Maternal and fetoplacental hypoxia do not alter circulating angiogenic growth effectors during human pregnancy

One causal model of preeclampsia (PE) postulates that placental hypoxia alters the production of angiogenic growth effectors (AGEs), causing an imbalance leading to maternal endothelial cell dysfunction. We tested this model using the natural experiment of high-altitude (HA) residence. We hypothesized that in HA pregnancies 1) circulating soluble fms-like tyrosine kinase 1 (sFlt-1) is increased and placental growth factor (PlGF) decreased, and 2) AGE concentrations correlate with measures of hypoxia. A cross-sectional study of healthy pregnancies at low altitude (LA) (400 m) versus HA (3600 m) compared normal (n = 80 at HA, n = 90 at LA) and PE pregnancies (n = 20 PE at HA, n = 19 PE at LA). Blood was collected using standard serum separation and, in parallel, by a method designed to inhibit platelet activation. AGEs were measured by enzyme-linked immunosorbent assays. AGEs did not differ between altitudes in normal or PE pregnancies. AGE concentrations were unrelated to measures of maternal or fetal hypoxia. PlGF was lower and sFlt-1 higher in PE, but overlapped considerably with the range observed in normal samples. PlGF correlated with placental mass in both normal and PE pregnancies. The contribution of peripheral cells to the values measured for AGEs was similar at LA and HA, but was greater in PE than in normotensive women. Hypoxia, across a wide physiological range in pregnancy, does not alter levels of circulating AGEs in otherwise normal pregnancies. Peripheral cell release of AGEs with the hemostasis characteristic of standard blood collection is highly variable and contributes to a doubling of the amount of sFlt-1 measured in PE as compared to normal pregnancies.

Abstract P5-13-01: Uptake of breast cancer chemoprevention among high-risk women and those with ductal carcinoma in situ

Background: Chemoprevention with antiestrogens, such as tamoxifen, raloxifene, and aromatase inhibitors (AIs), reduces breast cancer incidence in high-risk women. However, uptake has been poor in the prevention setting. We examined demographic and clinical factors that influenced chemoprevention uptake in women with an elevated Gail risk score (≥1.67%), lobular/ductal carcinoma in situ (LCIS/DCIS), and/or BRCA mutation carriers.

Methods: We enrolled women prospectively without a diagnosis of invasive breast cancer, who were seen for an initial consultation by breast surgery or medical oncology at Columbia University Medical Center. Eligibility for chemoprevention included a 5-year Gail risk ≥1.67%, LCIS, known BRCA1 or BRCA2 mutation, or hormone receptor (HR)-positive DCIS. Demographic and risk factor data were collected from a self-administered baseline questionnaire and clinical data from medical chart review, including prior/current chemoprevention, type of antiestrogen, duration of use, and toxicities. Differences in distribution of risk factors between women who ever took chemoprevention and those who did not were examined using chi-square statistics or Fisher's exact test. We used log-binomial regression models to estimate relative risks (RRs) and 95% confidence intervals (95% CI) using chemoprevention uptake as the dependent variable. A subset of high-risk women completed questionnaires assessing their attitudes towards chemoprevention and perceived risks/benefits.

Results: Among 412 women enrolled between March 2007 and April 2013, 316 (77%) were eligible for chemoprevention. Main reasons for ineligibility included 5-year Gail risk <1.67% (40%), age <35 (24%), HR-negative DCIS (17%), opting for bilateral mastectomies (11%), and medical contraindications (8%). Among those eligible for chemoprevention, median age 53 (26-88); White/Hispanic/Black/Asian/other (%): 55/29/8/7/1; risk category, 5-year Gail risk ≥1.67%/LCIS/DCIS/BRCA mutation (%): 36/22/40/2. Overall, 162 (51%) women started an antiestrogen (72% for DCIS and 37% among high-risk women), including 114 on tamoxifen, 40 on raloxifene, and 11 on an AI. Early discontinuation occurred in 27 (18%) women, but 7 switched to a different antiestrogen. In univariable analysis, postmenopausal status and medical oncology referral were associated with higher chemoprevention uptake. In multivariable analysis, only higher risk was a significant predictor of chemoprevention uptake. Among the subset of women who completed additional questionnaires on attitudes towards chemoprevention, they reported that the most important factors in chemoprevention decision-making included their healthcare provider (50%), results of chemoprevention studies (44%), and knowledge about others’ experience with chemoprevention (44%). The majority (69%) were concerned about side effects, specifically blood clots with tamoxifen and raloxifene and bone fractures with AIs.

Conclusions: In high-risk women seen at an academic breast center, chemoprevention uptake was relatively high compared to the published literature. Further research is needed to determine how the risks and benefits of chemoprevention are best communicated to women to enhance informed decision-making and increase uptake of chemoprevention strategies.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-13-01.

