Genome-wide transcription profile of endothelial cells after cardiac transplantation in the rat

Transcriptome analyses of organ transplants have until now usually focused on whole tissue samples containing activation profiles from different cell populations. Here, we enriched endothelial cells from rat cardiac allografts and isografts, establishing their activation profile at baseline and on days 2, 3 and 4 after transplantation. Modulated transcripts were assigned to three categories based on their regulation profile in allografts and isografts. Categories A and B contained the majority of transcripts and showed similar regulation in both graft types, appearing to represent responses to surgical trauma. By contrast, category C contained transcripts that were partly allograft-specific and to a large extent associated with interferon-gamma-responsiveness. Several transcripts were verified by immunohistochemical analysis of graft lesions, among them the matricellular protein periostin, which was one of the most highly upregulated transcripts but has not been associated with transplantation previously. In conclusion, the majority of the differentially expressed genes in graft endothelial cells are affected by the transplantation procedure whereas relatively few are associated with allograft rejection.

Use of fresh-frozen plasma at Royal Darwin Hospital: a retrospective audit

BACKGROUND

The aim of the study was to assess the appropriateness of use of fresh-frozen plasma (FFP) at Royal Darwin Hospital against the National Health and Medical Research Council and Australian and New Zealand Society for Blood Transfusion guidelines.

METHODS

A retrospective review of blood product request forms, online pathology storage system data, pathology records and clinical notes between 1 January 2006 and 31 December 2006 was carried out. The appropriateness of requests was assessed against existing guidelines. The percentage of appropriate and inappropriate FFP transfusions was obtained.

RESULTS

Six hundred and forty-eight of 950 units (68%) of FFP were used with an appropriate indication as per National Health and Medical Research Council/Australian and New Zealand Society for Blood Transfusion guidelines. Of the remaining units, 14% (137 units) was given without a clear indication and a decision of appropriateness could not be established for 17% (165 units) because of inadequate clinical or pathology information (e.g. coagulation results). Multiple issues around prescribing practice were identified.

CONCLUSION

There is significant use of FFP at Royal Darwin Hospital without clear clinical indication. The employment of a transfusion nurse to monitor use of FFP (and other blood products) and provide education is aimed at improving transfusion efficiency and patient safety.

Prenatal corticosteroid prophylaxis for women delivering at late preterm gestation

OBJECTIVE

We studied patterns of prenatal corticosteroid use, respiratory distress syndrome, and associated mortality rates to assess the congruence between knowledge and clinical practice related to such prophylaxis.

METHODS

We used data on all live births in the United States (for the years 1989-1991, 1995-1997, and 2002-2004) and Nova Scotia, Canada (for the years 1988-2007). Gestational age-specific temporal trends in infant deaths resulting from respiratory distress syndrome were quantified in the United States, and gestational age-specific temporal trends in corticosteroid use and morbidity (respiratory distress syndrome and intraventricular hemorrhage) were quantified in Nova Scotia.

RESULTS

In the United States, infant deaths associated with respiratory distress syndrome decreased by 48% (95% confidence interval: 46%-50%) from 1989-1991 to 1995-1997 and then decreased by another 18% (95% confidence interval: 15%-22%) by 2002-2004. The latter mortality reduction was evident at 28 to 32 weeks but not 33 to 36 weeks of gestation. Corticosteroid use at 28 to 32 weeks was high in Nova Scotia and increased from 30.7% in 1988-1989 to 50.0% in 1996-1997 and to 52.9% in 2006-2007, whereas rates of use at 33 to 36 weeks were much lower (eg, 6.7%, 17.0%, and 15.7% at 34 weeks in the 3 periods). Increased corticosteroid use at 33 and 34 weeks was estimated to reduce respiratory distress syndrome substantially.

CONCLUSION

Addressing the knowledge-practice gap in corticosteroid use at 33 to 34 weeks should reduce infant morbidity and mortality rates.

