these cells was measured by in vitro assay against laboratory strains of bacteria.

RESULTS

Treatment of NHBE cells with 1,25(OH)(2)D(3) (10(-8)M), resulted in a 10-fold up-regulation of cathelicidin mRNA levels after 12 h, which was augmented 2-fold with co-incubation of 1 mM Calcium. Moreover, 1,25(OH)(2)D(3) induced antimicrobial activity against the airway pathogens Bordetella bronchiseptica and Pseudomonas aeruginosa. 1,25(OH)(2)D(3) induced cathelicidin mRNA expression equally in both normal and CF bronchial epithelial cells.

CONCLUSIONS

Elucidation of the effect of 1,25(OH)(2)D(3) on cathelicidin expression in NHBE cells and CF bronchial epithelial cells will aid in the development of novel therapeutic agents for treatment of airway infections in CF.

Antimicrobial peptides in the airway

The airway provides numerous defense mechanisms to prevent microbial colonization by the large numbers of bacteria and viruses present in ambient air. An important component of this defense is the antimicrobial peptides and proteins present in the airway surface fluid (ASF), the mucin-rich fluid covering the respiratory epithelium. These include larger proteins such as lysozyme and lactoferrin, as well as the cationic defensin and cathelicidin peptides. While some of these peptides, such as human beta-defensin (hBD)-1, are present constitutively, others, including hBD2 and -3 are inducible in response to bacterial recognition by Toll-like receptor-mediated pathways. These peptides can act as microbicides in the ASF, but also exhibit other activities, including potent chemotactic activity for cells of the innate and adaptive immune systems, suggesting they play a complex role in the host defense of the airway. Inhibition of antimicrobial peptide activity or gene expression can result in increased susceptibility to infections. This has been observed with cystic fibrosis (CF), where the CF phenotype leads to reduced antimicrobial capacity of peptides in the airway. Pathogenic virulence factors can inhibit defensin gene expression, as can environmental factors such as air pollution. Such an interference can result in infections by airway-specific pathogens including Bordetella bronchiseptica, Mycobacterium tuberculosis, and influenza virus. Research into the modulation of peptide gene expression in animal models, as well as the optimization of peptide-based therapeutics shows promise for the treatment and prevention of airway infectious diseases.

Suppression of NF-kappaB-mediated beta-defensin gene expression in the mammalian airway by the Bordetella type III secretion system

Expression of innate immune genes such as beta-defensins is induced in airway epithelium by bacterial components via activation of NF-kappaB. We show here that live Gram-negative bacteria can similarly stimulate this pathway, resulting in upregulation of the beta-defensin tracheal antimicrobial peptide (TAP) in primary cultures of bovine tracheal epithelial cells (TECs), by a Toll-like receptor 4 (TLR4)-mediated pathway. The Gram-negative airway pathogen Bordetella bronchiseptica possesses a type III secretion system previously suggested to inhibit the nuclear translocation of NF-kappaB in a cell line by immunohistochemistry. We therefore hypothesized that this pathogen might interfere in the innate immune response of the epithelium. Exposure of TECs to wild-type B. bronchiseptica suppressed the activation of NF-kappaB and the subsequent induction of TAP mRNA levels, whereas a type III secretion-defective strain did not. These results suggest a mechanism for bacterial evasion of the innate immune response in the airway, which could allow for the observed persistent colonization of this pathogen.

A comparative study of seed crystals for the phosphorus crystallization process

This study was performed to select a preferred seed crystal material for the phosphorus crystallization process through a comparative study of four materials: electron arc furnace, blast furnace and converter slag, and phosphate rock. Leaching and phosphorus removal tests were conducted to evaluate the efficacy of the four materials as seeding agents. Converter slag demonstrated a much larger leaching capacity with respect to calcium and hydroxide ions than did either electron arc furnace or blast furnace slag. The average phosphorus removal efficiencies of phosphorus rock, and the electron arc furnace, blast furnace and converter slag were 35.9%, 74.2%, 99.1%, and 94.5% following 20, 17, 32, and 175 days of leach time, respectively. Consideration of both technical and cost factors suggests that converter slag may have competitive advantages over the other three seed materials. X-ray diffraction (XRD) analysis showed that peak patterns for hydroxyapatite increased slightly as the hydrous flow time was extended. Scanning electron micrograph (SEM) images revealed that finely distributed cubic crystals were deposited on the surfaces of converter slag. When analyzed by energy dispersive x-ray spectrometer (EDS) mapping, the crystals gave a composition mole ratio (Ca/P) of 1.97 and they were determined to be hydroxyapatite.

