Investigation of Maize streak virus pathogenicity determinants using chimaeric genomes

Genes and intergenic regions were reciprocally exchanged between a highly pathogenic Maize streak virus (MSV) isolate (MSV-MatA) and three less pathogenic isolates (MSV-Kom, MSV-R2, and MSV-VW) to determine the contribution of individual genome constituents to MSV pathogenicity in maize. Comparison of disease symptoms produced by the 54 resulting chimaeras and parental viruses enabled identification of genome constituents that are primarily responsible for the heightened pathogenicity of MSV-MatA in maize. Whereas pathogenicity determinants were detected in all of the MSV genomic regions examined, generally only chimaeras containing the MSV-MatA long intergenic region, coat protein gene, and/or movement protein gene were more pathogenic than the milder MSV isolates from which most of their genomes were derived. The pathogenicity of chimeras was strongly influenced by the relatedness of their parental viruses and evidence was found of nucleotide sequence-dependent interactions between both coding and intergenic regions.

Physicians' attitudes toward health care rationing

BACKGROUND

Optimal allocation of health care resources under a limited budget is controversial. Particularly important questions are whether rationing decisions should be based on efficiency considerations alone or in combination with equity considerations, and who should be in charge of such decisions. In this study, the authors sought to understand the position of Swiss physicians toward rationing using a previously developed rationing scenario.

METHODS

The authors examined the acceptability of various scenarios implementing health care rationing in a mail survey of 1,184 physicians practicing in Geneva, Switzerland. Respondents were asked to choose between providing a suboptimal cancer screening test A to the whole population, which would save 1,000 lives, or selecting half of the population to receive a better but more expensive test B, which would save 1,100 lives. Physicians were randomly assigned to 3 versions of the scenario: Beneficiaries of test B could be chosen by lottery, on a first-come-first-served basis, or by medical associations.

RESULTS

Only 26% of physicians chose the more effective selective rationing option; this proportion was lowest when test beneficiaries were selected by lottery (14%), intermediate for the first-come-first-served-scenario (26%), and highest when selection was left to medical associations (39%; P < 0.001). Hospital-based physicians and general practitioners were less likely to endorse selective rationing than community-based physicians and specialists.

CONCLUSION

Swiss physicians appear to be more concerned about equal allocation of health services than about maximizing health in society, and they prefer physicians to be in charge of rationing decisions.

Biological and Genomic Sequence Characterization of Maize streak virus Isolates from Wheat

ABSTRACT Maize streak virus (MSV) is best known as the causal agent of maize streak disease. However, only a genetically uniform subset of the viruses within this diverse species is actually capable of producing severe symptoms in maize. Whereas these "maize-type" viruses all share greater than 95% sequence identity, MSV strains isolated from grasses may share as little as 79% sequence identity with the maize-type viruses. Here, we present the complete genome sequences and biological characterization of two MSV isolates from wheat that share approximately 89% sequence identity with the maize-type viruses. Clonal populations of these two isolates, named MSV-Tas and MSV-VW, were leafhopper-transmitted to Digitaria sanguinalis and a range of maize, wheat, and barley genotypes. Whereas the two viruses showed some differences in their pathogenicity in maize, they were both equally pathogenic in D. sanguinalis and the various wheat and barley genotypes tested. Phylogenetic analyses involving the genome sequences of MSV-Tas and MSV-VW, a new maize-type virus also fully sequenced in this study (MSV-VM), and all other available African streak virus sequences, indicated that MSV-Tas and MSV-VW are close relatives that together represent a distinct MSV strain. Sequence analyses revealed that MSV-VM has a recombinant genome containing MSV-Tas/VW-like sequences within its movement protein gene.

Forced recombination between distinct strains of Maize streak virus

Recombination between divergent virus genomes is believed to be a major mechanism for generation of novel virus genotypes. We have examined the recombination process in geminiviruses by forcing recombination between two distinct isolates of Maize streak virus (MSV), MSV-Kom and MSV-Set. Heterodimeric agroinfectious constructs containing tandemly cloned mixtures of complete or partial MSV-Set and MSV-Kom genomes were used to simulate a circular dimeric form similar to that which would be expected to occur following a single intermolecular crossing-over event between MSV-Set and MSV-Kom replicative form DNAs at the long intergenic region (LIR)-movement protein gene (MP) interface. We isolated, analysed and biologically characterized many of the recombinant MSV genomes that were generated from the constructs in planta. Apart from having the same simulated breakpoint at the LIR-MP interface, all the genomes examined had a second breakpoint that had been generated through either intramolecular homologous recombination or a replicational release mechanism. The pathogenicities of six predominantly MSV-Kom-like recombinants were tested in maize. While all were capable of producing a symptomatic infection in this host, none was more virulent than MSV-Kom and only two were more virulent than MSV-Set. The two most virulent recombinants were leafhopper transmitted to a range of differentially MSV-resistant maize, wheat and barley genotypes and both were found to have unique biological properties.

