D-dimer testing in pregnant patients: towards determining the next 'level' in the diagnosis of deep vein thrombosis

SUMMARY BACKGROUND

The role of D-dimer in excluding deep vein thrombosis (DVT) in pregnancy is currently uncertain. We hypothesized that the specificity of sensitive D-dimer assays could be improved without compromising sensitivity by using higher D-dimer cut-off values.

OBJECTIVE

To determine the test characteristics of two rapid enzyme-linked immunosorbent assays and three latex agglutination assays in pregnancy.

METHOD

We recruited consecutive pregnant women who presented to participating centers with suspected DVT for the study. Symptomatic women were investigated with compression ultrasonography, and received 3 months of clinical follow-up to assess for the presence of venous thrombosis. Plasma samples for D-dimer were collected and frozen at the time of presentation. The median and mean D-dimer values for respective trimesters of pregnancy in patients with and without DVT were calculated. Receiver operating curves (ROCs) were plotted for respective assays to establish the best cut-points. The test characteristics corresponding to standard cut-points and these 'pregnancy' cut-points are presented.

RESULTS

The prevalence of DVT in our cohort was 6.6% (95% confidence interval 4.0-10.6%). The mean and median D-dimer values were significantly increased throughout pregnancy. Overall, women with confirmed DVT had higher D-dimer levels than women without DVT (P < 0.0001). Improved specificities (62-79%) were observed with the use of higher cut-points obtained from ROCs for all five assays, and high sensitivities were maintained (80-100%) for DVT diagnosis.

CONCLUSION

Using higher cut-points than those used in non-pregnant patients, the specificity of D-dimer assays for the diagnosis of DVT in pregnancy can be improved without compromising sensitivity. Validation in prospective management studies is needed.

Prolonged cardiac allograft survival in mouse model after complement depletion with Yunnan cobra venom factor

BACKGROUND

Activation of the complement system is the leading mechanism that causes antibody-mediated acute rejection and hyperacute rejection after xenotransplantation. The major cause of acute rejection in allogeneic transplantation is the T cell-mediated specific immune response. We studied the effects of complement on acute rejection after cardiac allotransplantation using complement depletion with cobra venom factor (CVF) in the mouse.

MATERIALS AND METHODS

The Balb/c-C57 mouse model of heterotopic cardiac allograft was used. The mice were divided into 2 groups, a control group and a CVF-treated group. After intravenous injection of CVF, the experimental group was observed for allograft survival time. Twelve mice from the control and experimental groups were sacrificed on days 3, 5, and 7 after the operation. The pathologic grade of acute rejection, deposition of C3 in tissue, extent of infiltration by CD4+ and CD8+ T cells, and expression of MHC-II, B7-1, and B7-2 were compared between the 2 groups.

RESULTS

In the CVF-treated group, mean (SD) survival of the cardiac allograft was 26.2 (1.7) days, and in the control group was 8.4 (0.4) days (P < .01). Pathologic examination and immunohistochemistry demonstrated that the grade of acute rejection, deposition of C3 in tissue, extent of infiltration of CD4+ and CD8+ T cells, and expression of MHC-II, B7-1, and B7-2 were significantly decreased in the CVF-treated group.

CONCLUSION

Depletion of complement in the serum with CVF inhibits acute cardiac allograft rejection in the mouse.

Measurements of h(c)(1P(1)) in psi' decays

We present measurements of the charmonium state h(c)(1P(1)) made with 106x10(6) psi' events collected by BESIII at BEPCII. Clear signals are observed for psi'-->pi0 h(c) with and without the subsequent radiative decay h(c)-->gamma eta(c). First measurements of the absolute branching ratios B(psi'-->pi0 h(c)) = (8.4+/-1.3+/-1.0) x 10(-4) and B(h(c)-->gamma eta(c)) = (54.3+/-6.7+/-5.2)% are presented. A statistics-limited determination of the previously unmeasured h(c) width leads to an upper limit Gamma(h(c))<1.44 MeV (90% confidence). Measurements of M(h(c)) = 3525.40+/-0.13+/-0.18 MeV/c2 and B(psi'-->pi0 h(c)) x B(h(c)-->gamma eta(c)) = (4.58+/-0.40+/-0.50) x 10(-4) are consistent with previous results.

