Transposition Of Great Vessels

Diagnostic Strategy for Suspected Unilateral Absence of the Pulmonary Artery

Background: Unilateral absence of the pulmonary artery (UAPA) is a very rare congenital anomaly.

Objective: To analyze the diagnostic strategy applied to seven patients with UAPA who were examined and subsequently treated at the National Lung Hospital, Hanoi, Vietnam.

Methods: All seven patients, including three pediatric cases (1, 2, and 14 years old) and four adult cases (21, 26, 44, and 53 years old), had a history of recurrent pneumonia, and the clinical symptoms on admission included cough, progressive dyspnea, chest pain, and fatigue. The patients were initially examined clinically, followed by hematological testing, blood biochemistry testing, and chest X-ray radiology. The results suggested UAPA, so echocardiography and contrast-enhanced chest computed tomography (CT) were performed as soon as practical.

Results: The echocardiographic and CT imaging findings confirmed the suspected diagnosis of UAPA in all seven patients, which was accompanied by congenital heart disease in three patients. Three of the seven patients had mild and medium pulmonary hypertension. All seven patients were treated with drugs, which led to improvement in symptoms.

Conclusion: Frontal chest X-ray provided the initial signs suggesting a diagnosis of UAPA. Subsequent echocardiography and contrast-enhanced chest CT were effective diagnostic tools for fast and accurate confirmation of UAPA.

Identifying Predictors for Hypoplastic Aortic Arch (HAA) in Pediatric Patients with Complex Coarctation of the Aorta (CoA)

Objective: HAA is a significant risk factor in complex CoA patients. We conducted a retrospective study to explore the relationship between HAA and other cardiovascular factors.

Methods: We analyzed 103 patients diagnosed with complex CoA using CT angiography and echocardiography. Aortic diameter was measured at six levels, and severe coarctation was defined as coarctation site to diaphragmatic level ratio (CDR) < 50%. Correlations between non-HAA and HAA groups were assessed. Univariate and multivariate logistic regression identified HAA risk factors.

Results: Among 103 children with complex CoA, 55 were in the non-HAA group and 48 in the HAA group. The incidence of PDA (56.3% vs. 32.7%, p < 0.05), severe coarctation (CDR < 50%, 81.3% vs. 34.5%, p < 0.01), and collateral arteries (39.6% vs. 0, p < 0.01) were higher in the HAA group than one in the non-HAA group. The aortic arch size was positively correlated with age and negatively correlated with severe coarctation, VSD, collateral arteries, and left heart dysfunction. Logistic regression results showed that collateral arteries were risk factors for the whole aortic arch (proximal arch OR = 11.458; p < 0.01, distal arch OR = 4.211; p < 0.05, and isthmus OR = 11.744; p < 0.01), severe coarctation (OR = 6.653; p < 0.01), and left heart dysfunction (OR = 5.149; p < 0.01) associated with isthmus hypoplasia.

Conclusion: This study highlights the prevalence of HAA in complex CoA patients and its associations with various cardiovascular factors. These insights improve diagnosis and treatment approaches.

Pulmonary Hypertension associated with Congenital Heart Disease

Pulmonary hypertension in patients with congenital heart disease is associated with significant mortality, morbidity and health services utilization. The predominant subtype of pulmonary hypertension in these patients is pulmonary arterial hypertension (PAH). PAH associated with congenital heart disease (PAH-CHD) comprises up to one-third of all PAH cases globally and is most commonly associated with anatomically simple shunt lesions. A myriad of clinical phenotypes of PAH-CHD are seen across the spectrum of shunt size, location and directionality. A conceptual framework to categorize these patients based on pathophysiology is described. Contemporary data regarding the management of the varied phenotypes are reviewed, and a novel algorithm to guide decision-making with shunt closure in patients with PAH-CHD is provided. Further data spanning the spectrum of basic, translational and clinical science are much needed to further inform the management of this highly complex and heterogeneous population.

Pulmonary Arterial Hypertension (PAH) Group 1 (Part A): Overview, Classification, Clinical Subsets, and Workup

Pulmonary hypertension is a rare, progressive disease characterized by increased pulmonary arterial pressure and right ventricular failure due to pulmonary vascular remodeling. The disease definition and management have evolved over time. The 6th WSPH now defines it as a mean pulmonary arterial pressure >20mmHg, while recent ESC/ERS guidelines recommend lowering the threshold for pulmonary vascular resistance to 2WU.

Understanding of the disease has improved through registries, classifying it into five distinct groups with similar histology, pathophysiology, and therapeutic approaches. These groups include PAH, with heritable and idiopathic causes, as well as various clinical subsets involving connective tissue disease, HIV, portopulmonary hypertension, congenital heart disease, and schistosomiasis. Long-term responders to calcium channel blockers, PAH with venous/capillaries involvement, and persistent PH of newborns are categorized under Group 1, now re-classified as IPAH.

A comprehensive workup for suspected patients includes various tests like electrocardiogram, pulmonary function testing, autoimmune workup, HIV testing, echocardiogram, right heart catheterization, and cardiopulmonary exercise testing.

This review emphasizes the disease's definition and epidemiology, delving into each subset and providing updated workup guidelines. The subsequent article will focus on risk stratification and treatment strategies.

Cardiovascular Diseases in Pregnancy - A Brief Overview

Even though, there have been many advances in maternal medical care and fertility treatments, the presence of cardiovascular disease has a significant impact on pregnancy. In pregnant women, several heart conditions, such as valvular heart disease, chronic hypertension, congenital heart defects and non-ischemic cardiomyopathies are linked to increased risk of fetal as well as maternal morbidity and mortality. To date, the management of the co-existing conditions of pregnancy and heart disease has been challenging. Therefore, in-depth information may be beneficial to tackle a difficult case scenario. Towards this end, this paper provides an overview of the recent updated knowledge of pregnancy-related cardiovascular diseases in women.

Current Non-viral Gene Therapy Strategies for the Treatment of Glioblastoma

Background: Glioblastoma constitutes the most frequent and aggressive primary malignant brain tumor in adults. Despite the advances in its treatment, its prognosis remains very poor. Gene therapy has been proposed as a complementary treatment since it may overcome the problem of the blood-brain barrier for systemic therapies, allowing to target tumor cells and their tumor microenvironment locally, without affecting the normal brain parenchyma. In comparison with viral vectors, non-viral vectors became an attractive tool due to their reduced potential of biosafety risks, lower cost, higher availability, and easy storage.

Objective: In this article, we aimed to outline the current preclinical and clinical developments of non-viral delivery systems for therapeutic transgene delivery in malignant gliomas.

Conclusion: Non-viral vectors are efficient tools for gene delivery since they exhibit reduced non-specific cytotoxicity and can go through several modifications in order to achieve high tumor tropism and the ability to cross the blood-brain barrier to access the tumor mass. However, further evaluations in preclinical models and clinical trials are required in order to translate it into the neuro-oncology clinic.

Revealing Insights into Natural Products Against mcr-1-Producing Bacteria

Bacterial resistance has become a major global concern, affecting about 500, 000 individuals in 22 countries. Thus, it is clear that Gram-negative bacteria have been receiving more attention in this scenario. These bacteria perform several resistance mechanisms, such as modifying lipid A from lipopolysaccharides as a product of the mcr-1 gene expression. This gene was initially identified in animals; however, it quickly spread to humans, spreading to 70 countries. Mcr-1 gene attributes resistance to polymyxin B and colistin, which are drugs established as the last alternative to combat Enterobacteriaceae bacteria.

Notwithstanding the prevalence and lack of antibiotic therapies for such bacteria, this article aimed to compile information about natural compounds against the resistance attributed by this gene, including the activity of isolated colistin or its associations with other antibiotics. Among the studies that evaluated colistin's synergistic action with other compounds, azidothymidine and isoalantholactone stood out. On the other hand, the paenipeptin 1 analog showed satisfactory activities when associated with other antibiotics. Besides, it is worth mentioning that molecular docking results between ostole and eugenol toward phosphoethanolamine transferase MCR-1 revealed that these compounds could interact with critical amino acid residues for the catalytic action of this enzyme. Based on this, natural agents' role is evident against infections caused by mcr-1-positive bacteria, directly contributing to the development of new effective pharmacotherapies.

Recent Advances in the Transition Metal-Catalyzed Addition of Carboxylic Acids to Alkynes

Recent advances in the metal-catalyzed hydrofunctionalization of alkynes with carboxylic acids are comprehensively reviewed. Both inter- and intramolecular processes, leading respectively to enol esters and lactones, are discussed, as well as the involvement of these transformations in the synthesis of natural products and biologically active molecules, and the assembly of elaborated heterocyclic compounds through cascade processes. Literature published since 2011 is covered.

Renin-Angiotensin System in Central Nervous System Diseases and its Interaction with COVID-19

Background: The Renin-Angiotensin System (RAS) comprises a complex molecular cascade with two counter-regulatory axes, the classical and the alternative. Angiotensin II and Angiotensin-(1-7), the main peptides of the RAS, exert opposite effects in multiple organs and systems, including the cardiovascular, renal, pulmonary, and immune systems. Strong evidence supports the hypothesis of a local RAS in the Central Nervous System (CNS) and its modulatory roles in neuroendocrinology and neurotransmission.

Objective: In this narrative review, we provide a comprehensive approach to experimental and clinical data regarding RAS molecule expression and their possible roles in the physiology and physiopathology of CNS diseases.

Methods: This non-systematic review summarizes evidence on RAS implications in CNS diseases and their possible relationships with COVID-19.

Results: We divided the possible RAS mechanisms in distinct conditions during the lifespan, approaching from congenital infections to neurodegenerative alterations, passing through mood disorders and cerebrovascular diseases. We also gathered current evidence about the possible effects of RAS in Covid-19, particularly in cases with neurological manifestations.

Conclusion: Although there are limitations and controversies, the analysis of RAS mechanisms in the CNS certainly represents an interesting field of research. However, further investigation is necessary to support the noteworthy interactions and provide a better comprehension of the cross-talk between RAS and the CNS. Investigations in this research field may shed light on the novel therapeutic targets.