Image-guided hypo-fractionated stereotactic radiosurgery to spinal lesions

OBJECTIVE

This article demonstrates the technical feasibility of noninvasive treatment of unresectable spinal vascular malformations and primary and metastatic spinal tumors by use of image-guided frameless stereotactic radiosurgery.

METHODS

Stereotactic radiosurgery delivers a high dose of radiation to a tumor volume or vascular malformation in a limited number of fractions and minimizes the dose to adjacent normal structures. Frameless image-guided radiosurgery was developed by coupling an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator that guides the therapy beam to treatment sites within the spine or spinal cord, in an outpatient setting, and without the use of frame-based fixation. The system relies on skeletal landmarks or implanted fiducial markers to locate treatment targets. Sixteen patients with spinal lesions (hemangioblastomas, vascular malformations, metastatic carcinomas, schwannomas, a meningioma, and a chordoma) were treated with total treatment doses of 1100 to 2500 cGy in one to five fractions by use of image-guided frameless radiosurgery with the CyberKnife system (Accuray, Inc., Sunnyvale, CA). Thirteen radiosurgery plans were analyzed for compliance with conventional radiation therapy.

RESULTS

Tests demonstrated alignment of the treatment dose with the target volume within +/-1 mm by use of spine fiducials and the CyberKnife treatment planning system. Tumor patients with at least 6 months of follow-up have demonstrated no progression of disease. Radiographic follow-up is pending for the remaining patients. To date, no patients have experienced complications as a result of the procedure.

CONCLUSION

This experience demonstrates the feasibility of image-guided robotic radiosurgery for previously untreatable spinal lesions.

Sequence diversity and virulence in Zea mays of Maize streak virus isolates

Full genomic sequences were determined for 12 Maize streak virus (MSV) isolates obtained from Zea mays and wild grass species. These and 10 other publicly available full-length sequences were used to classify a total of 66 additional MSV isolates that had been characterized by PCR-restriction fragment length polymorphism and/or partial nucleotide sequence analysis. A description is given of the host and geographical distribution of the MSV strain and subtype groupings identified. The relationship between the genotypes of 21 fully sequenced virus isolates and their virulence in differentially MSV-resistant Z. mays genotypes was examined. Within the only MSV strain grouping that produced severe symptoms in maize, highly virulent and widely distributed genotypes were identified that are likely to pose the most serious threat to maize production in Africa. Evidence is presented that certain of the isolates investigated may be the products of either intra- or interspecific recombination.

The relative infectivities and genomic characterisation of three distinct mastreviruses from South Africa

The genomic nucleotide sequences of the cloned agroinfectious genomes of three South African mastreviruses obtained from Zea mays, a Setaria sp., and Panicum maximum (designated MSV-Kom, MSV-Set, and PanSV-Kar respectively), were determined. Additionally, their relative infectivities and virulence were analysed in a range of differentially susceptible wheat, maize, and barley genotypes. MSV-Kom produced moderate to severe streak symptoms in all maize genotypes tested, but only moderate to very mild symptoms in the wheat and barley genotypes. MSV-Set infected only the susceptible to tolerant maize genotypes, but was generally more severe in the barley and wheat genotypes than MSV-Kom. PanSV-Kar was incapable of infecting any of the wheat and barley genotypes and only produced very mild symptoms on the three most sensitive maize genotypes. Genomic characteristics in common with related mastreviruses were identified. Phylogenetic analysis indicated that while MSV-Kom was closely related to previously sequenced MSV isolates, MSV-Set and PanSV-Kar represented distinctly novel strains of MSV and PanSV respectively. In the case of MSV-Set, this is the most distantly related MSV strain yet characterised.

Risk of uterine rupture during labor among women with a prior cesarean delivery

BACKGROUND

Each year in the United States, approximately 60 percent of women with a prior cesarean delivery who become pregnant again attempt labor. Concern persists that a trial of labor may increase the risk of uterine rupture, an uncommon but serious obstetrical complication.