Prenatal diagnosis by amniocentesis and chorionic villus biopsy of mtDNA mutation 8993T > G

The mtDNA mutation 8993T > G is associated with neurogenic muscle weakness, ataxia and retinitis pigmentosa (NARP) and Leigh syndrome. There are few reported cases of prenatal testing for mtDNA disorders. Specifically for 8993T > G, there are six cases in which prenatal diagnosis has been reported. We describe prenatal diagnosis in a 36-year-old G3P1 woman with 33% heteroplasmy in white blood cells. She had a previous child who died from Leigh disease (92% heteroplasmy). She underwent prenatal testing by both CVS and amniocentesis of the 8993T > G heteroplasmy levels. This is the first reported case in which both procedures were used. Heteroplasmy was similar in both tissues (58.6% CVS and 55% amniocentesis), in support of the theory that this testing is reliable and may be considered in prenatal cases where this mutation is known in the mother. To date, her child is 20 months old and developing normally. Heteroplasmy determination in the child was refused. Although the infant is developmentally normal, consistent with the observation that levels of heteroplasmy below 60% are compatible with a mild phenotype, this conclusion must be tempered by the limited period of observation and the fact that patients with the NARP phenotype often present later than 20 months of age.

Trends in state/population-based Down syndrome screening and invasive prenatal testing with the introduction of first-trimester combined Down syndrome screening, South Australia, 1995-2005

OBJECTIVE

The purpose of this study was to review trends in the us of maternal serum Down syndrome screening and invasive prenatal testing before and after the introduction of a state-based first-trimester combined Down syndrome screening program.

STUDY DESIGN

A retrospective population-based study was performed on first- and second-trimester Down syndrome screening, invasive prenatal testing, and prenatal detection of Down syndrome from 1995 to 2005 in South Australia with data from state-based registers. Chi-square tests were used to evaluate trends.

RESULTS

There was a significant decrease in the use of second-trimester Down syndrome maternal serum screening (from 75% in 1995 to 25% in 2005; P < .001) and a corresponding significant increase in first-trimester combined screening (from 0.8% in 2000 to 49% in 2005; P < .001). The proportion of all confinements that involved invasive prenatal testing fell (from 9.3% in 1995 to 7.6% in 2005; P < .001). There was a significant decrease in the number of invasive prenatal tests that were needed to detect 1 Down syndrome fetus (from 86 tests in 1995 to 40 tests in 2005; P < .001), with no significant change in the proportion of Down syndrome cases that were detected prenatally.

CONCLUSION

The introduction and increased use of first-trimester combined Down syndrome screening has been associated with more efficient use of invasive prenatal testing in South Australia and has maintained a high level of overall prenatal detection.

Increasing prevalence of cerebral palsy among very preterm infants: a population-based study

OBJECTIVES

It is unclear whether declines in neonatal and infant mortality have led to changes in the occurrence of cerebral palsy. We conducted a study to examine and investigate recent temporal changes in the prevalence of cerebral palsy in a population-based cohort of very preterm infants who were 24 to 30 weeks of gestational age.

METHODS

A population-based cohort of very preterm infants who were born between January 1, 1993, and December 31, 2002, was evaluated by the Perinatal Follow-up Program of Nova Scotia. Follow-up extended to age 2 years to ascertain the presence or absence of cerebral palsy and for overall survival. Infant survival and cerebral palsy rates were compared by year and also in two 5-year periods, 1993-1997 and 1998-2002. Logistic regression analyses were used to identify factors that potentially were responsible for temporal changes in cerebral palsy rates.

RESULTS

A total of 672 liveborn very preterm infants were born to mothers who resided in Nova Scotia between 1993 and 2002. Infant mortality among very preterm infants decreased from 256 per 1000 live births in 1993 to 114 per 1000 live births in 2002, whereas the cerebral palsy rates increased from 44.4 per 1000 live births in 1993 to 100.0 per 1000 live births in 2002. Low gestational age, postnatal dexamethasone use, patent ductus arteriosus, severe hyaline membrane disease, resuscitation in the delivery room, and intraventricular hemorrhage were associated with higher rates of cerebral palsy, whereas antenatal corticosteroid use was associated with a lower rate.

