Increased placental expression of angiotensin-converting enzyme 2, the receptor of SARS-CoV-2, associated with hypoxia in twin anemia-polycythemia sequence (TAPS)

INTRODUCTION

Recent reports suggest SARS-CoV-2, the virus causing COVID-19, may be transmittable from pregnant mother to placenta and fetus, albeit rarely. The efficacy of vertical transmission of SARS-CoV-2 critically depends on the availability of its receptor, ACE2, in the placenta. In the present study, we tested the hypothesis that placental ACE2 expression is oxygenation-dependent by studying the expression of ACE2 and associated cell entry regulators in the monochorionic twin anemia-polycythemia (TAPS) placenta, a model of discordant placental oxygenation.

METHODS

We performed a retrospective comparative immunohistochemical, immunofluorescence and Western blot analysis of ACE2, TMPRSS2 and Cathepsin B expression in anemic and polycythemic territories of TAPS placentas (N = 14).

RESULTS

ACE2 protein levels were significantly higher in the anemic twin territories than in the corresponding polycythemic territories, associated with upregulation of the key ACE2-related cell entry regulators, TMPRSS2 and Cathepsin B, immunolocalized to villous trophoblastic and stromal cells. Cellular colocalization of ACE2 and TMPRSS2, suggestive of functionality of this cell entry axis, was demonstrated by double immunofluorescence studies.

DISCUSSION

Placental hypoxia is associated with upregulation of ACE2 expression, concomitant with increased expression of its key cell entry proteases. ACE2-regulated placental functions, both infection- and non-infection related, may be highly oxygenation-dependent.

Correlation between chorionic plate vascularization and risk of bronchopulmonary dysplasia in extremely preterm infants

INTRODUCTION/OBJECTIVES

The chorionic plate vessels of the placenta are in direct continuity with the fetal vasculature, suggesting chorionic and fetal angiogenesis may be subjected to similar regulatory mechanisms. In this study, we determined the correlation between chorionic plate vascularization and complications of prematurity, focusing on bronchopulmonary dysplasia (BPD) and other conditions with important microvascular components.

METHODS

We performed a clinicoplacental analysis of 127 extremely preterm infants (23-28 weeks gestation). Chorionic plate vascularization was assessed by number and density of perforating chorionic vessels (PCVs). Charts were reviewed for relevant maternal and neonatal data, including respiratory, neurologic and gastrointestinal complications of prematurity.

RESULTS

The placentas displayed marked variability in number (36-523/placenta) and density of PCVs (0.46-3.74 PC V/cm²). The median PCV density of infants with severe BPD was significantly higher than that of infants without BPD (1.51 PC V/cm² versus 1.09 PC V/cm², P < 0.05). Conversely, the frequency of moderate-to-severe BPD was 33% higher in infants with PCV density ≥1.50 PC V/cm² than in those with PCV density <1.50 PC V/cm² (56% versus 40%, P < 0.01). There was no correlation with neonatal neurologic or gastrointestinal complications.

CONCLUSION

Chorionic plate vascularization correlates with frequency and severity of BPD, supporting a vascular basis that in part is antenatal in origin. Quantitative assessment of chorionic plate vascularization may allow early identification of preterm infants at high risk for BPD (proposed threshold: PCV density ≥1.50 PC V/cm²). The lack of correlation between chorionic vascularization and neurologic/gastrointestinal complications suggests these conditions may have less important antenatal and/or vascular contributions.

Discordant placental oxygenation and autophagy in twin anemia-polycythemia sequence (TAPS)

BACKGROUND

(Macro)autophagy is an important process of self-degradation of macromolecules and organelles that ensures cellular homeostasis and energy preservation during stressful conditions. Dysregulated placental autophagy has been implicated in a wide range of pregnancy complications. Recent studies identified hypoxia as a key regulator of trophoblast autophagy in vitro; however, its effects on placental autophagy in vivo remain incompletely understood. In this study, we evaluated the monochorionic twin anemia-polycythemia sequence (TAPS) placenta as model of discordant placental oxygenation to determine the effects of hypoxia on placental autophagy in utero.