METHODS

We conducted a population-based, retrospective cohort analysis using data from all primiparous women who gave birth to live singleton infants by cesarean section in civilian hospitals in Washington State from 1987 through 1996 and who delivered a second singleton child during the same period (a total of 20,095 women). We assessed the risk of uterine rupture for deliveries with spontaneous onset of labor, those with labor induced by prostaglandins, and those in which labor was induced by other means; these three groups of deliveries were compared with repeated cesarean delivery without labor.

RESULTS

Uterine rupture occurred at a rate of 1.6 per 1000 among women with repeated cesarean delivery without labor (11 women), 5.2 per 1000 among women with spontaneous onset of labor (56 women), 7.7 per 1000 among women whose labor was induced without prostaglandins (15 women), and 24.5 per 1000 among women with prostaglandin-induced labor (9 women). As compared with the risk in women with repeated cesarean delivery without labor, uterine rupture was more likely among women with spontaneous onset of labor (relative risk, 3.3; 95 percent confidence interval, 1.8 to 6.0), induction of labor without prostaglandins (relative risk, 4.9; 95 percent confidence interval, 2.4 to 9.7), and induction with prostaglandins (relative risk, 15.6; 95 percent confidence interval, 8.1 to 30.0).

CONCLUSIONS

For women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor. Labor induced with a prostaglandin confers the highest risk.

Delivery method and self-reported postpartum general health status among primiparous women

Despite nearly four million deliveries in the United States each year, minimal information exists on unintended health consequences following childbirth, particularly in relation to delivery method. The purpose of this study was to assess the association between method of delivery and the general health status, sexual, bowel and urinary functioning of primiparous women as measured at 7 weeks postpartum. Data from the Statewide Obstetrical Review of Quality System (StORQS) Survey of Maternity Care in Washington State were analysed. Participants included all primiparous women with a delivery of a singleton infant discharged alive between August and December 1991 from 10 non-federal short-stay hospitals who responded to the StORQS Survey of Maternity Care (n = 971). The main outcome measures included the modified Medical Outcomes Study 36-Item Short-Form Health Survey and self-reported sexual, bowel and urinary functioning. At 7 weeks postpartum, women who had caesarean or assisted vaginal deliveries reported significantly lower postpartum general health status scores than women with unassisted vaginal delivery. Additionally, women with assisted vaginal delivery reported significantly worse sexual, bowel and urinary functioning. Our results suggest that more careful attention to the postpartum general health and sexual functioning of women with caesarean and assisted vaginal delivery may be merited.

Pro- and Anti-inflammatory Cytokine Gene Expression in Rat Sciatic Nerve Chronic Constriction Injury Model of Neuropathic Pain

Cytokines may be pathophysiologically involved in hyperalgesia. Uncertainty exists about the types of cytokines and their site of action. To study the role of key pro- and anti-inflammatory cytokines in a chronic constriction model of neuropathic pain, mRNA expression of TNF, IL-1beta, IL-6, and IL-10 was quantified using competitive RT-PCR. Each cytokine mRNA in rat sciatic nerve was examined at days 3, 7, 14, and 45 after chronic constriction injury (CCI). We also undertook behavioral testing of these rats. Thermal warming and touch thresholds were significantly reduced at days 3, 7, and 14 in the CCI group, compared with the sham-operated group. Cytokine gene expression in sciatic nerve was significantly increased at day 7 for IL-1beta and IL-6 and at day 14 for TNF. Expression of IL-10 underwent a gradual and progressive increase, reaching statistical significance at day 45.

First-birth cesarean and placental abruption or previa at second birth(1)

OBJECTIVE

To assess the association between first-birth cesarean delivery and second-birth placental abruption and previa.

METHODS

We conducted a population-based, retrospective cohort analysis using data from the Washington State Birth Events Record Database. The study cohort included all primiparas who gave birth to live singleton infants in nonfederal short-stay hospitals from January 1, 1987, through December 31, 1996, and who had second singleton births during the same period (n = 96,975). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for placental abruption or previa at second births associated with first-birth cesareans.

RESULTS

Among our study cohort, abruptio placentae complicated 11.5 per 1000 and placenta previa 5.2 per 1000 singleton deliveries at second births. In logistic regression analyses adjusted for maternal age, women with first-birth cesareans had significantly increased risk of abruptio placentae (OR 1.3, 95% CI 1.1, 1.5), and placenta previa (OR 1.4, 95% CI 1.1, 1.6) at second births, compared with women with prior vaginal deliveries.

CONCLUSION

We found moderately increased risk of placental abruption and previa as a long-term effect of prior cesarean delivery on second births.

