Pulmonary arterial hypertension: basis of sex differences in incidence and treatment response

Pulmonary arterial hypertension (PAH) is a complex disease characterized by elevated pulmonary arterial pressure, pulmonary vascular remodelling and occlusive pulmonary vascular lesions, leading to right heart failure. Evidence from recent epidemiological studies suggests the influence of gender on the development of PAH with an approximate female to male ratio of 4:1, depending on the underlying disease pathology. Overall, the therapeutic strategy for PAH remains suboptimal with poor survival rates observed in both genders. Endogenous sex hormones, in particular 17β oestradiol and its metabolites, have been implicated in the development of the disease; however, the influence of sex hormones on the underlying pathobiology remains controversial. Further understanding of the influence of sex hormones on the normal and diseased pulmonary circulation will be critical to our understanding the pathology of PAH and future therapeutic strategies. In this review, we will discuss the influence of sex hormones on the development of PAH and address recent controversies.

First Report of Pseudoperonospora cubensis Causing Downy Mildew on Momordica balsamina and M. charantia in North Carolina

Momordica balsamina (balsam apple) and M. charantia L. (bitter melon/bitter gourd/balsam pear) commonly grow in the wild in Africa and Asia; bitter melon is also cultivated for food and medicinal purposes in Asia (1). In the United States, these cucurbits grow as weeds or ornamentals. Both species are found in southern states and bitter melon is also found in Pennsylvania and Connecticut (3). Cucurbit downy mildew (CDM), caused by the oomycete Pseudoperonospora cubensis, was observed on bitter melon and balsam apple between August and October of 2013 in six North Carolina sentinel plots belonging to the CDM ipmPIPE program (2). Plots were located at research stations in Johnston, Sampson, Lenoir, Henderson, Rowan, and Haywood counties, and contained six different commercial cucurbit species including cucumbers, melons, and squashes in addition to the Momordica spp. Leaves with symptoms typical of CDM were collected from the Momordica spp. and symptoms varied from irregular chlorotic lesions to circular lesions with chlorotic halos on the adaxial leaf surface. Sporulation on the abaxial side of the leaves was observed and a compound microscope revealed sporangiophores (180 to 200 μm height) bearing lemon-shaped, dark sporangia (20 to 35 × 10 to 20 μm diameter) with papilla on one end. Genomic DNA was extracted from lesions and regions of the NADH dehydrogynase subunit 1 (Nad1), NADH dehydrogynase subunit 5 (Nad5), and internal transcribed spacer (ITS) ribosomal RNA genes were amplified and sequenced (4). BLAST analysis revealed 100% identity to P. cubensis Nad1 (HQ636552.1, HQ636551.1), Nad5 (HQ636556.1), and ITS (HQ636491.1) sequences in GenBank. Sequences from a downy mildew isolate from each Momordica spp. were deposited in GenBank as accession nos. KJ496339 through 44. To further confirm host susceptibility, vein junctions on the abaxial leaf surface of five detached leaves of lab-grown balsam apple and bitter melon were either inoculated with a sporangia suspension (10 μl, 10⁴ sporangia/ml) of a P. cubensis isolate from Cucumis sativus ('Vlaspik' cucumber), or with water as a control. Inoculated leaves were placed in humidity chambers to promote infection and incubated using a 12-h light (21°C) and dark (18°C) cycle. Seven days post inoculation, CDM symptoms and sporulation were observed on inoculated balsam apple and bitter melon leaves. P. cubensis has been reported as a pathogen of both hosts in Iowa (5). To our knowledge, this is the first report of P. cubensis infecting these Momordica spp. in NC in the field. Identifying these Momordica spp. as hosts for P. cubensis is important since these cucurbits may serve as a source of CDM inoculum and potentially an overwintering mechanism for P. cubensis. Further research is needed to establish the role of non-commercial cucurbits in the yearly CDM epidemic, which will aid the efforts of the CDM ipmPIPE to predict disease outbreaks. References: (1) L. K. Bharathi and K. J. John. Momordica Genus in Asia-An Overview. Springer, New Delhi, India, 2013. (2) P. S. Ojiambo et al. Plant Health Prog. doi:10.1094/PHP-2011-0411-01-RV, 2011. (3) PLANTS Database. Natural Resources Conservation Service, USDA. Retrieved from http://plants.usda.gov/ , 7 February 2014. (4) L. M. Quesada-Ocampo et al. Plant Dis. 96:1459, 2012. (5) USDA. Index of Plant Disease in the United States. Agricultural Handbook 165, 1960.