METHODS

We performed a retrospective comparative analysis of tissue oxygenation and autophagy in anemic and polycythemic territories of TAPS placentas (N = 12). Archival tissues were subjected to immunohistochemical, immunofluorescence and Western blot analyses of carbonic anhydrase (CA) IX (hypoxia marker) and key autophagy/lysosomal markers.

RESULTS

CAIX protein levels were significantly higher in anemic twin territories than in corresponding polycythemic territories, consistent with relative tissue hypoxia. Anemic placental shares further displayed significantly higher levels of LC3I/II (autophagosome markers) and LAMP1/2 (lysosome markers), associated with upregulated expression of lysosome/autophagosome activity-associated markers, transcription factor EB and cathepsin D. The accumulation of autophagosomes and lysosomes in anemic shares was accompanied by elevated p62 protein expression, suggestive of inhibition of the downstream autophagy pathway.

CONCLUSIONS

TAPS placentas display striking intertwin discordance in tissue oxygenation and autophagic activity and may provide a suitable model for study of the interrelationship between hypoxia, autophagy, and pregnancy outcome in a monochorionic twin setting.

C-67 Cognitive Function in an 8-Year-Old Girl with Gray Matter Heterotopia Without Evidence of Seizures

Objective

Heterotopia is a rare condition typically identified in the context of seizures. This case study presents a cognitive profile in a child with a history of heterotopia and hearing problems but without any known seizure history.

Method

An 8-year-old referred for evaluation by her neurologist due to concerns about persistent academic and social difficulties. Medical history was remarkable for small size, hearing problems, multiple pressure equalization tube placements, food allergies, and a left lateral ventricle gray matter heterotopia found on brain MRI. EEG was normal. Genetic testing found no dysmorphia. Developmental history was remarkable for delayed speech and early intervention, as well as social delays. She began receiving special education for learning disability and speech/language impairment in first grade.

Results

WISC-V IQ was Low Average and significantly lower than GAI. WMI was Below Average and PSI was Low. Language performance was variable. Visual scanning was Below Average. Verbal memory ranged from Below Average to Impaired, with worse performance on WRAML-2 Story Memory subtests. Attention and hyperactivity deficits were found on a continuous performance task. Executive function was Average to Above Average on phonemic fluency, category switching and Stroop tasks. BASC-3 parent ratings indicated greatest concerns in areas of atypicality, withdrawal, and adaptive skills. ABAS-3 indicated Low conceptual skills and Average to Low Average skills on other composites.

Conclusions

Aside from language deficits likely related to hearing problems, these findings indicated deficits in visual scanning, attention/hyperactivity, visually-based processing speed, and memory in the context of heterotopia without seizures. Social delays may be multifactorial.

Oxygen-Induced Consumptive Coagulopathy and its Enhancement by Lead Acetate

The exposure of rats to 100% oxygen at 1 atmosphere leads to a prolongation of prothrombin times and activated partial thromboplastin times. This development is associated with a consumption of factor XII, VIII, and VII activities and with the appearance of fibrin monomers and fibrinogen degradation products. Lead acetate enhances all oxygen-induced changes of the coagulation systems drastically. The O2 survival time of chicks which are naturally deficient in factor XII is greatly increased over that of rats and is not affected by lead acetate. Oxygen survival times of rats suffering from chronic respiratory disease (CRD) are also significantly increased when compared with normal rats. It appears that consumptive coagulopathy and disseminated intravascular coagulation are early events in oxygen exposure, and that their development is accelerated by lead ions.

Fibrinolysis, Fibrinogen and Factor XIII in New Born Infants

Fibrinolysis and the last stage of clotting were examined in 20 healthy infants on days 1-4 after birth. Plasminogen was constantly at half its normal level: 1.2-1.4 u/ml. The euglobulin lysis was increased only on day 1 in 50% of the cases. The mean values on days 1 and 4 showed a statistically significant difference: 0.45 ± 0.20 and 0.14 ± 0.05 (t = 2.1 p < 0.05). Fibrinogen was low or low normal at birth (mean values: 230 ± 57 mg%) but increased significantly in the next days reaching a mean of 293 ± 41 mg% on day 4 (t = 3.6 ρ < 0.001). Factor XIII was normal in all cases. Increased fibrinolysis in day 1 is probably due to a high level of activator at birth and the low plasminogen and fibrinogen are probably a consequence of the physiological „immaturity” of the liver.