Analysis of the diversity of African streak mastreviruses using PCR-generated RFLPs and partial sequence data

Maize streak virus (MSV) is the most economically significant member of a diverse group of African grass-infecting Mastrevirus species in the family Geminiviridae. We designed a single set of degenerate primers which enables the PCR amplification of an approximately 1300 bp DNA fragment spanning both conserved (the RepA gene) and variable (the long intergenic region and MP gene) portions of these viruses' genomes. Using restriction fragment length polymorphism (RFLP) analysis of PCR products obtained from 39 MSV, one SSV, and two PanSV isolates, it was possible to both identify the different virus species, which differ in nucleotide sequence by up to 40%, and to differentiate between MSV isolates sharing up to 99% sequence identity. The reliability of the RFLP data for typing the MSV isolates was verified by the phylogenetic analysis of the partial genomic nucleotide sequences of a representative subset of the MSV isolates. Based on both the RFLP and sequence data, the MSV isolates could be clearly differentiated into the four groups: these were a group of predominantly maize-infecting isolates, and three groups containing grass/wheat-infecting isolates. RFLP analysis also revealed a number of mixed virus infections in which, in certain instances, it was possible to identify individual population members.

Remote-rendered 3D CT angiography (3DCTA) as an intraoperative aid in cerebrovascular neurosurgery

OBJECTIVE

To assess the viability and utility of network-based rendering in the treatment of patients with cerebral aneurysms, we implemented an intraoperative rendering system and protocol using both three-dimensional CT angiography (3DCTA) and perspective volume rendering (PVR).

MATERIALS AND METHODS

A Silicon Graphics InfiniteReality engine was connected via a Fast Ethernet network to a workstation in the neurosurgical operating room. A protocol was developed to isolate bone and vessels using an appropriate transfer function. Three-dimensional CT angiogram images were volume rendered and transmitted to the workstation using a bandwidth-conserving remote rendering system, and were rotated, cut using clipping planes, and viewed using normal and perspective views. Twelve patients with intracranial aneurysms were examined at surgery using this system.

RESULTS

Rendering performance at optimal operating bandwidths (50-60 Mb/s) was excellent, with regeneration of a high-resolution image in less than 1 s. Network performance varied in two cases, slowing image regeneration. Surgeons found the images to be useful as an adjunct to conventional imaging in understanding the morphology of complex aneurysms and their relationship to the skull base.

CONCLUSIONS

Intraoperative volume rendering using 3DCTA is achievable over a network, can reduce hardware costs by amortizing hardware among multiple users, and provides useful imaging information during the surgical treatment of cerebral aneurysms. Future operating suites may incorporate network-transmitted three-dimensional images as additional sources of imaging information.

Stereotactic radiosurgery and hypofractionated stereotactic radiotherapy for residual or recurrent cranial base and cervical chordomas

Object

In patients with chordomas the lesions often recur. Furthermore, the location of some chordomas within the base of the skull and the cervical spine can prevent complete resection from being achieved. Previous series have shown that stereotactic radiosurgery can be used as a treatment for residual chordomas with good overall results. The authors review their experience in using linear accelerator (LINAC) stereotactic radiosurgery to treat patients with recurrent and/or residual cranial base and cervical chordomas.

Methods

Ten patients with chordomas (eight with cranial base and two with cervical lesions [below C-2]) underwent LINAC stereotactic radiosurgery. The mean patient age was 49 years (range 30–73 years). There were seven men and three women. Three patients had undergone one prior surgery, five had undergone two previous surgeries, and two had undergone three prior operations. The mean radiation dose was 19.4 Gy (range 18–24 Gy), and the maximum intratumoral dose averaged 27 Gy (range 24.1–33.1 Gy). The mean secondary collimator size was 14.4 mm (range 7.5–20 mm). The volume of the tumor treated ranged from 1.1 to 21.5 ml. In five patients a standard frame-based LINAC radiosurgery system was used, whereas in the other five the CyberKnife, a frameless image-guided LINAC radiosurgical system, was used. All patients were available for follow-up review, which averaged 4 years (range 1–9 years). Over the course of follow up, one chordoma (10%) was smaller in size, seven were stable, and two chordomas progressed (one in a patient who underwent reoperation and a second course of stereotactic radiosurgery, and the second in a patient who underwent reoperation alone). There were no new neurological deficits noted following radiosurgery in the eight of 10 patients in whom there was no tumor progression, and no patient developed radiation-induced necrosis.