Maternal and fetal outcomes in placenta accreta after institution of team-managed care

INTRODUCTION

Placenta accreta significantly contributes to maternal morbidity and mortality. We evaluated whether planned delivery and experienced, team-managed surgical intervention results in improved outcomes. We also examined whether risk factors differed for accreta, increta, and percreta and evaluated whether excess lower segment uterine vascularity correlates with disease severity.

METHODS

We retrospectively analyzed patients before versus after institution of a management protocol. Of the 58 044 deliveries over 10 years, there were 67 women whose pregnancies were histopathologically confirmed as placenta accreta, increta, or percreta (1/866). Clinical outcome measures were estimated blood loss (EBL), packed red blood cells (pRBCs) transfused, maternal and fetal complications, intensive care unit admission, and length of stay.

RESULTS

There were no maternal or infant deaths. In the managed cohort, EBL was reduced by 48% (P < .001), intraoperative pRBCs transfused by 40% (P < .01), total transfused pRBCs per case by 50% (P < .01), and surgical intensive care unit admissions by >50% (P < .01). Assessment of maternal risk factors by diagnosis revealed marked differences between accreta versus increta and percreta. Clinically assessed excess vascularity of the lower uterine segment correlated with disease severity. The incidence of neonatal complications was similar in both cohorts.

CONCLUSIONS

Targeted delivery at 34 weeks and team-managed diagnosis, treatment, and care of patients with placenta accreta were associated with improved maternal, but not neonatal outcomes.

Can upwelling signals be detected in intertidal fishes of different trophic levels?

For intertidal fishes belonging to three species, the herbivore Scartichthys viridis (Blenniidae), the omnivore Girella laevifrons (Kyphosidae) and the carnivore Graus nigra (Kyphosidae), mass and body size relationships were higher in individuals from an upwelling zone compared with those from a non-upwelling zone. RNA:DNA were higher in the herbivores and omnivores from the upwelling zone. Higher biomass and RNA:DNA in the upwelling intertidal fishes may be a consequence of an increased exposure to higher nutrient availability, suggesting that increased physiological conditioning in vertebrates from upwelling areas can be detected and measured using intertidal fishes of different trophic levels.

Evidence for extraplacental sources of circulating angiogenic growth effectors in human pregnancy

Pregnancy complications such as preeclampsia (PE) and intrauterine growth restriction (IUGR) are associated with reduced blood flow, contributing to placental and fetal hypoxia. Placental hypoxia is thought to cause altered production of angiogenic growth effectors (AGEs), reflected in the circulation of mother and fetus. Vascular endothelial growth factor (VEGF), placental growth factor (PlGF) and their soluble binding protein (sFlt-1) are, in turn, postulated as being causally involved in PE via induction of systemic endothelial cell dysfunction. To dissect the role of AGEs, accurate measurement is of great importance. However, the values of AGEs are highly variable, contributing to heterogeneity in their association (or lack thereof) with preeclampsia. To test the hypothesis that variability may be due to peripheral cell release of AGEs we obtained blood samples from normal healthy pregnant women (n = 90) and the cord blood of a subset of their neonates using standard serum separation and compared results obtained in parallel samples collected into reagents designed to inhibit peripheral cell activation (sodium citrate, theophylline, adenosine and dipyridamole-CTAD). AGEs were measured by ELISA. CTAD collection reduced maternal and fetal free VEGF by 83%, and 98%, respectively. Free PlGF was decreased by 29%, maternal sFlt-1 by >20% and fetal sFlt-1 by 59% in the CTAD-treated vs. serum sample (p < 0.0001). In summary blood collection techniques can profoundly alter measured concentrations of AGEs in mother and fetus. This process is highly variable, contributes to variation reported in the literature, and renders questionable the true impact of alteration in AGEs on pregnancy pathologies.

Intra-amniotic IL-1β induces fetal inflammation in rhesus monkeys and alters the regulatory T cell/IL-17 balance

Very low birth weight preterm newborns are susceptible to the development of debilitating inflammatory diseases, many of which are associated with chorioamnionitis. To define the effects of chorioamnionitis on the fetal immune system, IL-1β was administered intra-amniotically at ~80% gestation in rhesus monkeys. IL-1β caused histological chorioamnionitis, as well as lung inflammation (infiltration of neutrophils or monocytes in the fetal airways). There were large increases in multiple proinflammatory cytokine mRNAs in the lungs at 24 h postadministration, which remained elevated relative to controls at 72 h. Intra-amniotic IL-1β also induced the sustained expression of the surfactant proteins in the lungs. Importantly, IL-1β significantly altered the balance between inflammatory and regulatory T cells. Twenty-four hours after IL-1β injection, the frequency of CD3(+)CD4(+)FOXP3(+) T cells was decreased in lymphoid organs. In contrast, IL-17A-producing cells (CD3(+)CD4(+), CD3(+)CD4(-), and CD3(-)CD4(-) subsets) were increased in lymphoid organs. The frequency of IFN-γ-expressing cells did not change. In this model of a single exposure to an inflammatory trigger, CD3(+)CD4(+)FOXP3(+) cells rebounded quickly, and their frequency was increased at 72 h compared with controls. IL-17 expression was also transient. Interestingly, the T cell profile alteration was confined to the lymphoid organs and not to circulating fetal T cells. Together, these results suggest that the chorioamnionitis-induced IL-1/IL-17 axis is involved in the severe inflammation that can develop in preterm newborns. Boosting regulatory T cells and/or controlling IL-17 may provide a means to ameliorate these abnormalities.

