Early focal brain injury after subarachnoid hemorrhage correlates with spreading depolarizations

OBJECTIVE

To investigate whether spreading depolarization (SD)-related variables at 2 different time windows (days 1-4 and 5-8) after aneurysmal subarachnoid hemorrhage (aSAH) correlate with the stereologically determined volume of early focal brain injury on the preinterventional CT scan.

METHODS

In this observational multicenter study of 54 patients, volumes of unaffected brain tissue, ventricles, cerebellum, aSAH, intracerebral hemorrhage, and focal parenchymal hypodensity were stereologically estimated. Patients were electrocorticographically monitored using subdural electrodes for 81.8 hours (median) (interquartile range: 70.6-90.5) during days 1-4 (n = 54) and for 75.9 (59.5-88.7) hours during days 5-8 (n = 51). Peak total SD-induced depression duration of a recording day (PTDDD) and peak numbers of (1) SDs, (2) isoelectric SDs, and (3) spreading depressions of a recording day were determined following the recommendations of the Co-Operative Studies on Brain Injury Depolarizations.

RESULTS

Thirty-three of 37 patients with early focal brain injury (intracerebral hemorrhage and/or hypodensity) in contrast to 7 of 17 without displayed SDs during days 1-4 (sensitivity: 89% [95% confidence interval, CI: 75%-97%], specificity: 59% [CI: 33%-82%], positive predictive value: 83% [CI: 67%-93%], negative predictive value: 71% [CI: 42%-92%], Fisher exact test, p < 0.001). All 4 SD-related variables during days 1-4 significantly correlated with the volume of early focal brain injury (Spearman rank order correlations). A multiple ordinal regression analysis identified the PTDDD as the most important predictor.

CONCLUSIONS

Our findings suggest that early focal brain injury after aSAH is associated with early SDs and further support the notion that SDs are a biomarker of focal brain lesions.

Recording, analysis, and interpretation of spreading depolarizations in neurointensive care: Review and recommendations of the COSBID research group

Spreading depolarizations (SD) are waves of abrupt, near-complete breakdown of neuronal transmembrane ion gradients, are the largest possible pathophysiologic disruption of viable cerebral gray matter, and are a crucial mechanism of lesion development. Spreading depolarizations are increasingly recorded during multimodal neuromonitoring in neurocritical care as a causal biomarker providing a diagnostic summary measure of metabolic failure and excitotoxic injury. Focal ischemia causes spreading depolarization within minutes. Further spreading depolarizations arise for hours to days due to energy supply-demand mismatch in viable tissue. Spreading depolarizations exacerbate neuronal injury through prolonged ionic breakdown and spreading depolarization-related hypoperfusion (spreading ischemia). Local duration of the depolarization indicates local tissue energy status and risk of injury. Regional electrocorticographic monitoring affords even remote detection of injury because spreading depolarizations propagate widely from ischemic or metabolically stressed zones; characteristic patterns, including temporal clusters of spreading depolarizations and persistent depression of spontaneous cortical activity, can be recognized and quantified. Here, we describe the experimental basis for interpreting these patterns and illustrate their translation to human disease. We further provide consensus recommendations for electrocorticographic methods to record, classify, and score spreading depolarizations and associated spreading depressions. These methods offer distinct advantages over other neuromonitoring modalities and allow for future refinement through less invasive and more automated approaches.

Quantitative relationships in delphinid neocortex

Possessing large brains and complex behavioral patterns, cetaceans are believed to be highly intelligent. Their brains, which are the largest in the Animal Kingdom and have enormous gyrification compared with terrestrial mammals, have long been of scientific interest. Few studies, however, report total number of brain cells in cetaceans, and even fewer have used unbiased counting methods. In this study, using stereological methods, we estimated the total number of cells in the neocortex of the long-finned pilot whale (Globicephala melas) brain. For the first time, we show that a species of dolphin has more neocortical neurons than any mammal studied to date including humans. These cell numbers are compared across various mammals with different brain sizes, and the function of possessing many neurons is discussed. We found that the long-finned pilot whale neocortex has approximately 37.2 × 10⁹ neurons, which is almost twice as many as humans, and 127 × 10⁹ glial cells. Thus, the absolute number of neurons in the human neocortex is not correlated with the superior cognitive abilities of humans (at least compared to cetaceans) as has previously been hypothesized. However, as neuron density in long-finned pilot whales is lower than that in humans, their higher cell number appears to be due to their larger brain. Accordingly, our findings make an important contribution to the ongoing debate over quantitative relationships in the mammalian brain.

Application of stereological methods to estimate post-mortem brain surface area using 3T MRI

The Cavalieri and Vertical Sections methods of design based stereology were applied in combination with 3 tesla (i.e. 3T) Magnetic Resonance Imaging (MRI) to estimate cortical and subcortical volume, area of the pial surface, area of the grey-white matter boundary, and thickness of the cerebral cortex. The material comprises eight human cadaveric cerebri which had been separated into sixteen cerebral hemisphere specimens prior to embedding in agar gel. The results from MRI were compared with corresponding 'gold standard' values subsequently obtained by application of the same methodology using physical sectioning of the specimens. 95% agreement intervals revealed poor agreement between MR imaging and physical sectioning, specially for pial surface and thickness, as well as cerebral cortex and subcortex volumes. On average, pial surface area was estimated to be almost half the extent using MRI compared to physical sectioning (i.e. 45%, p<0.05) and the average thickness of the cerebral cortex was calculated to be much greater (by 60.9%) on the MR images compared to the physical sections (3.7mm versus 2.3mm, p<0.001). The main cause of the discrepancies is that the resolution of the MR images is not sufficient to always allow reliable depiction of the cerebral sulci on 2D image sections. Accurate application of manual stereological methods for measuring the cortical surface area thus requires higher resolution MR imaging than is typically applied at 3T.