A Review of Selected Adult Congenital Heart Diseases Encountered in Daily Practice

The advancement in corrective surgical procedures and anaesthesia technology has resulted in the increased survival of patients with Congenital Heart Diseases (CHD). Most of the surviving CHD patients have successfully reached adulthood and those surviving adults now outnumber the infants born with the CHD. Unfortunately, the surviving adults with CHD do not get proper care due to either inconsistent follow-up or not getting care from a specialist in the field of CHD. It is imperative for general practicing clinicians to be aware of the congenital diseases as well as the current clinical recommendations. This manuscript reviews some of the common congenital diseases seen in adults such as cardiac shunts, left heart obstructive lesions, and aortopathies.

Benzimidazole: A Multifacted Nucelus for Anticancer Agents

Cancer is characterized by an uncontrolled proliferation of cells, dedifferentiation, invasiveness and metastasis. Endothelial growth factor (eGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), Fibroblast growth factor (FGF), Vascular endothelial growth factor (VEGF), checkpoint kinase 1 & 2 ( Chk1 & Chk2), aurora kinases, topoisomerases, histone deacetylators (HDAC), poly(ADP-Ribose)polymerase (PARP), farnesyl transferases, RAS-MAPK pathway and PI3K-Akt-mTOR pathway, are some of the prominent mediators implicated in the proliferation of tumor cells. Huge artillery of natural and synthetic compounds as anticancer, which act by inhibiting one or more of the enzymes and/or pathways responsible for the progression of tumor cells, is reported in the literature. The major limitations of anticancer agents used in clinics as well as of those under development in literature are normal cell toxicity and other side effects due to lack of specificity. Hence, medicinal chemists across the globe have been working for decades to develop potent and safe anticancer agents from natural sources as well as from different classes of heterocycles. Benzimidazole is one of the most important and explored heteronucelus because of their versatility in biological actions as well as synthetic applications in medicinal chemistry. The structural similarity of amino derivatives of benzimidazole with purines makes it a fascinating nucleus for the development of anticancer, antimicrobial and anti-HIV agents. This review article is an attempt to critically analyze various reports on benzimidazole derivatives acting on different targets to act as anticancer so as to understand the structural requirements around benzimidazole nucleus for each target and enable medicinal chemists to promote rational development of antitumor agents.

Targeted Delivery for Neurodegenerative Disorders Using Gene Therapy Vectors: Gene Next Therapeutic Goals

The technique of gene therapy, ever since its advent nearly fifty years ago, has been utilized by scientists as a potential treatment option for various disorders. This review discusses some of the major neurodegenerative diseases (NDDs) like Alzheimer’s disease (AD), Parkinson’s Disease (PD), Motor neuron diseases (MND), Spinal Muscular Atrophy (SMA), Huntington’s Disease (HD), Multiple Sclerosis (MS), etc. and their underlying genetic mechanisms along with the role that gene therapy can play in combating them. The pathogenesis and the molecular mechanisms specifying the altered gene expression of each of these NDDs have also been discussed in elaboration. The use of gene therapy vectors can prove to be an effective tool in the field of curative modern medicine for the generations to come. Therefore, consistent efforts and progressive research towards its implementation can provide us with powerful treatment options for disease conditions that have so far been considered as incurable.

Cardiovascular Complications in Patients with Klinefelter’s Syndrome

More than 70 years have passed since the first description of Klinefelter Syndrome (KS), the most frequent chromosome disorder causing male infertility and hypogonadism. KS is associated with increased cardiovascular (CV) mortality due to several comorbidities, including hypogonadism, as well as metabolic syndrome and type 2 diabetes, which are highly prevalent in these patients. Aside from metabolic disturbances, patients with KS suffer from both acquired and congenital CV abnormalities, cerebrovascular thromboembolic disease, subclinical atherosclerosis and endothelial dysfunction, which may all contribute to increased CV mortality. The mechanisms involved in this increased risk of CV morbidity and mortality are not entirely understood. More research is needed to better characterise the CV manifestations, elucidate the pathophysiological mechanisms and define the contribution of testosterone replacement to restoring CV health in KS patients. This review explores the complex association between KS, metabolic syndrome and CV risk in order to plan future studies and improve strategies to reduce mortality in this high-risk population.

Therapeutic Utilities of Pediatric Cardiac Catheterization

In an era when less invasive techniques are favored, therapeutic cardiac catheterization constantly evolves and widens its spectrum of usage in the pediatric population. The advent of sophisticated devices and well-designed equipment has made the management of many congenital cardiac lesions more efficient and safer, while providing more comfort to the patient. Nowadays, a large variety of heart diseases are managed with transcatheter techniques, such as patent foramen ovale, atrial and ventricular septal defects, valve stenosis, patent ductus arteriosus, aortic coarctation, pulmonary artery and vein stenosis and arteriovenous malformations. Moreover, hybrid procedures and catheter ablation have opened new paths in the treatment of complex cardiac lesions and arrhythmias, respectively. In this article, the main therapeutic utilities of cardiac catheterization in children are discussed.

Stem Cells in Skeletal Tissue Engineering: Technologies and Models

This review surveys the use of pluripotent and multipotent stem cells in skeletal tissue engineering. Specific emphasis is focused on evaluating the function and activities of these cells in the context of development in vivo, and how technologies and methods of stem cell-based tissue engineering for stem cells must draw inspiration from developmental biology. Information on the embryonic origin and in vivo differentiation of skeletal tissues is first reviewed, to shed light on the persistence and activities of adult stem cells that remain in skeletal tissues after embryogenesis. Next, the development and differentiation of pluripotent stem cells is discussed, and some of their advantages and disadvantages in the context of tissue engineering are presented. The final section highlights current use of multipotent adult mesenchymal stem cells, reviewing their origin, differentiation capacity, and potential applications to tissue engineering.

Preoperative and Follow up Multi-Detector Row CT Angiography (MDCTA) in the Evaluation of Interrupted Aortic Arch (IAA)

Purpose: The aim of our study is to investigate the ability of preoperative and follow-up multi-detector row CT angiography (MDCTA) in evaluating interrupted aortic arch (IAA).

Materials and Methods: MDCTA and echocardiography (ECHO) were performed preoperatively and postoperatively in nine patients (6 males and 3 females, average age: 4.7 years) with surgically confirmed IAA. The preoperative and follow-up images were analyzed retrospectively and compared with operative findings.

Results: Of the nine IAA cases, eight were type A, and one was type B. All cases were diagnosed correctly by MDCTA with 100% sensitivity. The MDCTA findings were highly concordant with the operative findings as well as with the various combined cardiac anomalies, including patent ductus arteriosus (PDA) (N=7); ventricular septal defect (VSD) (N=6); double outlet right ventricle and atrial septal defect (ASD) (N=1); aortopulmonary window and right pulmonary artery arising from the ascending aorta (N=1); and abnormal enlarged collateral vessels connecting with the descending aorta and enlarged internal mammary artery without PDA, ASD or VSD (N=2; ages 15 and 13 years old). Only five patients correctly diagnosed by ECHO with 56% sensitivity, two were misdiagnosed with coarctation of the aorta (CoA), and the remaining two were missed diagnoses. In the follow-up period, descending aorta saccular aneurysm combining thrombus at the distal end of the stoma was found in one case by MDCTA but missed by ECHO, and this MDCTA finding was further confirmed by operative findings. No postoperative complications were found in the other cases.

Conclusions: MDCTA can display the pathological anatomy of IAA and its combined malformations in a reliable manner. With an improved detection rate of malformations compared with that of ECHO, MDCTA may have high diagnostic value in detecting IAA and its postoperative complications.

Scaffolds for Bone Regeneration: State of the Art

Nowadays, millions of people worldwide are affected by problems of bones and articulations. These conditions represent about a half of the chronic diseases developed in individuals over 50 years, leading to problems of prolonged pain and physical inability, which usually require surgery, where bone grafts or implants are used. Nonetheless, despite the success of these therapeutic solutions, some drawbacks have been pointed out, related with the risk of developing infections after implant application within the body. Moreover, grafts are associated to pain, infection, tissue death at the donor site and immunological rejection.

To overcome these limitations, tissue engineering has an important role that constitutes a promising area for repair and rebuild bone lesions, through the development of three-dimensional (3D) porous matrices, commonly known as scaffolds. Associated with these structures are mesenchymal stem cells and growth factors, which lead to the formation of new bone by stimulating the natural regeneration ability of the patient's tissue.

In this review, we address the most important methodologies and concepts regarding tissue engineering for the replacement of bone tissue. The concept of scaffold, and examples of different types of scaffolds and their respective production methods are presented. In vitro and in vivo techniques to evaluate the suitability of scaffolds for human use are discussed. In addition, some of the most recent studies regarding the application of scaffolds for bone tissue engineering are described.

Management of the Low Cardiac Output Syndrome Following Surgery for Congenital Heart Disease

The purpose of this review is to discuss the management of the low cardiac output syndrome (LCOS) following surgery for congenital heart disease. The LCOS is a well-recognized, frequent post-operative complication with an accepted collection of hemodynamic and physiologic aberrations. Approximately 25% of children experience a decrease in cardiac index of less than 2 L/min/m2 within 6-18 hours after cardiac surgery. Post-operative strategies that may be used to manage patients as risk for or in a state of low cardiac output include the use of hemodynamic monitoring, enabling a timely and accurate assessment of cardiovascular function and tissue oxygenation; optimization of ventricular loading conditions; the judicious use of inotropic agents; an appreciation of and the utilization of positive pressure ventilation for circulatory support; and, in some circumstances, mechanical circulatory support. All interventions and strategies should culminate in improving the relationship between oxygen supply and demand, ensuring adequate tissue oxygenation.

Therapeutic Potential of N-Acetylcysteine for Wound Healing, Acute Bronchiolitis, and Congenital Heart Defects

Background: Wound healing is a composite and vital process in which devitalized tissue layers and cellular structures repair themselves. Bronchiolitis is generally prompted by respiratory syncytial virus or human metapneumovirus; this condition is an acute inflammatory injury of bronchioles. Heart problems that develop before birth are known as congenital heart defects (CHDs), and pregestational diabetes is considered a major predisposing factor of CHDs. N-Acetylcysteine (NAC) is a transformed kind of amino acid cysteine which restores the intracellular levels of the natural antioxidant glutathione when taken internally, thereby assisting the cells’ ability to diminish the damaging effects of reactive oxygen species (ROS).