The influence of various methods of cold storage of skin on the permeation of melatonin and nimesulide

The purpose of this study was to investigate the influence of different methods of skin preservation on the percutaneous permeation of two drugs with varied physicochemical properties (melatonin and nimesulide). Hairless rat skin was freshly excised and immediately stored at three different storage conditions: (a). 4 degrees C in minimal essential medium eagle (MEM), (b). frozen at -22 degrees C and (c) frozen at -22 degrees C in 10% glycerol (as a cryoprotective agent). The permeation of melatonin and nimesulide from saturated solutions was studied using the skin stored at various cold storage conditions for 6 months. At 4 degrees C, the flux of melatonin was similar to fresh skin for up to 7 days (P>0.05) and increased 2.4-fold at 14 days (P<0.001). The flux of melatonin was similar to fresh skin for 14 days with skin at -22 degrees C (P>0.05) and then steadily increased from 30 days onwards and at 180 days, the flux was 5-fold greater than fresh skin (P<0.001). Freezing of skin at -22 degrees C with 10% glycerol showed similar flux values for melatonin up to 60 days and at 180 days the flux increased 2.2-fold as compared to fresh skin (P<0.001). In the case of nimesulide, the skin stored for 2 days at 4 degrees C showed similar flux as compared to fresh skin (P>0.05) and increased steadily from 4 days onwards and at 14 days the flux was 3.5-fold higher than fresh skin (P<0.001). The skin frozen at -22 degrees C with or without 10% glycerol showed no difference in flux up to 4 days which however increased from 7 days onwards. At 180 days, the skin at -22 degrees C showed 2.5-fold increase in the flux (P<0.001) whereas the skin frozen with 10% glycerol showed 2-fold increase in the flux (P<0.001) as compared to fresh skin. The results of the present study demonstrate that the permeability of the drugs across the stored skin was dependent on the storage condition, the length of storage and the physicochemical properties of the drug under study. Overall, the freezing of skin at -22 degrees C with 10% glycerol was found to be very helpful for the long-term storage of skin for percutaneous permeation studies.

Cell Proliferation in Ovarian Carcinoma: Superior Accuracy of S-Phase Fraction (SPF) by DNA Labeling Index versus Flow Cytometric SPF, Lack of Independent Prognostic Power for SPF and DNA Ploidy, and Limited Effect of SPF on Tumor Growth Rate

OBJECTIVES

The goal of this work was to test the hypotheses that S-phase fraction (SPF) by DNA labeling index (SPF-LI) would predict the course of the disease for ovarian/peritoneal carcinomas and that SPF-LI would correlate better with pathologic classification and outcome than SPF by DNA flow cytometry (SPF-F).

METHODS

Tritiated thymidine (1985-1988) and bromodeoxyuridine (1988-1999) DNA labeling (SPF-LI) was evaluated in vitro on 178 tumors. Cellular DNA and SPF-F were measured flow cytometrically. During this time, 90% of ovarian/peritoneal tumors accessioned in surgical pathology were studied.

RESULTS

Tumors of low malignant potential (LMP, "borderline") had low SPF-LI (median = 1.2%). High-grade invasive carcinomas of various types and carcinosarcomas all had high SPF-LI (medians = 11.2-23.4%). Serous low-grade invasive carcinomas (median = 1.05) resembled LMP tumors. SPF-LI of ovarian carcinomas other than LMP tumors increased slightly as FIGO stage increased (P = 0.07). Survival of patients with high-grade ovarian carcinomas was not predicted by SPF-LI or SPF-F, nor was DNA ploidy predictive. SPF-LI produced tighter distributions for various tumor types than did SPF-F. Neither SPF nor DNA ploidy contributed to prediction of outcome when tumor type and stage were included in multivariate models. We calculated the mean cell loss rate of high-grade carcinomas to be 94%.

