Progesterone-releasing devices for cattle estrus induction and synchronization: Device optimization to anticipate shorter treatment durations and new device developments.

Synchronization programs using progesterone-releasing intravaginal devices that allow for fixed time artificial insemination are still finding increasing application in bovine reproduction. This practice is useful for rationalizing livestock management because an increased number of cows can be inseminated in one session without the need for estrus detection. Although much of the innovation related to the design and development of intravaginal devices for use in cattle took place in the previous century, progress in understanding the physiology of the bovine estrous cycle resulted in shorter treatment durations, a trend which is still continuing. In this competitive market, with little functional differentiation between the existing devices, the shorter treatment duration prompted for optimization of the progesterone content in the device, as the cost of the drug significantly contributes to the price per unit. For CIDR® a reduction of the progesterone content of about 30 per cent was realized. Price reduction remained an important target for further device development. Next to reduction of progesterone content, cheaper and easier to process materials like polyethylene vinyl acetate (EVA) copolymers have been explored to replace the commonly used silicone elastomers. The reengineering effort of CIDR® demonstrated that knowledge of release kinetics and insight into gradual depletion patterns in the device is critical for optimization of drug content without compromising performance (blood levels). More recent publications related to the use of alternative polymers like EVA and polyisoprene (IP) indicated encouraging results regarding further reduction of progesterone content. The use of EVA seems most promising, because it is in principle a low-cost polymer available in many grades and this thermoplastic polymer can be processed easily by means of commonly used techniques like injection molding and extrusion. The use of thermoplastic polymers, however, requires insight into the physical-chemical phenomena related to drug dissolution and re-crystallization taking place in the polymer during processing at high temperatures. These aspects, which may critically affect product stability, are often overlooked and are prompting to cover some of the background in this review. Finally, two different innovative approaches are discussed, one related to programable electronic devices for tailored simultaneous drug release and the other is a flexible drug-loaded helix, which is retained very well in several species without causing the usual inflammatory response.

Hypothyroidism as the cause of atrioventricular block in an elderly patient.

Syncope is a common problem in the older patient. Sometimes syncope is caused by extreme bradycardia secondary to atrioventricular (AV) block. We describe a case in which a 90-year-old woman presented with complete AV block due to severe hypothyroidism. After suppletion with levothyroxine, AV conduction was restored. (Neth Heart J 2008;16:57-9.).

[Severe bleeding in a patient with anti-c alloantibodies and a rare Rhesus phenotype treated with compatible erythrocyte concentrate from the blood bank of the Council of Europe]. / Ernstig bloedverlies bij een patient met anti-c-alloantistoffen en een bijzondere resusbloedgroep behandeld met compatibel erytrocytenconcentraat uit de bloedbank van de Raad van Europa.

An 84-year-old women had repeated gastrointestinal bleeding from a Dieulafoy lesion, i.e. a gastric or duodenal ulcer containing an aberrant artery. Her blood group was AB-D negative; her Rhesus phenotype was CCdee. In addition, antibody screening revealed anti-c alloantibodies as the result of a previous transfusion. Donors negative for D and c are very rare in Caucasian populations. Compatible red cell concentrates are available only from the European Bank of Frozen Blood of the Council of Europe, located at Sanquin in Amsterdam, Tthe Netherlands. The patient could be saved by requesting compatible erythrocyte concentrate from this blood bank. Severe blood loss poses a serious challenge in patients who are positive for alloantibodies against blood group antigens with a high frequency in the population, and in patients who are themselves negative for such antigens. The presence of alloantibodies is often the result of previous blood transfusions. In view of the large number of antigens on erythrocytes, one should therefore be conservative as to blood transfusion in order to prevent alloantibody formation.

Axial skeletal patterning in mice lacking all paralogous group 8 Hox genes.