Redness discordance in monochorionic twin placentas: Correlation with clinical and placental findings

INTRODUCTION/OBJECTIVES

Recent studies suggest redness (color) discordance of the placental basal plate may be a marker for twin anemia-polycythemia sequence (TAPS), a recently described complication of diamniotic-monochorionic twinning characterized by marked intertwin hemoglobin (Hb) discordance in the absence of oligohydramnios-polyhydramnios. In this study, we determined the clinicoplacental and choriovascular correlates of basal plate color discordance in monochorionic twin placentas, and assessed its value as postnatal indicator of TAPS.

METHODS

We performed a clinicoplacental analysis of 100 consecutive non-TTTS diamniotic-monochorionic twin placentas with available photographic documentation of the basal plate. Basal plate redness was quantified by computer-assisted analysis of digital images and expressed as intertwin color difference ratio (CDR).

RESULTS

The CDR ranged between 1.00 and 3.58 (median CDR: 1.14; 90^th %ile: 1.98). Compared to twins with low CDR (N = 90), twins with high CDR (≥2.0; N = 10) had significantly higher hemoglobin difference (11.25 g/dL versus 2.55 g/dL) and significantly fewer and smaller artery-to-artery (AA) and artery-to-vein (AV) anastomoses. Apgar scores and birth weights were equivalent in both groups. Among the 10 twin sets with high CDR, six (60%) qualified as TAPS, as defined by intertwin Hb difference >8 g/dL and absent or very small AA and AV anastomoses. Conversely, 6 of 8 (75%) twin sets with TAPS had a CDR ≥ 2.0.

CONCLUSION

Intertwin CDR correlates with intertwin hemoglobin difference and chorionic angioarchitecture. A CDR value ≥ 2.0 (the 90%ile value for CDR derived from the present cohort) has high specificity (96%), but relatively low positive predictive value (60%) as indicator of TAPS, as currently defined.

Florid Intussusceptive-like Microvascular Dysangiogenesis in a Preterm Lung

The cellular mechanisms underlying the microvascular dysangiogenesis of bronchopulmonary dysplasia (chronic lung disease of the newborn) remain largely undetermined. We report unusual pulmonary vascular findings in a 27-week-gestation male newborn who died on the second day of life from intractable respiratory failure, following a pregnancy complicated by prolonged membrane rupture and persistent severe oligohydramnios. As expected, postmortem examination revealed pulmonary hypoplasia (lung/body weight ratio: 2.23%; 10th percentile for 27 weeks: 2.59%). In addition, lung microscopy revealed complex networks of non-sprouting, tortuous, and bulbously dilated capillaries, randomly distributed in widened airspace septa. Anti-smooth muscle actin immunohistochemistry demonstrated immunoreactive central densities within capillary lumina, suggestive of intravascular pillar formation. The plexus-forming, non-sprouting type of angiogenesis and apparent transluminal pillar formation are consistent with intussusceptive ("longitudinal splitting") angiogenesis. In concordance with previous observations made in human fetal lung xenografts, these findings support the notion that human postcanalicular lungs have the capacity to switch from sprouting to non-sprouting, intussusceptive-like angiogenesis, possibly representing an adaptive response activated by hemodynamic flow alterations and/or hypoxia. The possible relationship between the intussusceptive-like vascular changes observed in this case and the microvascular dysangiogenesis characteristic of bronchopulmonary dysplasia remains to be determined.

Reversal of direct oral anticoagulants

An understanding of how to counteract the anticoagulant effect of direct oral anticoagulants is essential in the event of haemorrhage, emergency surgery and overdose. This review summarizes strategies for the reversal of direct oral anticoagulants, including the use of novel agents.