Clinicopathological Features of Solitary Fibrous Tumours in the Extremities: Four Case Reports and a Literature Review

This paper reports on the clinicopathological features of four patients with solitary fibrous tumours arising from the extremities and presents a review of the relevant literature. The patients consisted of three women and one man, with a mean age of 47.8 years. Standard pre-operative work-up data were examined, including: history, clinical examination, plain radiography, computed tomography scans of the lesion and chest, magnetic resonance imaging, angiography, technetium-99m bone scan, thallium-201 scintigraphy and routine laboratory tests. Immunohisto chemical staining was performed for CD34, Bcl-2 protein, vimentin, S-100 protein, desmin and smooth muscle actin, and pathological material was reviewed for the presence of histologically malignant components. Immunohistochemically, all of the tumours were diffusely positive for CD34. Clinical and radiological findings of solitary fibrous tumours affecting the extremities are reminiscent of those of aggressive or malignant soft tissue tumours. Pathological and immunohistochemical studies are important in making the correct diagnosis.

Synthesis and pharmacological effects of new, N-substituted soft anticholinergics based on glycopyrrolate

To reduce the possibility of systemic side-effects in locally administered anticholinergics, two new N-substituted glycopyrrolate analogues designed using soft drug design approaches have been synthesized and evaluated in vitro and in vivo. Because stereospecificity is known to be important at muscarinic receptors, the new compounds SGM and SGE also have been prepared as their pure 2R isomers, 2R-SGM and 2R-SGE, by starting from optically pure (-)-cyclopentylmandelic acid, and the corresponding isomers were indeed found to be more active. The new soft glycopyrrolates were chemically more stable under acidic conditions, and the ethyl esters SGE were more stable than the methyl esters SGM. The new compounds were also found to be quite susceptible to extrahepatic metabolism, having half-lives of 20–30 min in rat plasma (in vitro), consistent with their soft nature. Binding studies at human muscarinic receptors (M1−M4) and guinea-pig ileum assays found 2R-SGM and 2R-SGE to have potencies somewhat less than, but close to, those of glycopyrrolate and N-methylscopolamine. They caused pupil dilation in rabbit eyes, but their mydriatic effects lasted for considerably less time than that of glycopyrrolate, and they did not induce dilation of the pupil in the contralateral, water-treated eyes, indicating that, in agreement with their soft nature, they are locally active, but safe and with a low potential to cause systemic side-effects.

Brain tissue sodium concentration in multiple sclerosis: a sodium imaging study at 3 tesla

Neuro-axonal degeneration occurs progressively from the onset of multiple sclerosis and is thought to be a significant cause of increasing clinical disability. Several histopathological studies of multiple sclerosis and experimental autoimmune encephalomyelitis have shown that the accumulation of sodium in axons can promote reverse action of the sodium/calcium exchanger that, in turn, leads to a lethal overload in intra-axonal calcium. We hypothesized that sodium magnetic resonance imaging would provide an indicator of cellular and metabolic integrity and ion homeostasis in patients with multiple sclerosis. Using a three-dimensional radial gradient-echo sequence with short echo time, we performed sodium magnetic resonance imaging at 3 T in 17 patients with relapsing-remitting multiple sclerosis and in 13 normal subjects. The absolute total tissue sodium concentration was measured in lesions and in several areas of normal-appearing white and grey matter in patients, and corresponding areas of white and grey matter in controls. A mixed model analysis of covariance was performed to compare regional tissue sodium concentration levels in patients and controls. Spearman correlations were used to determine the association of regional tissue sodium concentration levels in T(2)- and T(1)-weighted lesions with measures of normalized whole brain and grey and white matter volumes, and with expanded disability status scale scores. In patients, tissue sodium concentration levels were found to be elevated in acute and chronic lesions compared to areas of normal-appearing white matter (P < 0.0001). The tissue sodium concentration levels in areas of normal-appearing white matter were significantly higher than those in corresponding white matter regions in healthy controls (P < 0.0001). The tissue sodium concentration value averaged over lesions and over regions of normal-appearing white and grey matter was positively associated with T(2)-weighted (P < or = 0.001 for all) and T(1)-weighted (P < or = 0.006 for all) lesion volumes. In patients, only the tissue sodium concentration value averaged over regions of normal-appearing grey matter was negatively associated with the normalized grey matter volume (P = 0.0009). Finally, the expanded disability status scale score showed a mild, positive association with the mean tissue sodium concentration value in chronic lesions (P = 0.002), in regions of normal-appearing white matter (P = 0.004) and normal-appearing grey matter (P = 0.002). This study shows the feasibility of using in vivo sodium magnetic resonance imaging at 3 T in patients with multiple sclerosis. Our findings suggest that the abnormal values of the tissue sodium concentration in patients with relapsing-remitting multiple sclerosis might reflect changes in cellular composition of the lesions and/or changes in cellular and metabolic integrity. Sodium magnetic resonance imaging has the potential to provide insight into the pathophysiological mechanisms of tissue injury when correlation with histopathology becomes available.