Objective: In the present communication, NAC’s therapeutic potential for wound healing, acute bronchiolitis, and congenital heart defects (CHDs) is critically analyzed by reviewing its effect on the various targets of these diseases. The multifunctional nature of NAC is outlined in a review of evidence from in vitro and in vivo studies.

Conclusion: In conclusion, NAC could be used as a therapeutic agent in the treatment of wound healing, acute bronchiolitis and congenital heart defects (CHDs). The focus of future research should be the following; (1) to examine NAC clinically to be considered in the treatment of wound healing; (2) to investigate whether NAC could be used alone or with insulin to prevent CHDs in infants with pregestational diabetes; (3) to evaluate the application of NAC as a potential agent for PAH treatment.

Pulmonary Vasodilators in the Management of Low Cardiac Output Syndrome After Pediatric Cardiac Surgery

Pulmonary hypertension is among the causes of low cardiac output syndrome after neonatal and pediatric cardiac surgery. In the setting of transient postoperative myocardial dysfunction, even a moderate elevation of pulmonary pressure can result in heart dysfunction and circulatory collapse. Although, specific pharmacological manipulation of pulmonary vascular resistance is frequently required in the perioperative period, there is no widely standardized management. In this review, a systematic literature search of PubMed and MEDLINE databases using relevant terms was performed. All clinical trials and relevant manuscripts, along with important physiological, pharmacological, and evidence-based considerations involving the use of pulmonary vasodilators in the management of low cardiac output syndrome after cardiac surgery were reviewed. This article addresses the fifth of eight topics comprising the special issue entitled “Pharmacologic strategies with afterload reduction in low cardiac output syndrome after pediatric cardiac surgery”.

Non-viral Delivery Systems for the Application in p53 Cancer Gene Therapy

A key barrier to the development of gene therapy remains the lack of safe, efficient and easily controllable vehicles for gene delivery. The fundamental problems associated with the viral vehicles, e.g. lack of specificity and immunogenic potential, have driven the development of non-viral systems of gene delivery. In the last decade, studies on p53 gene replacement therapy have dominated the literature. Although clinical trials of p53 gene therapy have achieved limited success, it remains the only tumor suppressor gene to be evaluated formally in clinical trials for cancer treatment, with increasing focus on delivery using non-viral systems. In this article, we particularly review current investigations on p53 gene delivery using non-viral methods, including both physical and chemical approaches, with an emphasis on the latter. The existing opportunities and challenges for successful p53 cancer gene therapy are also discussed.

A Review of Systemic Vasodilators in Low Cardiac Output Syndrome Following Pediatric Cardiac Surgery

Following surgery for congenital heart disease, patients develop a predictable and progressive decline in cardiac output known as low cardiac output syndrome. During low cardiac output states, a compensatory response to increase systemic perfusion occurs both innately and as part of the postoperative pharmacologic support strategies intended to increase or sustain adequate oxygen delivery. The result typically involves a rise in systemic vascular resistance and heart rate. These and other responses may actually limit the ability of the recently operated heart to provide sufficient cardiac output to meet the oxygen demands of the body. In order to improve systemic oxygen delivery, clinicians have increasingly employed systemic vasodilator therapy to reduce afterload and improve ventriculoarterial coupling. This review will summarize currently utilized pharmacologic agents that promote systemic vasodilation and improve cardiac output through afterload reduction. This article addresses the fourth of eight topics comprising the special issue entitled “Pharmacologic strategies with afterload reduction in low cardiac output syndrome after pediatric cardiac surgery”.

Current Genome Editing Tools in Gene Therapy: New Approaches to Treat Cancer

Gene therapy suggests a promising approach to treat genetic diseases by applying genes as pharmaceuticals. Cancer is a complex disease, which strongly depends on a particular genetic make-up and hence can be treated with gene therapy. From about 2,000 clinical trials carried out so far, more than 60% were cancer targeted. Development of precise and effective gene therapy approaches is intimately connected with achievements in the molecular biology techniques. The field of gene therapy was recently revolutionized by the introduction of “programmable” nucleases, including ZFNs, TALENs, and CRISPR, which target specific genomic loci with high efficacy and precision. Furthermore, when combined with DNA transposons for the delivery purposes into cells, these programmable nucleases represent a promising alternative to the conventional viral-mediated gene delivery. In addition to “programmable” nucleases, a new class of TALE- and CRISPR-based “artificial transcription effectors” has been developed to mediate precise regulation of specific genes. In sum, these new molecular tools may be used in a wide plethora of gene therapy strategies. This review highlights the current status of novel genome editing tools and discusses their suitability and perspectives in respect to cancer gene therapy studies.

Tetralogy of Fallot and Hypoplastic Left Heart Syndrome – Complex Clinical Phenotypes Meet Complex Genetic Networks

In many cases congenital heart disease (CHD) is represented by a complex phenotype and an array of several functional and morphological cardiac disorders. These malformations will be briefly summarized in the first part focusing on two severe CHD phenotypes, hypoplastic left heart syndrome (HLHS) and tetralogy of Fallot (TOF). In most cases of CHD the genetic origin remains largely unknown, though the complexity of the clinical picture strongly argues against a dysregulation which can be attributed to a single candidate gene but rather suggests a multifaceted polygenetic origin with elaborate interactions. Consistent with this idea, genome-wide approaches using whole exome sequencing, comparative sequence analysis of multiplex families to identify de novo mutations and global technologies to identify single nucleotide polymorphisms, copy number variants, dysregulation of the transcriptome and epigenetic variations have been conducted to obtain information about genetic alterations and potential predispositions possibly linked to the occurrence of a CHD phenotype. In the second part of this review we will summarize and discuss the available literature on identified genetic alterations linked to TOF and HLHS.

Biochemical Markers for Brain Injury Monitoring in Children with or without Congenital Heart Diseases

Perinatal asphyxia (PA) still constitutes a common complication involving a large number of infants with or without congenital heart diseases (CHD). PA affects 0.2-0.6% of full-term neonates, 20% of which suffer mortal hypoxic-ischemic encephalopathy, and among survivors 25% exhibit permanent consequences at neuropsychological level. Each year, about one third of 1000 live births underwent to surgical intervention in early infancy and/or are at risk for ominous outcome. Advances in brain monitoring, in anesthetic and cardiothoracic surgical techniques, including selective or total body cooling, cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest, have essentially reduced mortality expanding the possibility to address functional neurologic and cardiac outcomes in long-term survivors. However, open-heart surgery constitutes a time-frame of planned ischemia-reperfusion injury, which is a price to pay in the treatment or palliation of CHD. Infants who underwent heart surgery and non-CHD infants complicated by PA share similarities in their neurodevelopmental profile and a common form of brain damage due to hypoxic–ischemic injury.

The purpose of the present review was to evaluate different mechanisms implicated in brain injury following CPB and PA and how it is possible to monitor such injury by means of available biomarkers (S100B protein, Activin A, Adrenomedullin).

Congenital Heart Disease: The Crossroads of Genetics, Epigenetics and Environment

Congenital heart diseases (CHDs) are recognized as the most common type of birth malformations. Although recent advances in pre- and neonatal diagnosis as well as in surgical procedures have reduced the morbidity and mortality for many CHD, the etiology for CHD remains undefined. In non-syndromic and isolated (without a familial history or a Mendelian inheritance) forms of CHDs, a multifactorial pathogenesis with interplay between inherited and non-inherited causes is recognized. In this paper, we discuss the current knowledge of the potential molecular mechanisms, mediating abnormal cardiac development in non-syndromic and isolated CHD, including mutations in cardiac transcription factors, the role of somatic mutations and epigenetic alterations as well as the influence of gene-environment interactions. In the near future, the advent of high-throughput genomic technologies with the integration of system biology will expand our understanding of isolated, non-syndromic CHDs for their prevention, early diagnosis and therapy.

Pediatric Heart Failure in the Developing World

The exact prevalence of heart failure among children of developing countries is not known, as the data is limited. The relative frequency of different causes of pediatric heart failure varies widely across different countries and even among different parts of large countries like India. Children of developing countries face a double burden of etiologies. Conditions such us congenital heart disease, myocarditis and cardiomyopathies are common causes of pediatric of heart failure. In addition, diseases like rheumatic heart disease, nutritional deficiencies, and other tropical diseases also result in heart failure among children of the developing countries. However, most of the developing countries have low resources and hence management of pediatric heart failure becomes challenging. Advanced therapies for heart failure are rarely used in children of developing countries and cardiac transplant remains a distant dream.

The Role of Beta-Blocker in Heart Failure in Adults with Congenital Heart Disease

Thanks to the enormous progress in the field of cardiac surgery and paediatric cardiology since the mid of 20th century, more and more children with congenital heart defects reach the adulthood. This on the other hand encounter physician and patients various problems due to late complications after the heart surgery like congestive heart failure, arrhythmia and sudden death. One of the challenging area is the medical management of heart failure in these patients with complex anatomy and hemodynamics. The lack of evidence of the effectiveness of the anti congestive medications in this population in from of large randomized controlled trials, makes it difficult to establish universally accepted therapy guidelines.

In this article we will review the evidence of the beta-blockers in heart failure in patients with congenital heart disease. Also we will discuss the mechanisms of heart failure in this patient's cohort and will review the literature with respect to the use of neurohormonal antagonists in congenital heart disease. There is an urgent need to initiate well-designed clinical trials to prove if the positive results of neurohormonal blockade in acquired heart failure in adults can be translated in patients with congenital heart disease.

Eisenmenger Syndrome: Recent Advances in Pharmacotherapy

Over the last decade advanced therapies for the management of pulmonary arterial hypertension have been introduced. These agents have also been effective in reducing pulmonary vascular resistance in patients with Eisenmenger syndrome. Specific guidelines focusing on modern therapies for Eisenmenger syndrome however do not exist to date. More recently, clinical trials in patients with Eisenmenger syndrome demonstrated a significant clinical improvement with favorable safety and tolerability profile. This review aims to summarize newly reported pharmacological agents used in patients with Eisenmenger syndrome.

