Apoptosis cascade progresses during turnover of human trophoblast: analysis of villous cytotrophoblast and syncytial fragments in vitro

Growth and survival of the trophoblast layer of the human placenta depends on continuous incorporation of villous trophoblast stem cells (cytotrophoblast), by syncytial fusion, into the syncytiotrophoblast. Descriptive studies suggest that this process may be intimately related to apoptosis. We have analyzed the expression and activation of initiator and execution caspases, critical effectors of apoptosis, in relation to trophoblast turnover (differentiation) in human placental villi. We used immunohistochemistry, caspase enzyme histochemistry, caspase activity assays, Western blots, and autoradiography techniques on placental tissue sections, trophoblast lysates, villous explants, and isolated trophoblast fragments (villous cytotrophoblast and mononuclear syncytial elements) in vitro. Our data demonstrate expression of initiator caspases 8 and 10 and activity of caspase 8 in villous cytotrophoblast. Proforms of the execution caspases 3, 6, and 7 were also expressed in villous cytotrophoblast, but activation of execution caspases 3 and 6 could only be demonstrated in the syncytiotrophoblast after syncytial fusion. Down-regulation of the general transcription level (reduced incorporation of [3H]uridine) as well as cleavage of the execution caspase substrates poly-(ADP-ribose)polymerase and lamin B was confined to syncytiotrophoblast and preceded the final events of apoptotic death (terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling reactivity and nuclear collapse). Our data confirm that the apoptosis cascade in villous trophoblast is regulated in parallel with trophoblast differentiation, syncytial fusion, and trophoblast turnover.

Connexin expression patterns in human trophoblast cells during placental development

This study focuses on the gap junction expression pattern in trophoblast cells during human placental development in vivo and in vitro. Investigations of cell-cell communication properties within the subpopulations of trophoblast responsible for invasion, placental growth and feto-maternal transport seem of special interest because the intercellular channels are believed to coordinate proliferation and differentiation processes. From all gap junction connexins (Cx) investigated (Cx26, Cx31, Cx32, Cx37, Cx40, Cx43), Cx40 was the only connexin clearly detected within the cytotrophoblast of human placenta, and was restricted to the extravillous trophoblast of cell islands and cell columns. Most intense staining was found in the juxtastromal area correlated to the proliferating extravillous trophoblast cells. Connexin protein expression was missing during trophoblast migration into the decidua but was re-expressed in trophoblast aggregates within the decidua. Cx40 expression decreased with progressing pregnancy and no connexins could be detected in villous or extravillous trophoblast of mature placentae. In parallel, isolated trophoblast cells of first and second trimester placentae revealed Cx40 expression and, in contrast to the situation in vivo, Cx43 was also found. In isolated cells of mature placentae, expression of both Cx40 and Cx43 transcripts was decreased to low levels and Cx40 immunoreactivity was absent. Cx43 protein, however, was still detectable in trophoblast cultures of term placentae. Our studies suggest that Cx40 is the characteristic channel for the proliferating cell population of cell islands and cell columns of first and second trimester placentae and isolated trophoblast and is probably involved in regulation and coordination of the invasive pathway.

Different placentation patterns in viable compared with nonviable tubal pregnancy suggest a divergent clinical management

OBJECTIVE

In contrast to tubal abortions, viable ectopic pregnancies in color Doppler ultrasonography exhibit a signal-intensive ring around the gestational sac. We investigated the underlying differences in implantation and placentation.

STUDY DESIGN

Histologic sections of fallopian tubes carrying viable tubal pregnancies (13 patients) and tubal pregnancies that aborted (8 patients) were immunostained for cytokeratin, MIB-1, CD-34, and CD-68. The data were studied by computer-aided image analysis followed by statistical evaluation (Student t test, P <.05).

RESULTS

In contrast to tubal abortions, viable tubal pregnancies are characterized by implantation at the mesosalpingial rather than at the antimesosalpingial side of the organ. They exhibit deeper trophoblast invasion into the thickened tubal wall, more intense trophoblast proliferation (P <.001), and increased villous vascularization (P <.001).