Co-expression of fibulin-5 and VEGF165 increases long-term patency of synthetic vascular grafts seeded with autologous endothelial cells

Small caliber synthetic vascular grafts are commonly used for bypass surgery and dialysis access sites but have high failure rates because of neointima formation and thrombosis. Seeding synthetic grafts with endothelial cells (ECs) provides a biocompatible surface that may prevent graft failure. However, EC detachment following exposure to blood flow still remains a major obstacle in the development of biosynthetic grafts. We tested the hypothesis that induced expression by the seeded EC, of vascular endothelial growth factor165 (VEGF165) and of fibulin-5, an extracellular matrix glycoprotein that has a crucial role in elastin fiber organization and increase EC adherence to surfaces, may improve long-term graft patency. Autologous ECs were isolated from venous segments, and were transduced with retroviral vectors expressing fibulin-5 and VEGF165. The modified cells were seeded on expanded polytetrafluoroethylene (ePTFE) grafts and implanted in a large animal model. Three months after transplantation, all grafts seeded with modified EC were patent on a selective angiography, whereas only a third of the control grafts were patent. Similar results were shown at 6 months. Thus, seeding ePTFE vascular grafts with genetically modified EC improved long-term small caliber graft patency. The biosynthetic grafts may provide a novel therapeutic modality for patients with peripheral vascular disease and patients requiring vascular access for hemodialysis.

Prevention of diseases after menopause

Women may expect to spend more than a third of their lives after menopause. Beginning in the sixth decade, many chronic diseases will begin to emerge, which will affect both the quality and quantity of a woman's life. Thus, the onset of menopause heralds an opportunity for prevention strategies to improve the quality of life and enhance longevity. Obesity, metabolic syndrome and diabetes, cardiovascular disease, osteoporosis and osteoarthritis, cognitive decline, dementia and depression, and cancer are the major diseases of concern. Prevention strategies at menopause have to begin with screening and careful assessment for risk factors, which should also include molecular and genetic diagnostics, as these become available. Identification of certain risks will then allow directed therapy. Evidence-based prevention for the diseases noted above include lifestyle management, cessation of smoking, curtailing excessive alcohol consumption, a healthy diet and moderate exercise, as well as mentally stimulating activities. Although the most recent publications from the follow-up studies of the Women's Health Initiative do not recommend menopause hormonal therapy as a prevention strategy, these conclusions may not be fully valid for midlife women, on the basis of the existing data. For healthy women aged 50-59 years, estrogen therapy decreases coronary heart disease and all-cause mortality; this interpretation is entirely consistent with results from other randomized, controlled trials and observational studies. Thus. as part of a comprehensive strategy to prevent chronic disease after menopause, menopausal hormone therapy, particularly estrogen therapy may be considered as part of the armamentarium.

Risks and benefits of hormone therapy: has medical dogma now been overturned?

BACKGROUND

In an integrated overview of the benefits and risks of menopausal hormone therapy (HT), the Women's Health Initiative (WHI) investigators have claimed that their 'findings … do not support use of this therapy for chronic disease prevention'. In an accompanying editorial, it was claimed that 'the WHI overturned medical dogma regarding menopausal [HT]'.

OBJECTIVES

To evaluate those claims.

METHODS

Epidemiological criteria of causation were applied to the evidence.

RESULTS

A 'global index' purporting to summarize the overall benefit versus the risk of HT was not valid, and it was biased. For coronary heart disease, an increased risk in users of estrogen plus progestogen (E + P), previously reported by the WHI, was not confirmed. The WHI study did not establish that E+ P increases the risk of breast cancer; the findings suggest that unopposed estrogen therapy (ET) does not increase the risk, and may even reduce it. The findings for stroke and pulmonary embolism were compatible with an increased risk, and among E+ P users there were credible reductions in the risk of colorectal and endometrial cancer. For E+ P and ET users, there were credible reductions in the risk of hip fracture. Under 'worst case' and 'best case' assumptions, the changes in the incidence of the outcomes attributable to HT were minor.

CONCLUSIONS

Over-interpretation and misrepresentation of the WHI findings have damaged the health and well-being of menopausal women by convincing them and their health professionals that the risks of HT outweigh the benefits.

