Vesela P. Kovacheva

Gestational Choline Deficiency Causes Global and Igf2 Gene DNA Hypermethylation by Up-regulation of Dnmt1 Expression

During gestation there is a high demand for the essential nutrient choline. Adult rats supplemented with choline during embryonic days (E) 11-17 have improved memory performance and do not exhibit age-related memory decline, whereas prenatally choline-deficient animals have memory deficits. Choline, via betaine, provides methyl groups for the production of S-adenosylmethionine, a substrate of DNA methyltransferases (DNMTs). We describe an apparently adaptive epigenomic response to varied gestational choline supply in rat fetal liver and brain. S-Adenosylmethionine levels increased in both organs of E17 fetuses whose mothers consumed a choline-supplemented diet. Surprisingly, global DNA methylation increased in choline-deficient animals, and this was accompanied by overexpression of Dnmt1 mRNA. Previous studies showed that the prenatal choline supply affects the expression of multiple genes, including insulin-like growth factor 2 (Igf2), whose expression is regulated in a DNA methylation-dependent manner. The differentially methylated region 2 of Igf2 was hypermethylated in the liver of E17 choline-deficient fetuses, and this as well as Igf2 mRNA levels correlated with the expression of Dnmt1 and with hypomethylation of a regulatory CpG within the Dnmt1 locus. Moreover, mRNA expression of brain and liver Dnmt3a and methyl CpG-binding domain 2 (Mbd2) protein as well as cerebral Dnmt3l was inversely correlated to the intake of choline. Thus, choline deficiency modulates fetal DNA methylation machinery in a complex fashion that includes hypomethylation of the regulatory CpGs within the Dnmt1 gene, leading to its overexpression and the resultant increased global and gene-specific (e.g. Igf2) DNA methylation. These epigenomic responses to gestational choline supply may initiate the long term developmental changes observed in rats exposed to varied choline intake in utero.

Gestational Choline Supply Regulates Methylation of Histone H3, Expression of Histone Methyltransferases G9a (Kmt1c) and Suv39h1 (Kmt1a), and DNA Methylation of Their Genes in Rat Fetal Liver and Brain

Choline is an essential nutrient that, via its metabolite betaine, serves as a donor of methyl groups used in fetal development to establish the epigenetic DNA and histone methylation patterns. Supplementation with choline during embryonic days (E) 11–17 in rats improves memory performance in adulthood and protects against age-related memory decline, whereas choline deficiency impairs certain cognitive functions. We previously reported that global and gene-specific DNA methylation increased in choline-deficient fetal brain and liver, and these changes in DNA methylation correlated with an apparently compensatory up-regulation of the expression of DNA methyltransferase Dnmt1. In the current study, pregnant rats were fed a diet containing varying amounts of choline (mmol/kg: 0 (deficient), 8 (control), or 36 (supplemented)) during E11–17, and indices of histone methylation were assessed in liver and frontal cortex on E17. The mRNA and protein expression of histone methyltransferases G9a and Suv39h1 were directly related to the availability of choline. DNA methylation of the G9a and Suv39h1 genes was up-regulated by choline deficiency, suggesting that the expression of these enzymes is under negative control by methylation of their genes. The levels of H3K9Me2 and H3K27Me3, tags of transcriptionally repressed chromatin, were up-regulated by choline supplementation, whereas the levels of H3K4Me2, associated with active promoters, were highest in choline-deficient rats. These data show that maternal choline supply during pregnancy modifies fetal histone and DNA methylation, suggesting that a concerted epigenomic mechanism contributes to the long term developmental effects of varied choline intake in utero.

Developmental pattern of expression of BMP receptors and Smads and activation of Smad1 and Smad5 by BMP9 in mouse basal forebrain.

