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Introduction: Elevations of troponin after subarachnoid hemorrhage (SAH) frequently occur and are associated with cardiopulmonary complications. The time to peak elevation remains poorly described in terms of the natural history after SAH. Our two objectives were to define the temporal profile of troponin T elevation after SAH and correlate levels of troponin T with baseline neurological status. We hypothesized that troponin T would peak early after initial presentation. Methods: We reviewed the medical records of all aneurysmal and non-traumatic SAH patients from March 2011-December 2012. Troponin T from patients with ≥ 2 values was recorded with respect to SAH symptom onset. Patients with ≥ 1 Troponin T value were stratified according to admission Glasgow Coma Scale (GCS). GCS was dichotomized to > 8 or ≤ 8. Fisher’s exact test was performed comparing elevated peak troponin T (≥0.01 ng/ml) versus normal against GCS status cutoffs > 8 or 8 or less. Results: We identified 124 patients who had both troponin T and GCS reported, and 30 patients had ≥2 troponin T measurements within the first 40 hours of hospitalization. The median time to peak troponin T in these patients was 11.2 hours with a standard deviation of 6.2 hours (Range: 4.9-35.0 hours). Elevated troponin T was seen in 52 of 124. GCS of ≤ 8 was present in 43 of 124. Patients with elevated levels of troponin T had a greater chance of lower GCS [Odds ratio = 4.8 (95% CI: 2.2 to 10.7)] (P= Conclusions: The median time to peak troponin T after SAH injury was 11 hours. There was a statistically significant association between troponin T elevation and worse neurologic status at presentation (GCS ≤ 8). Although our small sample size found large variation in time to peak troponin, it supports the hypothesis that troponin peaks early after the initial presentation. Future studies using troponin elevation as a biomarker should focus on sample acquisition at the time of admission and in the first 1-2 days.

Gonadotropin-releasing hormone (GnRH) has been shown to play a role in the regulation of human chorionic gonadotropin (hCG) secretion by the human placenta. Molecular studies have demonstrated that human placental trophoblast cells synthesize a progonadotropin-releasing hormone (pro-GnRH) identical to its human hypothalamic counterpart. However, far less is known about nonhuman primates. To determine whether pro-GnRH exists in the rhesus placenta, pro-GnRH mRNA was cloned, sequenced, and shown to be 97.6% homologous to its human placental counterpart. A single base difference (base 1167) in the domain encoding GnRH results in the same amino acid, arginine, in position 8, whereas four base differences (bases 1200, 1253, 1268, 1292) in the domain encoding GnRH-associated peptide (GAP) result in four different amino acids in positions 19, 37, 42, and 50. The absence of a basic amino acid in position 50 suggests the rhesus sequence may be cleaved to yield GAP peptides different from the human placenta. Thus, these data justify the use of mammalian GnRH in studies of rhesus placental function, but indicate the need to investigate the roles unique GAP peptides may play in placental/uterine function.

Large V waves seen on the pulmonary capillary wedge pressure (PCWP) hemodynamic tracing signify elevated left atrial pressure during ventricular systole. Consideration of the differential diagnosis of large V waves is essential for appropriate treatment in symptomatic patients. A 64 year old man

Studies to date have demonstrated epidermal growth factor (EGF) receptors primarily on the outer plasma membrane of the human placental syncytiotrophoblasts facing maternal blood and to a lesser extent on the cytotrophoblast stem cells. In the present studies, first- and third-trimester human placental tissues were immunostained with monoclonal antibodies (MAb) to the EGF binding domain of the human EGF receptor or to the activated (tyrosine-phosphorylated) human EGF receptor. Cytotrophoblasts, syncytiotrophoblasts, and fetal connective tissue cells in first-trimester tissues immunostained with both MAb, with the notable exception of the absence of staining of activated EGF receptor over cytotrophoblast plasma membranes. In contrast, staining of third-trimester placentas with either MAb yielded little to no staining of either trophoblast cell layer but intense staining of fetal connective tissue cells. Staining for EGF receptors over cytotrophoblasts in the first trimester is consistent with the hypothesis that maternal EGF or TGF-alpha derived from the endometrium or placenta may be the mitogen responsible for cytotrophoblast cell division and that the receptors localized to the syncytiotrophoblast are involved in EGF regulation of differentiated function. The absence of heavy staining of activated EGF receptor on trophoblast plasma membranes in third-trimester placentas is consistent with down-regulation of EGF receptor activity.