Postmortem lung volume/body weight standards for term and preterm infants

Assessment of lung growth is a critical component of the perinatal autopsy. Increased lung liquid content may lead to overestimation of lung growth based on (wet) lung weight. In contrast, lung volume is not influenced by intraalveolar lung liquid. Our aim was to establish age-specific reference values for postmortem lung volume/BW in preterm and term infants. We performed a retrospective analysis of fetuses/infants (16-41 weeks' gestation) without (N = 134) or with (N = 79) risk factors for pulmonary hypoplasia. Lungs were inflated at standardized pressure and volumes determined by water immersion method. Lung volume increased 11-fold between 16 and 41 weeks' gestation, concomitant with a 16-fold increase in BW. Mean lung volume/BW remained constant at 33-34 ml/kg between 16 and 31 weeks' gestation and decreased to 23.4 ml/kg at term. Lung volume/BW of infants with severe risk factors (renal anomalies, diaphragmatic hernia) was significantly lower than age-matched standards. In this group, all fetuses/infants diagnosed as having lung hypoplasia by lung volume/BW also had lung hypoplasia LW/BW standards. However, in infants with "softer" risk factors (rupture of membranes, chromosomal anomalies), 5/26 cases diagnosed with lung hypoplasia based on lung volume/BW had normal LW/BW ratios. In these discrepant cases, lung sections showed significant inflammation and edema, likely accounting for increased wet lung weight. In conclusion, we determined age-specific lung volume/BW reference values for preterm and term infants. In selected situations assessment of lung volume/BW may represent a useful complementary tool to LW/BW for postmortem evaluation of lung size.

Is that a rodent in your luggage? A mixed method approach to describe bushmeat importation into the United States

Bushmeat, defined as meat derived from wild animals, is a potential source of zoonotic pathogens. Bushmeat from restricted animals is illegal to import into the United States under US federal regulations. We reviewed US Centers for Disease Control and Prevention (CDC) port of entry surveillance records from September 2005 through December 2010 and conducted focus group studies to describe trends in and reasons for bushmeat importation into the United States. In total, 543 confiscated bushmeat items were recorded. Half of the confiscated bushmeat items identified were rodents. Africa was the most frequent continent of origin. Seasonality was evident, with bushmeat confiscations peaking in late spring to early summer. Four times more bushmeat was confiscated during an enhanced surveillance period in June 2010 compared with the same period in previous years, suggesting that routine surveillance underestimated the amount of bushmeat detected at US Ports of Entry. Focus groups held in three major US cities revealed that bushmeat importation is a multifaceted issue. Longstanding cultural practices of hunting and eating bushmeat make it difficult for consumers to acknowledge potential health and ecologic risks. Also, US merchants selling African goods, including bushmeat, in their stores have caused confusion among importers as to whether importation is truly illegal. Enhancing routine surveillance for bushmeat and consistent enforcement of penalties at all ports of entry, along with health education aimed at bushmeat importers, might be useful to deter illegal importation.

Correlation between cord insertion type and chorionic villus vascularization of the co-twin in diamniotic-monochorionic twin pregnancies

BACKGROUND

Recent evidence suggests that cord insertion type of one twin correlates with chorionic plate vascularization of the monochorionic co-twin. Specifically, for twins with paracentral cords, chorionic plate vascularization is significantly greater when the co-twin has a velamentous, rather than paracentral cord insertion.

AIMS

To determine whether this correlation between cord insertion type and vascularization of the co-twin also extends to the deeper chorionic villus tree.

STUDY DESIGN

Morphometric analysis of chorionic villus vascularization in CD31-immunostained sections of a retrospective cohort of gestational age-matched third trimester monochorionic placentas with discordant paracentral/velamentous (PC/V) or concordant paracentral/paracentral (PC/PC) cord insertions.

OUTCOME MEASURES

Vascular numerical density (number of vascular profiles per unit villus stromal area) of intermediate villi (>80 μm diameter) and terminal villi (<80 μm).

RESULTS

For twins with paracentral cord insertion, the vascular numerical density of intermediate villi was significantly higher for twins in a discordant PC/V relationship than for those in a concordant PC/PC relationship (P<0.05), thus replicating previous findings in superficial chorionic vessels. For terminal villi, in contrast, the vascular numerical density of twins with paracentral cords in a PC/V combination was significantly lower than of those in a PC/PC combination, and similar to that of their co-twins with velamentous cord insertion.

CONCLUSIONS

Early placental angiogenesis in monochorionic twin gestations may be influenced by implantation and cord localization of the co-twin. The regulation of terminal villus angiogenesis appears to be dissociated from more proximal villus angiogenesis and independent of cord insertion of the co-twin.