Conclusions

Stereotactic radiosurgery can be used to treat patients with recurrent or residual chordomas with excellent tumor control rates. Longer follow-up review in larger series is warranted to confirm these findings.

Cesarean delivery and postpartum mortality among primiparas in Washington State, 1987-1996(1)

OBJECTIVE

To examine the association between delivery method and mortality within 6 months of delivery among primiparas.

METHODS

We conducted a population-based, retrospective cohort analysis using statewide, maternally linked birth certificate, hospital discharge, and death certificate data. The present cohort was all primiparas who gave birth to live-born infants in civilian hospitals in Washington State from January 1, 1987 through December 31, 1996 (n = 265,471). Odd ratios (OR) and 95% confidence intervals (CI) were calculated for overall mortality, pregnancy-related mortality, and pregnancy-unrelated mortality associated with delivery method.

RESULTS

Thirty-two women (12.1 per 100,000 singleton live births) died within 6 months of delivery of their first child. Eleven of 32 deaths were pregnancy related (4.1 per 100,000 singleton live births, 95% CI 1.6, 6.5), and 21 of the 32 deaths were not pregnancy related (7.9 per 100,000 singleton live births, 95% CI 4.5, 11.3). The pregnancy-related mortality rate was higher among women delivered by cesarean (10.3/100,000) than among women delivered vaginally (2.4/100,000). In logistic regression analyses, women who had cesarean delivery were not at significantly higher risk of death overall after adjustment for maternal age (OR 1.7, 95% CI 0.3, 3.6), pregnancy-related death after adjustment for maternal age and severe preeclampsia (OR 2.2, 95% CI 0.6, 7.9), or pregnancy-unrelated death after adjustment for maternal age and marital status (OR 0.9, 95% CI 0.3, 2.7), relative to women who had vaginal delivery.

CONCLUSION

Cesarean delivery might be a marker for serious preexisting morbidities associated with increased mortality risk rather than a risk factor for death in and of itself. Data from additional sources such as medical records and autopsy reports are necessary to disentangle preexisting mortality risk from risk associated solely with delivery method.

Development of a homogeneous MAP kinase reporter gene screen for the identification of agonists and antagonists at the CXCR1 chemokine receptor

Agonist activity at G protein-coupled receptors (GPCRs) that regulate heterotrimeric G proteins of the Galpha(i/o) or Galpha(q) families has been shown to result in activation of the mitogen-activated protein (MAP) kinase cascade. To facilitate compound screening for these classes of GPCR, we have developed a reporter gene that detects the activation of the ternary complex transcription factor Sap1a following MAP kinase activation. In contrast to other reporter gene assays for Galpha(i/o)-coupled GPCRs, the MAP kinase reporter generates an increase in signal in the presence of agonist. The reporter gene has been transfected into Chinese hamster ovary cells to generate a "host" reporter gene-containing cell line. The Galpha(i)-coupled human CXCR1 chemokine receptor was subsequently transfected into this cell line in order to develop a 384-well format screen for both agonists and antagonists of this receptor. Agonists activated the reporter gene with the expected rank order of potency and with similar concentration dependence as seen with the regulation of other signal transduction cascades in mammalian cells: interleukin-8 (IL-8) (pEC(50) = 7.0 +/- 0.1) > GCP-2 (pEC(50) = 6.3 +/- 0.1) > NAP-2 (pEC(50) < 6). CXCR1-mediated activation of MAP kinase was inhibited by pertussis toxin and the MEK inhibitor PD98059, demonstrating that receptor activation of MAP kinase is due to pertussis toxin-sensitive Galpha(i/o)-family G proteins to cause the activation of MEK kinase. Using the 384-well format, assay performance was unaffected by solvent concentrations of 0.5% ethanol, 0.15% glycerol, or 1% DMSO. Signal crosstalk between adjacent wells was less than 1%. The assay exhibited a Z factor of 0.53 and a coefficient of variation of response to repeated application of IL-8 (100 nM) of 15.9%.

Evaluation of a command-line parser-based order entry pathway for the Department of Veterans Affairs electronic patient record

OBJECTIVE

To improve and simplify electronic order entry in an existing electronic patient record, the authors developed an alternative system for entering orders, which is based on a command- interface using robust and simple natural-language techniques.

DESIGN

The authors conducted a randomized evaluation of the new entry pathway, measuring time to complete a standard set of orders, and users' satisfaction measured by questionnaire. A group of 16 physician volunteers from the staff of the Department of Veterans Affairs Puget Sound Health Care System-Seattle Division participated in the evaluation.