CONCLUSION

Cerebral palsy has increased substantially among very preterm infants in association with and possibly as a consequence of large declines in infant mortality.

Correlation between prenatal ultrasound and autopsy findings: A study of second-trimester abortions

OBJECTIVE

To evaluate discrepancies between sonographic and autopsy findings following termination of pregnancy (TOP) in the second trimester.

METHODS

This retrospective report is based on 288 consecutive second-trimester abortions carried out because of fetal malformations diagnosed by ultrasound examination at a tertiary referral center. The correlation between the results from the ultrasound and autopsy examinations was evaluated.

RESULTS

Autopsy was performed in 274 cases. In 160 of the 274 pregnancies (58.4%) there was full agreement between the two examination methods. Findings detected by autopsy (in addition to those leading to termination) were not observed by ultrasonography in 86 (31.4%) of the pregnancies; of the 64 malformations that occurred, 30 (46.9%) were judged as 'detectable'. In 27 (9.9%) pregnancies, observations made by ultrasound (in addition to those leading to termination) were not confirmed at autopsy. In one pregnancy, postmortem radiology examination-but not autopsy-confirmed the ultrasound observations. No pregnancies were terminated because of false positive ultrasound observations. The correlation between ultrasound and autopsy findings was evaluated by three investigators; the inter-rater agreement was high (kappa = 0.85).

CONCLUSION

Discrepancies between ultrasound and autopsy findings were observed in about 40% of the pregnancies. These discrepancies confirm the need for autopsy following TOP.

Group B Streptococcal Testing During Pregnancy: Survey of Postpartum Women and Audit of Current Prenatal Screening Practices

OBJECTIVE

Group B Streptococcus (GBS) can be transmitted from mother to child during delivery. At the time of the study, Nova Scotia guidelines for screening pregnant women for the presence of GBS recommended using one of two testing methods. The objective of this study was to determine the level of compliance with GBS testing recommendations and to determine women's knowledge of, attitudes towards, and beliefs about prenatal screening for this infection.

METHODS

All women who gave birth at a single tertiary care unit during a seven-week period were approached to participate in the study. Study participants were interviewed using a questionnaire to determine their knowledge of, attitudes towards, and beliefs about prenatal screening. Medical and laboratory records were reviewed in order to audit the prenatal screening practices.

RESULTS

A total of 24.5% of study participants were screened for the presence of GBS by culture of a vaginal-rectal swab taken at 35 37 weeks' gestation, and 75.5% were assessed using the risk factor approach. Of the women screened by culture, 19% were identified as needing antibiotic treatment compared with 25% of those screened by assessment of risk factors. Women were significantly less knowledgeable about GBS than about other specific infections, and they felt that the threat of GBS infection for their baby was lower than the threat of the other infections. However, many of these women were uncertain about the threat that GBS poses during pregnancy.

CONCLUSION

Screening for GBS by culture rather than by assessing risk factors would have reduced antibiotic usage in our study population by 23%. These results indicate that all women should be counselled regarding GBS infection and should be tested using the culture-based approach at 35 to 37 weeks' gestation.

Ovarian cancer complicated by invasive pulmonary aspergillus

BACKGROUND

Invasive aspergillus is a rarely reported infection in patients with solid tumors.

CASE

A 59-year-old woman developed invasive pulmonary aspergillus after surgical debulking of an advanced ovarian adenocarcinoma and initiation of adjuvant combination chemotherapy.

CONCLUSION

Invasive pulmonary aspergillus is rarely diagnosed in patients with solid tumors such as ovarian cancer. Risk factors for development of the disease can include neutropenia, immunosuppression and chronic steroid use. Successful treatment of the infection relies upon prompt diagnosis and utilization of effective antifungal medications for a prolonged period of time.

