Aggressive vs. conservative phototherapy for infants with extremely low birth weight.

BACKGROUND: It is unclear whether aggressive phototherapy to prevent neurotoxic effects of bilirubin benefits or harms infants with extremely low birth weight (1000 g or less). METHODS: We randomly assigned 1974 infants with extremely low birth weight at 12 to 36 hours of age to undergo either aggressive or conservative phototherapy. The primary outcome was a composite of death or neurodevelopmental impairment determined for 91% of the infants by investigators who were unaware of the treatment assignments. RESULTS: Aggressive phototherapy, as compared with conservative phototherapy, significantly reduced the mean peak serum bilirubin level (7.0 vs. 9.8 mg per deciliter [120 vs. 168 micromol per liter], P<0.01) but not the rate of the primary outcome (52% vs. 55%; relative risk, 0.94; 95% confidence interval [CI], 0.87 to 1.02; P=0.15). Aggressive phototherapy did reduce rates of neurodevelopmental impairment (26%, vs. 30% for conservative phototherapy; relative risk, 0.86; 95% CI, 0.74 to 0.99). Rates of death in the aggressive-phototherapy and conservative-phototherapy groups were 24% and 23%, respectively (relative risk, 1.05; 95% CI, 0.90 to 1.22). In preplanned subgroup analyses, the rates of death were 13% with aggressive phototherapy and 14% with conservative phototherapy for infants with a birth weight of 751 to 1000 g and 39% and 34%, respectively (relative risk, 1.13; 95% CI, 0.96 to 1.34), for infants with a birth weight of 501 to 750 g. CONCLUSIONS: Aggressive phototherapy did not significantly reduce the rate of death or neurodevelopmental impairment. The rate of neurodevelopmental impairment alone was significantly reduced with aggressive phototherapy. This reduction may be offset by an increase in mortality among infants weighing 501 to 750 g at birth. (ClinicalTrials.gov number, NCT00114543.)

Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network.

OBJECTIVE: This report presents data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network on care of and morbidity and mortality rates for very low birth weight infants, according to gestational age (GA). METHODS: Perinatal/neonatal data were collected for 9575 infants of extremely low GA (22-28 weeks) and very low birth weight (401-1500 g) who were born at network centers between January 1, 2003, and December 31, 2007. RESULTS: Rates of survival to discharge increased with increasing GA (6% at 22 weeks and 92% at 28 weeks); 1060 infants died at CONCLUSION: Although the majority of infants with GAs of >or=24 weeks survive, high rates of morbidity among survivors continue to be observed.

ANAPHYLACTICALLY - MEDIATED EPITHELIAL CHLORINE ION SECRETORY RESPONSE INISOLATED JEJUNUM OF PARASITIZED GUINEA PIGS (TRICHINELLA SPIRALIS)

Electrophysiological studies were conducted to test the hypothesis that alterations in intestinal epithelial function are associated with immunological responses directed against the enteric parasite, Trichinella spirals. Trichinella antigens were used to challenge sensitized jejunum from infected guinea pigs while monitoring ion transport properties of the tissue in an Ussing-type chamber. The addition of antigen caused increases in transepithelial PD and I(,sc) that were rapidly induced, peaked at 1.5 to 2 min after antigen-challenge, and lasted 10 to 20 min thereafter. The increase in I(,sc) ((DELTA)I(,sc)) varied in a dose-dependent manner until a maximal increase of 40 (mu)A/cm('2) was obtained by the addition of 13 (mu)g of antigenic protein per ml of serosal fluid in the Ussing chamber. Trichinella antigen did not elicit alterations in either PD or I(,sc) of nonimmune tissue. Jejunal tissue from guinea pigs immunized with ovalbumin according to a protocol that stimulated homocytotropic antibody production responded electrically to challenge with ovalbumin but not trichinella antigen. Jejunal tissue which was passively sensitized with immune serum having a passive cutaneous anaphylaxis (PCA) titer of 32 for both IgE and IgG(,1) anti-trichinella anti-bodies responded electrically after exposure to trichinella antigen. Heat treatment of immune serum abolished the anti-trichinella IgE titer as determined by the PCA test but did not decrease either the electrical response of passively sensitized tissue to antigen or the anaphylactically mediated intestinal smooth muscle contractile response to antigen in the classical Schultz-Dale assay. These results strongly support the hypothesis that immunological responses directed against Trichinella Spiralis alter intestinal epithelial function and suggest that immediate hypersensitivity is the immunological basis of the response.^ Additional studies were performed to test the hypothesis that histamine and prostaglandins that are released from mucosal mast cells during IgE or IgG(,1) - antigen stimulated degranulation mediate electrophysiological changes in the intestinal epithelium that are reflective of Cl('-) secretion and mediated intracellularly by cAMP. Pharmacological and biochemical studies were performed to determine the physiological messengers and ionic basis of electrical alterations in small intestinal epithelium of the guinea pig during in vitro anaphylaxis. Results suggest that Cl('-) secretion mediated, in part, by cAMP contributes to antigen-induced jejunal ion transport changes and that histamine and prostaglandins are involved in eliciting epithelial responses. ^