The epidemiology of malpractice claims in primary care: a systematic review

OBJECTIVES

The aim of this systematic review was to examine the epidemiology of malpractice claims in primary care.

DESIGN

A computerised systematic literature search was conducted. Studies were included if they reported original data (≥10 cases) pertinent to malpractice claims, were based in primary care and were published in the English language. Data were synthesised using a narrative approach.

SETTING

Primary care.

PARTICIPANTS

Malpractice claimants.

PRIMARY OUTCOME

Malpractice claim (defined as a written demand for compensation for medical injury). We recorded: medical misadventure cited in claims, missed/delayed diagnoses cited in claims, outcome of claims, prevalence of claims and compensation awarded to claimants.

RESULTS

Of the 7152 articles retrieved by electronic search, a total of 34 studies met the inclusion criteria and were included in the narrative analysis. Twenty-eight studies presented data from medical indemnity malpractice claims databases and six studies presented survey data. Fifteen studies were based in the USA, nine in the UK, seven in Australia, one in Canada and two in France. The commonest medical misadventure resulting in claims was failure to or delay in diagnosis, which represented 26-63% of all claims across included studies. Common missed or delayed diagnoses included cancer and myocardial infarction in adults and meningitis in children. Medication error represented the second commonest domain representing 5.6-20% of all claims across included studies. The prevalence of malpractice claims in primary care varied across countries. In the USA and Australia when compared with other clinical disciplines, general practice ranked in the top five specialties accounting for the most claims, representing 7.6-20% of all claims. However, the majority of claims were successfully defended.

CONCLUSIONS

This review of malpractice claims in primary care highlights diagnosis and medication error as areas to be prioritised in developing educational strategies and risk management systems.

Transanal irrigation in the management of neurogenic bowel dysfunction

Many patients with a spinal cord injury (SCI) or spina bifida suffer from neurogenic bowel dysfunction which causes significant physical and psychological morbidity. For the last four years at the National Rehabilitation Hospital, transanal irrigation (TAI) has been offered to patients who were dissatisfied with a conservative bowel management programme. This is an observational study of eleven patients who were offered TAI. Three questionnaires, scoring bowel symptoms at baseline and follow-up (3-28 months) were completed by patients. Nine patients had a SCl and two had spina bifida, mean age was 44 years. A reduction in mean scores for all three questionnaires occurred post TAI (39.5-42.1%) indicating fewer bowel symptoms. Statistically significant reductions in faecal incontinence (p < 0.05), abdominal pain (p < 0.05) and lifestyle alterations secondary to bowel management (p < 0.05) occurred. No serious adverse events occurred during the study. TAI is an effective treatment option for the management of neurogenic bowel dysfunction.

Gamma-ray emission concurrent with the nova in the symbiotic binary V407 Cygni

Novae are thermonuclear explosions on a white dwarf surface fueled by mass accreted from a companion star. Current physical models posit that shocked expanding gas from the nova shell can produce x-ray emission, but emission at higher energies has not been widely expected. Here, we report the Fermi Large Area Telescope detection of variable gamma-ray emission (0.1 to 10 billion electron volts) from the recently detected optical nova of the symbiotic star V407 Cygni. We propose that the material of the nova shell interacts with the dense ambient medium of the red giant primary and that particles can be accelerated effectively to produce pi(0) decay gamma-rays from proton-proton interactions. Emission involving inverse Compton scattering of the red giant radiation is also considered and is not ruled out.