Education in end-of-life care: bridging disciplinary and institutional boundaries

This paper describes the development of an interdisciplinary, interinstitutional seminar in palliative care for South Dakota students in medicine, nursing, pharmacy, chaplaincy, and social work. Student outcomes from six seminars conducted during 2001-2004 are reported, and recommendations for future educational efforts are outlined.

The perinatal effects of delayed childbearing

OBJECTIVE

To determine if the rates of pregnancy complications, preterm birth, small for gestational age, perinatal mortality, and serious neonatal morbidity are higher among mothers aged 35-39 years or 40 years or older, compared with mothers 20-24 years.

METHODS

We performed a population-based study of all women in Nova Scotia, Canada, who delivered a singleton fetus between 1988 and 2002 (N = 157,445). Family income of women who delivered between 1988 and 1995 was obtained through a confidential linkage with tax records (n = 76,300). The primary outcome was perinatal death (excluding congenital anomalies) or serious neonatal morbidity. Analysis was based on logistic models.

RESULTS

Older women were more likely to be married, affluent, weigh 70 kg or more, attend prenatal classes, and have a bad obstetric history but less likely to be nulliparous and to smoke. They were more likely to have hypertension, diabetes mellitus, placental abruption, or placenta previa. Preterm birth and small-for-gestational age rates were also higher; compared with women aged 20-24 years, adjusted rate ratios for preterm birth among women aged 35-39 years and 40 years or older were 1.61 (95% confidence interval [CI] 1.42-1.82; P < .001) and 1.80 (95% CI 1.37-2.36; P < .001), respectively. Adjusted rate ratios for perinatal mortality/morbidity were 1.46 (95% CI 1.11-1.92; P = .007) among women 35-39 years and 1.95 (95% CI 1.13-3.35; P = .02) among women 40 years or older. Perinatal mortality rates were low at all ages, especially in recent years.

CONCLUSION

Older maternal age is associated with relatively higher risks of perinatal mortality/morbidity, although the absolute rate of such outcomes is low.

Prevalence, Management, and Outcomes of Preterm Prelabour Rupture of the Membranes of Women in Canada

OBJECTIVES

To determine the prevalence of preterm prelabour rupture of the membranes (PPROM) at Canadian university-affiliated perinatal referral centres, to assess the different management strategies, and to review neonatal outcomes.

METHODS

Twelve Canadian university-affiliated perinatal referral centres provided information on their management of PPROM, and 9 participated in data collection to determine prevalence. All women presenting with PPROM during a 2-week period were observed until delivery, and obstetric and neonatal outcome data were subsequently obtained. The total number of deliveries in each centre was recorded for the same time period. We also determined the incidence of PPROM and the neonatal outcome for all women presenting with PPROM at the Kingston General Hospital from January 1999 to December 2001 by retrospective chart review.

RESULTS

In the 9 academic centres, 27 women (1 with a twin pregnancy) presented with PPROM during the 2-week period. There were 1168 deliveries during the same time period, giving a prevalence of PPROM of 2.3%. Overall, 53% of placentas submitted for histopathology after PPROM demonstrated evidence of chorioamnionitis. In the retrospective chart review, we found 153 cases of confirmed PPROM from January 1999 to December 2001,an incidence of 2.8%. Clinical management in all centres was similar for most women who presented with PPROM prior to 34 weeks' gestation. Management after 34 weeks' gestation varied among the 12 centres, ranging from immediate induction of labour to expectant management and induction at a greater gestational age (GA).

CONCLUSIONS

The increased neonatal morbidity associated with PPROM appears to be inversely related to GA. Increased risk of chorioamnionitis is related to increased time from PPROM to delivery.