We present a detailed study of the genetic basis of mesodermal axial patterning by paralogous group 8 Hox genes in the mouse. The phenotype of Hoxd8 loss-of-function mutants is presented, and compared with that of Hoxb8- and Hoxc8-null mice. Our analysis of single mutants reveals common features for the Hoxc8 and Hoxd8 genes in patterning lower thoracic and lumbar vertebrae. In the Hoxb8 mutant, more anterior axial regions are affected. The three paralogous Hox genes are expressed up to similar rostral boundaries in the mesoderm, but at levels that strongly vary with the axial position. We find that the axial region affected in each of the single mutants mostly corresponds to the area with the highest level of gene expression. However, analysis of double and triple mutants reveals that lower expression of the other two paralogous genes also plays a patterning role when the mainly expressed gene is defective. We therefore conclude that paralogous group 8 Hox genes are involved in patterning quite an extensive anteroposterior (AP) axial region. Phenotypes of double and triple mutants reveal that Hoxb8, Hoxc8 and Hoxd8 have redundant functions at upper thoracic and sacral levels, including positioning of the hindlimbs. Interestingly, loss of functional Hoxb8 alleles partially rescues the phenotype of Hoxc8- and Hoxc8/Hoxd8-null mutants at lower thoracic and lumbar levels. This suggests that Hoxb8 affects patterning at these axial positions differently from the other paralogous gene products. We conclude that paralogous Hox genes can have a unique role in patterning specific axial regions in addition to their redundant function at other AP levels.

Loss of the Y-chromosome in the primary metastasis of a male sex cord stromal tumor: pathogenetic implications.

The first published chromosomal pattern of the retroperitoneal lymph node metastasis of a malignant gonadal stroma cell tumor of the adult testis is presented. Karyotyping showed structural chromosomal abnormalities and loss of the Y-chromosome. This loss was confirmed in primary tumor and metastasis using fluorescence in situ hybridization (FISH). The characteristic chromosomal abnormality of adult testicular germ cell tumors, an i(12p), was not present. The results are compared with other data of testicular and ovarian sex cord stromal tumors. From the comparison of the male tumors, it is concluded that loss of the Y-chromosome might have a pathogenetic significance.

Initiation, establishment and maintenance of Hox gene expression patterns in the mouse.

Spatially and temporally restricted expression of the Hox genes along the main and appendicular axes is essential for correct patterning of vertebrate embryos. In this overview we discuss the latest data that shed light on the mechanisms underlying the generation of the expression domains of the Hox genes. The molecular genetic interactions governing initial transcription of the Hox genes in the posterior part of the primitive streak during mouse and chick gastrulation remain enigmatic. But the recent discovery by Kondo and Duboule (Cell, 97, 1999, 407-417) of a "cluster repressive regulation", will undoubtedly lead to a better understanding of the molecular genetic mechanism underlying colinear and sequential initiation of Hox gene transcription. Recently progress has been booked in characterizing the basal processes driving progression of the Hox expression domains during their establishment. Hox expression is still labile while being established. The transcriptional state of Hox genes in anterior tissues can be reprogrammed under the influence of more posterior locations. Posteriorizing activity may involve RA and FGF signaling. It is only when these interactions and, in some cases at least, regulatory interactions with Hox and cdx gene products occur appropriately, that the Hox expression domains would be correctly established. After the Hox expression domains have been established, regulatory processes involving the products of Polycomb and trithorax- Group genes start operating, perpetuating the transcriptional state of the Hox genes within and outside the expression domains. Whether control at the level of chromatin structure, believed to operate during the late maintenance phase of Hox gene expression, is also involved in regulating concerted initial expression of these genes, is a possibility that has been suggested.

Transducing positional information to the Hox genes: critical interaction of cdx gene products with position-sensitive regulatory elements.

