Activation of endocrine-related gene expression in placental choriocarcinoma cell lines following DNA methylation knock-down

Increasingly, placental DNA methylation is assessed as a factor in pregnancy-related complications, yet the transcriptional impact of such findings is not always clear. Using a proliferative in vitro placental model, the effect of DNA methylation loss on gene activation was evaluated at a number of genes selected for being differentially methylated in pre-eclampsia-associated placentae in vivo. We aimed to determine whether reduced DNA methylation at specific loci was associated with transcriptional changes at the corresponding gene, thus providing mechanistic underpinnings for previous clinical findings and to assess the degree of transcriptional response amongst our candidate genes. BeWo and JEG3 choriocarcinoma cells were exposed to 1 μM 5-Aza-2'-deoxycytidine (5-Aza-CdR) or vehicle control for 48 h, and re-plated and cultured for a further 72 h in normal media before cells were harvested for RNA and DNA. Bisulphite pyrosequencing confirmed that DNA methylation was reduced by ∼30-50% points at the selected loci studied in both cell lines. Gene activation, measured by qRT-PCR, was highly variable and transcript specific, indicating differential sensitivity to DNA methylation. Most notably, loss of DNA methylation at the leptin (LEP) promoter corresponded to a 200-fold and 40-fold increase in LEP expression in BeWo and JEG3 cells, respectively (P < 0.01). Transcripts of steroidogenic pathway enzymes CYP11A1 and HSD3B1 were up-regulated ∼40-fold in response to 5-Aza-CdR exposure in BeWo cells (P < 0.01). Other transcripts, including aromatase (CYP19), HSD11B2, inhibin (INHBA) and glucocorticoid receptor (NR3C1) were more moderately, although significantly, affected by loss of associated DNA methylation. These data present a mixed effect of DNA methylation changes at selected loci supporting cautionary interpretation of DNA methylation results in the absence of functional data.

Diagnosis of pulmonary embolism with CT pulmonary angiography: a systematic review

OBJECTIVE

To appraise the evidence on the diagnostic accuracy of CT pulmonary angiography and the prognostic value of a negative CT pulmonary angiogram in the diagnosis of pulmonary embolism.

METHODS

Medline, EMBASE, and grey literature were systematically searched by two researchers. Any study which compared CT pulmonary angiography to an acceptable reference standard or prospectively followed up a cohort of patients with a normal CT pulmonary angiogram was included. Study methods were appraised independently by two researchers, and data were extracted independently by three researchers.

RESULTS

Thirteen diagnostic and 11 follow up studies were identified. Studies varied in prevalence of pulmonary embolism (19-79%), patient groups, and method quality. Few studies recruited unselected emergency department patients. There was heterogeneity in the analysis of sensitivity (53 to 100%), specificity (79 to 100%), and false negative rate (1.0 to 10.7%). The pooled false negative rate of combined negative CT pulmonary angiography and negative deep vein thrombosis testing was 1.5% (95% CI 1.0 to 1.9%).

CONCLUSION

Diagnostic studies give conflicting results for the diagnostic accuracy of CT pulmonary angiography. Follow up studies show that CT pulmonary angiography can be used in combination with investigation for deep vein thrombosis to exclude pulmonary embolism.

Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) study

BACKGROUND AND OBJECTIVES

Pleuritic chest pain, a symptom of pulmonary embolism, is a common presenting symptom in the emergency department. The aim of this study was to validate an algorithm for the diagnosis of pulmonary embolism in emergency department patients with pleuritic chest pain.

METHODS

This was a prospective, diagnostic cohort study conducted in a large UK city centre emergency department. A total of 425 patients with pleuritic chest pain presenting to the emergency department between February 2002 and June 2003 were recruited. Patients scoring a low modified Wells clinical probability of pulmonary embolism, who had a normal latex agglutination D-dimer, were discharged. All others followed a diagnostic imaging protocol to exclude and diagnose pulmonary embolism using PIOPED interpreted ventilation-perfusion scanning, CT pulmonary angiography, and digital subtraction pulmonary angiography. All patients were followed up for three months for evidence of pulmonary embolism or deep vein thrombosis. An independent adjudication committee reviewed all deaths.

RESULTS

A total of 408 patients completed the diagnostic algorithm; 86.5% (353/408) were investigated as outpatients, 5.4% (22/408) were diagnosed as having pulmonary embolism, and 98.8% (403/408) were followed up for three months. Of the 381 patients without pulmonary embolism who completed follow up, the incidence of thromboembolic disease was 0.8% (95% CI 0.3% to 2.3%): two patients had pulmonary embolism and one had a deep vein thrombosis.

CONCLUSIONS

The MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) diagnostic protocol can safely exclude pulmonary embolism in outpatients with pleuritic chest pain.

Investigating pulmonary embolism in the emergency department with lower limb plethysmography: the Manchester Investigation of Pulmonary Embolism Diagnosis (MIOPED) study

OBJECTIVES

To measure the diagnostic accuracy of computerised strain gauge plethysmography in the diagnosis of pulmonary embolism (PE).