A South Australian population-based study of congenital talipes equinovarus

The aims of this study were to provide a population-based prevalence for congenital talipes equinovarus (CTEV), to conduct an epidemiological investigation into the risk factors for CTEV and describe associated features. The study used a retrospective case-control design of CTEV notified to the South Australian Birth Defects Register between 1986 and 1996 inclusive, linking characteristics of mother and baby from the perinatal data collection. The prevalence of isolated CTEV was 1.1/1000 total births (n = 231). Four factors were significantly associated with an increased risk of CTEV: maternal Aboriginal race (ORadj = 2.0; 95% CI 1.1, 3.6), male gender (ORadj = 2.4; 95% CI 1.8, 3.2), maternal anaemia (ORadj = 1.8; 95% CI 1.0, 2.9) and maternal hyperemesis (ORadj = 3.6; 95% CI 1.3, 9.8). The prevalence of CTEV associated with another birth defect or syndrome (n = 157) was 0.7/1000 total births. CTEV was associated with specific birth defects and also with oligohydramnios when another birth defect was present.

Utility of reverse phase protein arrays: applications to signalling pathways and human body arrays

Protein microarrays offer a new means by which to conduct quantitative profiling of disease-associated proteins. The knowledge gained may provide novel strategies for early detection, diagnosis and therapeutic intervention. A variety of sophisticated approaches, including gene arrays, sequencing consortiums and large-scale two-dimensional gel electrophoresis, continue to generate lists of proteins potentially linked to disease aetiology and progression. The challenge is to evaluate quantitatively promising lead protein candidates using matched normal and diseased cell populations. In contrast to the antibody array, the reverse phase protein microarrays (RPPA) do not require labelling of cellular protein lysates, and constitute a sensitive high throughput platform for marker screening, pathophysiology investigation and therapeutic monitoring. In this paper, examples will be provided using RPPAs in the study of the apoptotic signalling cascade and in the evaluation of the expression of organ-specific protein makers using microdissected human organ cell lysates configured as 'human body arrays'.

Glomerular monocyte/macrophage influx correlates strongly with complement activation in 1-week protocol kidney allograft biopsies

BACKGROUND

The specific role of monocytes/macrophages (MO) in kidney graft rejection is not yet fully elucidated. In a recent protocol biopsy study of living-donor recipients, we demonstrated massive capillary influx of MO, associated with severe complement activation and acute rejection (AR) 1 week after transplantation [Sund et al.]. To gain further insight into the possible relationship between MO and complement activation, we analyzed glomerular and interstitial MO in these biopsies.

METHODS

Twenty-seven protocol biopsies were stained with antibodies to calprotectin (L1) and CD68 as markers for MO. Cells were counted as an average number per glomerulus and as an average number per defined visual field in the interstitium. Polymorphonuclear leukocytes (PMN) were counted in glomeruli and interstitium by light microscopy. Baseline specimens from 10 of the patients served as controls. The results were compared with data on deposition of complement from the foregoing study, and with histopathologic and clinical data on AR.

RESULTS

Cases with diffuse C4d deposition in peritubular capillaries consistent with acute antibody-mediated rejection (AbAR) (n = 4) had significantly higher numbers of intraglomerular MO than the other protocol biopsies (L1: median 20.7 vs 3.6, p = 0.0002; CD68: median 10.1 vs. 2.0, p = 0.0008). With a cut-off of 10 L1-positive and 6 CD68-positive MO, the specificity for the diagnosis of AbAR was 96% and 91%, respectively. The number of interstitial MO was significantly higher in patients with AR than in those without, but in contrast to glomerular MO, interstitial MO could not discriminate between complement positive and negative AR. The number of glomerular and interstitial PMNs was significantly higher in the AbAR group than in the other protocol biopsies.

CONCLUSIONS

The strong correlation between complement activation and early glomerular influx of MO in the kidney allograft suggests a causal relationship between these 2 events. At 1 week after transplantation, a number of 10 L1-positive and 6 CD68-positive MO per glomerulus indicates AbAR.