Basal forebrain cholinergic neurons play critical roles in the organization of brain cortical structures and in processes such as learning and memory. We have previously shown that bone morphogenetic protein (BMP) 9, a member of the transforming growth factor (TGF) beta superfamily of cytokines, is a differentiating factor for cholinergic central nervous system neurons. However, whereas the basic signal transduction pathways for most known members of the TGF-beta superfamily have been well characterized in brain and other organs, nothing is known about the signal transduction pathway of BMP9 in the brain. Here, we describe the pattern of expression of BMP receptors, including Bmpr-Ia, Bmpr-Ib, Bmpr-II, Actr-I. Actr-Ib, Actr-II and Actr-IIb, Alk-1, and Smad proteins (Smads 1-5 and Smad8) in the septal region of the basal forebrain during mouse development. Using cultured basal forebrain cells derived from embryonic day (E) 14 mice, we show that BMP9 causes phosphorylation of Smad1 and Smad5, formation of a complex of Smad4 with Samd1 and/or Smad5, and translocation of these proteins into the nucleus. These data show that BMP9 activates the canonical BMP signaling pathway and suggest that this could be one of the mechanisms responsible for the induction of the cholinergic phenotype by BMP9 in the basal forebrain.

A Randomized, Double-blinded Trial of a “Rule of Threes” Algorithm versus Continuous Infusion of Oxytocin during Elective Cesarean Delivery

Background:The administration of uterotonic agents during cesarean delivery is highly variable. The authors hypothesized a “rule of threes” algorithm, featuring oxytocin 3 IU, timed uterine tone evaluations, and a systematic approach to alternative uterotonic agents, would reduce the oxytocin dose required to obtain adequate uterine tone. Methods:Sixty women undergoing elective cesarean delivery were randomized to receive a low-dose bolus or continuous infusion of oxytocin. To blind participants, the rule group simultaneously received intravenous oxytocin (3 IU/3 ml) and a “wide-open” infusion of 0.9% normal saline (500 ml); the standard care group received intravenous 0.9% normal saline (3 ml) and a “wide-open” infusion of oxytocin (30 IU in 0.9% normal saline/500 ml). Uterine tone was assessed at 3, 6, 9, and 12 min, and if inadequate, additional uterotonic agents were administered. Uterine tone, total dose and timing of uterotonic agent use, maternal hemodynamics, side effects, and blood loss were recorded. Results:Adequate uterine tone was achieved with lower oxytocin doses in the rule versus standard care group (mean, 4.0 vs. 8.4 IU; point estimate of the difference, 4.4 ± 1.0 IU; 95% CI, 2.60 to 6.15; P < 0.0001). No additional oxytocin or alternative uterotonic agents were needed in either group after 6 min. No differences in the uterine tone, maternal hemodynamics, side effects, or blood loss were observed. Conclusion:A “rule of threes” algorithm using oxytocin 3 IU results in lower oxytocin doses when compared with continuous-infusion oxytocin in women undergoing elective cesarean delivery.

Comparing the development of free movement and social citizenship for internal migrants in the European Union and China – converging trends?

Even though the European Union (EU) and China are different types of political units, this article explains why they can be compared in a meaningful way as internal migration areas. National citizenship of an EU member state is compared to hukou status in China, as both constitute relevant affiliations to geopolitical units with decisive implications for social citizenship. The development of social citizenship with regard to these affiliations is described. A periodization of developments in relation to legal affiliation and social rights since the 1950s is suggested showing that there are converging trends between the EU and China. Nowadays, the EU and China are areas of virtually free movement. However, the EU is far ahead concerning the social rights of internal migrants, while China has only recently started putting efforts in this direction. As a result, internal migrants in the EU are much better protected against the loss of social rights when leaving their country of national citizenship than Chinese migrants who leave their hukou region. The issue of whether free movement and more accessible social rights for migrants represent a step on the road towards a full set of civil and political entitlements of citizenship is reflected in the conclusions.

Acute Kidney Injury After Craniotomy Is Associated With Increased Mortality: A Cohort Study.