Sterol regulatory element-binding protein-1c knockdown protected INS-1E cells from lipotoxicity

OBJECTIVE

The reduction in insulin secretory capacity and beta-cell mass has been attributed, at least partially, to lipotoxicity, which may contribute to the development of type 2 diabetes. Chronic free fatty acids (FFA) exposure impairs pancreatic beta-cell function and induces beta-cell apoptosis. This study is to elucidate the underlying molecular mechanisms.

RESEARCH DESIGN AND METHODS

We exposed INS-1E pancreatic beta-cell line to palmitate or oleate, and measured the glucose stimulated insulin secretion (GSIS). The effect of FFA on sterol regulatory element-binding protein (SREBP)-1c lipogenic pathway, and expression of genes involved in beta-cell functions, including AMPK (AMP-activated protein kinase), UCP-2 (uncoupling protein-2), IRS-2 (insulin receptor substrate-2), PDX-1 (pancreatic duodenal homeobox-1), GLUT-2 (glucose transporter-2) and B cell lymphoma/leukaemia-2 (Bcl-2) were investigated. Apoptosis of these exposed cells was determined by MitoCapture, Annexin V-Cy3 or terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay. Cell lipid accumulation was measured by oil red O staining or TG extraction. Also SREBP-1c expression knockdown were used.

RESULTS

FFA treatment resulted in SREBP-1c overexpression, impaired GSIS, lipid accumulation, apoptosis of INS-1E cells. In addition, the expression of lipogenic genes and UCP-2 were upregulated, but AMPK, IRS-2, PDX-1, GLUT-2 and Bcl-2 were downregulated in the exposed cells. However, these lipotoxic effects of FFA were largely prevented by induction of a SREBP-1c small interfering RNA.

CONCLUSIONS

These data suggest a strong correlation between FFA treatment and SREBP-1c activation in INS-1E cells. SREBP-1c might be a major factor responsible for beta-cell lipotoxicity, and SREBP-1c knockdown could protect INS-1E cells from lipotoxicity, which is implicating a therapeutic potential for treating diabetes related to lipotoxicity.

An Approach To Correlate the Temporal Information To Facilitate Specimen Selection in the Breast Cancer Research Project

Background: Temporal information management is very important in translational research. In the Clinical Breast Care Project (CBCP), the information on subjects and their specimens may be collected at multiple time points using multiple instruments.All such information is stored in an in-house data warehouse. Currently, 4000+ subjects have been enrolled in the study following HIPAA-compliant IRB-approved protocols with 35,000+ specimens collected. Some of the patient's information is static but other data are time dependent. As a result, selecting samples for experiments is a challenge due to complicated temporal relationships between samples and information collected through various instruments.Methods and Results: In the CBCP, the clinical information, blood, and solid tissues of a subject may be collected at multiple time points, associated with the completion of a Core Questionnaire (CQ) for clinical information, and/or a Pathology Checklist (PC) for pathology and sample information. We have designed and implemented an algorithm to use a set of pre-defined flags to precisely describe each sample related to patient's clinical and pathology information in the temporal domain. Five categories (flags) were created to describe the relationship between the sample date (SD) and the CQ date based on whether SD is within 60 days of the CQ date or there is missing data or not. The relationship between blood samples and pathology information is more complicated. Within 90 days, any of the 15 surgical procedures might be performed on a patient and blood samples might be collected before, at the time of, or between any procedures. For some experiments, it is crucial to select blood samples taken before tumor is impacted or severely impacted. Thus, we defined a dozen categories to describe the relationship between the SD and the procedure date (PD), including when the SD is earlier than any PD, equals to the first PD, or between certain procedures. Using these flags we have characterized the relationships between SDs and CQ dates, and between SDs and PDs for all the samples and all the subjects, and stored all the information into two relational tables. The temporal criteria for sample selection are now represented by the relationships between these flags, and can be implemented through several filtering processes. The described algorithm drastically reduces the time needed for precise sample selection from several days for manual efforts to several hours.Discussion: We are in the process of developing a general data model for temporal information management. The method described here is a transitional solution that fulfills our current needs. As an initial effort some of the thresholds for categorizing different temporal conditions are arbitrary, and we are validating them with experimental results for future improvement. Nonetheless, this algorithm has greatly enhanced the efficiency of our subject and specimen selection for wet bench experiments. The same principle can be applied to the future temporal data model solution, for CBCP and other human disease studies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4173.