CONCLUSIONS

LMP ovarian/peritoneal tumors have low proliferation rates in contrast to high-grade carcinomas. Proliferation correlated with tumor type and stage, but neither it nor DNA ploidy predicted survival independently. Proliferation rate is growth limiting only when low. At higher levels cell loss limits growth. SPF-LI measures proliferation more accurately than SPF-F; SPF-F is not sufficiently reliable for clinical use.

Patient survival after renal transplantation: II. The impact of smoking

Renal transplant recipients have significantly higher mortality than individuals without kidney disease and the excess mortality is mainly due to cardiovascular causes. In this study, we sought to determine the impact of smoking, a major cardiovascular risk factor, on patient and renal graft survival. The study population included all adult recipients of first cadaveric kidney transplants done in our institution from 1984 to 1991. By selection, all patients were alive and had a functioning graft for at least 1 yr after transplantation. Smoking history was gathered prior to transplantation. The follow-up period was 84.3 + 41 months and during this time 28%, of the patients died and 21%, lost their graft. By univariate and multivariate analysis, patient survival, censored at the time of graft loss, correlated with these pre-transplant variables: age (p < 0.0001); diabetes (p = 0.0002); history of cigarette smoking (p = 0.004); time on dialysis prior to the transplant (p = 0.0005); and cardiomegaly by chest X-ray (p = 0.0005). Post-transplant variables did not correlate with patient mortality. By Cox regression, patient survival time was significantly shorter in diabetics (p < 0.0001), smokers (p = 0.0005), and recipients older than 40 yr. However, there were no significant differences between the survival of smokers, non-diabetics, diabetics, and older recipients. Patient death was the most common cause of renal transplant failure in smokers, in patients older than 40 yr, and in diabetics, but these patient characteristics did not correlate with graft survival. The prevalence of different causes of death was not significantly different between smokers and non-smokers. In conclusion, a history of cigarette smoking correlates with decreased patient survival after transplantation, and the magnitude of the negative impact of smoking in renal transplant recipients is quantitatively similar to that of diabetes.

Patient survival after renal transplantation: I. The impact of dialysis pre-transplant

Patients on dialysis and recipients of renal transplants have higher mortality than individuals without kidney disease. In this study we evaluated the possible impact of dialysis therapy before transplantation on patient survival after the transplant. This analysis includes all of the patients who received a cadaveric renal transplant at The Ohio State University from 1984 to 1991 and who remained alive with functioning grafts for at least six months after the transplant (N = 523). After a follow-up of 84 +/- 14 months, 28% of the patients died and 23% lost their grafts. By multivariate analysis, reduced patient survival (censored at the time of graft loss) correlated with these pre-transplant variables: Older age (P < 0.0001), the presence of diabetes (P = 0.0002), smoking (P = 0.009), and the length of time on dialysis (P = 0.0002). Thus, 7% of patients who were never dialyzed, 23% of those dialyzed for less than three years, and 44% of patients dialyzed for > or = three years died post-transplant. By Cox regression, patient survival months correlated with time on dialysis pre-transplant (P = 0.0003). The type of dialysis (CAPD vs. hemodialysis) did not correlate with patient survival. Graft survival, censored for patient death, did not correlate with any of these pre-transplant variables. The relationship between time on dialysis and patient mortality is due to at least two factors: (1) transplant recipients who had dialysis for > or = 3 years had higher mortality due to infections (22%) than those who had dialysis for < 3 years (3%, P = 0.01 by X2); and (2) increasing time on dialysis increases the prevalence of both left ventricular hypertrophy (P = 0.008) and cardiomegaly (P = 0.004), and these relationships are statistically independent of other factors that also correlate with the prevalence of cardiovascular disease. In conclusion, increased time on dialysis prior to renal transplantation is associated with decreased survival of transplant recipients.

Misdiagnosis of an interstitial ectopic pregnancy after unilateral salpingectomy

A 36-year-old primigravida presented to us with symptoms and signs of ectopic pregnancy repeatedly but was misdiagnosed to have an intrauterine pregnancy based on 1 early ultrasound examination showing an 'intrauterine sac'. She suffered the morbidity due to ectopic pregnancy which included hysterectomy which may have been prevented had the correct diagnosis been made.