RESULTS

Thirteen of the 16 physicians (81%) were able to enter medical orders more quickly using the natural-language-based entry system than the standard graphical user interface that uses menus and dialogs (mean time spared, 16.06 +/- 4.52 minutes; P=0.029). Compared with the graphical user interface, the command--based pathway was perceived as easier to learn (P<0.01), was considered easier to use and faster (P<0.01), and was rated better overall (P<0.05).

CONCLUSION

Physicians found the command- interface easier to learn and faster to use than the usual menu-driven system. The major advantage of the system is that it combines an intuitive graphical user interface with the power and speed of a natural-language analyzer.

Patch augmentation of the pulmonary artery with bioabsorbable polymers and autologous cell seeding

OBJECTIVE

In recent years bioabsorbable synthetic or biologic materials have been used to augment the pulmonary artery or the right ventricular outflow tract. However, each of these polymers has one or more shortcomings. None of these patch materials has been seeded with cells. Thus, we have tested a fast-absorbing biopolymer, poly-4-hydroxybutyric acid, with autologous cell seeding for patch augmentation of the pulmonary artery in a juvenile sheep model.

METHODS

Vascular cells were isolated from ovine peripheral veins (n = 6). Bioabsorbable porous poly-4-hydroxybutyric acid patches (porosity > 95%) were seeded on 3 consecutive days with a mixed vascular cell suspension (21.3 +/- 1.3 x 10(6) cells). Forty-five (+/- 2) days after the vessel harvest, 1 unseeded and 6 autologously seeded control patches were implanted into the proximal pulmonary artery. The animals received no postoperative anticoagulation. Follow-up was performed with echocardiography after 1 week and before explantation after 1, 7, and 24 weeks (2 animals each) for the seeded control patches and after 20 weeks for the nonseeded control patch.

RESULTS

All animals survived the procedure. Postoperative echocardiography of the seeded patches demonstrated a smooth surface without dilatation or stenosis. Macroscopic appearance showed a smooth internal surface with increasing tissue formation. Histology at 169 days demonstrated a near-complete resorption of the polymer and formation of organized and functional tissue. Biochemical assays revealed increasing cellular and extracellular matrix contents. The control patch showed a slight bulging, indicating a beginning dilatation.

CONCLUSION

This experiment showed that poly-4-hydroxybutyric acid is a feasible patch material in the pulmonary circulation.

Functional living trileaflet heart valves grown in vitro

BACKGROUND

Previous tissue engineering approaches to create heart valves have been limited by the structural immaturity and mechanical properties of the valve constructs. This study used an in vitro pulse duplicator system to provide a biomimetic environment during tissue formation to yield more mature implantable heart valves derived from autologous tissue.

METHODS AND RESULTS

Trileaflet heart valves were fabricated from novel bioabsorbable polymers and sequentially seeded with autologous ovine myofibroblasts and endothelial cells. The constructs were grown for 14 days in a pulse duplicator in vitro system under gradually increasing flow and pressure conditions. By use of cardiopulmonary bypass, the native pulmonary leaflets were resected, and the valve constructs were implanted into 6 lambs (weight 19+/-2.8 kg). All animals had uneventful postoperative courses, and the valves were explanted at 1 day and at 4, 6, 8, 16, and 20 weeks. Echocardiography demonstrated mobile functioning leaflets without stenosis, thrombus, or aneurysm up to 20 weeks. Histology (16 and 20 weeks) showed uniform layered cuspal tissue with endothelium. Environmental scanning electron microscopy revealed a confluent smooth valvular surface. Mechanical properties were comparable to those of native tissue at 20 weeks. Complete degradation of the polymers occurred by 8 weeks. Extracellular matrix content (collagen, glycosaminoglycans, and elastin) and DNA content increased to levels of native tissue and higher at 20 weeks.

CONCLUSIONS

This study demonstrates in vitro generation of implantable complete living heart valves based on a biomimetic flow culture system. These autologous tissue-engineered valves functioned up to 5 months and resembled normal heart valves in microstructure, mechanical properties, and extracellular matrix formation.

Early in vivo experience with tissue-engineered trileaflet heart valves

BACKGROUND

Tissue engineering is a new approach in which techniques are being developed to transplant autologous cells onto biodegradable scaffolds to ultimately form new functional autologous tissue. Workers at our laboratory have focused on tissue engineering of heart valves. The present study was designed to evaluate the implantation of a whole trileaflet tissue-engineered heart valve in the pulmonary position in a lamb model.

