Evaluation of previous management against a developed clinical pathway for chronic rhinosinusitis with nasal polyposis in Universiti Kebangsaan Malaysia Medical Center

The study aims to evaluate previous management of CRSwNP patients in Universiti Kebangsaan Malaysia Medical Center (UKMMC) against a developed CP.Chronic rhinosinusitis with nasal polyposis (CRSwNP) has high economic burden and impacts patient''s quality of life. Implementation of clinical pathway (CP) can standardize care while optimizing resources.Analytical cross-sectionalThis study utilized medical records of 103 CRSwNP patients at UKMMC otorhinolaryngology clinic from 2010 to 2015. Patients were divided into groups who underwent or did not undergo surgery. Information was obtained regarding sociodemographic, follow-ups, pharmaceutical regimes, and treatment cost. Cost analysis was done using top-down analysis and activity-based costing and CP was formulated. Cost was calculated using year 2020 rates to adjust for inflation. (United States Dollars [USD]1 = Ringgit Malaysia [RM] 4.2015)Study showed non-CP patients were undertreated compared to CP. This affects clinical outcomes as optimal treatment demanded by CP was not achieved. Total cost for non-CP, non-surgery patients were lower (USD660) compared to CP (USD780) due to under treatment and shorter follow-ups. Meanwhile, total cost for non-CP surgery patients were higher (USD3600) compared to CP (USD2706) due to longer visit durations and hospital stays. Non-CP surgery group underwent lengthy follow-up duration (20.7 months) prior to operation compared to 12 months expected in CP.Study showed non-CP patients were undertreated compared to CP. We identified aspects which resulted in resource wastage and unnecessary burden to our healthcare system. This study enables development of a written CP by fine-tuning various aspects of CP which could be applied to our future practice.     

Antiphospholipid antibodies and coagulation defects in women with implantation failure after IVF and recurrent miscarriage

Evaluation of patients with IVF implantation failure or recurrent miscarriage often frustratingly fails to elicit any particular cause for their problem. Testing for antiphospholipid antibodies or thrombophilia is commonly carried out, and interpretation of results in the light of the current evidence is extremely difficult. This paper reviews the purported pathogenetic mechanisms and clinical associations between both antiphospholipid antibodies and inherited thrombophilias, and reproductive failure. The current management strategies are also critically evaluated and recommendations are made for optimal, evidence-based clinical practice.     

Trophoblast debris extruded from preeclamptic placentae activates endothelial cells: A mechanism by which the placenta communicates with the maternal endothelium

Introduction

Preeclampsia is characterized by maternal endothelial dysfunction. While the mechanisms leading to preeclampsia are unclear, a factor(s) from the placenta is responsible for triggering the disease. One placental factor implicated in triggering preeclampsia is trophoblast debris which may transmit pathogenic signals from the placenta to endothelial cells. In this study, we investigated whether trophoblast debris from preeclamptic placentae triggered endothelial cell activation.

Methods

Trophoblast debris from preeclamptic or normotensive placentae, or trophoblast debris from normal placental explants that had been cultured with preeclamptic (n = 14) or normotensive sera (n = 14) was exposed to endothelial cells. Activation of the endothelial cells was quantified by cell surface ICAM-1 and U937 adhesion to endothelial cells. The levels of IL-1β, pro-caspase-1 and active caspase-1 in the trophoblast debris were measured.

Results

Compared to controls, the levels of ICAM-1 and U937 adhesion to endothelial cells were significantly increased following exposure of the endothelial cells to trophoblast debris from preeclamptic placentae or placentae treated with preeclamptic sera. The levels IL-1β, pro-caspase-1 and active caspase-1 were significantly increased in both trophoblast debris from preeclamptic placentae and placentae treated with preeclamptic sera.

Discussion

These results provide the first direct evidence that trophoblast debris produced from preeclamptic placentae or placentae treated with preeclamptic sera can activate the endothelium.

Conclusions

Trophoblast debris from preeclamptic but not normotensive placentae can induce endothelial cell activation. This may be one mechanism by which the preeclamptic placenta communicates with the maternal endothelium to induce activation of the endothelium.     