Interaction of mineral salts with the skin: a literature survey

There is growing scientific evidence that the health, well-being and the attractiveness of the skin are strongly influenced by nutrition. Consumers recognize this and have supported the creation of a global cosmeceuticals market estimated in 2010 at $27.2 billion. Early in 2011, the US Department of Health and Human Services and Department of Agriculture issued the Dietary Guidelines for Americans, 2010. Twelve vitamins and nine minerals were recognized as essential. The minerals include calcium, copper, iron, magnesium, phosphorus, selenium, zinc, potassium and sodium. Although the topical benefits of several minerals such as zinc, magnesium and iron are recognized and, in some cases, approved by the FDA, the topical benefits of the others to the skin are largely unexplored and unexploited. This review attempts to summarize what has been published in the literature on the interactions of the eight of the nine essential elements with the skin.

Correlation between cord insertion type and superficial choriovasculature in diamniotic-monochorionic twin placentas

BACKGROUND

Non-central cord insertion has been associated with diminished chorionic vascular distribution in singleton placentas. The choriovascular correlates of peripheral cord insertion in diamniotic-monochorionic twin placentas remain undetermined.

AIM

To study the association between type of cord insertion and choriovascular distribution of both twin territories in diamniotic-monochorionic twin placentas.

DESIGN

A prospective cohort of 138 monochorionic placentas was examined at Women and Infants Hospital between 2009 and early 2011. Thirty-five cases (25%), including disrupted placentas, placentas from higher order multiples and placentas from pregnancies complicated by twin-to-twin transfusion syndrome, were excluded. The correlation between cord insertion type and superficial choriovascular distribution was studied in the remaining 103 dye-injected diamniotic-monochorionic placentas. Cord insertion was categorized as paracentral, marginal or velamentous. The choriovascular distribution of each individual twin territory was assessed by analysis of number and density (number per surface area) of perforating chorionic arteries (PCA).

RESULTS

In contrast with singleton placentas, there was no correlation between cord insertion type and a twin's own choriovascular distribution in diamniotic-monochorionic placentas. However, a strong correlation was found between the choriovascular distribution of one twin and the cord insertion type of the opposite twin. For a twin with paracentral or marginal cord insertion, the PCA density was significantly higher if the co-twin had a velamentous cord insertion than if the co-twin had a paracentral cord insertion (P < 0.001 and P < 0.05, respectively). Similarly, the PCA density of a twin with velamentous cord insertion tended to be higher if the co-twin had a velamentous, rather than paracentral cord insertion (P = 0.09).

CONCLUSIONS

This is the first study to suggest that in diamniotic-monochorionic twin gestations, the choriovascular architecture correlates with the cord insertion type of the co-twin. In general, velamentous cord insertion is associated with expanded choriovascular distribution in the opposite twin territory. Our observations may reflect novel manifestations of twin interdependence in monochorionic pregnancies.

Placental intravascular organisms: a case report

Ascending amniotic fluid bacterial infection is a cause of perinatal morbidity and mortality. A diagnosis of amniotic cavity infection can be inferred by documenting maternal (acute chorioamnionitis) and/or fetal (chorionic plate vasculitis; umbilical vasculitis/funisitis) inflammatory response. A definitive diagnosis of intrauterine/neonatal sepsis as a cause of stillbirth requires positive blood cultures obtained at postmortem examination. However, if postmortem examination is not performed, acute chorioamnionitis with/without fetal inflammatory response cannot be classified as a cause of demise. We present a case of intrauterine demise associated with acute chorioamnionitis, villitis, and intervillositis of the placenta. Although postmortem examination was denied, a conclusive diagnosis of intrauterine sepsis could be rendered by demonstration of gram-positive cocci within fetal vessels of umbilical cord, chorionic plate, and stem villi. This report highlights the importance of identification of placental intravascular organisms as unequivocal evidence of fetal sepsis, especially in cases where cultures cannot be obtained.