Potential Replication of Induced Pluripotent Stem Cells for Craniofacial Reconstruction

The craniofacial region contains many specified tissues, including bone, cartilage, muscle, blood vessels, fat, skin and neurons. A defect or dysfunction of the craniofacial tissue after post-cancer ablative surgery, trauma, congenital malformations and progressive deforming skeletal diseases has a huge influence on the patient’s life. Therefore, functional reconstruction of damaged tissues is highly sought. The use of cell-based therapies represents one of the most advanced methods for enhancing the regenerative response for craniofacial wound-healing. The recently acquired ability to reprogram human adult somatic cells to induced pluripotent stem cells (iPSCs) in culture may provide a powerful tool for in vitro disease modeling and an unlimited source for cell replacement therapy. This review focuses on the generation, biological characterization and discussion of the potential application of iPSCs for craniofacial tissue-engineering applications.

Epidemiology of Major Congenital Malformations with Specific Focus on Teratogens

Background: Major congenital malformations (MCMs) are a significant cause of infant morbidity and mortality and constitute an important societal and economic burden.

Methods: We conducted a literature review to synthesize current evidence on MCMs. Specific objectives were to: 1) summarize internationally reported prevalence of MCMs based on registries and surveillance systems; 2) describe the epidemiology of different MCM types including critical periods and causative factors; 3) to identify the role played by principal known teratogens on the increase in the risk of MCMs; and 4) determine challenges associated with the epidemiologic assessment of potential risk factors for MCMs as well as potential preventive measures.

Results: It is estimated that 7.9 million infants worldwide are born every year with a MCM, yet there is considerable variation in reported rates across countries. This may be attributable to varying definitions arising from heterogeneity among different classes with respect to critical periods for embryogenesis and organogenesis. There is also substantial etiologic heterogeneity among MCMs classes that potentially contribute to challenges in epidemiologic studies. Modifiable factors such as pharmacologic exposures have received considerable attention and a number of drugs have been shown to be teratogenic including folic acid antagonists, angiotensin converting enzyme inhibitors, antidepressants, anticonvulsants, coumarin derivatives and retinoids including isotretinoin.

Conclusion: The majority of MCMs are due to unexplained causes. Other contributing factors include genetics, environmental factors, multifactorial inheritance, maternal-related conditions, and maternal drug or chemical exposure. However, there remains a need to better understand the epidemiology of MCMs when studying drug effect during gestation.

Development of Patient-Specific Hematopoietic Stem and Progenitor Cell Grafts from Pluripotent Stem Cells, In Vitro

Pluripotent stem cells hold great promise for future applications in many areas of regenerative medicine. Their defining property of differentiation towards any of the three germ layers and all derivatives thereof, including somatic stem cells, explains the special interest of the biomedical community in this cell type. In this review, we focus on the current state of directed differentiation of pluripotent stem cells towards hematopoietic stem cells (HSCs). HSCs are especially interesting because they are the longest known and, thus, most intensively investigated somatic stem cells. They were the first stem cells successfully used for regenerative purposes in clinical human medicine, namely in bone marrow transplantation, and also the first stem cells to be genetically altered for the first successful gene therapy trial in humans. However, because of the technical difficulties associated with this rare type of cell, such as the current incapability of prospective isolation, in vitro expansion and gene repair by homologous recombination, there is great interest in using pluripotent stem cells, such as Embryonic Stem (ES-) cells, as a source for generating and genetically altering HSCs, ex vivo. This has been hampered by ethical concerns associated with the use of human ES-cells. However, since Shinya Yamanaka´s successful attempts to reprogram somatic cells of mice and men to an ES-cell like state, so-called induced pluripotent stem (iPS) cells, this field of research has experienced a huge boost. In this brief review, we will reflect on the status quo of directed hematopoietic differentiation of human and mouse pluripotent stem cells.

Stem Cell Therapy for Ischaemic Stroke: Translation from Preclinical Studies to Clinical Treatment

No pharmacological intervention has been shown convincingly to improve neurological outcome in stroke patients after the brain tissue is infarcted. While conventional therapeutic strategies focus on preventing brain damage, stem cell treatment has the potential to repair the injured brain tissue. Stem cells not only produce a source of trophic molecules to minimize brain damage caused by ischaemia/reperfusion and promote recovery, but also potentially turn to new cells to replace those lost in ischaemic core. Although preclinical studies have shown promise, stem cell therapy for stroke treatment in human is still at an early stage and it is difficult to draw conclusions from current clinical trials about the efficacy of the different treatments used in humans. This article reviews the potential of various types of stem cells, from embryonic to adult to induced pluripotent stem cells, in stroke therapy, highlights new evidence from the ongoing clinical trials and discusses some of the problems associated with translating stem cell technology to a clinical therapy for stroke.

Normal Ventricular Functional Reference Parameters on Magnetic Resonance Imaging in Healthy Children

We aimed to research right and left ventricular functional reference values on magnetic resonance imaging in healthy children. Echocardiographically normal sixty healthy children were performed cardiac MRI between January 2009 and June 2010. Biventricular volumes, left myocardial mass, septal thickness, diameter of the ascending aorta and main pulmonary artery were calculated. It was investigated whether there was a difference or not between ventricular volumes and sexes, and the relationship age and body surface area with functional parameter results. The minimum, maximum, mean values of every parameters were determined in all children, boys, girls, and in the groups of age 8-12 and 13-18. There was a statistically significant difference in the left ventricular end-systolic diameter results between the sexes. There were statistical significant differences in parameter results except biventricular cardiac output and ejection fraction, right ventricular end-diastolic and end-systolic diameter between the age groups when the children were grouped as 8-12 and 13-18 years by ignoring their sexes. When it was compared the mean value of normal functional parameters after normalized to body surface area; the mean values of all parameters were higher in males, but there was a significant difference in only between right ventricular end-diastolic volumes. Biventricular cardiac output mean values were higher in the age group of 8-12 years.

Consequently, we determined the mean, minimum, and maximum values of normal ventricular volumes, left myocardial mass, septal thickness, diameter of the ascending aorta and main pulmonary artery in the 8-18 age group to be used as a reference in all diagnostic and follow-up stage.

Persistent Pulmonary Hypertension of the Newborn: Physiology, Hemodynamic Assessment and Novel Therapies

Persistent pulmonary hypertension of the newborn (PPHN) remains a serious disorder with significant mortality and long term morbidity. Inhaled nitric oxide is the only approved vasodilator therapy in neonates, but 40% of infants are non-responders. Recent biological evidence has enhanced our understanding of the cellular mechanisms involved in cardiopulmonary transition at birth, paving the way for potential alternate therapies as published in recent reviews. Optimal clinical care of infants with PPHN necessitates a comprehensive understanding and evaluation of cardiopulmonary hemodynamics. Targeted neonatal echocardiography (TnECHO) is increasingly being implemented to guide clinical decision making. The purpose of this review is to outline the role of TnECHO in better defining the cardiopulmonary physiology in PPHN and its application in clinical practice. In addition we briefly review the physiology, pathogenesis and novel therapeutic agents currently under investigation for management of PPHN.

Planar Cell Polarity Signaling in Collective Cell Movements During Morphogenesis and Disease

Collective and directed cell movements are crucial for diverse developmental processes in the animal kingdom, but they are also involved in wound repair and disease. During these processes groups of cells are oriented within the tissue plane, which is referred to as planar cell polarity (PCP). This requires a tight regulation that is in part conducted by the PCP pathway. Although this pathway was initially characterized in flies, subsequent studies in vertebrates revealed a set of conserved core factors but also effector molecules and signal modulators, which build the fundamental PCP machinery. The PCP pathway in Drosophila regulates several developmental processes involving collective cell movements such as border cell migration during oogenesis, ommatidial rotation during eye development, and embryonic dorsal closure. During vertebrate embryogenesis, PCP signaling also controls collective and directed cell movements including convergent extension during gastrulation, neural tube closure, neural crest cell migration, or heart morphogenesis. Similarly, PCP signaling is linked to processes such as wound repair, and cancer invasion and metastasis in adults. As a consequence, disruption of PCP signaling leads to pathological conditions. In this review, we will summarize recent findings about the role of PCP signaling in collective cell movements in flies and vertebrates. In addition, we will focus on how studies in Drosophila have been relevant to our understanding of the PCP molecular machinery and will describe several developmental defects and human disorders in which PCP signaling is compromised. Therefore, new discoveries about the contribution of this pathway to collective cell movements could provide new potential diagnostic and therapeutic targets for these disorders.

Therapeutic Strategies in Pulmonary Hypertension of the Newborn: Where Are We Now?

Despite recent advances, Persistent Pulmonary Hypertension of the Newborn (PPHN) still represents an important challenge for neonatologists. The care of newborns with PPHN requires meticulous therapeutic and ventilation strategies including, besides the stabilization of the newborn, the use of selective pulmonary vasodilators as inhaled Nitric Oxide (iNO). However, not all the neonates with PPHN are responsive to this clinical approach. Recent studies have proposed the use of alternative therapies to iNO, when it is not available, or there is no or only a transitory response. Sildenafil, a phosphodiesterase 5 inhibitor, appears as a frequent used therapy in refractory forms of PPHN. The aim of this review is to analyze the current therapeutic strategies in PPHN with special emphasis on iNO.

Prospectives for Gene Therapy of Retinal Degenerations

Retinal degenerations encompass a large number of diseases in which the retina and associated retinal pigment epithelial (RPE) cells progressively degenerate leading to severe visual disorders or blindness. Retinal degenerations can be divided into two groups, a group in which the defect has been linked to a specific gene and a second group that has a complex etiology that includes environmental and genetic influences. The first group encompasses a number of relatively rare diseases with the most prevalent being Retinitis pigmentosa that affects approximately 1 million individuals worldwide. Attempts have been made to correct the defective gene by transfecting the appropriate cells with the wild-type gene and while these attempts have been successful in animal models, human gene therapy for these inherited retinal degenerations has only begun recently and the results are promising. To the second group belong glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy (DR). These retinal degenerations have a genetic component since they occur more often in families with affected probands but they are also linked to environmental factors, specifically elevated intraocular pressure, age and high blood sugar levels respectively. The economic and medical impact of these three diseases can be assessed by the number of individuals affected; AMD affects over 30 million, DR over 40 million and glaucoma over 65 million individuals worldwide. The basic defect in these diseases appears to be the relative lack of a neurogenic environment; the neovascularization that often accompanies these diseases has suggested that a decrease in pigment epithelium-derived factor (PEDF), at least in part, may be responsible for the neurodegeneration since PEDF is not only an effective neurogenic and neuroprotective agent but also a potent inhibitor of neovascularization. In the last few years inhibitors of vascularization, especially antibodies against vascular endothelial cell growth factors (VEGF), have been used to prevent the neovascularization that accompanies AMD and DR resulting in the amelioration of vision in a significant number of patients. In animal models it has been shown that transfection of RPE cells with the gene for PEDF and other growth factors can prevent or slow degeneration. A limited number of studies in humans have also shown that transfection of RPE cells in vivo with the gene for PEDF is effective in preventing degeneration and restore vision. Most of these studies have used virally mediated gene delivery with all its accompanying side effects and have not been widely used. New techniques using non-viral protocols that allow efficient delivery and permanent integration of the transgene into the host cell genome offer novel opportunities for effective treatment of retinal degenerations.