Comparison of quantitative estimation of intracerebral hemorrhage and infarct volumes after thromboembolism in an embolic stroke model

BACKGROUND

Strokes have both ischemic and hemorrhagic components, but most studies of experimental stroke only address the ischemic component. This is likely because investigations of hemorrhagic transformation are hindered by the lack of methods based on unbiased principles for volume estimation.

AIMS

We evaluated different methods for estimating the volume of infarcts, hemorrhages, after embolic middle cerebral artery occlusion with or without thrombolysis.

METHODS

An experimental thromboembolytic rat model was used in this study. The rats underwent surgery and were placed in two groups. Group 1 was treated with saline, and group 2 was treated with 20 mg/kg recombinant tissue plasminogen activator to promote intracerebral hemorrhages. Stereology, semiautomated computer estimation, and manual erythrocyte counting were used to test the precision and efficiency of determining the size of the infarct and intracerebral hemorrhage.

RESULTS

No differences were observed in the infarct volume or amount of bleeding when comparing the three methods of volume estimation. Although semiautomated computer estimation and manual erythrocyte counting provided similar results as the stereological measurements, the stereological method was the most efficient and advantageous.

CONCLUSIONS

We found that stereology was the superior method for quantification of hemorrhagic volume, especially for rodent petechial bleeding, which is otherwise difficult to measure. Our results suggest the possibility of measuring both the ischemic and the hemorrhagic components of stroke, two parameters that may be differentially regulated when therapeutic regimens are tested.

The temporal pattern of postnatal neurogenesis found in the neocortex of the Göttingen minipig brain

The Göttingen minipig (G-mini) is increasingly used as a non-primate model for human neurological diseases. We applied design-based stereology on five groups of G-minis aged 1 day, 14 days, 30 days, 100 days, and 2 years or older to estimate the pattern of postnatal neuron number development in the neocortex. Two time periods for the postnatal increase of neocortical neuron number were observed from the time of birth to day 14 (P=0.013) and from day 30 to day 100 (P<0.001). No significant change in neuron number was found from day 14 to 30 (P=0.58) and day 100 onward (P=0.39). The average estimated total number of neurons in the neocortex was 236, 274, 264, 338, and 353 million, respectively. Since neurogenesis and neuronal migration in the human neocortex are generally accepted to be complete before term, the application of G-mini as human disease models may be inappropriate before day 100. However, G-mini may serve as a valuable model for the studies of ongoing neurogenesis in the living brain.

A neurological comparative study of the harp seal (Pagophilus groenlandicus) and harbor porpoise (Phocoena phocoena) brain

The cetacean brain is well studied. However, few comparisons have been done with other marine mammals. In this study, we compared the harp seal (Pagophilus groenlandicus) and the harbor porpoise brain (Phocoena phocoena). Stereological methods were applied to compare three areas of interest: the entire neocortex and two subdivisions of the neocortex, the auditory and visual cortices. The total number of neurons and glial cells in the three regions was estimated. The main results showed that the harbor porpoise have an estimated 14.9 × 10(9) neocortical neurons and 34.8 × 10(9) neocortical glial cells, whereas the harp seal have 6.1 × 10(9) neocortical neurons and 17.5 × 10(9) neocortical glial cells. The harbor porpoise have significantly more neurons and glial cells in the auditory cortex than in the visual cortex, whereas the pattern was opposite for the harp seal. These results are the first to provide estimates of the number of neurons and glial cells in the neocortex of the harp seal and harbor porpoise brain and offer new data to the comparative field of mammalian brain evolution.

Trouble-shooting deployment and recovery options for various stationary passive acoustic monitoring devices in both shallow- and deep-water applications

Deployment of any type of measuring device into the ocean, whether to shallow or deeper depths, is accompanied by the hope that this equipment and associated data will be recovered. The ocean is harsh on gear. Salt water corrodes. Currents, tides, surge, storms, and winds collaborate to increase the severity of the conditions that monitoring devices will endure. All ocean-related research has encountered the situations described in this paper. In collating the details of various deployment and recovery scenarios related to stationary passive acoustic monitoring use in the ocean, it is the intent of this paper to share trouble-shooting successes and failures to guide future work with this gear to monitor marine mammal, fish, and ambient (biologic and anthropogenic) sounds in the ocean-in both coastal and open waters.

Age and Parkinson's disease-related neuronal death in the substantia nigra pars compacta

During aging, decline in memory and cognitive abilities as well as motor weakening is of great concern. The dopaminergic system mediates some aspects of manual dexterity, in addition to cognition and emotion, and may be especially vulnerable to aging. A common neurodegenerative disorder of this system, Parkinson's disease, is characterized by a selective, progressive loss of dopaminergic neurons in the substantia nigra pars compacta. This review includes studies quantifying age and Parkinson's-related changes of the substantia nigra, with emphasis on stereological studies performed in the substantia nigra pars compacta.