Risk Factor Combinations for Estimating the Probability of Breast Cancer Related Lymphedema

Background: LE is a common complication from BC surgery, leading to a decreased quality of life. In our previous study; both the risk and severity of LE were associated with 1) infection of the arm and breast, 2) body mass index (BMI), and 3) the level of hand use (p&lt;0.05 for all associations). The aim of this study was to estimate the probability of LE following BC surgery by using previously published incidence rates and the risk factors of BMI, infection, and level of hand use.Method: A retrospective review was undertaken of the 2983 women treated surgically for breast cancer at MWH of the UPMC from 1990-2000. Fifty-two women were identified for whom the diagnosis of LE was established and data existed on the study variables. The design was a n:m matched case control study; data were analyzed on 52 patients with LE and 126 available controls matched on age, radiation therapy, and type of operation. In conjunction with conditional logistic regression and published estimates of LE incidence rates, Bayes' Theorem was used to estimate the probability of developing LE. This probability was estimated for 8 combinations of BMI, infection, and level of hand use.Results: LE probabilities of 8 combinations for 6 different incidence rates of LE are shown in Table 1. For example, assuming a 16% incidence rate of LE a BMI&lt;25, no infection, and a low level of hand use; the estimated probability of LE was 6.8%. At the other extreme, assuming a LE incidence rate of 46.3%, a BMI ≥ 25, infection, and a high level of hand use led to an estimated LE probability of 93.7%. As shown in Table 1, other assumed incidence rates and risk factor combinations led to intermediate LE probabilities.Table 1 - Estimated LE probabilities for risk factor combinations according to LE incidences.  AssumedLEIncidenceRate Risk Factor Combinations16%17%19.5%20.7%25.5%46.3%BMI&lt;25, No infection, Low level of hand use0.070.070.080.090.110.24BMI≥25, Infection, Medium/high level of hand use0.760.770.800.880.850.94 Conclusion: This study demonstrates that in both high and low risk situations for the development of LE that control of predisposing factors can have a marked effect on the probability of LE formation. Low risk patients with poor control of predisposing factors have a higher probability of developing LE than high risk patients in whom known predisposing factors are avoided.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5115.

Landau model for the elastic properties of the ferroelastic crystal Rb(4)LiH(3)(SO(4))(4)

Using sound velocity measurements, we report a detailed investigation of the elastic properties of Rb(4)LiH(3)(SO(4))(4) realized as a function of temperature and pressure. Results are compared to predictions of a phenomenological Landau model. Supported by recent Raman scattering measurements, we assume that the [Formula: see text] structural transformation observed at T(c) = 134 K corresponds to a pseudo-proper ferroelastic transition. For the numerical analysis, all coupling parameters are determined using the temperature dependence of the frequency of the soft optical B mode, the temperature dependence of spontaneous strains, and the pressure dependence dT(c)/dP = 191 ± 2 K GPa(-1) also determined in this work. Our comparison indicates that the [Formula: see text] structural transition in Rb(4)LiH(3)(SO(4))(4) is fully consistent with predictions derived using our pseudo-proper ferroelastic model. Thus, all data presented in this paper corroborate that the mechanism leading to the structural transition at T(c) = 134 K results from the softening of the B optical mode observed at 31 cm(-1). This detailed analysis also refutes the idea that Rb(4)LiH(3)(SO(4))(4) shows incomplete softening of the soft acoustic mode also associated with that structural transition.