BACKGROUND Acute kidney injury (AKI) is a serious postoperative complication. OBJECTIVE To determine whether AKI in patients after craniotomy is associated with heightened 30-day mortality. METHODS We performed a 2-center, retrospective cohort study of 1656 craniotomy patients who received critical care between 1998 and 2011. The exposure of interest was AKI defined as meeting RIFLE (Risk, Injury, Failure, Loss of Kidney Function, and End-stage Kidney Disease) class risk, injury, and failure criteria, and the primary outcome was 30-day mortality. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both AKI and mortality. Additionally, mortality in craniotomy patients with AKI was analyzed with a risk-adjusted Cox proportional hazards regression model and propensity score matching as a sensitivity analysis. RESULTS The incidences of RIFLE class risk, injury, and failure were 5.7%, 2.9%, and 1.3%, respectively. The odds of 30-day mortality in patients with RIFLE class risk, injury, or failure fully adjusted were 2.79 (95% confidence interval [CI], 1.76-4.42), 7.65 (95% CI, 4.16-14.07), and 14.41 (95% CI, 5.51-37.64), respectively. Patients with AKI experienced a significantly higher risk of death during follow-up; hazard ratio, 1.82 (95% CI, 1.34-2.46), 3.37 (95% CI, 2.36-4.81), and 5.06 (95% CI, 2.99-8.58), respectively, fully adjusted. In a cohort of propensity score-matched patients, RIFLE class remained a significant predictor of 30-day mortality. CONCLUSION Craniotomy patients who suffer postoperative AKI are among a high-risk group for mortality. The severity of AKI after craniotomy is predictive of 30-day mortality. ABBREVIATIONS AKI, acute kidney injuryAPACHE II, Acute Physiology and Chronic Health Evaluation IICI, confidence intervalCPT, Current Procedural TerminologyICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical ModificationRIFLE, risk, injury, failure, loss of kidney function, and end-stage kidney diseaseRPDR, Research Patient Data Registry.

Serum uric acid as a novel marker for uterine atony and post-spinal vasopressor use during cesarean delivery.

INTRODUCTION Serum uric acid is a marker for oxidative stress in preeclampsia. Because oxidative stress can result in diminished uterine contractility and impaired vascular relaxation, we hypothesized that an elevated serum uric acid level in women undergoing neuraxial anesthesia for cesarean delivery would be associated with greater uterine atony, as measured by supplemental uterotonic agent use and blood loss, and less hypotension, as measured by total vasopressor use. METHODS All records of patients (n=2527) undergoing cesarean delivery in 2009 were reviewed. Serum uric acid was measured within 24h of delivery in 509 patients; data from 345 patients with singleton pregnancies undergoing neuraxial anesthesia were analyzed. Demographic data, medical and obstetric history, anesthetic management and peripartum course were evaluated. ANOVA, Chi-square, and multivariate logistic and linear regression analyses were performed. RESULTS Increased serum uric acid correlated positively with preeclampsia and the need for supplemental uterotonic agents (odds ratio 1.53, 95%CI 1.2-2.0, P=0.002), but not blood loss. The presence of preeclampsia also correlated with greater supplemental uterotonic agent use (P=0.01). The correlation between serum uric acid and post-spinal vasopressor use (i.e., none, moderate, and high) was of borderline significance (P=0.05). In patients without diabetes, serum uric acid levels correlated inversely with post-spinal vasopressor use (P=0.04). CONCLUSIONS Elevated serum uric acid in parturients undergoing cesarean delivery with neuraxial anesthesia correlated with increased use of supplemental uterotonic agents and decreased use of post-spinal vasopressors. Further validation of this study is required to determine if serum uric acid in parturients can serve as a reliable predictor for higher and lower occurrences of uterine atony and spinal-induced hypotension, respectively.