GnRH has been shown to play a role in the regulation of secretion of hCG by human placenta. Immunocytochemical studies have demonstrated the presence of the peptide, but do not address whether the GnRH is maternal, fetal, or placental in origin. In situ hybridization studies using a biotinylated pro-GnRH cDNA were, therefore, undertaken to determine the distribution of pro-GnRH mRNA in first trimester placental samples. Using an avidin-biotin-Cy.5 detection system in conjunction with laser scanning confocal microscopy, pro-GnRH mRNA was shown to be present in both the cytotrophoblast and syncytiotrophoblast cells of placental villi, although not in the cells of the fetal connective tissue. Prior hybridization with a 200-fold excess of unlabeled probe blocked hybridization of the labeled pro-GnRH probe. Southern and sequence analysis demonstrated that the probe hybridized to a transcript identical to hypothalamic GnRH. Immunocytochemical staining using an antiserum to amino acids 6-16 of pro-GnRH demonstrated the presence of translated pro-GnRH in both the cytotrophoblast and syncytiotrophoblast epithelia. We conclude that the synthesis of pro-GnRH by both the cytotrophoblast and the syncytiotrophoblast of human placenta is consistent with either an autocrine or a paracrine mode of GnRH regulation of hCG secretion.

A primary cell culture system was developed to study the epidermal growth factor (EGF) receptor in the fetal bovine mesonephros and its urogenital derivatives. Radioreceptor assays demonstrated EGF binding as early as Day 37 in mesonephric cells and in cells derived from the fetal reproductive ducts, gonads, and metanephros--all mesonephric derivatives. Immunocytochemical studies revealed that EGF receptors were localized in the ductal and tubular epithelium of these urogenital organs. EGF induced DNA synthesis and tyrosine phosphorylation in the bovine mesonephric cells, suggesting that EGF receptors detected in these cells were functional. In addition, transforming growth factor alpha, the putative fetal ligand for the EGF receptor, was found to specifically compete for EGF binding to the receptor, as well as to induce DNA synthesis in a manner similar to that of EGF. Estrogen did not regulate EGF receptors or specifically bind to bovine mesonephric cells. The development of estrogen receptors in the bovine species occurs markedly later than that of the EGF receptor, in contrast to the mouse, where both receptors are observed at very early stages of reproductive tract development.

Editors' Note: Is brain natriuretic peptide a good predictor of outcome in neurologic diseases? Duello et al. and Montaner et al. agree that, in order to find a statistically significant relationship between brain natriuretic peptide and mortality in patients with stroke or subarachnoid hemorrhage, a very large number of patients is needed. Does widespread Bacille Calmette-Guerin vaccination at birth explain the low incidence of multiple sclerosis in the Indian subcontinent? Sethi and Ristori et al. discuss. —Chafic Karam, MD, and Robert C. Griggs, MD We read with interest the article by Garcia-Berrocoso et al.1 The correlation of B-type natriuretic peptides (BNP) elevation with stroke mortality is noteworthy …

Although African American women have an overall lower incidence of breast cancer, African American women40 years of age are more likely than Caucasian women of all ages and postmenopausal African American women to be diagnosed with breast cancer and exhibit tumor characteristics associated with poorer survival. To begin to address this disparity, studies must be conducted to examine breast cancer preventive factors in this subpopulation of women. However, the strategies needed to recruit younger African American women have not been well defined.In this study, we assessed methods used for recruiting and retaining healthy premenopausal African American women into the African American Nutrition for Life (A NULIFE) Study. The number of women contacted, enrolled, and retained by each recruitment strategy and the efficiency of individual strategies were calculated.Overall, recruitment through social networking was most effective in contacting large numbers of healthy premenopausal African American women. The worksite recruitment method was the most efficient recruitment strategy employed, with a ratio of 40%. The study participants (n = 164) were more likely to beor=35 years of age and have completed some college. Additionally, the interpersonal relationships recruitment approach proved most efficient (33%) in retaining participants who completed the yearlong study.The findings from this study add to the evolving research literature on minority recruitment strategies for research studies but specifically address effective recruitment of healthy young premenopausal African American women. The results demonstrate the need to use multiple recruitment strategies when recruiting this subgroup of African American women.