CONCLUSION

The morphologic findings correlate with preoperative Doppler ultrasonography. They suggest that trophoblast invasion, placental growth, and the fate of tubal pregnancies depend on the implantation site. They encourage a conservative management of anti-mesosalpingially implanted, nonviable ectopic pregnancies in clinically stable patients.

Relation of serial measurements of plasma-soluble intercellular adhesion molecule-1 to severity of acute pancreatitis

OBJECTIVE

Acute pancreatitis remains a clinical challenge because it is difficult to predict whether, in a given patient, the disease will be mild or will run a severe course with a possibly fatal outcome. The aim of this study was to investigate whether circulating soluble intercellular adhesion molecule-1 (sICAM-1) as a marker of leukocyte activation is related to the severity of the disease.

METHODS

The study included 29 consecutive adults admitted with acute pancreatitis. Plasma sICAM-1 levels were measured serially over a period of 6 days, and values and time courses were correlated with clinical severity.

RESULTS

Our patients fell into four groups on the basis of the following measurements: 1) Decreasing sICAM- levels with maximal values of 446 +/- 90 ng/ml (mean +/- SEM) slightly above the upper limit of normal were associated with uncomplicated mild disease in seven patients. 2) In nine patients with sICAM-1 concentrations reaching a peak of 743 +/- 121 ng/ml after 3 days, severe pancreatitis was present in 11% and pancreatic necrosis occurred in 33%. 3) A second increase of sICAM-1 (maximal level: 993 +/- 169 ng/ml) after an initial decrease (relapsing pattern, 7 patients) was associated with a severe course of disease in 71% including pancreatic necrosis in 43% and nosocomial pneumonia in 42%. 4) A rapid increase of sICAM-1 reaching highest maximal values of 1738 +/- 104 ng/ml (p < 0.0001) indicated fulminant pancreatic necrosis and a fatal outcome in six patients.

CONCLUSIONS

Serial plasma sICAM-1 levels in patients with acute pancreatitis within the first 6 days after admission fall into four different groups of severity according to the shape of the curves. This suggests that the time course of elevated plasma sICAM-1 concentrations reflects the risk of developing necrosis and clinical complications in acute pancreatitis.

Time course of plasma soluble intercellular adhesion molecule-1 (sICAM-1) is related to severity of acute pancreatitis

BACKGROUND/AIMS

In severe acute pancreatitis the release of cytokines indicates a key step from local to systemic inflammation. Increased plasma concentrations of circulating soluble intercellular adhesion molecule-1 (sICAM-1), a marker of leukocyte activation, were detected in necrotizing pancreatitis at the time of diagnosis, however, the exact role of sICAM-1 in the development of complications such as shock or organ dysfunction is unclear. Therefore, we investigated in what manner the time course of plasma sICAM-1 is associated with the development of severe pancreatitis and whether these results are of any predictive value for the further course of the disease.

METHODOLOGY

In a medical intensive care unit we studied 29 consecutive patients admitted for acute pancreatitis. Plasma levels of sICAM-1 were measured serially over a period of 6 days and the time courses were assigned either to a group of patients with uncomplicated, mild disease or to patients who developed complications including multiple organ failure.

RESULTS

In mild pancreatitis, decreasing and peak sICAM-1 concentrations were found in 88% of the patients with a mean maximal level of 574 +/- 59 ng/ml (SE) (upper limit of normal: 400 ng/ml) on day 1. Partial pancreatic necrosis was present in 24% and no deaths were observed. In severe pancreatitis an increase of sICAM-1 levels or an initial fall followed by an increase (relapsing response) was the predominant pattern (92%). Maximal values of 1453 +/- 136 ng/ml occurred on day 6, significantly different when compared to mild disease (p < 0.0001). Necrotizing pancreatitis was diagnosed in 75% and the mortality rate was 58%. The sensitivity in predicting severe pancreatitis using sICAM-1 plasma levels with an increasing or relapsing pattern was much higher (92%) when compared with serial C-reactive protein measurements (42%).

CONCLUSIONS

In acute pancreatitis, increasing or relapsing plasma levels of sICAM-1 over 6 days after admission to hospital are associated with a high rate of pancreatic necrosis and a high mortality. Daily measurements of sICAM-1 would allow early recognition of patients prone to develop complications and follow a severe course.