Studies of pattern formation in the vertebrate central nervous system indicate that anteroposterior positional information is generated in the embryo by signalling gradients of an as yet unknown nature. We searched for transcription factors that transduce this information to the Hox genes. Based on the assumption that the activity levels of such factors might vary with position along the anteroposterior axis, we devised an in vivo assay to detect responsiveness of cis-acting sequences to such differentially active factors. We used this assay to analyze a Hoxb8 regulatory element, and detected the most pronounced response in a short stretch of DNA containing a cluster of potential CDX binding sites. We show that differentially expressed DNA binding proteins are present in gastrulating embryos that bind to these sites in vitro, that cdx gene products are among these, and that binding site mutations that abolish binding of these proteins completely destroy the ability of the regulatory element to drive regionally restricted expression in the embryo. Finally, we show that ectopic expression of cdx gene products anteriorizes expression of reporter transgenes driven by this regulatory element, as well as that of the endogenous Hoxb8 gene, in a manner that is consistent with them being essential transducers of positional information. These data suggest that, in contrast to Drosophila Caudal, vertebrate cdx gene products transduce positional information directly to the Hox genes, acting through CDX binding sites in their enhancers. This may represent the ancestral mode of action of caudal homologues, which are involved in anteroposterior patterning in organisms with widely divergent body plans and modes of development.

Hoxb-8 gain-of-function transgenic mice exhibit alterations in the peripheral nervous system.

To understand the developmental role of Hoxb-8, this relatively 5' Hoxb gene was ectopically expressed in embryonic regions where only more 3' Hox genes are normally expressed. Hoxb-8 coding sequences driven by a retinoic acid receptor beta2 promoter fragment were introduced in the mouse germ line by pronuclear injection. The promoter was chosen with the aim to extend rostrally the expression domain of the gene in neurectoderm and mesoderm at the time of development when Hox gene expression domains are being established. Embryos developing from DNA-injected zygotes, and from transgenic mouse lines were analyzed. Pattern alterations were observed in transgenic embryos, some of which involved the peripheral nervous system. Spinal ganglia in the mouse are first detectable around embryonic day 9.5. By day 11.5, the first of these ganglia (C1, Froriep's ganglion) has degenerated in the mouse and other amniotes. In contrast, this first ganglion did persist in the Hoxb-8 gain-of-function transgenic mice. We have started to take advantage of the phenotype of transgenic versus wild-type embryos to understand the mechanisms underlying the ontogeny and degeneration of Froriep's ganglion in wild-type mice, and the role of Hoxb-8 in C1 maintenance in transgenic embryos. The present work describes a morphological, histological and immunocytological analysis of both the degenerating and the permanent C1, and a preliminary characterization of the axonal extensions from the transgenic C1. We discuss the methodology of generating gain-of-function transgenic mice to study the genetics of pattern formation along the antero-posterior axis, and the usefulness of analyzing these particular Hoxb-8 transgenic embryos to understand some aspects of the ontogenesis and development of the upper cervical dorsal root ganglia.

A 3' remote control region is a candidate to modulate Hoxb-8 expression boundaries.

Hox genes have been shown to play a key role in the acquisition of positional identity by precursors of embryonic axial, paraxial and limb structures. This function is thought to depend on the sequential, concerted expression of these genes in time and space. However the underlying molecular mechanisms of this collinear expression are still largely unknown. So far we had identified proximal regulatory elements driving expression of Hoxb-8/LacZ transgenes in Hox-like expression patterns with rostral boundaries more posterior than those of the endogenous gene. In this work we have analyzed 30 kb of 3' genomic sequences for Hoxb-8 regulatory activity in transgenic mice. We have identified a control region in the Hoxb-5/b-4 intergenic region that rostrally extends the Hoxb-8/LacZ expression domain into the posterior hindbrain. In combination with the Hoxb-8 minimal promoter, the 3' control region drives transgene expression with boundaries more anterior than those of Hoxb-8 in the neural tube. When combined with a 4.5 kb Hoxb-8 upstream sequence, where essential proximal regulatory sequences are located, the 3' control region drives transgene expression in a domain which seems to correspond to that of the endogenous Hoxb-8. By deletion analysis we have narrowed down to 550bp the regulatory activity interacting with the Hoxb-8 minimal promoter. We discuss the possibility that this remote 3' enhancer, which is the closest regulatory region found in the cluster to rostrally extend Hoxb-8/LacZ expression, could be involved in the regulation of Hoxb-8 and interact with the proximal control elements.

Regulation of the Hoxb-8 gene: synergism between multimerized cis-acting elements increases responsiveness to positional information.