THE INFLUENCE OF THYROIDECTOMY, SPLENECTOMY, GONADECTOMY, AND SUPRARENALECTOMY UPON THE DEVELOPMENT OF EXPERIMENTAL ATHEROSCLEROSIS IN RABBITS

Alimentary hypercholesterolemia acting over a sufficient period of time (in rabbits with all organs intact, 110 days or longer) causes deposition of cholesterol within the intima of the aorta. Deposition of cholesterol within the intima of the aorta initiates the formation of experimental atheromata. Thyroidectomy, splenectomy, and gonadectomy augment hypercholesterolemia and thereby facilitate and accelerate the development of experimental atheromata of the aorta in rabbits. Sublethal suprarenal insufficiency does not increase the susceptibility of rabbits to the development of such atheromata.

Systemic sclerosis and bilateral lung transplantation: a single centre experience

Lung involvement is the leading cause of death in systemic sclerosis (SSc), but lung transplantation (LT) for systemic disease remains controversial. Our objective was to comprehensively evaluate post-LT outcomes for SSc compared to idiopathic pulmonary fibrosis (IPF). We retrospectively evaluated bilateral LT recipients (LTRs) with SSc or IPF at our centre between January 1, 2003 and December 31, 2007. The primary end-point was all-cause mortality at 1 yr post-LT. Secondary end-points included assessments of acute rejection (AR), pulmonary function, infection and chronic rejection. 14 patients with SSc and 38 patients with IPF underwent LT. Apart from a younger SSc cohort (53.2 versus 58.8 yrs; p = 0.02), the two groups were well matched. 1-yr all-cause mortality was no different between SSc (6.6%) and IPF (13.1%) groups, after adjusting for age (p = 0.62). Rates of (AR) ≥2 were significantly increased for the SSc compared with the IPF group (hazard ratio (HR) 2.91; p = 0.007). Other end-points, including chronic rejection, infection and pulmonary function, showed no differences. SSc LTRs experience similar survival 1 yr post-LT when compared to IPF. AR rates may be significantly higher in the SSc group. Longer follow-up is necessary to determine the effects of gastrointestinal dysfunction and AR on late allograft function in SSc LTR.

Negative impacts of unreported COPD exacerbations on health-related quality of life at 1 year

Unreported chronic obstructive pulmonary disease (COPD) exacerbations are common, but their intermediate-to-long-term impacts on health-related quality of life (HRQoL) are unknown. The aim of the present study was to examine the impact of unreported exacerbations on HRQoL at 1 yr. A multicentric prospective cohort study in 491 COPD patients was conducted in China. HRQoL was measured using the St George's Respiratory Questionnaire (SGRQ). Other measurements included sociodemographic, clinical, psychosocial and treatment profiles. Patients were monitored monthly for 12 months to document exacerbations (at least one symptom worsening for > or =48 h). Patients were categorised into six groups: no exacerbation, one unreported exacerbation only, more than one unreported exacerbation only, one reported exacerbation only, more than one reported exacerbation only, and both unreported and reported exacerbations. Generalised estimating equations were used to estimate the adjusted associations between exacerbations and HRQoL change. A total of 466 unreported and 410 reported exacerbations were recorded. Compared with patients with no exacerbations, the change in SGRQ total score was similar amongst patients with one unreported exacerbation (adjusted mean change 1.22 points (95% CI -4.05-6.48)), but significantly worse among patients with more than one unreported exacerbation (4.61 (95% CI 0.09-9.13)). Development and evaluation of self-management programmes emphasising early recognition of exacerbations and consequent action appear to be warranted.

Does retention of the ovaries improve long-term survival after hysterectomy? The validity of the epidemiological evidence

Based on a decision analysis of multiple epidemiological studies, it has been claimed that, among women hysterectomized for benign disease, removal of the ovaries before the age of 65 years decreases long-term survival, and that the benefit conferred by retaining the ovaries outweighs any reduction in ovarian cancer mortality among oophorectomized women who are at average risk of ovarian cancer. The decision analysis failed to allow for the inevitable complexity involved in an overarching quantitative analysis of multiple outcomes, and to do so would not have been feasible; it made multiple assumptions, some of which could not be defended; a definition of 'average risk' of ovarian cancer was not provided, and the validity of the concept of 'average risk' was not considered; sensitivity analyses designed to test the robustness of the data were inadequate. The findings from decision analysis cannot be used as evidence to determine whether bilateral oophorectomy poses a public health problem in terms of long-term survival.