Application of stereological estimates in patients with severe head injuries using CT and MR scanning images

Severe brain damage is often followed by serious complications. Quantitative measurements, such as regional volume and surface area under various conditions, are essential for understanding functional changes in the brain and assessing prognosis. The affected brain tissue is variable, hence traditional imaging methods are not always applicable and automatic methods may not be able to match the individual observer. Stereological techniques are alternative tools in the quantitative description of biological structures, and have been increasingly applied to the human brain. In the present study, we applied stereological techniques to representative CT and MRI brain scans from five patients to describe how stereological methods, when applied to scans of trauma patients, can provide a useful supplement to the estimation of structural brain changes in head injuries. The reliability of the estimates was tested by obtaining repeated intra- and interobserver estimates of selected subdivisions of the brain in patients with acute head injury, as well as in an MR phantom. The estimates of different subdivisions showed a coefficient of variation (CV) below 12% in the patients and below 7% for phantom estimation. The validity of phantom estimates was tested by the average deviation from the true geometric values, and was below 10%. The stereological methods were compared with more traditional region-based methods performed on medical imaging, which showed a CV below 7% and bias below 14%. It is concluded that the stereological estimates may be useful tools in head injury quantification.

Validation of in vitro probabilistic tractography

Diffusion weighted imaging (DWI) and tractography allow the non-invasive study of anatomical brain connectivity. However, a gold standard for validating tractography of complex connections is lacking. Using the porcine brain as a highly gyrated brain model, we quantitatively and qualitatively assessed the anatomical validity and reproducibility of in vitro multi-fiber probabilistic tractography against two invasive tracers: the histochemically detectable biotinylated dextran amine and manganese enhanced magnetic resonance imaging. Post mortem DWI was used to ensure that most of the sources known to degrade the anatomical accuracy of in vivo DWI did not influence the tracking results. We demonstrate that probabilistic tractography reliably detected specific pathways. Moreover, the applied model allowed identification of the limitations that are likely to appear in many of the current tractography methods. Nevertheless, we conclude that DWI tractography can be a precise tool in studying anatomical brain connectivity.

Total neocortical cell number in the mysticete brain

The cetacean brain has long been of scientific interest, not only because of its large size - the largest in the animal kingdom - but also because of its high gyrification. It shows several adaptations to the aquatic environment, especially in the cortical arrangements of functional areas. To study structural aspects of the mysticete brain we estimated neocortical features in the common minke whale using stereological methods. The neocortex was surprisingly thick, equal to that in humans. The total neocortical neuron number was 12.8 x 10(9), and the total neocortical glia number 98.2 x 10(9). Total cell numbers in the auditory and visual cortex were also estimated, and showed that the auditory cortex contained more cells than the visual cortex. In this small sample, no sexual dimorphism was seen within the neocortex of the common minke whale. Our aim was to estimate the total cell number, cortical volume and cell density in the entire mysticete neocortex and compare the total cell number in the auditory cortex with that of the visual cortex using stereological methods. Here, we used the common minke whale as a model of all mysticetes. We wanted to compare these neocortical features to those of other mammals to forward understanding of the evolution of the mammalian brain.

Cultural change in the songs of humpback whales (Megaptera novaeangliae) from Tonga

Some humpback whales migrate annually from Antarctic feeding grounds to the seas around the Tongan Islands to give birth and mate. The Tongan humpbacks are considered part of Southern Hemisphere Group V that splits during migration, some swimming to Eastern Australia and others to various Polynesian Islands. During this time long complex songs are produced. The song is thought to be a male breeding display and may serve either as an intra-sexual or an inter-sexual signal or both. It is in a constant state of change that occurs every season. Since these changes are directional they cannot be described by drift, and singers incorporate changes as they occur, thus song must be shared through cultural transmission. This investigation describes the cultural changes that occurred in 158 songs recorded from Tongan humpbacks through the 1990s. The rate of change differed within years, some themes were retained for as much as five years and others were lost after only two years. The farther apart the years the less similar are the songs, as in the humpback songs of the Northern Hemisphere. The largest number of changes seems to have occurred in the early 1990s where all themes seemed to have been lost and new ones originated. What initiates these changes remains speculative, but we assess some hypotheses in relation to humpback whale behaviour and cultural transmission in avian song.

Vaginal infections in human immunodeficiency virus-infected women

OBJECTIVE

This study was undertaken to compare the frequencies of vaginal infections among human immunodeficiency virus-infected women with those among human immunodeficiency virus-seronegative women.

STUDY DESIGN

Human immunodeficiency virus-seropositive women attending a comprehensive care center for human immunodeficiency virus disease at the outpatient department of an inner-city hospital in Houston underwent rigorous gynecologic evaluation for sexually transmitted diseases, including evidence of vaginal infections such as bacterial vaginosis, vulvovaginal candidiasis, and trichomonal vaginitis. Demographic information was collected, as was information regarding disease classification and degree of immunosuppression. Data regarding sexually transmitted diseases, data regarding vaginal infections, and demographic information were collected from a cohort of human immunodeficiency virus-seronegative women attending a sexually transmitted disease and family planning clinic at the same institution. The two groups were compared to determine whether there were any differences between them in the frequencies of sexually transmitted diseases and vaginal infection. Data analysis used the t test for parametric data and the Fisher exact test for nonparametric data where appropriate. P <.05 was considered significant. Statistical analysis was performed with the SAS (SAS Institute, Inc, Cary, NC) statistical software package.