METHODS AND RESULTS

We constructed a biodegradable and biocompatible trileaflet heart valve scaffold that was fabricated from a porous polyhydroxyalkanoate (pore size 180 to 240 microm; Tepha Inc). Vascular cells were harvested from ovine carotid arteries, expanded in vitro, and seeded onto our heart valve scaffold. With the use of cardiopulmonary bypass, the native pulmonary leaflets were resected, and 2-cm segments of pulmonary artery were replaced by autologous cell-seeded heart valve constructs (n=4). One animal received an acellular valved conduit. No animal received any anticoagulation therapy. Animals were killed at 1, 5, 13, and 17 weeks. Explanted valves were examined histologically with scanning electron microscopy, biochemically, and biomechanically. All animals survived the procedure. The valves showed minimal regurgitation, and valve gradients were <20 mm Hg on echocardiography. The maximum gradient was 10 mm Hg with direct pressures. Macroscopically, the tissue-engineered constructs were covered with tissue, and there was no thrombus formation on any of the specimens. Scanning electron microscopy showed smooth flow surfaces during the follow-up period. Histological examination demonstrated laminated fibrous tissue with predominant glycosaminoglycans as extracellular matrix. 4-Hydroxyproline assays demonstrated an increase in collagen content as a percentage of native pulmonary artery (1 week 45.8%, 17 weeks 116%). DNA assays showed a comparable number of cells in all explanted samples. There was no tissue formation in the acellular control.

CONCLUSIONS

Tissue-engineered heart valve scaffolds fabricated from polyhydroxyalkanoates can be used for implantation in the pulmonary position with an appropriate function for 120 days in lambs.

Improved Efficiency of Zea mays Agroinoculation with Maize streak virus

Agroinoculation is a technique permitting the transmission of geminivirus genomes cloned in Agrobacterium tumefaciens into a wide variety of mono- and dicotyledonous host plants. Most geminiviruses are obligately transmitted by insect vector species under natural conditions; therefore, agroinoculation has greatly simplified the study of this group of viruses. In many cases, agroinoculation has replaced insect transmission, and has been used to compare virulence characteristics among viruses. Here we report on the discovery that, in agroinfectious Maize streak virus constructs, the orientation of cloned viral genomes relative to the Cauliflower mosaic virus 35S (CaMV35S) promoter of the binary cloning vector pBI121 can significantly affect agroinfectivity of the constructs. Rates at which plants became symptomatic were significantly higher when agroinoculating maize seedlings with constructs containing the CaMV35S promoter upstream of the viral replication-associated protein (Rep) gene than when the same viruses were cloned either in the opposite orientation or into a vector without a strong eukaryotic promoter sequence. Plants infected using the construct with Rep cloned downstream of the CaMV35S promoter also displayed more stunting and, in the early stages of the infection, more severe chlorotic streak symptoms.

Treatment of nasopharyngeal carcinoma: stereotactic radiosurgical boost following fractionated radiotherapy

Treatment of patients with nasopharyngeal carcinoma (NPC) using external beam radiation therapy (XRT) alone results in significant local recurrence. To improve local control, stereotactic radiosurgery (SRS) was used to boost radiation to the primary tumor site following XRT in 23 patients with NPC. SRS was delivered utilizing a frame-based linear accelerator as a boost (range 7-15 Gy, median 12 Gy) following XRT (range 64.8- 70 Gy, median 66 Gy). In all 23 patients (100%) receiving SRS following XRT local control was achieved at a mean follow-up of 21 months (range 2-64 months). There have been no complications of treatment caused by SRS. However, 8 patients (35%) have subsequently developed regional or distant metastases. SRS boost following XRT provides excellent local control in NPC and should be considered for patients with skull base involvement.

LINAC radiosurgery for cavernous sinus meningiomas

Radiosurgery is increasingly used to treat unresectable cavernous sinus tumors. Since 1989, 24 patients with cavernous sinus meningiomas have been treated at Stanford University Medical Center with linear accelerator (LINAC) radiosurgery. The mean age of the patients was 47.8 years (range 28-78). The mean volume treated was 6. 83 cm3 (range 0.45-22.45 cm3), covered with an average of 2.3 isocenters (range 1-5). Radiation dose averaged 17.7 Gy (range 14-20 Gy). This group of patients was retrospectively studied by sending clinical questionnaires to both the patient/family and referring physicians, and reviewing clinic charts. In addition, follow-up imaging studies were obtained to measure residual tumor volume. Follow-up averaged 45.6 months (range 19-80). Tumor control (stabilization) following radiosurgery was noted in 15 (63%) and tumor shrinkage in 9 (37%). Seven meningiomas (29%) showed evidence of central tumor necrosis on MRI imaging 1-3 years after radiosurgery. Neurologic status was improved in 10 patients (42%) and unchanged in 12 patients (50%). There was 1 case of symptomatic brain necrosis and 1 case of radiation edema (asymptomatic). All other complications were transient, including 4 cases of trigeminal hypesthesia and 1 case of worsening diplopia. The 2-year actuarial tumor control rate was 100%. Although follow-up is still short, this experience corroborates prior reports that radiosurgery can be used to treat selected small cavernous sinus meningiomas with good to excellent clinical results and minimal morbidity.