Hox genes play a key role in the specification of regional development in the vertebrate embryo. They are expressed in regionally restricted domains along the anterior-posterior axis, generally extending from a sharp rostral boundary toward the posterior end. We have studied the regulation of the murine Hoxb-8 gene in vivo using reporter constructs and found that 11 kb of genomic sequences upstream of Hoxb-8 confer a Hox-like pattern of expression on a lacZ reporter gene fused in-frame to the first exon of Hoxb-8. Reporter gene expression was detectable from early stages onwards, but reached rostral expression boundaries in mesoderm and neurectoderm that were more posterior than those of the endogenous gene. Within the upstream region, we have identified several cis-acting elements which are individually capable of driving regionally restricted expression in combination with the Hoxb-8 promoter, and we have investigated their relative contributions to the expression pattern. The results suggest that, in this experimental context, these upstream elements, as well as previously identified elements located within the Hoxb-8 gene, cooperate in setting the rostral expression boundaries. Furthermore, we show that multiple identical copies of cis-acting elements can cooperate, causing a pronounced anterior shift in the expression boundaries. This indicates that the rostral extent of expression is limited by the activity of a transcription factor binding to these elements and that this activity was, at some point in development, higher in precursors of more posterior structures than in precursors of anterior structures. This factor is thus very likely to be involved in the transduction of positional signals.

Specification of multiple vertebral identities by ectopically expressed Hoxb-8.

We have recently generated Hoxb-8 gain-of-function mutant embryos, using a Hoxb-8 transgene driven by a retinoic acid receptor beta 2 promoter to extend the expression domain to more anterior regions of the embryo (Charité et al. [1994] Cell 78:589-601). Here we describe the phenotype in the axial skeleton of transgenic embryos. The severity of the phenotype was variable, and cervical vertebrae and the base of the skull were affected in different ways. We observed fusion of the anterior arch of the atlas to the dens of the axis, partial splitting of the vertebral body and the neural arch of the axis, and abnormal morphology of the basioccipital and exoccipital bones. The basioccipital bone projected into the atlas, sometimes fusing to the dens of the axis; the exoccipitial bones appeared to be transformed towards neural arch-like structures. A novel pattern of posterior homeotic transformations was observed, involving cervical vertebrae C3 to C7: the ventral aspect of vertebrae C5 to C7 could acquire different morphologies characteristic of more posterior vertebrae: C5 could be transformed into C6, C7, or T1, C6 into C7 or T1, and C7 into T1. Phenotypes of different severity could be arranged into a phenotypic series, starting with the transformation of C7 to T1 and involving transformation of increasingly more anterior vertebrae into increasingly more posterior identities; no vertebra acquired a more posterior morphology than that of the vertebra immediately caudal to it. Ribs appeared to be formed relatively independently of rib heads; cervical ribs (but not rib heads) could be observed as anterior as C3. The results suggest that higher levels of ectopically expressed Hoxb-8 result in specification of more posterior vertebral identities.

Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease.

In 12 patients with chronic obstructive pulmonary disease (COPD) receiving pressure support ventilation (PSV), we studied the variability of respiratory muscle unloading and defined its physiologic determinants using a modified pressure-time product (PTP). Inspiratory PTP/min decreased as PSV was increased (p < 0.001), but there was considerable interindividual variation: coefficients of variations of up to 96%. On multiple linear regression analysis, 73 to 83% of the variability in inspiratory PTP was explained by inspiratory resistance, minute ventilation, and intrinsic positive end-expiratory pressure. Taking an inspiratory PTP/min of < 125 cm H2O.sec/min to represent a desirable level of inspiratory effort during PSV, a respiratory frequency of < or = 30 breaths/min was more accurate than a tidal volume > 0.6 L in predicting this threshold (p < 0.001). At PSV of 20 cm H2O, expiratory effort, quantitated by an expiratory PTP, was clearly evident in five patients before the cessation of inspiratory flow, signifying that the patient was "fighting" the ventilator; of note, these five patients had a frequency of < or = 30 breaths/min. In conclusion, patient-ventilator interactions in patients with COPD are complex, and events in expiration need to be considered in addition to those of inspiration.