The apoptosis cascade--morphological and immunohistochemical methods for its visualization

Apoptosis is involved in morphogenesis of embryonic tissues as well as in homeostasis of adult organs and tissues. It is the main process by which organs maintain cell mass and at the same time eliminate excess and aged cells that have lost their functional importance. The typical morphological signs of apoptosis (cellular shrinkage, membrane blebbing, nuclear condensation and fragmentation) are the final results of a complex biochemical cascade of events, some of which are inextricably linked to the process of differentiation. Studies that analyze all stages of this cascade, rather than the final morphological stages of apoptotic death, are essential in order that specific link(s) between differentiation and apoptosis are appreciated. This review outlines the main stages of the apoptosis cascade together with current methods for their morphological visualization. Starting with (a) receptors and ligands known to induce apoptosis, we continue with (b) early initiator stages of apoptosis, and (c) proteins regulating and potentially inhibiting further progression of the cascade, into (d) irreversible execution stages of the cascade, and finally (d) the morphological events of apoptotic death. For each stage we present those aspects of the biochemical background that are morphologically relevant, together with proven methods for their visualization. We offer technical advice at each stage based upon our experience of studying differentiation and apoptosis in human placental trophoblast.

Q.E.D. Alcohol test: a simple and quick method to detect ethanol in saliva of patients in emergency departments. Comparison with the conventional determination in blood

OBJECTIVE

The aim of this pilot study was to assess whether ethanol concentrations in saliva are comparable to those in blood and to evaluate whether this new non-invasive saliva alcohol test is suitable for use in emergency departments.

DESIGN

Prospective, open, non-randomised study.

SETTING

University hospital emergency department.

PATIENTS AND METHODS

100 consecutive patients who were admitted to the emergency department whose smell and/or behaviour indicated alcohol abuse. Fifteen patients participated as a control group after they were asked to abstain from alcohol consumption for 24 h before the study.

INTERVENTIONS

Blood and saliva samples were obtained at the same time for ethanol measurement. The Q.E.D. Alcohol Test A350 was used in order to measure the concentration of ethanol in saliva. Blood samples were analysed by the alcohol dehydrogenase method.

RESULTS

The mean difference between the ethanol levels in blood and saliva was -0.1 mg/dl, whereas the values measured in saliva were on average 0.1 mg/dl higher than those measured in blood (p = 0.002).

CONCLUSION

The Q.E.D. Alcohol Test A 350, which uses saliva, is well suited for quantitative determination of alcohol levels. The levels measured in saliva correlate well with those measured in blood at both the lower and the upper end of the scale. Because this test is quick and easy to perform by emergency room personnel and the results are accurate enough for clinical purposes, it should prove valuable to determine whether impaired consciousness is related to alcohol intoxication or to other likely causes.

Umbilical Doppler waveforms and placental villous angiogenesis in pregnancies complicated by fetal growth restriction

OBJECTIVE

To test the hypothesis that the characteristics of umbilical artery Doppler flow velocity waveforms in growth-restricted fetuses indicate angiogenesis within placental stem and gas-exchanging villi.

METHODS

We examined 18 placentas from singleton fetuses that were normal structurally and chromosomally but were growth-restricted, preterm, and complicated by preeclampsia. Ten cases with positive end-diastolic flow and eight with absent or reverse end-diastolic flow were compared with six gestational age-matched controls. Sections of villous placenta were examined to determine structural composition (percentage of fibrinoid, intervillous space, and villous tissue), relative proportion of villous types (stem, immature intermediate, and gas-exchanging villi), and the frequency distribution of stem arterial vessel calibers and their branching pattern.

RESULTS

Placentas with positive end-diastolic flow had a significantly (P < .05) higher percentage of gas-exchanging villi (median 69.6%, range 62.5-80.8%) than those with absent or reverse end-diastolic flow (58.3%, 29.9-71.9%) or controls (60.8%, 43.1-65.6%). The gas-exchanging villi from placentas with absent or reverse end-diastolic flow were slender, elongated, poorly branched, and poorly capillarized. There was a progressive trend toward reduced branching of the stem arteries from the controls (median 22%, range 2-38%), through the positive end-diastolic group (17%, 11-20%), to the absent or reverse end-diastolic group (13%, 4-23%).