METHODS

Two researchers prospectively recruited 425 patients with pleuritic chest pain presenting to the emergency department (ED). Lower limb computerised strain gauge plethysmography was performed in the ED. All patients underwent an independent reference standard diagnostic algorithm to establish the presence or absence of PE. A low modified Wells' clinical probability combined with a normal D-dimer excluded PE. All others required diagnostic imaging with PIOPED interpreted ventilation perfusion scanning and/or computerised tomography (CT) pulmonary angiography. Patients with a nondiagnostic CT had digital subtraction pulmonary angiography. All patients were followed up clinically for 3 months.

RESULTS

The sensitivity of computerised strain gauge plethysmography was 33.3% (95% confidence interval (CI) 16.3 to 56.2%) and specificity 64.1% (95% CI 59.0 to 68.8%). The negative likelihood ratio was 1.04 (95% CI 0.68 to 1.33) and positive likelihood ratio 0.93 (95% CI 0.45 to 1.60).

CONCLUSIONS

Lower limb computerised strain gauge plethysmography does not aid in the diagnosis of PE.

Heart failure with preserved left ventricular systolic function: a hospital cohort study

OBJECTIVE

To investigate how patients with heart failure with preserved left ventricular systolic function (LVSF) compare with patients with reduced LVSF.

DESIGN

Cohort study.

SETTING

Urban university hospital.

PATIENTS

528 index emergency admissions with heart failure during the year 2000. Information on LVSF and follow up was available for 445 (84%) of these patients.

RESULTS

130 (29%) patients had preserved LVSF (defined as an ejection fraction > 40%). The median follow up was 814 days (range 632-978 days). The average (SD) age was 72 (13) years. Women accounted for 62% and 45% of patients with preserved and reduced LVSF, respectively (p = 0.001). Patients with preserved LVSF (compared with those with reduced LVSF) had a higher prevalence of left ventricular hypertrophy (56% v 29%) and aortic valve disease (mean gradient > 20 mm Hg; 31% v 9%). Fewer patients with preserved LVSF received an angiotensin converting enzyme inhibitor (65% v 78%, p = 0.008) or spironolactone (12% v 21%, p = 0.027). Anaemia tended to occur more often in patients with preserved LVSF than in those with reduced LVSF (43% v 33% for women, p = 0.12; 59% v 49% for men, p = 0.22). There was a similarly high prevalence of significant renal dysfunction in both groups (estimated glomerular filtration rate < 60 ml/min/1.73 m2 in 68% with preserved and 64% with reduced LVSF, p = 0.40). Mortality was similar in both groups (preserved versus reduced 51 (39%) v 132 (42%), p = 0.51). Compared with patients with reduced LVSF, patients with preserved LVSF tended to have a lower risk of death or hospital admission for heart failure (56 (42%) v 165 (53%), p = 0.072) but a similar rate of death or readmission for any reason.

CONCLUSION

Patients with preserved LVSF had more co-morbid problems than those with reduced LVSF; however, prognosis was similar for both groups.

Poor concordance of commonly used echocardiographic measures of left ventricular diastolic function in patients with suspected heart failure but preserved systolic function: is there a reliable echocardiographic measure of diastolic dysfunction?

OBJECTIVE

To determine the concordance of different Doppler echocardiographic criteria for "diastolic dysfunction" in patients with suspected heart failure but preserved left ventricular systolic function.

DESIGN

Prospective, descriptive study.

SETTING

Outpatient based direct access echocardiography service.

PATIENTS

Consecutive patients referred with suspected heart failure but preserved left ventricular systolic function.

MEASUREMENTS

Echocardiographic measurements of systolic and diastolic function. Eight published studies giving age and sex specific ranges for measures of diastolic function in healthy subjects were reviewed and the proportion of patients outside the normal limits for each of these published ranges was calculated.

RESULTS

There was very poor concordance between measures with up to a 16-fold difference in the prevalence of diastolic dysfunction in the overall patient cohort. Even for a given measure, there was relatively poor agreement between the published reference ranges. In subsets likely to include patients at high risk of having diastolic dysfunction, an increased prevalence of diastolic dysfunction was not evident with any measure in any patient subset.

CONCLUSIONS

Our findings challenge the use of the diagnosis of diastolic heart failure based on the most commonly used echocardiographic criteria. Physicians should be cautious about echocardiographic reports describing diastolic dysfunction and only apply the diagnosis of diastolic heart failure with great care.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Colourimetric CO(2) detector compared with capnography for confirming ET tube placement

A short cut review was carried out to establish whether colourimetric carbon dioxide detectors are as reliable as capnometry at verifying tracheal placement of endotracheal tubes after emergency intubation. A total of 69 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Glucagon in tricyclic overdose

A short cut review was carried out to establish whether the addition of glucagon to standard treatments improves clinical outcome in patients who have taken an overdose of tricyclic antidepressants. Altogether 31 papers were found using the reported search, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Don't let cure be at the expense of care. Is the increased technicality of ICU nursing reducing the care given?

Nurses in intensive care units cope with a vast array of technology. The prime aim of nursing, however, is to care for patients. This article discusses whether intensive care nurses care for their patients or are merely an extension of the machines and monitors surrounding them.