General Anesthetics in Pediatric Anesthesia: Influences on the Developing Brain

Millions of newborn and infants receive anesthetic, sedative and analgesic drugs for surgery and painful procedures on a daily basis. However, recent laboratory reports clearly demonstrate that anesthetic and sedative drugs induced both neuroapoptosis and neurocognitive deficits in laboratory models. This issue is of paramount interest to pediatric anesthesiologists and intensivists because it questions the safety of anesthetics used for fetal and neonatal anesthesia. Most clinically utilized anesthetic drugs have been found to induce neuronal cell death in the developing brain and to potentially cause long-term neurological impairment. Conversely, painful stimuli without analgesia and anesthesia have been implicated in triggering neuro-apoptosis in juvenile mammalian models. Published retrospective reviews demonstrate temporary neurological sequelae after prolonged anesthetic exposure in young children and larger studies identify long-term neurodevelopmental impairment after neonatal surgery and anesthesia. This paper examines the evidence for the effects of commonly used anesthetics on neuronal structure and neurocognitive function in laboratory models and reviews the relevant clinical human epidemiologic data.

Cell Therapy Using Induced Pluripotent Stem Cells or Somatic Stem Cells: This is the Question

A lot of effort has been developed to bypass the use of embryonic stem cells (ES) in human therapies, because of several concerns and ethical issues. Some unsolved problems of using stem cells for human therapies, excluding the human embryonic origin, are: how to regulate cell plasticity and proliferation, immunological compatibility, potential adverse side-effects when stem cells are systemically administrated, and the in vivo signals to rule out a specific cell fate after transplantation. Currently, it is known that almost all tissues of an adult organism have somatic stem cells (SSC). Whereas ES are primary involved in the genesis of new tissues and organs, SSC are involved in regeneration processes, immuno-regulatory and homeostasis mechanisms. Although the differentiating potential of ES is higher than SSC, several studies suggest that some types of SSC, such as mesenchymal stem cells (MSC), can be induced epigenetically to differentiate into tissue-specific cells of different lineages. This unexpected pluripotency and the variety of sources that they come from, can make MSC-like cells suitable for the treatment of diverse pathologies and injuries. New hopes for cell therapy came from somatic/mature cells and the discovery that could be reprogrammed to a pluripotent stage similar to ES, thus generating induced pluripotent stem cells (iPS). For this, it is necessary to overexpress four main reprogramming factors, Sox2, Oct4, Klf4 and c-Myc. The aim of this review is to analyze the potential and requirements of cellular based tools in human therapy strategies, focusing on the advantage of using MSC over iPS

Fertility Preservation in Women After the Cancer

Thanks to the recent advances in cancer care, more and more young women can survive but suffer from infertility as a result of cancer treatment that had to be submitted. There are a variety of methods to preserve fertility, as chemoprotection, ovariopexy, and some assisted reproductive technologies, although some of these are promising but still highly experimental techniques. Cryopreservation of embryos for example is already established, while the oocyte banking is still considered an experimental practice. Many experiments have been conducted around the world on the cryopreservation of ovarian tissue and maturation of ovarian follicles, in an attempt to demonstrate its potential use in fertility preservation. Although in recent years there has been major improvements in the preservation of ovarian tissue, there are still many unresolved technical issues related to these procedures. In this chapter we examine the recent evidence of the pathophysiology of chemotherapy / radiotherapy-induced gonadal toxicity, and recent data regarding the indications and results of the techniques used to preserve fertility in women with cancer.

Efficacy and Safety of Sleeping Beauty Transposon-Mediated Gene Transfer in Preclinical Animal Studies

Sleeping Beauty (SB) transposons have been effective in delivering therapeutic genes to treat certain diseases in mice. Hydrodynamic gene delivery of integrating transposons to 5-20% of the hepatocytes in a mouse results in persistent elevated expression of the therapeutic polypeptides that can be secreted into the blood for activity throughout the animal. An alternative route of delivery is ex vivo transformation with SB transposons of hematopoietic cells, which then can be reintroduced into the animal for treatment of cancer. We discuss issues associated with the scale-up of hydrodynamic delivery to the liver of larger animals as well as ex vivo delivery. Based on our and others experience with inefficient delivery to larger animals, we hypothesize that impulse, rather than pressure, is a critical determinant of the effectiveness of hydrodynamic delivery. Accordingly, we propose some alterations in delivery strategies that may yield efficacious levels of gene delivery in dogs and swine that will be applicable to humans. To ready hydrodynamic delivery for human application we address a second issue facing transposons used for gene delivery regarding their potential to “re-hop” from one site to another and thereby destabilize the genome. The ability to correct genetic diseases through the infusion of DNA plasmids remains an appealing goal.

Targeting the Coagulation Factor Fibrinogen for Arthritis Therapy

Fibrinogen is a provisional matrix protein of the coagulation system that following proteolytic cleavage by the protease thrombin polymerizes to form fibrin, the structural basis of the blood clot. Fibrin polymer formation at sites of vessel injury is critical to normal hemostasis. However, fibrin deposition within damaged tissues is also a common pathological feature of inflammatory diseases, including rheumatoid arthritis. Fibrin deposition has been readily detected along articular surfaces, within inflamed hyperplastic synovial tissue, and as a component of insoluble “rice bodies” within the synovial fluid of arthritic joints. Recent data has suggested that fibrin deposition within inflamed tissues is not simply a reflection of a disease process but rather actively contributes to disease pathogenesis. One mechanism that has been demonstrated to directly link fibrin(ogen) to the regulation of inflammation is the ability of fibrin(ogen) to serve as a ligand for cell-surface receptors, particularly integrins. Indeed, engagement of fibrin(ogen) by the leukocyte integrin receptor αMβ2 appears to be a common and fundamental event driving local inflammation. Recent studies have demonstrated that eliminating fibrin(ogen)-αMβ2 interactions can significantly limit the progression of multiple inflammatory diseases, including arthritis, without compromising the ability of fibrinogen to function in coagulation. These exciting findings have opened the door to new opportunities for targeting fibrinogen as an inflammatory mediator while leaving intact its hemostatic properties.

Adult Stem Cell Transplants for Spinal Cord Injury Repair: Current State in Preclinical Research

Spinal cord injury (SCI) is a traumatic disorder resulting in a functional deficit that usually leads to severe and permanent paralysis. After the initial insult to the spinal cord, additional structure and function are lost through an active and complex secondary process. Since there is not effective treatment for SCI, several strategies including cellular, pharmacological and rehabilitation therapies have been approached in animal models. Some of them have been proved in clinical trials. In this review we focus on the current state of cell therapies, particularly on cells from adult origin, assayed in preclinical research. Cell types used in SCI therapy include Schwann cells, olfactory ensheathing cells and adult stem cells, such as neural stem cells, umbilical cord blood derived cells, mesenchymal stem cells or induced pluripotent stem cells. There are not yet conclusive evidences on which types of glial or adult stem cells are most effective in SCI treatment. Their ability to incorporate into the damaged spinal cord, to differentiate into neural lineages, to exert neuroprotective effects, to promote regeneration of damaged axons, and to improve functional deficits are still discussed, before translation towards clinical use, as a single therapy or in combination with other strategies.

The Human L1 Element: A Potential Biomarker in Cancer Prognosis, Current Status and Future Directions

The discovery of new biomarkers is a rapidly advancing area in cancer biology. The challenge of biomarker development for broad clinical use requires the translation of lab-based knowledge into clinical practice. The Long Interspersed Nuclear Elements-1 (LINE-1s or L1 elements) are active members of an autonomous family of non-LTR retrotransposons and occupy nearly 17% of the human genome. There is strong experimental evidence that the global hypomethylation of genomic DNA in cancer cells results in the activation of L1s and their expression is detectable at genome, transcriptome and proteome levels in human cancer cells. Thus, human L1s constitute a potential marker for cancer cells. In this review we have attempted to scrutinize L1 expression profiles in clinical cancer studies by undertaking a comprehensive systematic analysis of papers published in the field so far with a view to providing a more complete picture of the detection methods used, improvements achieved and potential future directions. Ultimately, we will try to evaluate the potential of L1s as a molecular marker in cancer detection.

Impact of Pulmonary Vascular Resistances in Heart Transplantation for Congenital Heart Disease

Congenital heart disease is one of the major diagnoses in pediatric heart transplantation recipients of all age groups. Assessment of pulmonary vascular resistance in these patients prior to transplantation is crucial to determine their candidacy, however, it is frequently inaccurate because of their abnormal anatomy and physiology. This problem places them at significant risk for pulmonary hypertension and right ventricular failure post transplantation. The pathophysiology of pulmonary vascular disease in children with congenital heart disease depends on their pulmonary blood flow patterns, systemic ventricle function, as well as semilunar valves and atrioventricular valves structure and function. In our review we analyze the pathophysiology of pulmonary vascular disease in children with congenital heart disease and end-stage heart failure, and outline the state of the art pre-transplantation medical and surgical management to achieve reverse remodeling of the pulmonary vasculature by using pulmonary vasodilators and mechanical circulatory support.