RESULTS

There was no difference in age between the 2 groups. The human immunodeficiency virus-infected group was predominantly African American (80.5%), whereas the human immunodeficiency virus-seronegative control group was more evenly divided between African American women (45.8%) and Latinos (41.7%; P <.0001). Although there was no significant association between HIV infection and sexually transmitted diseases in general, there were significant associations between human immunodeficiency virus infection and bacterial vaginosis (P =.02), vulvovaginal candidiasis (P =.001), and trichomonal vaginitis (P =. 003).

CONCLUSION

Human immunodeficiency virus-infected women had increased frequencies of vaginal infections, including bacterial vaginosis, vulvovaginal candidiasis, and trichomonal vaginitis, with respect to human immunodeficiency virus-seronegative control subjects. No differences between the 2 groups were seen in the frequencies of sexually transmitted diseases.

Synthesis of IFN-gamma by CD8(+) T cells is preserved in HIV-infected women with HPV-related cervical squamous intraepithelial lesions

OBJECTIVE

The aim of this study was to investigate whether coinfection with HIV affects the synthesis of Th1 and Th2 cytokines by peripheral blood T cells of women infected with human papillomavirus (HPV).

METHODS

Cervical swabs and peripheral blood were obtained from women referred for colposcopy. HPV DNA by Digene's hybrid capture assay, HIV RNA by Roche's Amplicor assay, and cytokine synthesis of T-cell subsets by flow cytometry were assessed. HPV-associated cervical and HIV-associated immune deficiency diseases were staged using the Bethesda System and the Centers for Disease Control criteria, respectively.

RESULTS

Patients with HIV and/or HPV infections had lower percentages of IL-2(+) and higher percentages of IL-10(+) T cells than healthy women. Furthermore, women with both virus infections (HIV(+)/HPV(+)) had significantly fewer IL-2(+) CD4(+), IFN-gamma(+) CD4(+), and TNF-alpha(+) CD4(+) T cells than women with HPV infection alone (HPV(+)). Whereas HIV(+) and healthy women had similar numbers of IFN-gamma(+) CD8(+) T cells, HPV(+) women had significantly fewer IFN-gamma(+) CD8(+) T cells than healthy women.

CONCLUSION

HIV infection adversely affects the synthesis of Th1 cytokines by CD4(+), but not IFN-gamma synthesis by CD8(+) T cells of women with active HPV infection. The increase in IFNgamma(+) CD8(+) T cells, a phenotype consistent with cytotoxic T lymphocytes, may account for the stable HIV disease of the women studied. However, the increase in IFN-gamma(+) CD8(+) T cells is less likely to be HPV-specific as there was a higher incidence of HPV-related cervical SIL in HIV(+)/HPV(+) women compared with HPV(+) women.

[Dementia and psychiatric service]

The study objective was to describe the service provision in geriatric psychiatry in 1997 and the trends in admission patterns for the elderly to psychiatric hospitals in Denmark from 1988 to 1996. Information concerning admission pattern was obtained from the Danish Psychiatric Case Register. The information on the supply of geriatric psychiatric services was collected by a questionnaire to the individual geriatric psychiatric departments. All geriatric psychiatric departments in Denmark have been identified. The number of demented patients admitted to psychiatric hospitals decreased considerably as did the length of stay for demented patients admitted from 1988 to 1996. For all other diagnoses the number of admissions increased in the same period. Four counties out of 14 did not have a special unit for geriatric psychiatry. There were considerable geographical variations in supply as well as target groups in the counties that supplied geriatric psychiatric service. The unequal access to geriatric psychiatric services and variations in target groups underlines the need for a discussion of future directions for this service provision.

Cervical dysplasia on cervicovaginal Papanicolaou smear among HIV-1-infected pregnant and nonpregnant women. Women and Infants Transmission Study

OBJECTIVE

To assess the association of squamous intraepithelial lesions (SIL) on cervicovaginal Papanicolaou (Pap) smear among women infected with HIV-1 and their pregnancy status, and historical and clinical factors.

METHODS

Study enrollment Pap smears of 452 pregnant and 126 nonpregnant HIV-infected women had cytologic evaluation. The rates of SIL were compared with pregnancy status, immunosuppression, presence of sexually transmitted diseases (STDs) and demographic features.

RESULTS

Rates of low grade SIL were similar for pregnant and nonpregnant HIV-1-infected women (17% and 23.8%, respectively; p = .09). Of them, 12 women, 9 pregnant and 3 nonpregnant, had high grade SIL. None had invasive cervical cancer. Low CD4 percentage (odds ratio, [OR] = 3.8; 95% confidence interval [CI], 2.0-7.3) and inflammation (OR = 2.8; 95% CI, 1.8-4.3) were associated with SIL. An association between herpes simplex and SIL (OR = 3.3; 95% CI, 1.1-9.5) was less certain due to clinical diagnosis and low prevalence of herpes simplex (17 of 456 women).