The Third Reich’s conception of a race was predicated on the belief that a “race”* was distinguished by a distinct group of genetically transmitted physical characteristics and that the inheritance of a small number of certain physical characteristics, such as white skin, blond hair, and blue eye?, was genetically linked to the inheritance of other traits deemed superior. The Nordic people bearing these characteristics were considered Aryans, or the “Master Race.”

An immunocytochemical assay for estrogen receptor (ER) was used to study the distribution of receptor in fetal and immature female mouse reproductive tracts. Immunoblots confirmed that a single band, the size of the ER, immunostained in extracts from day 15 and 17 fetal reproductive tracts. Staining was observed over nuclei of epithelial cells of the Mullerian duct and over nuclei of cells of the developing connective tissue (mesenchymal cells) of the reproductive tract on fetal day 15. By day 17 when a primitive uterus could be distinguished, ERs were detected in nuclei of mesenchymal cells, but in only a small portion of epithelial cells. A different pattern of immunocytochemical staining was observed in uteri from animals killed on the day of birth; cells of the connective tissue contained ER, but the epithelial cells did not. By 4 or 6 days after birth, more nuclei in the connective tissue stained for ER with a greater intensity compared to nuclear staining in epithelial cells. ERs were detectable in nuclei of both uterine epithelial cells and connective tissue cells on days 10 and 19 after birth.

To execute interdisciplinary care for complex dentofacial abnormalities, a team of providers must develop a consistent philosophy and mission regarding examination, diagnostic, and treatment planning procedures. To obtain optimum therapeutic results, patients must rely on the collaborative expertise of a team. This article and case study illustrates a multidisciplinary team's role in the prosthetic and esthetic rehabilitation of the maxillary anterior region.

Gonadotropin-releasing hormone (GnRH) interacts with a putative receptor in human placenta to cause the dose-dependent release of human chorionic gonadotropin (hCG) in a manner analogous to hypothalamic GnRH stimulation of luteinizing hormone (LH), and follicle-stimulating hormone (FSH) by the pituitary gland. However, GnRH agonists bind a placental binding site at a lower affinity than they bind the pituitary GnRH receptor, suggesting the two sites differ. To address this issue, human placental GnRH receptor mRNA from an 8-wk placental sample was amplified using primers based on the sequence of the human pituitary receptor, cloned, and sequenced. The sequence of the placental transcript was found to be identical to its pituitary counterpart. Thus, as with the pituitary receptor, this placental receptor transcript appears to encode a single polypeptide chain with seven intramembranous domains and two glycosylation sites. However, it is possible these receptors differ in their posttranslational processing or there is more than one placental GnRH receptor. In addition, subsequent gene amplification studies, modified to increase the sensitivity of the method, revealed a band of the predicted size (approximately 1051 bp) in a 6-wk and two 8-wk placental samples, but not in 5-wk and 7-wk samples. The failure to amplify GnRH receptor mRNA at these gestational ages did not appear to be an issue of cell health or sample degradation, since GnRH, alpha hCG, and beta hCG mRNA were amplified from each of these tissues. Instead these data suggest GnRH receptor mRNA may have a short half-life or the mRNA may be translated as rapidly as it is transcribed, with the result that it has not accumulated in the cell.