Measurement of the cosmic ray e+ +e- spectrum from 20 GeV to 1 TeV with the Fermi Large Area Telescope

Designed as a high-sensitivity gamma-ray observatory, the Fermi Large Area Telescope is also an electron detector with a large acceptance exceeding 2 m;{2} sr at 300 GeV. Building on the gamma-ray analysis, we have developed an efficient electron detection strategy which provides sufficient background rejection for measurement of the steeply falling electron spectrum up to 1 TeV. Our high precision data show that the electron spectrum falls with energy as E-3.0 and does not exhibit prominent spectral features. Interpretations in terms of a conventional diffusive model as well as a potential local extra component are briefly discussed.

Observational study of perioperative P tc co2 and S p o2 in non-ventilated patients receiving epidural infusion or patient-controlled analgesia using a single earlobe monitor (TOSCA) †

BACKGROUND

TOSCA, a non-invasive monitor with a single earlobe probe incorporating a Stow-Severinghaus electrode and optical sensor (Linde Medical Sensors AG, Basel, Switzerland), has previously been used with ventilated patients and in sleep laboratories. We recorded transcutaneous carbon dioxide pressures (Ptc(co(2)) and oxygen saturations (Sp(o(2)) in non-ventilated patients to investigate opioid-induced respiratory depression.

METHODS

This observational cohort study included 28 ASA I and II patients, monitored between 10 p.m. and 6 a.m., before and after elective major laparotomy. After operation, patients were kept on oxygen, 4 litre min(-1), and received either bupivacaine (0.1%) containing fentanyl (2 microg ml(-1) via epidural catheter (epidural analgesia group, EPI; n = 14) or morphine via patient-controlled analgesia infusion pump (PCA-morphine group, PCA; n = 14).

RESULTS

The preoperative median (lower/upper quartile) Ptc(co(2)) was similar in both groups at around 5.5 kPa, but significantly higher after operation in PCA with 6.9 kPa (5.6/7.3) (P = 0.02), accompanied by a longer hypercarbia time >6 kPa of 6.6 h (0.1/8.0) (P = 0.04), and lower respiratory rates of 13.9 breaths min(-1) (13.3/15.4) (P = 0.04). In EPI, the corresponding results were 5.8 kPa (5.5/6.0), 1.2 h (0.1/4.3), and 16.2 breaths min(-1) (14.8/16.7). The perioperative median Sp(o(2)) in both groups was comparable within the normal range, although generally higher when on supplemental oxygen (P = 0.26). The Sp(o(2)) time <94% was similar in both groups (P = 0.33) as were pain scores (P = 0.25).

CONCLUSIONS

Ptc(co(2)) recording in patients on PCA-morphine and supplemental oxygen revealed hypercapnia in the presence of normal respiratory rates and Sp(o(2)) values. This is recommended as an easy and sensitive monitor of respiratory depression and may have a role in the safe administration of opioid-analgesia.

58. CHLAMYDIA SCREENING OF ANTENATAL WOMEN IN MELBOURNE BETWEEN 16-25 YEARS

Objective: Routine chlamydia screening of pregnant women is not widely practiced in Australia and limited data are available on the prevalence of infection in this population. This cross-sectional study sought to determine the prevalence of genital chlamydial infection among pregnant women aged 16-25 attending antenatal clinics in Melbourne. Methods: Consecutive women attending 4 major maternity services covering northern, western, eastern and south-eastern Melbourne were approached between October 2006 and May 2007. Of 931 eligible women (those aged 16-25 who had not already been tested for chlamydia) attending the clinics at the time of recruitment, 882 (95%) were approached and 845 (96%) agreed to participate. Participants completed a questionnaire which was translated into Chinese, Vietnamese and Arabic, and provided first-void urine which was tested for Chlamydia trachomatis using polymerase chain reaction. Results: Eighteen percent of women had a preferred language other than English. Of the 826 tests which were non assessable, 30 were positive representing a prevalence rate of 3.6% (95% CI: 2.5-5.1%). However, among women aged 16-20, 14 of 203 women were infected, representing a prevalence rate of 6.9% (95% CI: 3.8-11.3%). All infected women received treatment with azithromycin and all who have had repeat chlamydia tests to date have been negative. Conclusion: In this study of a wide cross-section of pregnant Melbourne women, chlamydial infection was common, particularly among teenagers. Screening was highly acceptable, with the great majority of women approached agreeing to be screened.