CONCLUSIONS

Pap smears for a cohort of HIV-infected pregnant and nonpregnant women revealed a high prevalence of LGSIL but a low prevalence of HGSIL and no cases of cervical cancer. Although pregnancy may not affect the rate of Pap smear abnormalities, SIL is associated with immunosuppression, cervical inflammation, and herpes simplex. Closer surveillance of HIV-1-infected women with these risk factors may be warranted.

Fetal fibronectin as a predictor of preterm birth in patients with symptoms: a multicenter trial

OBJECTIVE

Our aim was to determine whether the presence of fetal fibronectin in vaginal secretions of patients with symptoms suggestive of preterm labor predicts preterm delivery.

STUDY DESIGN

Patients who were examined at the hospital between 24 weeks' and 34 weeks 6 days' gestation with intact membranes, no prior tocolysis, symptoms suggestive of preterm labor, and cervical dilation < 3 cm were recruited at 10 sites. Swabs of the posterior fornix were assayed for the presence of fetal fibronectin by monoclonal antibody assay, with a positive result defined as > or = 50 ng/ml. Results were not available to the managing physicians. Tocolysis was used when clinically indicated after specimen collection.

RESULTS

A total of 763 patients had fetal fibronectin results and pregnancy outcome data available for analysis. Fetal fibronectin was detected in specimens from 150 (20%) patients. Compared with patients who had negative results, patients who had positive results for fetal fibronectin were more likely to be delivered within 7 days (relative risk 25.9 [95% confidence interval 7.8 to 86]), within 14 days (relative risk 20.4 [95% confidence interval 8.0 to 53]), and before 37 completed weeks (relative risk 2.9 [95% confidence interval 2.2 to 3.7]). The negative predictive values for delivery within 7 days, within 14 days, and at < 37 weeks were 99.5%, 99.2%, and 84.5%, respectively. When we used multiple logistic regression analysis to control for potential confounding variables among singleton pregnancies, only the presence of fetal fibronectin (odds ratio 48.8, 95% confidence interval 7.4 to 320), prior preterm birth (odds ratio 8.3, 95% confidence interval 1.5 to 46.6), and tocolysis (odds ratio 4.1, 95% confidence interval 1.0 to 16.0) were associated with birth within 7 days; fetal fibronectin (odds ratio 3.6, 95% confidence interval 2.2 to 5.9), prior preterm birth (odds ratio 2.5, 95% confidence interval 1.4 to 4.4), cervical dilatation > 1 cm (odds ratio 2.9, 95% confidence interval 1.6 to 5.2), and tocolysis (odds ratio 4.5, 95% confidence interval 2.8 to 7.2) were all independently associated with delivery before 37 weeks.

CONCLUSION

In a population of patients with symptoms, the presence of fetal fibronectin in vaginal secretions best defines a subgroup at increased risk for delivery within 7 days; the high negative predictive value of fetal fibronectin sampling supports less intervention for patients with this result.

Inflammatory cytokine expression is correlated with the level of human immunodeficiency virus (HIV) transcripts in HIV-infected placental trophoblastic cells

The inflammatory cytokines interleukin-1beta (IL-1beta), IL-6, and tumor necrosis factor alpha (TNF-alpha) have been associated with increased human immunodeficiency virus (HIV) expression and enhanced lymphocyte adhesion to trophoblastic cells in experimental systems. To determine if there is a correlation between the expression of these cytokines and the levels of HIV transcripts in trophoblasts of term placentas from HIV-infected women, we studied the placentae of 30 HIV-positive and 13 control gravidae. Twenty-three of the HIV-positive women received zidovudine (ZDV) as prophylaxis against HIV vertical transmission; only one of the seven women who did not receive ZDV was a transmitter, for an overall vertical transmission rate of 3.8%. Cytokine production was measured by enzyme-linked immunosorbent assay in the supernatants of trophoblastic cell cultures. Additionally, cytokine transcripts and HIV gag sequences were determined by a quantitative reverse transcription-PCR assay. In general, trophoblastic cells of HIV-positive placentas expressed significantly higher levels of IL-1beta, IL-6, and TNF-alpha than those of control placentas. All placentas from HIV-positive women expressed HIV gag transcripts at either a low (<156 copies per microg of total RNA) or a high (>156 copies per microg of total RNA) level. There was a statistically significant positive association between the basal level of TNF-alpha production and the level of HIV gag transcripts of HIV-positive placental trophoblastic cells. Nevertheless, these data, coupled with a low transmission rate, would indicate that some other factors, perhaps working in concert with cytokines, are necessary for vertical transmission of HIV from mother to infant.

Quality of life assessment in pregnant women with the human immunodeficiency virus

OBJECTIVE

To describe the perceived quality of life and functional status of women with human immunodeficiency virus (HIV) during the antenatal, perinatal, and postpartum periods.

METHODS

Medical Outcome Survey-Short Form questionnaires were completed during antenatal visits, 24 hours after delivery, and 6 months postpartum by 21 HIV-positive women and 21 HIV-negative controls matched for age, race, parity, and education. The Medical Outcome Survey-Short Form measures subject perceptions of overall health, pain, physical role, social and cognitive function, mental health, energy/fatigue, health distress, quality of life, and health transition. Median scores between 0 and 100 (with 0 indicating poorest health) were compared using the Wilcoxon signed-rank and Kruskal Wallis/Dunn tests.