Police cooperation in internal enforcement of immigration control: learning from international comparison

Purpose – This is a comparison of the role of the police in the enforcement of immigration law in the interiors of three nations: Germany, the United Kingdom, and the United States. Methodology – The study builds upon research the authors have already done as well as desk research on recent developments. It uses three dimensions of the problem to focus the report: the hardware, software, and culture of police involvement in this issue. Findings – In Germany, the local police are responsible for the enforcement of immigration control and have relatively fast and reliable means to identify undocumented immigrants. This is not the case in the United Kingdom and the United States, but there are trends toward more local police involvement, both by institutional cooperation and by the development of better databases and documents for faster identification. These trends are highly controversial in an environment that values community relations and is highly sensitive to racial profiling. However, there are also indications that the differences in typical police work such as traffic controls and crime investigation may not be as pronounced as the differences between the countries would suggest. Research implications – This study highlights the need for ethnographic work with the police and with unauthorized immigrants to empirically describe and assess the role that the police are playing and its impact on police–community relations. Practical implications – The German experience supports the value of a comprehensive information system for rapidly determining the immigration status of suspects, but it may not work as expected in the United States and the United Kingdom, where registration and identification obligations apply to foreign citizens only. With the US and UK experiences, one could predict that discriminating identification practices may become more sensitive issues in a Germany with increasing numbers of immigrated citizens.

Gene-Centric Analysis of Preeclampsia Identifies Maternal Association at PLEKHG1Novelty and Significance

The genetic susceptibility to preeclampsia, a pregnancy-specific complication with significant maternal and fetal morbidity, has been poorly characterized. To identify maternal genes associated with preeclampsia risk, we assembled 498 cases and 1864 controls of European ancestry from preeclampsia case-control collections in 5 different US sites (with additional matched population controls), genotyped samples on a cardiovascular gene-centric array composed of variants from ≈2000 genes selected based on prior genetic studies of cardiovascular and metabolic diseases and performed case-control genetic association analysis on 27 429 variants passing quality control. In silico replication testing of 9 lead signals with P<10−4 was performed in independent European samples from the SOPHIA (Study of Pregnancy Hypertension in Iowa) and Inova cohorts (212 cases, 456 controls). Multiethnic assessment of lead signals was then performed in samples of black (26 cases, 136 controls), Hispanic (132 cases, 468 controls), and East Asian (9 cases, 80 controls) ancestry. Multiethnic meta-analysis (877 cases, 3004 controls) revealed a study-wide statistically significant association of the rs9478812 variant in the pleiotropic PLEKHG1 gene (odds ratio, 1.40 [1.23–1.60]; Pmeta=5.90×10−7). The rs9478812 effect was even stronger in the subset of European cases with known early-onset preeclampsia (236 cases diagnosed <37 weeks, 1864 controls; odds ratio, 1.59 [1.27–1.98]; P=4.01×10−5). PLEKHG1 variants have previously been implicated in genome-wide association studies of blood pressure, body weight, and neurological disorders. Although larger studies are required to further define maternal preeclampsia heritability, this study identifies a novel maternal risk locus for further investigation.

Labor and Delivery

There are multiple options for pain control during labor. The labor epidural is very safe and efficient technique. It is indicated upon request in women who are in established labor and do not have contraindications like coagulation disorders, infection, CNS space-occupying diseases or inability to cooperate. The complications of labor epidural include uneven block, multiple attempts, and failed epidural necessitating replacement, accidental intrathecal or intravascular placement, extensive or prolonged block, neurological injury, epidural abscess, and epidural hematoma. Common side effects of the labor epidural are: pruritus, nausea and vomiting, urinary retention, maternal hypotension and fever. In addition to epidural, other techniques for neuraxial anesthesia include combined spinal epidural (CSE), dural puncture epidural (DPE), and continuous spinal analgesia. The alternatives to epidural include pharmacologic medications like opioids, ketamine, dexmedetomidine and nitrous oxide, and non-pharmacologic methods like emotional support by spouse or friend, massage, hypnotherapy, hydrotherapy, and doulas. The obstetric anesthesiologist needs to have various skills not only in epidural placement and troubleshooting, but also knowledge about the fetal heart monitoring and experience in teamwork.