Abstract 1128 Background Dysfunctional or mismatched prosthetic heart valves can results in high shear stress related von Willebrand factor (VWF) impairment, and clinical bleeding. This mechanism is similar to that seen in aortic stenosis patients, where gastrointestinal bleeding related to VWF multimer loss is well described (Heyde syndrome). In this study, we compared the results of VWF testing of patients with normally functioning cardiac valve prostheses, dysfunctional prosthetic valves, severe native aortic stenosis, and normal controls. Methods A total of 75 patients, 31 female and 44 male with a median age of 79.5 years were recruited to this study. Thirty patients had severe aortic stenosis (mean gradient > 40 mm Hg); 39 patients had normally functioning prosthetic valves, 21 aortic (AVR) and 18 mitral valves (MVR); and 6 patients had with dysfunctional valves (4 aortic and 2 mitral). Whole blood and plasma samples were drawn from patients and tested for platelet function analyzer-100 collagen ADP closure time (PFA-CADP), VWF antigen (VWF:Ag), VWF activity by latex immunoassay (VWF:Ltx), VWF multimer analysis and VWF multimer densitometry ratio of large vs medium to low molecular weight multimers (>15 mers/2–15 mers). Results The 6 dysfunctional prosthetic valve patients included patient-prosthesis mismatch (2) and (one each), thrombosed mechanical aortic prosthesis, torn biological aortic prosthesis, severe tissue mitral prosthetic regurgitation, and post-mitral valve repair severe mitral regurgitation. Four of six patients had clinically significant bleeding. Most aortic stenosis and all 6 prosthetic dysfunction patients had abnormal VWF multimers which is rare in normally functioning prostheses and completely absent in normal donors. VWF:Ltx/Ag was lower in AS and MVR than normal. VWF:Ltx/Ag ratio, VWF:multimer ratio and PFA-CADP were all significantly abnormal in patients with dysfunctional prosthetic valve. VWF:multimer ratios in normally functioning prostheses tended to be intermediate between normals and than those of patients with severe AS or prosthetic valve dysfunction (Table). Conclusions VWF testing including quantitative von Willebrand multimer analysis and PFA-CADP reliably separate dysfunctional from normally functioning cardiac prostheses, and should be considered in the evaluation of patients with cardiac prostheses, especially those who have clinically significant bleeding. Disclosures: No relevant conflicts of interest to declare.

3377 Background Bleeding from AVWS may occur in aortic stenosis (AS), hypertrophic cardiomyopathy (HCM), mitral regurgitation (MR), and prosthetic valve dysfunction (PVD) due to loss of von Willebrand factor (VWF) high molecular weight multimers caused by shear stress. Traditional laboratory testing for AVWS, including VWF antigen (VWF:Ag) and ristocetin cofactor activity lack sensitivity in this setting, and VWF multimer analysis, a costly and time-consuming test, must be used for confirmative diagnosis. The goal of this study is to develop a clinical and laboratory approach to predict the likelihood of AVWS, and consequently obviate the need for multimer analysis. Methods 160 patients with or without a bleeding history were prospectively enrolled with mild, moderate, or severe AS (n=65), HCM (n=32), MR (n=25), or with heart valve replacement (n=38). These patients were investigated at the time of clinically indicated echocardiography with VWF latex immunoturbidic activity (VWF:Ltx), VWF:Ag, (abnormal versus normal cutoff of VWF:Ltx/VWF:Ag is 180 | 48 | 83 (70–91) | | | VWF:Ltx/Ag ratio | | | 180 | 3.52 (2.31–5.37) | | * P-values result from likelihood ratio tests in a logistic regression model containing peak velocity and PFA-CADP. Abbreviations: RR= relative risk, CI=confidence interval. Due to strong association between peak velocity and PFA-CADP, estimated relative risks result from single variable models. Table 2 From these relative risks a scoring algorithm was created in order to determine who should be screened for abnormal multimers. A value of 1 was subtracted from each relative risk and rounded to the nearest integer to obtain a score for peak velocity ( 5.0 m/sec=7), and for PFA-CADP (≤120 sec=0, 121–180 sec=2, > 180 sec=3). The score from each of the two variables was added to obtain a total score ranging from 0 to 10. The risk score was categorized into four levels, which are 0, 2–3, 5–7, and 8–10, as shown in [Table 3][3]. | | N | % Abnormal multimers (95% CI) | P-value | |:---------- | -- | ----------------------------- | ------- | | Risk score | |