RESULTS

All HIV-positive patients were asymptomatic; the median CD4 count was 386 on entry into the study. Seropositive patients reported increased health distress (50.0 versus 87.5; P < .001) and worse health transition (60.0 versus 80.0; P = .01) during antenatal visits. During the perinatal period, HIV-negative patients had a decreased sense of overall health (40 versus 80; P < .001) and worse health transition (40.0 versus 60.0; P = .04). Six months postpartum, the HIV-positive women reported decreased cognitive function (41.7 versus 62.5; P < .005) and worse social function (33.3 versus 66.7; P = .02). In general, HIV-negative women reported better quality of life in the antepartum as compared with the perinatal or postpartum period. This overall trend was also seen in the HIV-positive population.

CONCLUSIONS

This is the first longitudinal evaluation of perceived quality of life in HIV-positive pregnant subjects. We conclude that perceived quality of life differs between HIV-positive and HIV-negative pregnant women. These differences may not be manifest during initial antenatal visits but may develop as pregnancy, the disease process, and other life events specific to delivery and the postpartum period interact and affect overall perceived quality of life. Longitudinal evaluation of quality-of-life issues may be important in the comprehensive care of HIV-positive women during pregnancy.

Molecular mimicry: histone H3 and mycobacterial protein epitopes

A 15-kDa protein detected initially in amyloidotic ileum from a transgenic mouse and subsequently in control (nontransgenic) ileum by various polyclonal rabbit antiserums applied to electroblots of extracts derived from these tissues was identified by partial sequence analysis as histone H3. Antiserums were made against immunogens unrelated to the histone, but they recognized calf thymus histone H3 (14.7 kDa) on Western blots. The bacterial component of the Freund's medium used as an adjuvant for the immunogens was either Mycobacterium butyricum or Mycobacterium smegmatis. Absorption tests with histone H3 and sonicated M. butyricum substantiated the presence of anti-histone H3 activity in the antiserums. These findings indicate that the two mycobacterium species make a protein with epitopes perceived as nonself by recipient rabbits but sufficiently similar to epitopes of mammalian histone H3 that the rabbits produced antibodies cross-reactive with the histone.

Human serum amyloid A genes are expressed in monocyte/macrophage cell lines

Serum amyloid A (apoSAA) is a family of proteins found, mainly associated with high density lipoproteins, in the blood plasma of mammals and at least one avian species, the Pekin duck. These proteins are present in small amounts under normal circumstances, but their concentration is capable of rising 100- to 1,000-fold in situations involving tissue injury or infection. Like classic acute phase proteins they are produced in the liver; however, expression of one of the apoSAA genes is known to occur in activated macrophages of mice. We examined three human macrophage precursor cell lines (THP-1, U-937, and HL-60), before and after differentiation with phorbol 12-myristate 13-acetate or 1 alpha,25-dihydroxy-vitamin D3, for apoSAA messenger (m)-RNA expression and found that: 1) induction of steady-state apoSAA mRNA by lipopolysaccharide, interleukin-1, or interleukin-6 required the presence of the synthetic glucocorticoid dexamethasone; 2) the three known active genes, apoSAA1, apoSAA2, and apoSAA4, were induced in THP-1 cells, whereas the pseudogene apoSAA3 was not; 3) differentiated and undifferentiated THP-1 cells expressed apoSAA mRNA, but U-937 cells expressed apoSAA mRNA (low levels) only after phorbol 12-myristate 13-acetate differentiation and HL-60 cells did not express apoSAA mRNA whether differentiated or not; 4) apoSAA protein was detectable immunologically at a low level in lyophilized medium from induced THP-1 cells. Our findings are compatible with the hypotheses that 1) apoSAA gene expression in human monocytes/macrophages in vivo is differentiation dependent; 2) activated macrophages provide a local source of apoSAA at sites of tissue injury or inflammation; 3) apoSAA is induced in tissue macrophages by local stimuli, under conditions that may not evoke the systemic acute phase response.

Single-dose ampicillin prophylaxis does not eradicate enterococcus from the lower genital tract

OBJECTIVES

To determine the carriage rate of enterococcus in the lower genital tract of women having a cesarean delivery and to determine whether a single 2-g intraoperative dose of ampicillin eradicates enterococcus from the lower genital tract.

METHODS

Lower genital tract cultures were taken in 84 women who were in labor or had ruptured membranes and who were about to have an indicated cesarean delivery. The subjects were randomized to receive either a single 2-g dose of ampicillin or a cephalosporin as prophylaxis. Cultures were repeated 24 hours postpartum.

RESULTS

Enterococcus was isolated preoperatively in 33 subjects (39.3%) and postoperatively in 36 (42.9%). The enterococcus was eradicated in five of 17 women (29.5%) who received ampicillin.

CONCLUSION

These results suggest that a single 2-g dose of ampicillin does not eradicate enterococcus from the lower genital tract.