Phagocytosis of apoptotic trophoblastic debris protects endothelial cells against activation

During normal pregnancy trophoblastic debris is shed from the placenta into the maternal blood and endothelial cells may contribute to the phagocytosis of this material. Many researchers believe the majority of this trophoblastic material is apoptotic in normal pregnancy. Previously we demonstrated that phagocytosis of necrotic, but not apoptotic trophoblastic debris induced endothelial cell activation. In macrophages, phagocytosis of necrotic cell bodies leads to inflammation but phagocytosis of apoptotic bodies actively induces tolerogenic immune responses. We undertook this study to determine whether phagocytosis of apoptotic trophoblastic debris had a "tolerogenic" effect on endothelial cells analogous to their effect in macrophages. Apoptotic or necrotic trophoblastic debris was obtained from placental explants and endothelial cell activation was examined by quantifying, cell surface ICAM-1 expression using ELISAs, or monocyte adhesion. The response of endothelial cells to the activating stimuli of necrotic trophoblastic debris, interleukin-6 (IL-6), Lipopolysaccharide (LPS) or phorbol mysterate acetate (PMA) was reduced in endothelial cells that had phagocytosed apoptotic trophoblastic debris. This protective effect was short-lived being not apparent 24 h after removal of the trophoblastic debris. This work demonstrates that the ability of the endothelial cells to respond to a variety of activating stimuli is reduced by prior phagocytosis of apoptotic trophoblast debris. This might explain why endothelial cells are not activated by the small numbers of necrotic trophoblastic debris that may be found in normal pregnancy. This phenomenon may also contribute to the maternal vascular adaptation that occurs in normal pregnancy.     

Pre-treatment with calcium prevents endothelial cell activation induced by multiple activators,necrotic trophoblastic debris or IL-6 or preeclamptic sera: Possible relevance to the pathogenesis of preeclampsia

Introduction

A hallmark of preeclampsia is endothelial cell dysfunction/activation in response to “toxins” from the placenta. Necrotic trophoblastic debris (NTD) is one possible placental toxin and others include inflammatory cytokines. Calcium supplementation appears to protect “at-risk” women from developing preeclampsia by an unknown mechanism. In this study we investigate whether the addition of high levels of calcium to endothelial cells prior to their exposure to the preeclampsia-associated activators could reduce the endothelial cell activation.

Methods

NTD was harvested from 1st trimester placental explants. Endothelial cells were treated with varied concentrations of calcium prior to exposure to NTD, IL-6 or preeclamptic sera or low levels of calcium. Activation was monitored by quantifying endothelial cell-surface ICAM-1 by ELISA or U937 adhesion to endothelial cells. The activity of endothelial cell nitric oxide synthetase was blocked with L-NAME.

Results

Pre-treatment with increasing concentrations of calcium inhibited the activation of endothelial cells in response to NTD or IL-6 or preeclamptic sera. Inhibiting nitric oxide synthetase, using L-NAME, reduced the ability of high calcium levels to protect endothelial cell activation. Pre-treatment with calcium did not prevent endothelial cell activation induced by the reduction of the levels of calcium but additional calcium treatment did prevent endothelial cell activation induced by low calcium.

Conclusion

Our results demonstrate calcium supplementation may prevent the activation of the endothelium in response to activators. These results may partially explain the benefits of calcium supplementation in the reduction of risk for developing preeclampsia and provide in vitro mechanistic support for the use of calcium supplementation in at-risk women.     

Does oxygen concentration affect shedding of trophoblastic debris or production of inflammatory mediators from first trimester human placenta?

Preeclampsia is a major cause of pregnancy morbidity and mortality. It is hypothesised that necrotic syncytial knots and/or inflammatory factors released from the placenta into the maternal circulation are responsible for inducing the widespread endothelial cell activation that is seen in preeclampsia. Poor placental perfusion has been associated with preeclampsia, this had led to the hypothesis that placental hypoxia has an important role in the pathogenesis of preeclampsia. In this study, using a placental explant model, we investigated whether different oxygen environments induced abnormal shedding of trophoblastic debris or secretion of cytokines from the placenta. There was no significant difference in the numbers of trophoblasts shed from explants cultured in 1% or 8% oxygen containing environments. There was also no difference in the levels of activated caspases in trophoblasts shed from explants cultured in these two oxygen environments nor was there a significant difference in the endothelial cell responses to trophoblasts shed from explants cultured in 1% or 8% oxygen. Similarly, there was no significant change in the secretion of nine cytokines into the conditioned medium from explants cultured in 1% or 8% oxygen. This study supports the growing evidence that levels of oxygen in the placental environment during the first trimester of pregnancy may not in itself be the essential component contributing to the pathogenesis of preeclampsia.     

Trophoblast deportation: just a waste disposal system or antigen sharing?