THE MECHANISM OF RETINOIC ACID REGULATION OF TISSUE TRANSGLUTAMINASE GENE EXPRESSION

Retinoic acid regulates cellular growth and differentiation by altering the expression of specific sets of genes, but the molecular mechanism by which this is achieved is unknown. We have used the rapid induction of a specific enzyme, tissue transglutaminase in mouse macrophages, human leukemia cells and a variety of other cell types to study the regulation of gene expression by retinoic acid. Soluble retinoic acid binding proteins, such as cellular Retinoic Acid Binding Protein (cRABP), have been proposed as specific mediators of retinoic acid regulation of gene expression. This thesis demonstrates the lack of cRABP in a number of cell lines which are sensitive to retinoic acid regulation of tissue transglutaminase expression. These cells are also devoid of other soluble retinoic acid binding activity. The level of retinoic acid binding activity that could have been detected (6 fmol) is far below that of most cells and tissues which are sensitive to the effects of retinoic acid on growth and differentiation. A mouse melanoma cell line, S91-C2, was found to contain an unusual retinoic acid binding protein which has a lower affinity for retinoic acid than mouse tissue cRABP and also behaves differently on gel filtration HPLC chromatography.^ The induction of tissue transglutaminase by retinoic acid in macrophages is specifically inhibited by pertussis toxin. Pertussis toxin ADP-riblosylates membrane GTP-binding proteins such as N(,i) and interferes with signalling from plasma membrane receptors to regulatory enzymes. Pertussis toxin inhibition of transglutaminase induction is due to inhibition of tissue transglutaminase mRNA accumulation and is paralleled by the ADP-ribosylation of a 41,000 dalton macrophage membrane protein. It is concluded that soluble retinoic acid binding proteins are not essential for retinoic acid induction of tissue transglutaminase and that a membrane GTP-binding protein is closely linked to the sensitive response of macrophages to retinoic acid. ^

Association between glycemic index and glycemic load and the risk of incident coronary heart disease among whites and African Americans with and without type 2 diabetes: The Atherosclerosis Risk in Communities study

Several studies have examined the association between high glycemic index (GI) and glycemic load (GL) diets and the risk for coronary heart disease (CHD). However, most of these studies were conducted primarily on white populations. The primary aim of this study was to examine whether high GI and GL diets are associated with increased risk for developing CHD in whites and African Americans, non-diabetics and diabetics, and within stratifications of body mass index (BMI) and hypertension (HTN). Baseline and 17-year follow-up data from ARIC (Atherosclerosis Risk in Communities) study was used. The study population (13,051) consisted of 74% whites, 26% African Americans, 89% non-diabetics, 11% diabetics, 43% male, 57% female aged 44 to 66 years at baseline. Data from the ARIC food frequency questionnaire at baseline were analyzed to provide GI and GL indices for each subject. Increases of 25 and 30 units for GI and GL respectively were used to describe relationships on incident CHD risk. Adjusted hazard ratios for propensity score with 95% confidence intervals (CI) were used to assess associations. During 17 years of follow-up (1987 to 2004), 1,683 cases of CHD was recorded. Glycemic index was associated with 2.12 fold (95% CI: 1.05, 4.30) increased incident CHD risk for all African Americans and GL was associated with 1.14 fold (95% CI: 1.04, 1.25) increased CHD risk for all whites. In addition, GL was also an important CHD risk factor for white non-diabetics (HR=1.59; 95% CI: 1.33, 1.90). Furthermore, within stratum of BMI 23.0 to 29.9 in non-diabetics, GI was associated with an increased hazard ratio of 11.99 (95% CI: 2.31, 62.18) for CHD in African Americans, and GL was associated with 1.23 fold (1.08, 1.39) increased CHD risk in whites. Body mass index modified the effect of GI and GL on CHD risk in all whites and white non-diabetics. For HTN, both systolic blood pressure and diastolic blood pressure modified the effect on GI and GL on CHD risk in all whites and African Americans, white and African American non-diabetics, and white diabetics. Further studies should examine other factors that could influence the effects of GI and GL on CHD risk, including dietary factors, physical activity, and diet-gene interactions. ^

MODULATION OF HOST INTESTINAL MYOELECTRIC ACTIVITY BY LOCAL ANAPHYLAXIS: A COMPONENT OF PROTECTIVE IMMUNITY TO AN ENTERIC PARASITE (TRICHINELLA SPIRALIS, EIMERIA NIESCHULZI, BOWEL MOTILITY)