Murine serum amyloid A3 is a high density apolipoprotein and is secreted by macrophages

The serum amyloid A (SAA) proteins make up a multigene family of apolipoproteins associated with high density lipoproteins. They are of ancient origin; the finding of a highly homologous protein in mammals and ducks indicates that SAAs have been in existence for at least 300 million years. The interspecies similarity among the SAAs makes the mouse, in which they have been most thoroughly studied, a reasonable model to use for defining the function(s) of this family of proteins in humans. Originally it was observed that the SAA proteins were made in the liver and represented a set of proteins belonging to acute-phase reactants. SAA3 is a unique member of the SAA multigene family in mice in that its mRNA is also expressed in extrahepatic tissues by a variety of cell types, mainly macrophages and adipocytes. To date, nothing has been reported regarding the fate or function of the SAA3 translation product. To identify the SAA3 protein, we developed SAA3-specific antibodies by immunizing rabbits against a portion of SAA3 protein synthesized in a bacterial fusion protein expression system. Electroimmunoblot analysis of serum and lipoprotein fractions of it showed SAA3 to be associated with high density lipoproteins of mice treated with lipopolysaccharide. Furthermore, a continuous mouse macrophage cell line (J-774.1), when exposed to lipopolysaccharide, expressed SAA3 mRNA in a dose-dependent manner and secreted SAA3 protein. The expression and secretion of SAA3 by macrophages stimulated with lipopolysaccharide suggest a role for this SAA in local responses to injury and inflammation.

Serum amyloid A in the mouse. Sites of uptake and mRNA expression

Murine serum amyloid A1 (SAA1) and serum amyloid A2 (SAA2) are circulating, acute phase, high density apolipoproteins of unknown function. To pursue issues relating to their possible function their uptake and formation were studied. Kinetics of SAA protein distribution and gene expression after acute phase stimulation by casein or lipopolysaccharide were examined using immunocytochemistry for protein and RNA blot and in situ hybridization with probes for SAA1 and SAA2 mRNA. After casein injection, interstitial cells of testes, cells of adrenal cortex, kidney proximal convoluted tubule epithelia, and some parafollicular cells of spleen took up SAA in a time pattern related to plasma SAA levels. Extrahepatic SAA1 and SAA2 mRNA were induced by lipopolysaccharide in kidney proximal and distal convoluted tubule epithelia, and SAA1 mRNA was induced in epithelial lining the mucosa of the ileum and large intestine, indicating that there may be more than one function for the apoSAA gene family related to site of and stimulus for expression.

Primary structure of duck amyloid protein A. The form deposited in tissues may be identical to its serum precursor

The amino acid sequence has been determined for the major protein that accumulates in amyloid fibrils in tissues of the Pekin duck. With the exception of 16 residues at the amino terminus, this 106-residue protein is homologous with human serum amyloid protein A (104-residue apoSAA), which is the putative precursor of the 76-residue protein that accumulates in human patients with amyloidosis. Duck serum is shown to contain a protein that is immunologically related and approximately equal in size (12 kDa) to the deposited form in ducks. These results indicate that proteolytic processing of the precursor is not a necessary step in the deposition of amyloid fibrils, at least in the duck.

Trauma, high density lipoproteins, and serum amyloid protein A

Several apoproteins not readily detectable in normal serum lipoproteins were found in markedly increased amounts in the lipoprotein density interval 1.125-1.21 g/ml (HDL3) of serum obtained from victims of severe trauma. Following electrophoretic separations, they were shown to be isotypes of the acute-phase protein serum amyloid A (SAA) by immunoreaction with antiserum to the structurally related tissue amyloid protein A (AA). The two principal apoSAA isotypes in the HDL3 of trauma patients appear to be identical to the two principal isotypes (apoSAA1 and apoSAA2) previously isolated from the HDL3 of pooled serum representing an unselected patient population. Concentrations of apolipoproteins A-I and A-II in the HDL3 of the trauma patients were significantly lower than in the HDL3 of normal serum. Evidence is presented that several recently described 'new' families of HDL apoproteins, all of an acute-phase nature, are SAA apoproteins, which are emerging as sensitive indicators of tissue damage.

Murine tissue amyloid protein AA. NH2-terminal sequence identity with only one of two serum amyloid protein (ApoSAA) gene products

Amyloid protein AA is the presumptive fragment of an acute phase serum apolipoprotein, apoSAA. Two major murine apoSAA isotypes (apoSAA1 and apoSAA2) have been identified. The NH2-terminal amino acid sequences of purified murine apoSAA1 and apoSAA2 have been examined and compared with that of murine amyloid protein AA. Our results indicate that apoSAA1 and apoSAA2 are separate gene products and that amyloid protein AA has NH2-terminal amino acid sequence identity with only one of these isotypes, namely apoSAA2.