CONCLUSION

Compared with absent or reverse end-diastolic flow, the placentas from growth-restricted fetuses with positive end-diastolic flow showed a normal pattern of stem artery development, accompanied by increased capillary angiogenesis and terminal villous development. These features suggest an adaptive pathway for the placenta in the face of uteroplacental ischemia.

The distribution of macrophages in spiral arteries of the placental bed in pre-eclampsia differs from that in healthy patients

Placental bed biopsies taken during caesarean section from 10 patients with pre-eclampsia and six healthy pregnancies were studied. We applied antibodies against cytokeratin and different macrophage markers to analyse the distribution of invasive extravillous trophoblast cells as compared to that of macrophages in myometrial segments of uteroplacental arteries. The data were evaluated quantitatively. We found a clear inverse relationship between local infiltration with macrophages and trophoblast invasion. In pre-eclampsia, vessel cross-sections prevailed which were characterized by large numbers of macrophages but a low degree of trophoblast invasion. In contrast, in normal third trimester pregnancies the respective arterial segments had a high degree of trophoblast invasion but were largely void of macrophages. These data suggest causal links between macrophages and inhibition of intra-arterial trophoblast invasion in pre-eclampsia.

Behavioral and pharmacologic interventions: the Raynaud's Treatment Study

The Raynaud's Treatment Study (RTS) exemplified clinical trials with treatments that differ qualitatively both in their modes and in their methods of delivery. The RTS compared finger-temperature biofeedback to slow-release nifedipine, a calcium channel blocker, in patients with primary Raynaud's disease. Factors influencing the study design were the nature of the interventions and control measures of the protocol, the possibility of perceived differences by the patients between the treatments once the final protocol was developed, and concern on the part of the investigators over the fact that the primary endpoint was self-reported. This paper presents the final statistical model: a double parallel design with both a placebo group and a nonspecific behavioral control group.

[Pseudomonas pneumonia--an important differential pulmonary infiltration diagnosis in AIDS]

Bacterial pneumonias are the most common pulmonary complication in HIV-infected patients. Up to now, H. influenzae and S. pneumoniae have been described as the most important germs. Within a period of 4 years we diagnosed 15 cases of pneumonia caused by P. aeruginosa. All patients were in HIV stage C3; 3F, 12M; median age 34 (24-54) years; median CD4 count 10 (0-130) microliters. Except for 3 nosocomial pneumonias, all others were community-acquired. Only 3 patients had neutropenia < 1000/microliter; 7 were intravenous drug abusers. Morphologically there were 6 cases of abscess pneumonia, in 3 of which pleural drainage was necessary because of pyopneumothorax. 4 patients showed bilateral infiltrates that could not be differentiated from those of P. carinii pneumonia. Our diagnosis was based on quantitative cultures of broncho-alveolar lavage fluid (9 cases, two of them with concurrent positive blood cultures/positive cultures of the pleural fluid), pleural puncture (one case), sputum in pneumonias responding only to antipseudomonas therapy (3 cases), and autopsy (2 cases). 8 patients died of pseudomonas pneumonia within 1-3 months despite therapy. 7 patients received pseudomonas-specific combination therapy, but all died after median 9 (4-15) months of the underlying illness. In 3 cases recurrent pseudomonas pneumonia could be documented bacteriologically. We conclude that in HIV-infected patients pneumonia caused by P. aeruginosa is a significant and severe pulmonary complication.

Enhanced coronary vasoconstriction after PTCA in patients with acute ischemia

Coronary vasoconstriction of the distal vessel segment has been reported after percutaneous transluminal coronary angiography (PTCA), which was explained by increased vasoconstrictor influences. In patients with acute ischemia these changes may be even enhanced. Thus, vasomotion of the epicardial coronary arteries was studied before and after PTCA in patients with acute ischemia due to unstable angina or acute infarction.