ARRY-649, a member of a novel class of Eg5 kinesin inhibitors

13045

Background: Inhibitors of the Eg5 motor kinesin selectively disrupt mitotic spindles in dividing cells. This selective targeting of microtubule dynamics in dividing cells is expected to translate to broad-spectrum anti-tumor activity while avoiding neuropathic side effects caused by taxanes. To date, quinazolinone Eg5 inhibitors, exemplified by ispinesib, represent the only Eg5 inhibitors reported in clinical trials. Methods: We used X-ray crystallography, biochemical and cell-based assays, pharmacokinetic profiling and in vivo efficacy studies to identify and optimize a potent series of Eg5 inhibitors. Results: We have discovered a distinct series of potent Eg5 inhibitors, exemplified by ARRY-649. ARRY-649 inhibited Eg5 with an IC50 of 0.7 nM, blocked phosphorylation of histone H3 in HeLa cells with an IC50 of 0.3 nM and showed sub-nanomolar activity against a broad panel of human tumor cells lines in in vitro viability assays. Further evaluation of mechanism-of-action in tumor cell lines revealed that ARRY-649 induced a monopolar spindle phenotype and subsequent apoptosis characteristic of Eg5 inhibition. In contrast to paclitaxel, ARRY-649 retained potent activity against multi-drug resistant human tumor cells lines selected to overexpress P-glycoprotein. ARRY-649 demonstrated robust efficacy in the HT-29 human colon tumor xenograft model and was well-tolerated at efficacious doses and schedules. Durable complete- and partial-regressions were observed upon intraperitoneal administration on a 5 mg/kg q4dx3 schedule in the HT-29 model. Similar results were obtained using the HL-60 myelomonocytic xenograft model. Conclusions: ARRY-649 represents a distinct class of potent Eg5 inhibitors with robust activity in preclinical models of human cancer. Based on these observations, we have progressed novel Eg5 inhibitors toward clinical development.

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A cross-sectional survey to estimate the prevalence of family history of colorectal, breast and ovarian cancer in a Scottish general practice population

A cross-sectional survey of all patients aged 30–65 in four general practices within one Local Health Care Co-operative in Fife, Scotland was undertaken to measure the prevalence of family history of colorectal, breast and ovarian cancer. A total of 7619 patients aged 30–65 responded to a postal questionnaire (response rate 59%). In all, 17% of respondents (1324, 95% Cl 16–18%) reported a relative affected by colorectal, breast or ovarian cancer. Of those, 6% (78, 95% CI 5–7%) met the Scottish guidelines for referral for genetics counselling. In all, 2% (24, 95% CI 1–3%) of all individuals with an affected relative had received genetic counselling and risk assessment. Of these, 25% (6, 95% CI 8–42%) met the moderate- or high-risk criteria for developing a cancer. In conclusion, the number of patients who are at a significantly increased risk of cancer on the basis of a family history is small (approximately 10 per General Practitioner (GP) list). It is therefore unrealistic to expect GPs to develop expertise in genetic risk estimation. A simple family history chart or pedigree is one way that a GP can, within the constraints of a GP consultation, determine which patients should be reassured and which referred to the local cancer genetic clinic.

270.Macrophage inhibitory cytokine-1 at the maternal - fetal interface in early pregnancy