Sequestration and release of polycyclic aromatic hydrocarbons by vertebrate cells in vitro

Vertebrate fibroblasts grown in vitro and exposed to various concentrations of the mutagen/carcinogen benzo(a)pyrene (B(a)P) internalized the compound and recrystallized it in lysosomes by 6-18 h postexposure. This phenomenon occurred when B(a)P at or above 10 micrograms/ml was introduced to the culture medium in a solvent such as DMSO or acetone but not when introduced dissolved in serum. Likewise, high fetal bovine serum concentrations in the culture medium (greater than 20%) as well as human serum (10%) inhibited crystal formation, presumably owing to lipid competition for the compound. Electron-microscopic observations of the cells during the uptake and crystal forming periods revealed that the cell membrane became altered within 3 h of exposure to B(a)P. This was followed by a return to normal of the membrane and the appearance of vesicles within the cell by 6-8 h. The vesicles then became filled with crystals which continued to grow while in the presence of B(a)P and disappeared when the cells were exposed to B(a)P-free culture medium or serum lipids. Introduction of B(a)P into culture medium containing delipidated serum resulted in crystal formation indistinguishable from that which occurred when whole serum was present. Crystals were not formed when total lipoprotein and the lipoprotein components VLDL, LDL, HDL2, and HDL3 were used as solvents for B(a)P. The process of crystal formation was inhibited by the addition of 10(-3) M KCN, and removal of the crystals was dependent on the concentration of lipoprotein in the culture medium.

SAA, an apoprotein of HDL: its structure and function

The putative precursor of amyloid protein AA appears in serum as an apoprotein (apoSAA) of heavier HDL fractions of lipoproteins found in humans and mice. ApoSAA is found by precipitation with specific anti-AA antibodies to be on a particle that also carries apoA-I and some C-apoproteins. In endotoxin-treated mice a lipoprotein fraction with about 2 moles of apoSAA to 1 mole of apoA-I can be isolated, an apoSAA-carrying subset of HDL being thus suggested. In mice, rapid clearance from plasma of native apoSAA compared to apoA-I suggests a special function for apoSAA. The C-terminal amino acid portion of apoSAA may play a role in this function.

Isolation and characterization of the amyloid-related apoprotein (SAA) from human high density lipoprotein

Two apoproteins immunologically related to the 9000-dalton abnormal tissue constituent known as amyloid protein AA were isolated from the lipoprotein density interval 1.125-1.21 g/cm3 (HDL3) of a pool of human serums by delipidation, gel filtration, and ion-exchange chromatography. Lesser amounts of the same apoproteins were isolated from the density interval 1.063-1.125 g/cm3 (HDL2). These apoproteins, designated apoSAA1 and apoSAA2, have molecular weights near 11,500, almost identical amino acid compositions, and slightly different isoelectric points. Their amino acid sequences are identical as far as determined (30 residues), except that apoSAA2 lacks the NH2-terminal arginine found in apoSAA1. The sequence is homologous with that of amyloid protein AA, which thus has residing in the plasma high density lipoproteins a potential precursor whose biological significance and function remain to be determined.

Amyloid protein SAA is an apoprotein of mouse plasma high density lipoprotein

Mouse plasma contains a protein antigenically related to mouse protein AA, the principal protein derived from tissue deposits of amyloid substance in mice. In this work the plasma antigen, SAA, was found mainly as a high molecular weight form (2 x 10(5)) residing for the most part in the density interval 1.063-1.21 g/cm3 (high density lipoprotein, HDL); the largest amount of SAA, absolute and relative to total protein, was found in the density interval 1.125-12.1 g/cm3 (HDL3). When apoproteins of the mouse HDL obtained by delipidation of the lipoprotein particles were chromatographed in acid/urea, the antigenic activity appeared in the 10,000- to 15,000-dalton portion of the apoprotein complex. In these characteristics mouse SAA closely resembles human SAA and the behavior of the protein related to amyloid protein AA indicates that is one of the apoproteins of the HDL complex in both species. Therefore we suggest that it be named apoSAA.

Amyloid protein SAA is associated with high density lipoprotein from human serum

Human serums contain a protein antigenically related to protein AA, the principal protein of a major class of amyloid substance. The serum antigen, SAA, occurs mainly in a high molecular weight form, 1 to 2 X 10(5). This work shows that the bulk of the SAA sediments at density 1.12 g/cm3 and floats at density 1.21 g/cm3, as does the high density lipoprotein HDL3. SAA is associated with the apolipoproteins ApoA-I and ApoA-II. The total cholesterol:total protein ratio of the fraction with density 1.12-1.21 g/cm3 is 0.2:1, consistent with that of SAA constituent of the HDL3 fraction into low molecular weight species of the order of 13,000. The quantity of SAA may vary from 0.1% or more of the total protein of HDL3.

Urinary excretion of position isomers of penta-and hexa-carboxylated porphyrins belonging to the isomer III series in a case of congenital erythropoietic porphyria

The excretion of position isomers of penta- and hexa-carboxylated porphyrins type III in the urine in a case of congenital erythropoietic porphyria characterized by the excretion of large amounts of penta-, hexa- and hepta-carboxylated porphyrins type III together with isocoproporphyrins both in the urine and faeces, and a simple method for the synthesis and separation of such position isomers has been described. The implications of the finding of position isomers type III have been discussed and it is suggested that the decarboxylation of uroporphyrinogen III both in the present case and under physiological conditions is a random process.

Mouse amyloid protein AA: Homology with nonimmunoglobulin protein of human and monkey amyloid substance

The major protein extracted from anyloid deposits induced in mice by injection of either Candida albicans cells or sodium caseinate was found to have chromatographic and electrophoretic properties and an amino-acid compostiion characteristic of the AA class of amyloid proteins. The homology of the mouse protein with protein AA from man and monkey was established by determination of the sequence of the first 28 amino-acid residues.