Heart Transplantation in Biventricular Congenital Heart Disease: Indications, Techniques, and Outcomes

Heart transplantation is an accepted therapeutic modality for end-stage congenital heart disease for both biventricular and univentricular anomalies. Many transplant centers have pushed the limits of transplantation to include patients with high pulmonary vascular resistance, high panel reactive antibodies, positive cross-matches, and ABOincompatibility. Excellent results have been possible, particularly with the development of improved diagnostic and therapeutic algorithms to prevent and treat rejection, infection, and post-transplant lymphoproliferative disease. Late graft failure and chronic rejection remain vexing problems. The vast majority of patients with biventricular congenital heart disease have undergone prior cardiac surgical procedures. Indications for transplantation in this subgroup are primarily progressive refractory heart failure following prior cardiac surgical reconstructive procedures. Contraindications to transplantation mimic those for other forms of end-stage heart disease. A determination of pulmonary vascular resistance is important in listing patients with biventricular congenital heart disease for heart transplantation. Modifications in the implant technique are necessary and vary depending on underlying recipient anatomy. Risk factors for perioperative outcomes in patients with biventricular congenital heart disease include the need for reoperation, the degree of anatomic reconstruction necessary during the implant procedure, and the degree of antibody sensitization, in addition to a number of other recipient and donor factors. Postoperative outcomes and survival are very good but remain inferior to those with cardiomyopathy in most series. In conclusion, patients with end-stage biventricular congenital heart disease represent a complex group of patients for heart transplantation, and require careful evaluation and management to ensure optimal outcomes.

Robotic Assisted Surgery in Gynecology: Current Insights and Future Perspectives

To focus on the recent adoption, patents, experience, and future of Robotic assisted surgery (RAS) applications in gynecologic surgery, a computer aided and manual search for clinical and systematic reviews, randomized controlled trials, prospective observational studies, retrospective studies and case reports published between 1970 and January of 2011 has been performed. The use of RAS in gynecologic patients includes hysterectomy, myomectomy, tubal reanastomoses, radical hysterectomy, lymph node dissection, and sacrocolpopexies. Although individual studies vary, gynecological RAS is often associated with longer operating room time but similar clinical outcomes, decreased blood loss, and shorter hospital stay. RAS procedures on women have, however, their own limitations: the patented equipment is very large, bulky, and expensive, the staff must be trained specifically on draping and docking the instruments, the lack of surgical haptic feedback, a limited vaginal access, a limited specific instrumentation, and the need for larger port incisions requiring fascial closure. The RAS significantly facilitates gynecologic surgery, even if well-designed, prospective studies are needed to fully assess the value of this equipments in particular studies with well-defined clinical and long-term outcomes, including complications, cost, pain, return to normal activity, and quality of life. The future of robotic surgery in gynecology may be bright, but currently, caution is advisable and clinically meaningful long-term outcomes are needed. These recent patents, however, has exciting potential for future applications, especially in long-distance telesurgery and might change the paradigm of gynecologic surgery in the future.

Complications of the Chest Wall and the Respiratory System After Surgery and Functional Performance

In a population of patients after successful heart surgery for congenital heart defects (CHD) might emerge noncardiac morbidities. Malfunction of the respiratory system (RS) including chest wall deformities (CWD) may represent risk for a long-term functional performance and QoL of these subjects. This review aims for the long-term (abnormal pulmonary hemodynamics prior to surgery) or short-term (e.g. thoracotomy) harmful impacts on the developing RS. CHD with redundant lung recoil may induce dramatic worsening of the mechanical properties of the RS. Despite successful repair of CHD harmful and successive adaptive processes may affect future development of the RS. Surgical treatment of CHD requires thoracic wall incision (median sternotomy or lateral thoracotomy), which currently with other perioperative impacts may represent unfavourable formation of CWD. Surprisingly, heart surgery itself does not lead either to an improvement or marked change in the severity or frequency of preoperative lung abnormalities (mostly lung volume restriction, hyperinflation, stiff lung or airway obstruction). Causes of RS dysfunction and CWD in patients after surgical repair of CHD are multifactorial. Therefore, a management of these abnormalities especially in adult and aged CHD is difficult. The early primary repair of CHD and recent interventional approaches (e.g., superior ministernotomy or usage of Amplatz occluder) may provide advantages regarding developing organ systems and prevent secondary changes of the heart and the RS. Further research should focus on individual factors in the development of CWD and postoperative respiratory changes. Long-term and/or probably permanent follow up of subjects after CHD repair is a must.

Self-assembly of Functional Molecular Shuttles Based on Organic Conjugated Molecules

The aim of this article is to explore the molecular design, synthesis and construction of molecular shuttles based on conjugated organic molecules with photo-electronic activity by self-assembly techniques. The new functions of molecular shuttles, such as switching surface properties, protecting dyes and insulating molecular wires, controlling the energy transfer, controlling nanostructural morphologies, molecular transporting and multilevel fluorescence switching, are also discussed.

Large-Scale Production Means for the Manufacturing of Lentiviral Vectors

Lentiviral vectors become more and more famous for the use as gene vector for gene therapy purposes for the treatment of acquired or inherited diseases. In this review, the present state of the art of the production of lentiviral vectors is presented with particular emphasis on the large scale production of these vectors for preclinical and clinical purposes. In contrast to oncoretroviral vectors which are produced using stable producer cell lines, clinical grade lentiviral vectors are essentially produced by transient transfection of 293 or 293T cells grown in Cell Factories. The main reason is that these production processes have been developed when good and safe LV producer cell lines were not available. With respect to the purification of lentiviral and in agreement with actual developments in the biotech industry, rather sophisticated downstream processing protocols have been established in order to remove any potentially dangerous process derived contaminant, such as plasmid or host cell DNA or host cell proteins. This review presents large scale production means for LV vectors, the different downstream processing steps as used for the purification of LV vectors as well as LV specific safety issues. Published large scale production and purification processes of lentiviral vectors and their process performances are compared.

The Adult Patient with Eisenmenger Syndrome: A Medical Update After Dana Point Part I: Epidemiology, Clinical Aspects and Diagnostic Options

Eisenmenger syndrome is the most severe form of pulmonary arterial hypertension and arises on the basis of congenital heart disease with a systemic-to-pulmonary shunt. Due to the chronic slow progressive hypoxemia with central cyanosis, adult patients with the Eisenmenger syndrome suffer from a complex and multisystemic disorder including coagulation disorders (bleeding complications and paradoxical embolisms), renal dysfunction, hypertrophic osteoarthropathy, heart failure, reduced quality of life and premature death. For a long time, therapy has been limited to symptomatic options or lung or combined heart-lung transplantation. As new selective pulmonary vasodilators have become available and proven to be beneficial in various forms of pulmonary arterial hypertension, this targeted medical treatment has been expected to show promising effects with a delay of deterioration also in Eisenmenger patients. Unfortunately, data in Eisenmenger patients suffer from small patient numbers and a lack of randomized controlled studies. To optimize the quality of life and the outcome, referral of Eisenmenger patients to spezialized centers is required. In such centers, specific interdisciplinary management strategies of physicians specialized on congenital heart diseases and PAH should be warranted. This medical update emphasizes the current diagnostic and therapeutic options for Eisenmenger patients with particularly focussing on epidemiology, clinical aspects and specific diagnostic options.

Emerging Technologies for Fertility Preservation in Female Patients

A wide variety of fertility preservation options in women is available; however, most of the currently available strategies are still experimental and do not guarantee subsequent fertility. The only established method is in vitro fertilization with embryo cryopreservation prior to cancer therapy. Other proposed strategies to preserve fertility in women with cancer include: storage of frozen ovarian tissue or the whole ovary for future transplantation, storage isolated follicles for in vitro growth and maturation and ovarian transposition before radiotherapy. The effectiveness of ovarian protection during chemotherapy with GnRH analogs is yet to be shown.

Smoking and Congenital Heart Disease: The Epidemiological and Biological Link

Cigarette smoking is a powerful human germ cell mutagen and teratogen. Congenital heart defects (CHD) are the most prevalent of all birth defects and leading cause of death in the first year of life. The purpose of this article is to review the epidemiology of the impact of cigarette smoking on CHD risk as well as to discuss the potential biological mechanisms of smoking – mediated abnormal cardiac development. Although epidemiological studies of association between parental smoking and CHD are limited, biological evidence supports the concept that cigarette smoking may substantially contribute to the aetiology of CHD through induction of either male and female germ-cell mutation or interference with epigenetic pathways. Further research is needed to better define the relationship between parental smoking and the risk of heart defects as well as to assess parental – fetal gene-smoking interactions.

Baculovirus as a Gene Delivery Vector for Cartilage and Bone Tissue Engineering

Baculovirus is an effective vector for gene delivery into various mammalian cells, including chondrocytes and mesenchymal stem cells, and has been employed for diverse applications. By gene delivery and expression of the growth factor, recombinant baculovirus has been shown to modulate the differentiation state of the cells and stimulates the production of extracellular matrix and tissue formation, hence repairing the damaged cartilage and bone in vivo. This article reviews the studies pertaining to the applications of baculovirus-mediated gene delivery in cartilage and bone tissue engineering and discusses recent progress, future applications and potential hurdles.

Genetics of Congenital Heart Disease

Cardiovascular malformations are the most common type of birth defect and result in significant mortality worldwide. The etiology for the majority of these anomalies remains unknown but genetic factors are being recognized as playing an increasingly important role. Advances in our molecular understanding of normal heart development have led to the identification of numerous genes necessary for cardiac morphogenesis. This work has aided the discovery of an increasing number of monogenic causes of human cardiovascular malformations. More recently, studies have identified single nucleotide polymorphisms and submicroscopic copy number abnormalities as having a role in the pathogenesis of congenital heart disease. This review discusses these discoveries and summarizes our increasing understanding of the genetic basis of congenital heart disease.

In Vitro Blood-Brain Barrier Models – Latest Advances and Therapeutic Applications in a Chronological Perspective

The first generation of in vitro models providing successful isolation of viable brain endothelial cells from different species, which could be maintained in cell culture, have emerged around thirty years ago. However, the time consuming and the difficulty of working with primary culture cells led to the development of simpler models employing cell lines with blood-brain barrier properties. The creation, in late nineties, of a transgenic mouse harboring the temperature sensitive simian virus 40 large T-antigen as a source of conditionally immortalized brain endothelial cell lines circumvented the problems of in vitro transfection of tumour inducing gene in primary cells. These different ways to obtain cultures of brain endothelial cells have profited from the discovery of different cellular factors that allow the growth of differentiated cells on plastic filters. Although cell preparations and culture conditions of brain endothelial cells are based on the same principle, there are two main models for studying the blood-brain barrier: the static and the more recently described dynamic model. Dynamic models were created in order to replicate the physiological in vivo environment of the blood-brain barrier. The large pool of in vitro models is being enlarged since each laboratory improves its model adding small differences adapted to the research interests. The great impact of blood-brain barrier studies in the development of therapies related to the central nervous system supports the interests of this review about in vitro models.