Macrophage inhibitory cytokine-1 (MIC-1) is a transforming growth factor-β (TGF-β) superfamily member, first isolated from activated macrophages and subsequently localised in the human placenta. We previously reported that decreased circulating levels in very early pregnancy are associated with subsequent miscarriage. We undertook these current in vitro studies to investigate possible roles for MIC-1 in early pregnancy: (1) regulation of placental matrix metalloproteinase-2 and -9 (MMP-2 and -9); (2) effect on placental apoptosis; and (3) regulation of endometrial stromal cell decidualisation. (1) First trimester placental explant cultures were treated with 100–200 ng/mL MIC-1 � 1/1000 (v/v) anti-MIC-1 antibody. MMP-2 and -9 were measured by gelatin zymography. MMP activation via the plasminogen activation pathway was examined by measuring mRNA expression for urokinase plasminogen activator and its receptor (uPA, uPAR) and type-1 plasminogen activation inhibitor (PAI-1). (2) In first trimester trophoblast explants, apoptosis was induced in vitro with tumor necrosis factor-α (TNF-α) and interferon-β (IFN-β) � 200 ng/mL MIC-1. The pro-apoptosis factor caspase-3 was localised by immunohistochemistry. (3) Using an established model of oestrogen and progesterone induced endometrial stromal cell decidualisation, MIC-1 production was measured and correlated with morphological changes. Cultures were also treated with 20 ng/mL MIC-1. MIC-1 treatment inhibited activation of both MMP-2 and MMP-9 while treatment with anti-MIC-1 antibody blocked the inhibition. uPA, uPAR and PAI-1 mRNA did not change with either treatment. MIC-1 treatment mitigated TNF-α/IFN-β induced trophoblast apoptosis. MIC-1 production increased during induced decidualisation and MIC-1 treatment facilitates further decidualisation in this model. MIC-1 appears to have a number of potentially important functions in the human placenta and decidua consistent with physiological roles in normal placentation. Whether these functions are key to successful pregnancy remains to be studied.

IL-11 and IL-11Ralpha immunolocalisation at primate implantation sites supports a role for IL-11 in placentation and fetal development

Embryo implantation, endometrial stromal cell decidualization and formation of a functional placenta are critical processes in the establishment and maintenance of pregnancy. Interleukin (IL)-11 signalling is essential for adequate decidualization in the mouse uterus and IL-11 promotes decidualization in the human. IL-11 action is mediated via binding to the specific IL-11 receptor alpha (IL-11Ralpha). The present study examined immunoreactive IL-11 and IL-11Ralpha in cycling rhesus monkey endometrium, at implantation sites in cynomolgus and rhesus monkeys and in human first trimester decidua and defined distinct spatial and temporal patterns. In cycling rhesus monkey endometrium, IL-11 and IL-11Ralpha increased in both basalis and functionalis regions during the secretory compared with the proliferative phase, with changing cellular locations in luminal and glandular epithelium and stroma. The patterns were similar overall to those previously described in human endometrium. Differences were seen in immunostaining during implantation in cynomologus and rhesus monkey. In the cynomolgus, very little staining for IL-11 or IL-11Ralpha was seen in syncytio- and cyto-trophoblast cells in the villi between days 12 and 150 of pregnancy although there was moderate staining in cytotrophoblast in the shell between days 12 and 17 and in subpopulations of cytotrophoblast cells invading the arteries at day 17. By contrast in the rhesus monkey between days 24 and 35 of pregnancy and in human first trimester placenta, cyto- and syncytio-trophoblast in the villi but not cytotrophoblast in the shell were positively stained. The most intense staining for both IL-11 and IL-11Ralpha was present within the decidua in the maternal component of implantation sites in all three primates but moderate staining was also present in maternal vascular smooth muscle and glands perivascular cells and epithelial plaques. These results are consistent with a role for IL-11 both during decidualization and placentation in primates.

Diaminoindanes as microsomal triglyceride transfer protein inhibitors

The synthesis and biological activities of biarylamide-substituted diaminoindanes as microsomal triglyceride transfer protein (MTP) inhibitors are described. One of the more potent compounds, 8aR, inhibited both the secretion of apoB from Hep G2 cells and the MTP-mediated transfer of triglycerides between synthetic acceptor and donor liposomes with IC(50) values of 0.7 and 70 nM, respectively. In normolipidemic rats and dogs, oral administration of 8aR dose-dependently reduced both plasma triglycerides and total cholesterol. Moreover, in rats and dogs, 8aR also prevented the postprandial rise in plasma triglycerides following a bolus administration of a fat load. Because MTP inhibitors decrease very low density lipoprotein assembly in the liver, the potential for hepatic lipid accumulation was evaluated. In normolipidemic rats, hepatic cholesterol and triglyceride contents were dose-dependently increased by 8aR. However, hepatic lipid accumulation resulted in negligible change in total liver weight and was reversible after withdrawal of the compound.