Trophoblast deportation, the removal of trophoblastic debris from the placenta via the maternal blood, was first described over 100 years ago. Deported trophoblastic debris ranges in size from nano-meter scale subcellular particles to large multinucleated syncytial knots. Whether trophoblast deportation has any biological significance remains unclear. However, the (semi) allogeneic fetus must induce maternal tolerance to paternally inherited placental antigens. We propose that the clearance of deported trophoblasts may be a mechanism by which the maternal immune system is maintained in a state of tolerance towards paternal antigens. Using an in vitro model, we have shown that when syncytial knots are shed by an apoptosis-like programmed cell death process, then phagocytosed by macrophages, the macrophages produce a tolerogenic response. However, necrotic syncytial knots, when phagocytosed, appear to be immunostimulatory. We have also shown that endothelial cells are likely to be involved in the clearance of syncytial knots from the pulmonary vessels. Phagocytosis of apoptotic syncytial knots by endothelial cells is silent while phagocytosis of necrotic syncytial knots leads to endothelial cell activation characterised by increased endothelial cell-surface adhesion molecule expression and secretion of IL-6 and TGFβ1. All of these molecules may interact with the maternal immune system to exacerbate any adverse maternal response. We propose that in normal pregnancy clearance of apoptotic syncytial knots is important to maintain maternal immune tolerance to the fetus and that in abnormal pregnancies, especially preeclampsia, clearance of necrotic syncytial knots may contribute to the pathogenesis of that condition.     

De novo 16p13.11 microdeletion identified by high-resolution array CGH in a fetus with increased nuchal translucency

Objective  We investigated the application of high-resolution microarray-based comparative genomic hybridisation (array CGH) on a fetus showing increased nuchal translucency (NT).
Design  Case study.
Setting  Tertiary referral obstetrics unit.
Sample  Pregnant woman attended the antenatal clinic.
Methods  Conventional karyotyping and genetic test was carried out for the alpha-globin gene. High-resolution array CGH using the high-density 244K Agilent microarray was performed on fetal blood sample by cordocentesis to investigate the possibility of any genomic imbalance.
Main outcome measures  Detection of chromosomal abnormality.
Results  Karyotyping analysis showed 46,XY. Molecular genetic diagnosis confirms the fetus has Hb-H constant spring disease but cannot explain the increased NT to 3.2 mm. Array CGH analysis discovered a 1.32-Mb microdeletion on chromosome 16p13.11. Deletion at 16p13.11 has been implicated to predispose to autism and/or mental retardation. Baby was delivered at 40 weeks of gestation, and follow up was carried out at 3 months of age without sign of mental retardation/developmental delay.
Conclusions  This case study demonstrated that array CGH can accurately calibrate the size and identify de novo interstitial chromosome imbalances. However, the presence of chromosome copy variants with unknown clinical significance currently limits its wider scale application in prenatal diagnosis and needs further investigations.     

Spreading endothelial cell dysfunction in response to necrotic trophoblasts. Soluble factors released from endothelial cells that have phagocytosed necrotic shed trophoblasts reduce the proliferation of additional endothelial cells

The pathogenesis of preeclampsia is not clear but the disease is characterised by systemic endothelial cell dysfunction that is considered to be triggered by a placental factor. Necrotic trophoblastic debris that is deported in the maternal blood is one possible placental trigger for preeclampsia. Syncytial knots were first associated with preeclampsia over 100 years ago. However, syncytial knots are very large and most are trapped in the pulmonary capillaries making it difficult to envisage how they could lead to widespread systemic endothelial cell dysfunction. This study was undertaken to examine whether conditioned medium from endothelial cells that have phagocytosed necrotic trophoblastic debris could adversely affect the proliferation or survival of fresh endothelial cells. Trophoblastic cellular debris, harvested from placental explants was added to endothelial cell monolayers directly or after induction of necrosis by freeze-thawing. Conditioned medium from the endothelial cell cultures was exposed to fresh endothelial cells and their proliferation measured by Alamar Blue, and CyQUANTNF cell proliferation assays. Endothelial cell death was examined by a fluorogenic caspase-3 activity assay and LDH release. Conditioned medium from endothelial cells that had phagocytosed necrotic but not apoptotic trophoblastic debris significantly inhibited the proliferation of fresh endothelial cells but did not induce their death. The conditioned medium also reduced cell-surface endoglin expression by fresh endothelial cells. These results confirm that phagocytosis of necrotic trophoblastic debris by endothelial cells results in the secretion of soluble factors that might explain how necrotic trophoblastic debris trapped in the pulmonary capillaries could induce systemic endothelial cell dysfunction.