Ectopic expression of Hoxb-8 causes duplication of the ZPA in the forelimb and homeotic transformation of axial structures.

Transgenic embryos were generated carrying a Hoxb-8 transgene under control of the mouse RAR beta 2 promoter, which extends the normal expression domain to more anterior regions of the embryo. These embryos showed mirror-image duplications in the forelimb, analogous to the duplications observed in chick in response to transplantation of a ZPA to the anterior margin of the limb bud. Examination of Sonic hedgehog, Fgf-4, and Hoxd-11 gene expression confirmed that a second ZPA had been generated at the anterior side of the limb bud. Besides other alterations, posterior homeotic transformations of axial structures were observed, involving the first spinal (Froriep's) ganglion and several cervical vertebrae.

Magnesium sulfate potentiates several cardiovascular and metabolic actions of terbutaline.

beta-Adrenergic agonists are useful for the emergency treatment of asthma. Recently, magnesium sulfate (MgSO4) has also been shown to be efficacious in this situation. beta-Agonists have unwanted cardiovascular and metabolic actions: increased systolic blood pressure, corrected QT interval (QTc), serum glucose and insulin, and decreased RR interval, diastolic blood pressure, serum potassium, phosphate, and calcium. As beta-agonists and MgSO4 quite possibly will be used in combination, we sought to determine how MgSO4 would affect these actions. Healthy young male adults were administered two doses of terbutaline sulfate, 0.25 mg subcutaneously, 30 min apart on two separate occasions, in a randomized, double-blind fashion. On one occasion, 4 g of MgSO4 was administered intravenously over the same 30-min period. On the other, normal saline solution was given as a placebo. Cardiovascular and metabolic variables were measured sequentially for 2 h. Data at 60 min with p values given for a summation of all time points are as follows: MgSO4 increased terbutaline's effects on the RR interval by 0.09 s, p < 0.0001; QTc interval by 0.01 s, p < 0.0007; diastolic blood pressure by 8 mm Hg, p = 0.0001; serum calcium by 0.13 mg/dl, p = 0.01; and glucose by 9 mg/dl, p < 0.0001. MgSO4 also mitigated the systolic blood pressure elevating the effect of terbutaline by 5 mm Hg (p = 0.007). The magnitude of the response potentiations was modest. We conclude that combining terbutaline and MgSO4 is unlikely to result in serious short-term adverse events, if used acutely in patients with relatively normal cardiac and metabolic function. MgSO4 may act by potentiating the effect of beta-agonists on magnesium requiring enzymes such as adenyl cyclase.

Cytogenetic abnormalities and clinical stage in testicular nonseminomatous germ cell tumors.

To study the impact of chromosomal abnormalities on the clinical behavior of testicular nonseminomatous germ cell tumors (TNSGCTs), we compared the chromosomal constitution of primary tumors of patients who initially presented and remained without metastases to those with metastatic disease. Furthermore, the chromosomal pattern of primary TNSGCTs was compared to ploidy and the clinicopathologic risk factors histology and small-vessel invasion. The modal chromosome number and the ploidy were in agreement. No correlation was found between the modal chromosome number and histology, presence of vascular invasion, or clinical stage. No correlation was found between structural chromosome abnormalities, like the number of copies of the i(12p) chromosome, and clinical stage. No obvious differences were found in chromosomal constitution of metastatic and non-metastatic tumors. The results of the present study suggest that in TNSGCTs differences in clinical behavior are not associated with gross chromosomal differences.

Significance of aneuploid stemlines in testicular nonseminomatous germ cell tumors.

BACKGROUND: Hyperpentaploidy in testicular nonseminomatous germ cell tumors (TNSGCT) has been associated with progression of disease of patients who initially had TNSGCT in Stage I. METHODS: The authors used flow cytometry to investigate the relationship between ploidy and the clinical behavior in TNSGCT, focusing on hypertetraploid values (DNA index, > 2.00). RESULTS: Patients with TNSGCT containing an aneuploid stemline with a hypertetraploid value more often had higher clinical stage of disease and a higher chance of relapse in advanced stages. The presence of multiple aneuploid stemlines in the tumors was found more frequently in patients who had higher clinical stage disease. CONCLUSIONS: The results suggest that the presence of highly aneuploid or multiple aneuploid stemlines in TNSGCT are associated with a clinically more malignant behavior.