METHODS

52 patients were divided into 2 groups: Group 1 (controls) consisted of 31 patients who underwent elective (PTCA) and group 2 of 21 patients who underwent emergency PTCA for unstable angina or acute infarction. Coronary artery dimensions proximal and distal to the culprit lesion were determined by quantitative coronary angiography before and after PTCA as well as after 0.2 mg nitroglycerin i.c. at the end of the procedure.

RESULTS

Stenosis severity was similar before and after PTCA in both groups (before, 91 +/- 8% in group 1 vs 90 +/- 9% in group 2; after, 28 +/- 9% vs 23 +/- 10%, resp.). Heart rate and mean blood pressure remained unchanged. In the group with acute ischemia no vasodilation of the proximal (2 +/- 3%) and distal vessel (-1 +/- 4%) occurred after PTCA, whereas in the control group significant vasodilation of both vessel segments (11 +/- 2% resp. 13 +/- 3%) was found. The response to nitroglycerin was maintained in both groups. In the control group there was a significant correlation between stenosis severity and percent diameter change of the distal vessel segment. However, in the acute ischemic group this relationship was shifted downwards suggesting an enhanced vasoconstrictor response in these patients.

CONCLUSIONS

Epicardial coronary arteries in patients with acute ischemia show an enhanced vasoconstriction after PTCA. Nevertheless, the response to nitroglycerin is maintained suggesting that functional (endothelial dysfunction) rather than structural factors are responsible for this phenomenon.

Increased fetoplacental angiogenesis during first trimester in anaemic women

BACKGROUND

Epidemiological studies describe an association between relative size of the placenta at delivery and cardiovascular morbidity and mortality during adult life. Some determinants of placental size, such as maternal anaemia, have been acknowledged, but no plausible mechanism has been advanced to explain the initiation of postnatal disease.

METHODS

Placental villous vascularisation in anaemic women (Hb<90 g/L) was assessed in the first and third trimesters of pregnancy by immunohistochemical identification of villous capillaries and compared with that of gestational age-matched groups of women with normal (Hb>110 g/L; control group) concentrations of haemoglobin, and an intermediate group (Hb 90-110 g/L).

FINDINGS

Anaemia, especially in the first trimester, was associated with increased numbers of capillaries per villous cross section (mean 11.70 [SE 0.35] vs 4.14 [0.27]) located mainly in the outer third of the stroma beneath the trophoblast (94% [1.15] vs 67% [1.82]) and with increased numbers of villous macrophages and of proliferating MIB-1-positive cells compared with the control group.

INTERPRETATION

Maternal anaemia in early pregnancy seems to influence the pattern of placental vascularisation. Such changes might alter placental vascular impedance during early fetal life, thereby exerting important effects on cardiovascular development.

Villous cytotrophoblast regulation of the syncytial apoptotic cascade in the human placenta

Villous trophoblast in the human placenta consists of a population of proliferating stem cells which differentiate and individually fuse into the syncytiotrophoblast. We studied the apoptotic cascade in this complex epithelial layer by immunohistochemical localization of Fas, FasL, Bcl-2, Mcl-1, pro-caspase-3 and caspase-3, T-cell-restricted intracellular antigen-related protein (TIAR), poly(ADP-ribose) polymerase (PARP), lamin B, topoisomerase IIalpha, and transglutaminase II in cryostat and paraffin-fixed tissue sections from normal human first-trimester and term placental villi. The relationship between the apoptotic cascade and syncytial fusion was studied by coincubation of intact villi with FITC-coupled annexin-V, to detect the phosphatidylserine flip, and propidium iodide, to detect plasma membrane permeability. The final events of the apoptotic cascade were studied by the TUNEL reaction and ultrastructural appearance of the trophoblast. The phosphatidylserine flip was identified in some of the villous cytotrophoblastic cells, but the presence of both Bcl-2 and Mcl-1 proteins presumably prevented continuation of the apoptotic cascade. The syncytiotrophoblast demonstrated heterogeneous findings, suggesting variable progression along the apoptotic cascade. In some areas Bcl-2 and Mcl-1 predominated, with preservation of the nuclear proteins PARP, lamin B, and topoisomerase IIalpha; in other areas, especially in and around syncytial sprouts, Bcl-2 and Mcl-1 were absent, accompanied by loss of nuclear proteins, presence of phosphatidylserine flip, and TUNEL positivity. These data suggest that the apoptotic cascade is initiated in the villous cytotrophoblast, which in turn promotes syncytial fusion. Donation of anti-apoptotic proteins into the syncytium, such as Bcl-2 and Mcl-1, focally inhibits further progression along this cascade. Completion of the apoptotic cascade takes place in and around syncytial sprouts, providing further evidence that these are the sites of trophoblast shedding into the maternal circulation.