FDG-PET/CT findings during immune reconstitution in an HIV-1 patient infected with visceral leishmaniasis

Visceral leishmaniasis can rarely be unmasked by immune reconstitution in human immunodeficiency virus (HIV)-1-infected patients. We report the first case of immune reconstitution associated with leishmaniasis in an HIV patient to be imaged with [(18)F]fluorodeoxyglucose positron emission tomography (FDG/PET), at both baseline and after therapy.

The antioxidant effects of soybean lecithin- or low-density lipoprotein-based extenders for the cryopreservation of brown-bear (Ursus arctos) spermatozoa

Egg yolk low-density lipoproteins (LDL) and soybean lecithin were evaluated as replacements for egg yolk in extenders used for the cryopreservation of brown-bear spermatozoa. The motility, viability and acrosomal status of post-thawed spermatozoa were analysed, and an egg-yolk extender was used as a control. The total antioxidant capacity of these extenders was tested. Soybean lecithin showed an effect that was dependent on the soybean concentration (2%, 3.5% and 5%) and source (Type A: 24% L-α-phosphatidylcholine, and Type B: 14-23% L-α-phosphatidylcholine). Only semen cryopreserved with 5% Type A soybean exhibited a sperm motility similar to that of semen cryopreserved in egg-yolk-based extender after thawing, although the sperm viability and acrosome status were not as high. Semen frozen in an extender containing LDL (10-15%) exhibited improved sperm viability in comparison with the control, but sperm motility was lower. The LDL-based extender exhibited a higher anti-oxidant activity than the egg-yolk extender and soy lecithin-based extenders. The extenders with higher anti-oxidant activity showed improvements in frozen sperm viability but lower semen motility. These results indicate that soybean lecithin did not have the same protective effect as egg yolk during the freezing of brown-bear spermatozoa but suggest that LDL (10-15%) could be a useful substitute for egg yolk in these extenders.

Clinical diagnostic clues in Crohn's disease: a 41-year experience

Determining the diagnosis of Crohn's disease has been highly difficult mainly during the first years of this study carried out at the Pontificia Universidad Catolica (PUC) Clinical Hospital. For instance, it has been frequently confused with Irritable bowel syndrome and sometimes misdiagnosed as ulcerative colitis, infectious colitis or enterocolitis, intestinal lymphoma, or coeliac disease. Consequently, it seems advisable to characterize what the most relevant clinical features are, in order to establish a clear concept of Crohn's disease. This difficulty may still be a problem at other medical centers in developing countries. Thus, sharing this information may contribute to a better understanding of this disease. Based on the clinical experience gained between 1963 and 2004 and reported herein, the main clinical characteristics of the disease are long-lasting day and night abdominal pain, which becomes more intense after eating and diarrhoea, sometimes associated to a mass in the abdomen, anal lesions, and other additional digestive and nondigestive clinical features. Nevertheless, the main aim of this work has been the following: is it possible to make, in an early stage, the diagnosis of Crohn's disease with a high degree of certainty exclusively with clinical data?

Psychometric properties of the Spanish version of the diagnostic interview for depressive personality

The aim of this study was to evaluate the reliability and validity of the Spanish-language version of the diagnostic interview for depressive personality (DIDP). The DIDP was administered to 328 consecutive outpatients and the test-retest and inter-rater reliability were assessed. Factor analysis was used in search of factors capable of explaining the scale and a cutoff point was established. The DIDP scales showed adequate Cronbach's α values and acceptable test-retest and inter-rater reliability coefficients. Convergent and discriminant validity were explored, the latter with respect to avoidant and borderline personality disorders. The results of the factor analysis were consistent with the four-factor structure of the DIDP scales. The receiver operating characteristic (ROC) analysis revealed the area under the curve to be 0.848. We found 30 to be a good cutoff point, with a sensitivity of 74.5% and a specificity of 78.5%. The DIDP proved to be a reliable and valid instrument for assessing depressive personality disorder, at least among our outpatients. The psychometric properties of the DIDP support its clinical usefulness in assessing depressive personality.