Proximal cis-acting elements cooperate to set Hoxb-7 (Hox-2.3) expression boundaries in transgenic mice.

The Hox genes have been proved to be instrumental in establishing the positional identity of cells along the embryonic anteroposterior (A-P) axis. Studying the regulation of these genes is a first step toward elucidating the molecular basis of regionalization during embryogenesis. We report here on the identification of cis-acting elements controlling the expression of Hoxb-7 (Hox-2.3). We show that elements driving A-P restricted gene expression are located within the 3.5 kb proximal upstream sequences of the Hoxb-7 gene. A deletion analysis provides evidence for at least three cis-acting control elements upstream from Hoxb-7, and for cooperative interactions between some of these elements in generating the A-P restricted transgenic pattern. One element, conferring by itself Hox-like expression boundaries to the transgene, has been studied in more detail and found to act in an orientation-and promoter-dependent manner. Together the 3.5 kb sequences proximal to Hoxb-7 mediate A-P restricted Hoxb-7/lacZ gene expression in a domain showing rostral boundaries more posterior than those of Hoxb-7. The evolution throughout embryogenesis of the expression pattern of a transgene carrying these sequences has been analysed and shown to mimick that of the endogenous gene, except for a slight delay in the initial expression. We conclude that the transgenes that we tested, spanning a total of 27 kb genomic sequences, do not reproduce all the features of the Hoxb-7 expression pattern. The differences in expression between Hoxb-7 and the transgenes may reveal an aspect of the Hox regulation for which either remote cis-acting control elements and/or gene clustering is required. Additional features that may have favoured maintenance of clustered organisation during evolution are partial overlap of transcription units with the regulatory regions of the neighbouring genes, and cis-regulatory interactions between multiple Hox genes: not only do cis-acting control elements of the Hoxb-7 gene map in the 3' untranslated sequences of the Hoxb-8 (Hox-2.4) gene, but our experiments suggest that Hoxb-7 control sequences modulate expression of the Hoxb-8 gene as well.

Nutrition in acute pulmonary disease.

Acutely stressed patients with chronic pulmonary disease have a particular need for accurate nutritional assessment and appropriate nutritional therapy. Loss of skeletal muscle, often extensive, can be paralleled by dramatic alterations in cellular function; inadvertent provision of excessive calories or of individual substrates may produce more harm than benefit. In the absence of a single "gold standard" for nutritional assessment and monitoring, no single value should take precedence over the entire clinical picture, which should be thoughtfully assessed and reassessed, with both the patient's nutritional needs and the consequences of their provision kept in mind. In the future, assessments of the impact of nutritional intervention will probably rely more heavily on functional tests of specific organs and of the immune system. Intervention will be based not only on provision of calories, individual substrates, vitamins, and minerals, but also on control of the inflammatory response in order that the nutrients may be properly utilized.

Serum lactate dehydrogenase isoenzyme 1 activity in patients with testicular germ cell tumors correlates with the total number of copies of the short arm of chromosome 12 in the tumor.

The aim of our study was to assess the relationship between the serum lactate dehydrogenase isoenzyme 1 (S-LDH-1) activity in patients with testicular germ cell tumors and the number of copies of the short arm of chromosome 12 (12p) present in tumor. Twenty-seven adult patients with measurable tumor lesions were studied. Twenty-five had three or more copies of chromosome 12 per cell in the tumors. Nineteen had one or more copies of a specific chromosomal abnormality, an isochromosome of the short arm of chromosome 12, i(12p). Fourteen had increased S-LDH-1 levels. S-LDH-1 activity correlated significantly with the product of total tumor volume and the total number of copies of the short arm of chromosome 12 present per cell (total tumor 12p). We conclude that the total number of copies of the short arm of chromosome 12 in the tumors is most probably a factor contributing to the LDH-1 activity released from the tumors.