Abstract 2230 Background: Heyde syndrome describes patients with severe aortic stenosis (AS) who have bleeding diathesis, especially gastrointestinal bleeding. Although acquired won Willebrand syndrome (AVWS) due to loss of the highest molecular weight multimers (HMWM) presents in most patients with severe AS, not all such patients develop Heyde syndrome. The goal of this study was to explore whether the severity of HMWM loss was significantly associated with Heyde syndrome. Methods: We first performed chart reviews on patients referred for double balloon enteroscopy (DBE) for GI bleeding or iron-deficiency anemia (GIB/FeDefic) in two time periods, from 2005–2008, and from 2009–2011. Next, patients who could have AVWS due to AS or other cardiovascular or hematologic disorders were identified. Laboratory tests including VWF antigen (VWF:Ag), VWF ristocetin cofactor activity or VWF latex immunoturgidic activity (VWF:Ltx) and/or VWF multimer analysis were performed as requested by physicians. From this population, patients with Heyde syndrome were identified. Their clinical and VWF laboratory testing results were compared to a separated group of patients with severe AS patients who had no clinically significant bleeding, but had matched gender and hemodynamic severity by echocardiogram (Matched AS Controls). These patients all had VWF:Ag, VWF:Ltx, and VWF multimers performed. In both Heyde syndrome patients and Matched AS controls, VWF multimer densitometry ratio of the HMWM (>15 mers) to low to intermediate multimers (2–15 mers) was assessed (VWF:multi ratio). Results: Overall, 437 patients underwent DBE for GIB/FeDef. Between 2005 and 2008, 1% of 318 patients had VWF testing. From 2009 to 2011, 23% of 119 patients were tested. Heyde syndrome was noted in 15 patients. Of the 437 patients, 134 patients (31%) likely had AVWS based on diagnoses of moderate-severe AS (30%), moderate to severe mitral regurgitation (25%), moderate to severe pulmonary hypertension (16%), prosthetic valve regurgitation or stenosis (13%), hypertrophic cardiomyopathy (10%), and hematologic disorders (4%). Among these 134 patients, 29 patients had VWF tests performed, and 22 had VWF multimer analysis. VWF antigen levels were similar in Heyde syndrome and Matched AS Controls (176±89% versus 155±77% respectively). Despite similar hemodynamic severity, more severe HMWM loss as indicated by lower VWF:Ltx/Ag and VWF:multi ratios was present in Heyde syndrome patients than matched AS controls (table, P Conclusion: If AVWS is suspected in patients with GIB/FeDef, laboratory testing for VWF indices is important to confirm the diagnosis of AVWS. Despite similar hemodynamic severity, Heyde syndrome patients have more severe VWF HMWM loss indicated by significantly decreased VWF:Ltx/VWF:Ag and VWF:multi ratios. Conversely, though highly sensitive for AVWS, PFA-CADP does not predict bleeding tendency in patients with severe AS. Disclosures: No relevant conflicts of interest to declare.

A primary cell culture system was developed to study the epidermal growth factor (EGF) receptor in the fetal bovine mesonephros and its urogenital derivatives. Radioreceptor assays demonstrated EGF binding as early as Day 37 in mesonephric cells and in cells derived from the fetal reproductive ducts, gonads, and metanephros--all mesonephric derivatives. Immunocytochemical studies revealed that EGF receptors were localized in the ductal and tubular epithelium of these urogenital organs. EGF induced DNA synthesis and tyrosine phosphorylation in the bovine mesonephric cells, suggesting that EGF receptors detected in these cells were functional. In addition, transforming growth factor alpha, the putative fetal ligand for the EGF receptor, was found to specifically compete for EGF binding to the receptor, as well as to induce DNA synthesis in a manner similar to that of EGF. Estrogen did not regulate EGF receptors or specifically bind to bovine mesonephric cells. The development of estrogen receptors in the bovine species occurs markedly later than that of the EGF receptor, in contrast to the mouse, where both receptors are observed at very early stages of reproductive tract development.