Measuring the "managedness" and covered benefits of health plans

STUDY AIMS

(1) To develop indexes measuring the degree of managedness and the covered benefits of health insurance plans, (2) to describe the variation in these indexes among plans in one health insurance market, (3) to assess the validity of the health plan indexes, and (4) to examine the association between patient characteristics and the health plan indexes. Measures of the "managedness" and covered benefits of health plans are requisite for studying the effects of managed care on clinical practice and health system performance, and they may improve people's understanding of our complex health care system.

DATA SOURCES/STUDY SETTING

As part of our larger Physician Referral Study, we collected health insurance information for 189 insurance product lines and 755 products in the Seattle, Washington metropolitan area, which we linked with the study's data for 2,277 patients recruited in local primary care offices.

STUDY DESIGN

Managed care and benefit variables were constructed through content analysis of health plan information. Principal component analysis of the variables produced a managedness index, an in-network benefits index, and an out-of-network benefits index. Bivariable analyses examined associations between patient characteristics and the three indexes.

PRINCIPAL FINDINGS

From the managed care variables, we constructed three provider-oriented indexes for the financial, utilization management, and network domains of health plans. From these, we constructed a single managedness index, which correlated as expected with the individual measures, with the domain indexes, with plan type (FFS, PPO, POS, HMO), with independent assessments of local experts, and with patients' attitudes about their health insurance. For benefits, we constructed an in-network benefits index and an out-of-network benefits index, which were correlated with the managedness index. The personal characteristics of study patients were associated with the managed care and benefit indexes. Study patients in more managed plans reported somewhat better health than patients in less managed plans.

CONCLUSIONS

Indexes of the managedness and benefits of health plans can be constructed from publicly available information. The managedness and benefit indexes are associated with the personal characteristics and health status of study patients. Potential uses of the managed care and benefits indexes are discussed.

Tissue engineering of heart valves: in vitro experiences

BACKGROUND

Tissue engineering is a new approach, whereby techniques are being developed to transplant autologous cells onto biodegradable scaffolds to ultimately form new functional tissue in vitro and in vivo. Our laboratory has focused on the tissue engineering of heart valves, and we have fabricated a trileaflet heart valve scaffold from a biodegradable polymer, a polyhydroxyalkanoate. In this experiment we evaluated the suitability of this scaffold material as well as in vitro conditioning to create viable tissue for tissue engineering of a trileaflet heart valve.

METHODS

We constructed a biodegradable and biocompatible trileaflet heart valve scaffold from a porous polyhydroxyalkanoate (Meatabolix Inc, Cambridge, MA). The scaffold consisted of a cylindrical stent (1 x 15 x 20 mm inner diameter) and leaflets (0.3 mm thick), which were attached to the stent by thermal processing techniques. The porous heart valve scaffold (pore size 100 to 240 microm) was seeded with vascular cells grown and expanded from an ovine carotid artery and placed into a pulsatile flow bioreactor for 1, 4, and 8 days. Analysis of the engineered tissue included biochemical examination, enviromental scanning electron microscopy, and histology.

RESULTS

It was possible to create a trileaflet heart valve scaffold from polyhydroxyalkanoate, which opened and closed synchronously in a pulsatile flow bioreactor. The cells grew into the pores and formed a confluent layer after incubation and pulsatile flow exposure. The cells were mostly viable and formed connective tissue between the inside and the outside of the porous heart valve scaffold. Additionally, we demonstrated cell proliferation (DNA assay) and the capacity to generate collagen as measured by hydroxyproline assay and movat-stained glycosaminoglycans under in vitro pulsatile flow conditions.

CONCLUSIONS

Polyhydroxyalkanoates can be used to fabricate a porous, biodegradable heart valve scaffold. The cells appear to be viable and extracellular matrix formation was induced after pulsatile flow exposure.