Mechanical Circulatory Support of the Critically Ill Child Awaiting Heart Transplantation

The majority of children awaiting heart transplantation require inotropic support, mechanical ventilation, and/or extracorporeal membrane oxygenation (ECMO) support. Unfortunately, due to the limited pool of organs, many of these children do not survive to transplant. Mechanical circulatory support of the failing heart in pediatrics is a new and rapidly developing field world-wide. It is utilized in children with acute congestive heart failure associated with congenital heart disease, cardiomyopathy, and myocarditis, both as a bridge to transplantation and as a bridge to myocardial recovery. The current arsenal of mechanical assist devices available for children is limited to ECMO, intra-aortic balloon counterpulsation, centrifugal pump ventricular assist devices, the DeBakey ventricular assist device Child; the Thoratec ventricular assist device; and the Berlin Heart. In the spring of 2004, five contracts were awarded by the National Heart, Lung and Blood Institute to support preclinical development for a range of pediatric ventricular assist devices and similar circulatory support systems. The support of early development efforts provided by this program is expected to yield several devices that will be ready for clinical trials within the next few years. Our work reviews the current international experience with mechanical circulatory support in children and summarizes our own experience since 2005 with the Berlin Heart, comparing the indications for use, length of support, and outcome between these modalities.

Troponin in Newborns and Pediatric Patients

Cardiac troponin represents a sensitive and specific marker of ischemic myocardial damage in adult and neonatal populations. Cardiac function in neonates could be influenced by the severity of respiratory distress and its ventilatory management. This short review summarizes the experimental and clinical evidence regarding the role of cardiac troponin in assessment of cardiac function, in following findings: neonatal intensive care, respiratory distress syndrome, asphyxia, congenital heart disease and post cardiac surgery.

The Implication of Platelet Activating Factor in Cancer Growth and Metastasis: Potent Beneficial Role of PAF-Inhibitors and Antioxidants

Cancer is one of the leading causes of death in Europe and United States. New blood vessel formation penetrating into solid tumors seems to be required for their growth and metastasis. Several protein growth factors can induce endothelial cell proliferation and angiogenesis, through signal transduction cascades that result in the production of several inflammatory mediators and lipid second messengers such as prostaglandins and Platelet Activating Factor (PAF). PAF is a potent mediator of inflammation that is implicated in several inflammatory pathological conditions such as atherosclerosis, cardiovascular and renal diseases, allergy, AIDS, cancer etc. It exerts its biological activities through Gprotein- coupled receptors. The presence of PAF in the microenvironment of tumors may be due to its synthesis from circulating and / or cancer cells. Moreover, cancer cells and activated endothelial cells expose PAF-receptor on their membrane surface. PAF binding on its receptor induces several pathways that result in the onset and development of tumor induced angiogenesis and metastasis. PAF-receptor antagonists have exhibited promising results in vitro and in vivo as anti-angiogenic molecules in several cancer cells and tumors. A dietary profile reach in antioxidants and PAF-inhibitors (such as the Mediterranean Diet) may provide beneficial preventive and protective effects against development, growth and metastatic manifestations of cancer cells, through either their inhibition of PAF activity and / or its biosynthesis. The clarification of factors that may down regulate pathologically increased PAF-levels in a tumor microenvironment may also contribute to the planning of a potent nontoxic preventive and therapeutic approach against cancer.

Current Management of Traumatic Rupture of the Descending Thoracic Aorta

Traumatic rupture of the descending thoracic aorta remains a leading cause of death following major blunt trauma. Management has evolved from uniformly performing emergent open repair with clamp and sew technique to include open repair with mechanical circulatory support, medical management and most recently, endovascular repair. This latter approach appears, in the short term, to be associated with perhaps better outcome, but long term data is still accruing. While an attractive option, there are specific anatomic and physiologic factors to be considered in each individual case.

Apis mellifera Proteomics: Where Will the Future Bee?

Honey bees play a crucial role in pollinating wild and cultivated vegetation, with substantial implications on our economy and food supply. Our scientific knowledge of bees consists largely of behavioral or macroscopic-level biological studies. Although in the past several decades there have been some advances in our knowledge of specific hormones, genes, and proteins, molecular biology of bees remain poorly understood relative to the depth to which we understand humans, and typical model organisms such as the mouse or fruit fly. This is due in part to the lack of available reagents for interrogating protein-specific information in standard assays such as Western blot, immunolocalization, and immunoaffinity purification, as well as a relatively difficult system for introducing small, interfering RNAs. Given the available genome sequence then, mass spectrometry-based proteomics techniques are ideally suited to studies in bees; starting from so little knowledge, the discovery-based nature of proteomics should allow for a very steep learning curve relative to better-studied systems such as fruit fly. To this end, twenty-two honey bee proteomics papers have been published since 2005. Here we present a brief summary of biochemical/molecular biological research in bees, including some of the challenges; we focus on the proteomics work to date, and relate these findings to recent transcriptomic work and proteomic studies in other social insects. We end with some speculation on where proteomics is most likely able to provide insight into bee biology where other methods would fail. As the general population and scientific community become increasingly aware of the value of honey bees to both our economy and ecosystem, proteomics will play an important role in improving our understanding of this beneficial insect.

Dissections of the Thoracic Aorta and Evolving Endovascular Strategies

Acute dissection is the most common life threatening condition of the aorta affecting 5-30 per million people per year [1]. Left untreated, the majority of patients with dissections involving the ascending aorta will die within days of an acute episode [2]. Patients presenting with descending thoracic aortic dissections seem to fare better, with one in ten patients dying before leaving hospital. Ultimately, these patients are at risk of aortic rupture with nearly 20% of these patients requiring some form of surgical or endovascular intervention [3]. Judicious medical, surgical and endovascular management of this condition aims to reduce propagation of the dissection plane and concomitant branch vessel compromise, halt aortic expansion and prevent fatal aortic rupture. Early recognition of these disease entities in conjunction with urgent and pertinent management is the key to a successful outcome in these patients.

The Extracellular Matrix of Blood Vessels

Blood vessels are highly organized and complex structure, which are far more than simple tubes conducting the blood to almost any tissue of the body. They are able to autonomously regulate the blood flow, thus providing the tissues an optimal support of oxygen and nutrients and an efficient removal of waste products. In higher organisms, the blood vessel forms a closed circuit system, which additionally has the ability to seal itself in case of leakage as a result of injury. The blood vessel system does not only transport soluble substances, but also serves as “highway” system for leukocytes to patrol the body during the immunological surveillance and to reach the inflammation site quickly. In a complex interplay with the vascular wall, leukocytes are able to penetrate the blood vessel without any obvious leakage. Pathologically, tumor cells subvert the blood vessel system to disseminate from the primary tumor and colonize distant organs during metastasis. The extracellular matrix (ECM) of a blood vessel contributes substantially to the diverse functions of the blood vessel. First, the ECM constitutes the scaffold which keeps the histological structure of the vessel wall in shape but also bears the enormous and permanent mechanical forces levied on the vessel by the pulsatile blood flow in the arteries and by vasoconstriction, which regulates blood flow and pressure. The complex network of elastic fibers and tensile forces-bearing networks are well adapted to accomplish these mechanical tasks. Second, the ECM provides informational cues to the vascular cells, thus regulating their proliferation and differentiation. Third, ECM molecules can store, mask, present or sequester growth factors, thereby modulating their effects remarkably. Furthermore, several ECM molecules serve additional functions within the blood vessel. Their expression is altered in a spatial and temporal pattern during blood vessel formation and remodeling. In contrast to vasculogenesis during embryonic development, blood vessel shows a remarkably and life-long plasticity, which allows the formation and regeneration of new blood vessel even in adulthood. Both physiologically during wound healing and pathologically during tumor growth, the sprouting of new blood vessels during angiogenesis is an important process, in which the ECM takes a key role.

Neurocognitive Monitoring and Care During Pediatric Cardiopulmonary Bypass — Current and Future Directions

Neurologic injury in patients with congenital heart disease remains an important source of morbidity and mortality. Advances in surgical repair and perioperative management have resulted in longer life expectancies for these patients. Current practice and research must focus on identifying treatable risk factors for neurocognitive dysfunction, advancing methods for perioperative neuromonitoring, and refining treatment and care of the congenital heart patient with potential neurologic injury. Techniques for neuromonitoring and future directions will be discussed.

Baculovirus Expression Vectors for Insect and Mammalian Cells

Functional expression of recombinant proteins has become a routine, but critical tool in modern molecular biology. Since their introduction, the use of baculovirus vectors to produce proteins for purification has become one of the most widely-used viral gene delivery systems as expression levels obtained are difficult to match with any other eukaryotic expression system. Extensive engineering to simplify and accelerate the process of recombinant virus construction has made this system acessible to virtually any modern biological laboratory. The utility of baculoviruses has been broadened with the discovery that appropriately modified virus can mediate gene expression in a wide variety of mammalian cell lines, and thus can function as a flexible cell-based assay development tool. The wide range of applications and potential for commercialization of products leads to consideration of a number of aspects of the system.

Fibrinogen: A Predictor of Vascular Disease

Raised plasma fibrinogen levels are associated with an increased risk of vascular events. This may be mediated by adverse effects of fibrinogen on plasma viscosity, coagulation, platelet activity, inflammation and atherogenesis. However, there is as yet no drug that specifically lowers plasma fibrinogen levels on a long-term basis. Thus, we do not have intervention trials demonstrating that lowering plasma fibrinogen levels will result in a decreased risk of vascular events. However, such a trial may never happen unless a specific agent is discovered or designed. Several drugs that are used in vascular disease prevention (e.g. lipid lowering agents and antihypertensives) may influence plasma fibrinogen levels. Whether such an additional effect accounts for variations in the benefit resulting from the use of different drugs within the same class remains to be established. The debate continues as to whether fibrinogen is just a marker of vascular risk or whether lowering its circulating levels will result in a significant decrease in clinically relevant endpoints. Whatever the case, the measurement of plasma fibrinogen levels is likely to provide a more comprehensive estimation of risk.