To date, there is no conclusive evidence that ERs are present in preimplantation embryos. There are reports that estrogen is made by the rabbit blastocyst (61), and estrogens have been used to induce implantation in mice (62), but whether estrogens act through ERs in the embryo or in the maternal uterus is not known. ERs may be present in early embryos, but if so, levels are below the methods of detection used thus far. Perhaps with more sensitive immunodetection methods, it may be possible to detect ERs in embryos if they are present. Using PCR, messenger RNA for ER has been detected as early as the oocyte stage in mouse embryos (Q. Hou and J. Gorski, unpublished results). This was confirmed recently by Wu et al. (83a). Figure 7 shows a model for the pattern of ER expression in the developing mouse fetus based on the various reports discussed in this review. ERs are present in the 10-day mouse fetus, possibly in the developing ambisexual reproductive tract. Analysis of seven individual 10-day-old fetuses taken from the same litter showed similar levels of an immunostained protein the size of the ER in each fetus (57). The pattern of expression of ER between implantation and the development of the reproductive tract may be the same in male and female mice. Estrogen, acting through ERs, may be one factor (of many) that determines which cells are destined to be part of the indifferent reproductive tract. We were not able to isolate fetal mouse reproductive tracts at an indifferent stage (day 10) due to their very small size. One way to study ER in the indifferent reproductive tract would be to examine these tissues in a larger animal, such as the bovine, using similar immunodetection methods. The distribution of ER in the fetal mouse reproductive tract on fetal days 13 (before sexual differentiation) and 15 (initiation of sexual differentiation) is similar in males and females (71, 72). Thus, estrogen does not appear to be responsible for the initiation of sexual differentiation. Early experiments by Jost (41) showed that removal of the gonad from male or female rabbit fetuses resulted in the female phenotype, which lent weight to the hypothesis that ovarian hormones are not critical in the development of the female phenotype, whereas testicular hormones are essential for the development of the male phenotype.(ABSTRACT TRUNCATED AT 400 WORDS)

Immunodetection methods were used to detect estrogen receptors (ER) in male reproductive tracts on fetal days 13, 15, and 17 and on the day of birth. Immunocytochemistry revealed that most of the cells of the gonad and associated Wolffian duct stained for ER on fetal day 13. During the next 6 days, ER distribution changed, and by the day of birth, ERs were observed only in epithelial cells of the epididymis (derived from the Wolffian duct) and in a portion of cells from the testis. Immunoblots confirmed that a band the size of the ER stained in reproductive tracts for all ages studied. Similar to the fetal female, ERs are present throughout the early development of the fetal male reproductive tract. However, in contrast to the female, ERs appear to decrease in the male fetal reproductive tract at the time of birth.

Hormones related to the pituitary hormones PRL and GH are produced by the utero-placental unit of many species. In the cow, these include bovine placental lactogen (bPL) and a distantly related subfamily including the protein encoded by bovine PRL-related complementary DNA I (bPRCI). In the present studies, we defined the onset of expression of these genes in order to begin to study the regulation of their expression and function before implantation. Messenger RNA levels of both bPL and bPRCI were assessed by dot blot analysis of total RNAs prepared from conceptuses on days 15-25. Specific transcripts were not detectable at day 15 but were readily apparent beginning at day 17. To define the portions of the placenta responsible for expressing these genes, RNA was prepared from chorion (separated into cotyledons and intercotyledonary membrane), allantois, and amnion from day 58 gestation and analyzed by Northern hybridization. Transcripts for both these hormones were confined to the chorion, with intercotyledonary RNA containing at least as much as that prepared from cotyledons. To localize the product of these genes, extraembryonic membranes were immunostained with bPL and bPRCI antisera. Mononucleated trophoblastic cells stained for bPL and bPRCI at day 18; similar staining was apparent at days 23 and 24, as well as in some but not all binucleated cells. Microsomes prepared from endometrium exhibited specific binding of bPL throughout pregnancy as well as during the luteal phase of the cycle. At midgestation, these high affinity, low capacity receptors (dissociation constant of 1.27 x 10(-10) M, maximum binding capacity of 44.2 fmol/mg protein) demonstrated a selective affinity for bPL in preference to bGH and bPRL. Using this radioreceptor assay, we demonstrated the presence of bPL at nanomolar concentrations in washings from the uterine lumen, suggesting that bPL may exert paracrine effects on the endometrium.