[Diagnosis and indication for aortic valve replacement in asymptomatic and symptomatic patients with aortic regurgitation]

Chronic volume overload is associated with dilatation and eccentric hypertrophy of the left ventricle (= ventricular remodeling). With the dilatation of the left ventricle and the shift of the pressure-volume-relationship to the right, the filling pressures can be kept normal despite severe regurgitation. Therefore, the patient with aortic regurgitation can remain asymptomatic over many years. Thus, the indication for aortic valve replacement in patients with severe aortic regurgitation is sometimes difficult and may lead to problems to choose the optimal time point for operation. As a general rule, symptomatic patients with severe aortic regurgitation should be operated as soon as possible. In asymptomatic patients with significant dilatation of the left ventricle and reduction of systolic pump function the therapy of choice is aortic valve replacement. Asymptomatic patients with normal left ventricular function have usually a good prognosis with a yearly mortality rate of approximately 0.04%. However, in the presence of significant dilatation of the left ventricle, i.e. enddiastolic chamber diameter more than 70 mm respectively endsystolic diameter more than 50 mm, patients have to be checked on a regular basis, i.e. in yearly intervals to detect left ventricular dysfunction in due time. According to the literature, asymptomatic patients with severe aortic regurgitation develop left ventricular dysfunction in a yearly rate of 4%. However, approximately 50% of all patients are even after 10 years asymptomatic. The indication for aortic valve replacement is given when the patient shows a deterioration of left ventricular function or becomes symptomatic. Valve replacement is also indicated in patients with an ejection fraction below 50% and/or endsytolic chamber diameter of more than 55 mm. Therapy of choice in symptomatic patients with severe aortic regurgitation is aortic valve replacement. In asymptomatic patients, operation depends on the degree of chamber dilatation respectively the severity of left ventricular dysfunction. In patients with severe aortic regurgitation but without clinical symptoms and moderate enlargement of the left ventricle regular check-ups in yearly intervals are indicated. In the presence of severe left ventricular dilatation check-ups should be performed on a half-year basis to prevent irreversible damage to the heart muscle.

Percutaneous transluminal coronary angioplasty reverses vasoconstriction of stenotic coronary arteries in hypertensive patients

BACKGROUND

Endothelial dysfunction of coronary arteries with impaired vasodilation has been reported in patients with arterial hypertension. However, the effect of dynamic exercise on coronary vasomotion of a stenotic vessel segment before and after PTCA has not yet been evaluated in these patients.

METHODS AND RESULTS

Coronary vasomotion of a normal and a stenotic vessel segment was studied in 39 patients with coronary artery disease during supine bicycle exercise before and 9+/-3 months after PTCA. Luminal area changes were determined by biplane quantitative coronary arteriography. There were 21 normotensive and 18 hypertensive patients who did not differ with regard to clinical characteristics. Percent area stenosis decreased after PTCA from 90% to 39% (P<0.001) in normotensive and from 86% to 33% (P<0.001) in hypertensive patients. Exercise-induced vasomotion of the normal vessel segment was significantly different between normotensives and hypertensives before (+19% versus +1%, P<0.01) and after (+16% versus +3%, P<0.01) PTCA. In contrast, stenotic vessel segments showed vasoconstriction in both normotensive and hypertensive patients (Deltaexercise, -11% versus - 20%, P=NS), which was reversed after PTCA (+3% versus +2%, P=NS).