Plasmid DNA Manufacturing Technology

Today, plasmid DNA is becoming increasingly important as the next generation of biotechnology products (gene medicines and DNA vaccines) make their way into clinical trials, and eventually into the pharmaceutical marketplace. This review summarizes recent patents and patent applications relating to plasmid manufacturing, in the context of a comprehensive description of the plasmid manufacturing intellectual property landscape. Strategies for plasmid manufacturers to develop or in-license key plasmid manufacturing technologies are described with the endpoint of efficiently producing kg quantities of plasmid DNA of a quality that meets anticipated European and FDA quality specifications for commercial plasmid products.

Remote Control of Pulmonary Blood Flow

Pulmonary artery banding is a suitable approach for complex heart defects suitable to later bi-ventricular repair, functionally uni-ventricular hearts, and left ventricular retraining. Despite the existence of a very large spectrum of congenital heart defects and clinical situations with potential indication for pulmonary artery banding, the availability of only the conventional surgical technique is still limiting the application of this approach. A solution to the clinical need for an adjustable pulmonary artery banding has been found with a telemetrically controlled adjustable pulmonary artery banding, FloWatch® (EndoArt, Lausanne, Switzerland). This new implantable, wireless, bat-tery free, device (FloWatch®), demonstrated the feasibility of repeated progressive occlusions and re-openings of the de-vice at the wanted percentage of occlusion through a remote control, with long-term experimental evaluation in animals, followed by successful introduction in clinical practice in different institutions. The availability of a reliable adjustable pulmonary artery banding, avoiding any re-operation and the need for pulmonary artery reconstruction at the moment of de-banding, has substantially modified the clinical management of infants with congenital heart defects with increased pulmonary artery blood flow and pressures. New therapeutic strategies can now be considered to expand the applicability of this device.

Ex Vivo Modification of Cells to Induce a Muscle-Based Expression

Ex vivo gene therapy is a possible treatment for several muscular dystrophies. The best transgene to be expressed and the appropriate cell type to be used currently remain the subject of many investigations. The most adequate gene modification technique also remains to be established. Different transgenes have already been tested in animal models and transgenic mice. Several cell types were evaluated during the last decades and several vectors or transfection methods were analysed. From these essays, over time, several proofs of principles were made to demonstrate the feasibility of this type of therapy. For DMD, it is possible to express several truncated versions of dystrophin or exon skipping molecules. It is also possible to express other molecules that would mitigate the phenotype. Different cell types are also available. From the well documented myoblasts to the AC133 positive cells, the choice of cell types is exploding. Gene modification also evolved during the last decade. Efficient transfection technique and viral vectors are currently available. Given all these possibilities, the researcher has to make several choices. This review is trying to give clues of how to make those choices.

Chest Pain in Children

Pain arising from the chest area creates anxiety in children and their parents, often leading to unnecessary activity restriction, school absences, and medical utilization. A thorough but pragmatic evaluation requires a grasp of the pathophysiology of several organ systems and an understanding of epidemiologic and behavioral patterns specific to children. Few symptoms in pediatrics test a clinicians skill more than chest pain. Though the etiology is frequently benign, it is often uncertain, and sprinkled among cases of chest pain are potentially fatal conditions. This review summarizes chest pain in children of all ages, with particular emphasis on adolescents. We review the organic causes including musculoskeletal trauma, strain and inflammation, respiratory conditions such as occult asthma, pneumonia and bronchitis, and the important role of esophageal disease. We discuss the relatively minor role of cardiac disease, but highlight the conditions that are vital to consider, such as arrhythmia, mitral valve disease, Kawasaki syndrome, Marfan syndrome, and cocaine use. Anxiety, depression, and other psychological factors often further complicate the presentation. A pediatricians best tools are diagnostic acumen, which may be lifesaving, and supportive dialogue, to impart reassurance to a worried family. We explore the most common and most lethal causes by age, organ system, and predisposing illness. We review the neuroanatomic considerations important in visceral, chest wall, and mediastinal pain, and the sensation within the lung,airways, and pleurae. Lastly, we highlight pragmatic take-home tips for the clinician, most of which involve good history-taking and physical examination, but also include the utility of basic testing that can detect the rare cases of fatal cardiopulmonary disease.

RNA-Mediated Therapeutics: From Gene Inactivation to Clinical Application

The specific targeting and inactivation of gene expression represents nowdays the goal of the mainstream basic and applied biomedical research. Both researchers and pharmaceutical companies, taking advantage of the vast amount of genomic data, have been focusing on effective endogenous mechanisms of the cell that can be used against abnormal gene expression. In this context, RNA represents a key molecule that serves both as tool and target for deploying molecular strategies based on the suppression of genes of interest. The main RNA-mediated therapeutic methodologies, deriving from studies on catalytic activity of ribozymes, blockage of mRNA translation and the recently identified RNA interference, will be discussed in an effort to understand the utilities of RNA as a central molecule during gene expression.

Targets and Tools: Recent Advances in the Development of Anti-HCV Nucleic Acids

Hepatitis C virus (HCV), the major etiological agent of transfusion-associated non-A, non-B hepatitis, is a severe health problem affecting up to 3% of the world population. Since its identification in 1989, enormous efforts have been made to characterize the viral cycle. However, many details regarding the virus penetration of hepatocytes, its replication and translation, and the assembling of virions remain unknown, mostly because of a lack of an efficient culture system. This has also hampered the development of fully effective antiviral drugs. Current treatments based on the combination of interferon and ribavirin trigger a sustained virological response in only 40% of infected individuals, thus the development of alternative therapeutic strategies is a major research goal. Nucleic acid based therapeutic agents may be of some potential in hepatitis C treatment. In recent years, much effort has gone into the improvement of DNA and RNA molecules as specific gene silencing tools. This review summarizes the state of the art in the development of new HCV therapies, paying special attention to those involving antisense oligonucleotides, aptamers, ribozymes, decoys and siRNA inhibitors. The identification of potential viral targets is also discussed.

The Secondary Heart Field: Understanding Conotruncal Defects from a Developmental Perspective

The development of a septated outflow is complicated, and insight into this process has been limited. However, our lab and others have recently described a secondary source of myocardium that adds to the lengthening outflow tract at later stages of development. Without the addition of this secondary heart field (SHF), the outflow is shortened and can not undergo the rotation necessary to make appropriate ventriculoarterial connections. Defects of outflow alignment such as tetralogy of Fallot and double outlet right ventricle may therefore be the result of problems with the addition of the secondary heart field. Moreover, the SHF adds a smooth muscle component to the outflow above the semilunar valves which may be necessary for proper insertion of the coronary stems into the aorta. This review will use the newly discovered SHF as well as other recent advances in the understanding of outflow development to shed light on the developmental pathology behind conotruncal defects.

Nonviral Vectors for Cancer Gene Therapy: Prospects for Integrating Vectors and Combination Therapies

Gene therapy has the potential to improve the clinical outcome of many cancers by transferring therapeutic genes into tumor cells or normal host tissue. Gene transfer into tumor cells or tumor-associated stroma is being employed to induce tumor cell death, stimulate anti-tumor immune response, inhibit angiogenesis, and control tumor cell growth. Viral vectors have been used to achieve this proof of principle in animal models and, in select cases, in human clinical trials. Nevertheless, there has been considerable interest in developing nonviral vectors for cancer gene therapy. Nonviral vectors are simpler, more amenable to large-scale manufacture, and potentially safer for clinical use. Nonviral vectors were once limited by low gene transfer efficiency and transient or steadily declining gene expression. However, recent improvements in plasmid-based vectors and delivery methods are showing promise in circumventing these obstacles. This article reviews the current status of nonviral cancer gene therapy, with an emphasis on combination strategies, long-term gene transfer using transposons and bacteriophage integrases, and future directions.

Conserved Molecular Players for Axon Guidance and Angiogenesis

Neuronal guidance cues attract or repel axons and/or neurons and play important roles in the pathfinding of neuronal networks and the functioning of nervous system. Prominent among them are the families of ephrins, semaphorins, Slits and netrins and their cognate cell-surface receptors. Due to their biological significance, extensive research has been carried out in the last ten years or so. Angiogenesis is a cellular process of capillary sprouting and configuring of neovasculatures, which shares many developmental, anatomical, physiological and pathophysiological features with the neural counterparts. This review will summarize the emerging evidence indicating the common molecular mechanisms underlying both axon guidance (including neuronal migration) and angiogenesis for exquisite regulation of proper wiring of both systems.

Neuromodulation of the Perinatal Respiratory Network

Breathing movements are initiated and controlled by a neuronal network within the lower brainstem that is influenced by peripheral and suprapontine inputs. To provide adaptation of breathing to vocalisation, exercise or hypoxia, rhythmogenic neurons of the ventral respiratory group (VRG) within the ventrolateral medulla (VLM) are controlled by numerous neuromodulators. Underlying cellular mechanisms are currently analysed in respiratory active medulla preparations from perinatal rodents. This reveals properties of the perinatal respiratory network pivotal for understanding spontaneous or drug-induced perturbation of breathing in preterm and term infants. Already at birth, ligand-gated anion channels can inhibit VLM-VRG neurons. But impairment of Cl- extrusion by hormones or growth factors may interfere with respiratory functions. During severe hypoxia, resulting in anoxia of the VLM-VRG, perinatal respiratory activity persists for more than twenty minutes, although at a greatly reduced frequency. This frequency depression, associated with a hyperpolarisation of rhythmogenic VLM-VRG neurons, is reversed by K+ channel blockers, thyrotropin-releasing hormone or substance-P, for example. This response may represent an adaptive mechanism for energy conservation during oxygen depletion. Endogenous frequency depression of the normoxic perinatal respiratory rhythm, possibly mediated by endorphins or prostaglandins, may serve to dampen excessive respiratory activity in utero. Opiates and prostaglandins, known to impair breathing in infants during clinical administration, likely act directly to depress rhythmogenic VLM-VRG neurons. Based upon such findings in perinatal rodent models on synaptic inhibition and responses to hypoxia-anoxia or clinically-applicable drugs, novel pharmacological strategies are discussed that aim to stabilise infant breathing by targeting rhythmogenic respiratory neurons.