Forever Young: How to Control the Elongation, Differentiation, and Proliferation of Cells Using Nanotechnology

Within the emerging field of stem cells there is a need for an environment that can regulate cell activity, to slow down differentiation or proliferation, in vitro or in vivo while remaining invisible to the immune system. By creating a nanoenvironment surrounding PC12 cells, Schwann cells, and neural precursor cells (NPCs), we were able to control the proliferation, elongation, differentiation, and maturation in vitro. We extended the method, using self-assembling nanofiber scaffold (SAPNS), to living animals with implants in the brain and spinal cord. Here we show that when cells are placed in a defined system we can delay their proliferation, differentiation, and maturation depending on the density of the cell population, density of the matrix, and the local environment. A combination of SAPNS and young cells can be implanted into the central nervous system (CNS), eliminating the need for immunosuppressants.

Transgenic silencing of neurons in the mammalian brain by expression of the allatostatin receptor (AlstR)

The mammalian brain is an enormously complex set of circuits composed of interconnected neuronal cell types. The analysis of central neural circuits will be greatly served by the ability to turn off specific neuronal cell types while recording from others in intact brains. Because drug delivery cannot be restricted to specific cell types, this can only be achieved by putting "silencer" transgenes under the control of neuron-specific promoters. Towards this end we have created a line of transgenic mice putting the Drosophila allatostatin (AL) neuropeptide receptor (AlstR) under the control of the tetO element, thus enabling its inducible expression when crossed to tet-transactivator lines. Mammals have no endogenous AL or AlstR, but activation of exogenously expressed AlstR in mammalian neurons leads to membrane hyperpolarization via endogenous G-protein-coupled inward rectifier K(+) channels, making the neurons much less likely to fire action potentials. Here we show that this tetO/AlstR line is capable of broadly expressing AlstR mRNA in principal neurons throughout the forebrain when crossed to a commercially-available transactivator line. We electrophysiologically characterize this cross in hippocampal slices, demonstrating that bath application of AL leads to hyperpolarization of CA1 pyramidal neurons, making them refractory to the induction of action potentials by injected current. Finally, we demonstrate the ability of AL application to silence the sound-evoked spiking responses of auditory cortical neurons in intact brains of AlstR/tetO transgenic mice. When crossed to other transactivator lines expressing in defined neuronal cell types, this AlstR/tetO line should prove a very useful tool for the analysis of intact central neural circuits.

Impaired mobilization of hematopoietic stem/progenitor cells in C5-deficient mice supports the pivotal involvement of innate immunity in this process and reveals novel promobilization effects of granulocytes

We reported that complement cascade (CC) becomes activated in bone marrow (BM) during granulocyte colony-stimulating factor (G-CSF) mobilization of hematopoietic stem/progenitor cells (HSPCs) and showed that, although third CC component (C3)-deficient mice are easy mobilizers, fifth CC component (C5)-deficient mice mobilize very poorly. To explain this, we postulated that activation/cleavage of CC releases C3a and C5a anaphylatoxins that differently regulate mobilization. Accordingly, C3a, by enhancing responsiveness of HSPCs to decreasing concentrations of stromal-derived growth factor-1 (SDF-1) in BM, prevents mobilization and promotes their BM retention. Therefore, in this study, we focused on the mobilization-enhancing role of C5a. We found that C5a receptor (C5aR) is not expressed on the surface of HSPCs, and that C5a-mediated promobilization effects are mediated by stimulation of granulocytes. Overall, our data support the following model. First C5aR(+) granulocytes are chemoattracted by plasma C5 cleavage fragments, being the first wave of cells leaving BM. This facilitates a subsequent egress of HSPCs. In the next step, after leaving BM, granulocytes undergo degranulation in response to plasma C5a and secrete some cationic peptides (cathelicidin, beta-defensin) that, as shown here for the first time, highly enhance the responsiveness of HSPCs to plasma SDF-1 gradient. In conclusion, our data reveal the underappreciated central role of innate immunity in mobilization, in which C5 cleavage fragments through granulocytes orchestrate this process.