CONCLUSIONS

Normal coronary arteries show reduced vasodilation during exercise in hypertensive patients that may be explained by the presence of endothelial dysfunction. Stenotic vessels demonstrate paradoxical vasoconstriction during exercise in both normotensive and hypertensive patients. PTCA reverses vasoconstriction by elimination of the flow-limiting stenosis and prevention of coronary stenosis narrowing during exercise in normotensive and hypertensive patients.

Immunohistochemical identification of the receptor for urokinase plasminogen activator associated with fibrin deposition in normal and ectopic human placenta

The receptor for urokinase plasminogen activator (uPAR) is a key molecule in cell surface-directed plasminogen activation. uPAR binds urokinase plasminogen activator (uPA) and thereby focuses plasminogen activation on the cell surface. Plasmin dissolves fibrin deposits and facilitates cell migration during tissue repair processes by degrading the extracellular matrix. During human implantation and placental development, plasmin is considered important for both trophoblast migration/invasion and for fibrin surveillance. This study examined the expression of uPAR in normal and ectopic human placentae by immunohistochemistry. In first and third trimester normal placentae as well as in tubal ectopic placental tissues, a high uPAR expression was seen in the trophoblast associated with deposits of fibrin-type fibrinoid. Extravillous trophoblast of the basal plate, of the cell islands, and of the cell columns was also positive for uPAR in the first trimester whereas at term the expression of the protein was decreased. Moreover, uPAR immunostaining was observed in decidual cells throughout normal gestation and in endometrial tissues of patients with ectopic pregnancies. These findings suggest that uPAR participates in placental development and in trophoblast invasion particularly in the first trimester of pregnancy and that uPAR is involved in repair mechanisms of the trophoblast and fibrin surveillance.

Influence of the culprit lesion on clinical symptoms of coronary artery disease, with special emphasis on exercise data

BACKGROUND

Clinical symptoms have been found to correlate only poorly with the severity of the culprit lesion in coronary artery disease. The purpose of the present study was to evaluate the influence of the culprit lesion and its change during exercise on clinical symptoms in patients with this condition.

METHODS

Minimal luminal area was determined using biplane quantitative coronary angiography in 42 patients (aged 53 +/- 8 years) with coronary artery disease. Percent diameter stenosis and minimal luminal area and its change during exercise were assessed in all patients and compared with clinical symptoms judged according to the functional classification of the New York Heart Association (NYHA). Coronary dimensions were determined with the patient at rest, during supine bicycle exercise and after sublingual administration of 1.6 mg glyceryl trinitrate.

RESULTS

Exercise-induced vasoconstriction of the culprit lesion was found in all patients (-14.0% at 102 W), but there was exercise-induced vasodilatation in the normal vessel segments (+13.0%). However, only minimal vasoconstriction was found in groups 1 (NYHA I: -0.5%, NS) and 2 (NYHA II: -4.7%, NS), but significant constriction in groups 3 (NYHA II-III: -18.0%, P < 0.01) and 4 (NYHA III: -31.4, P < 0.01). Vasodilatation of the normal vessel segments was similar in the four groups. The observed inverse relationship between exercise-induced changes in minimal luminal area and NYHA classification was stronger than the relationship between NYHA and minimal luminal area when the patient was at rest. There was no correlation between glyceryl trinitrate-induced vasodilatation and NYHA classification.

CONCLUSIONS

The more severe the culprit lesion, the more pronounced the exercise-induced vasoconstriction. This effect of the culprit lesion was reflected by the clinical symptoms: the greater the exercise-induced vasoconstriction, the higher the NYHA classification. Thus the anatomy of the lesion (= severity) and the functional integrity of the endothelium (= exercise-induced vasomotion) are two major determinants of clinical symptoms.

Near fatal anticholinergic intoxication after routine fundoscopy

We describe a case of severe anticholinergic intoxication following the topical instillation of tropicamide-containing eyedrops. Tropicamide is a short-acting atropine-like derivative and has been regarded as an effective and safe mydriatic. Half an hour after routine fundoscopy, a 62-year-old man experienced two generalized seizures with respiratory arrest and required intubation and mechanical ventilation. The patient was treated with physostigmine and made a full recovery.