The hypothesis tested was that rapid rejection of Trichinella spiralis infective larvae from immunized rats following a challenge infection is associated with a local anaphylactic reaction, and this response should be reflected in altered small intestinal motility. The objective was to determine if altered gut smooth muscle function accompanies worm rejection based on the assumption that anaphylaxis in vivo could be detected by changes in intestinal smooth muscle contractile activity (ie. an equivalent of the Schultz-Dale reaction or in vitro anaphylaxis). The aims were to (1) characterize motility changes by monitoring intestinal myoelectric activity in conscious rats during the enteric phase of T. spiralis infection in immunized hosts, (2) detect the onset and magnitude of myoelectric changes caused by challenge infection in immunized rats, (3) determine the parasite stimulus causing changes, and (4) determine the specificity of host response to stimulation. Electrical slow wave frequency, spiking activity, normal interdigestive migrating myoelectric complexes and abnormal migrating action potential complexes were measured. Changes in myoelectric parameters induced by larvae inoculated into the duodenum of immune hosts differed from those associated with primary infection with respect to time of onset, magnitude and duration. Myoelectric changes elicited by live larvae could not be reproduced by inoculation of hosts with dead larvae, larval excretory-secretory products, or by challenge with a heterologous parasite, Eimeria nieschulzi. These results indicate that (1) local anaphylaxis is a component of the initial response to T. spiralis in immune hosts, since the rapid onset of altered smooth muscle function parallels in time the expression of rapid rejection of infective larvae, and (2) an active mucosal penetration attempt by the worm is necessary to elicit this host response. These findings provide evidence that worm rejection is a consequence of, or sequel to, an immediate hypersensitivity reaction elicited when parasites attempt to invade the gut mucosa of immunized hosts. ^

Control of the master virulence regulatory gene atxA in Bacillus anthracis

Transcription of the Bacillus anthracis structural genes for the anthrax toxin proteins and biosynthetic operon for capsule are positively regulated by AtxA, a transcription regulator with unique properties. Consistent with the role of atxA in virulence factor expression, a B. anthracis atxA-null mutant is avirulent in a murine model for anthrax. In batch culture, multiple signals impact atxA transcript levels, and the timing and steady state level of atxA expression is critical for optimal toxin and capsule synthesis. Despite the apparent complex control of atxA transcription, only one trans-acting protein, the transition state regulator AbrB, has been demonstrated to directly interact with the atxA promoter. The AbrB-binding site has been described, but additional cis-acting control sequences have not been defined. Using transcriptional lacZ fusions, electrophoretic mobility shift assays, and Western blot analysis, the cis-acting elements and trans-acting factors involved in regulation of atxA in B. anthracis strains containing either both virulence plasmids, pXO1 and pXO2, or only one plasmid, pXO1, were studied. This work demonstrates that atxA transcription from the major start site P1 is dependent upon a consensus sequence for the housekeeping sigma factor SigA, and an A+T-rich upstream element (UP-element) for RNA polymerase (RNAP). In addition, the data show that a trans-acting protein(s) other than AbrB negatively impacts atxA transcription when it binds specifically to a 9-bp palindrome within atxA promoter sequences located downstream of P1. Mutation of the palindrome prevents binding of the trans-acting protein(s) and results in a corresponding increase in AtxA and anthrax toxin production in a strain- and culture-dependent manner. The identity of the trans-acting repressor protein(s) remains elusive; however, phenotypes associated with mutation of the repressor binding site have revealed that the trans-acting repressor protein(s) indirectly controls B. anthracis development. Mutation of the repressor binding site results in misregulation and overexpression of AtxA in conditions conducive for development, leading to a marked sporulation defect that is both atxA- and pXO2-61-dependent. pXO2-61 is homologous to the sensor domain of sporulation sensor histidine kinases and is proposed to titrate an activating signal away from the sporulation phosphorelay when overexpressed by AtxA. These results indicate that AtxA is not only a master virulence regulator, but also a modulator of proper B. anthracis development. Also demonstrated in this work is the impact of the developmental regulators AbrB, Spo0A, and SigH on atxA expression and anthrax toxin production in a genetically incomplete (pXO1+, pXO2-) and genetically complete (pXO1+, pXO2+) strain background. AtxA and anthrax toxin production resulting from deletion of the developmental regulators are strain-dependent suggesting that factors on pXO2 are involved in control of atxA. The only developmental deletion mutant that resulted in a prominent and consistent strain-independent increase in AtxA protein levels was an abrB-null mutant. As a result of increased AtxA levels, there is early and increased production of anthrax toxins in an abrB-null mutant. In addition, the abrB-null mutant exhibited an increase in virulence in a murine model for anthrax. In contrast, virulence of the atxA promoter mutant was unaffected in a murine model for anthrax despite the production of 5-fold more AtxA than the abrB-null mutant. These results imply that AtxA is not the only factor impacting pathogenesis in an abrB-null mutant. Overall, this work highlights the complex regulatory network that governs expression of atxA and provides an additional role for AtxA in B. anthracis development.