Adjuvant Breast Radiation Therapy for Early-Stage Breast Cancer or Ductal Carcinoma In-Situ in the Breast: A Systematic Review and Network Meta-Analysis of Randomized Trials

PURPOSE/OBJECTIVE(S)

For selected patients with early-stage breast cancer (BC) or ductal carcinoma in-situ (DCIS) in the breast, adjuvant breast radiation therapy (RT) approaches include partial breast irradiation (PBI), altered fractionation (AF) whole breast irradiation (WBI) or tumor bed boost (TBB). However, it is unclear which is the optimal approach. This study aims to compare the effects of different PBI, AF-WBI and TBB options on ipsilateral breast tumor recurrence (IBTR), overall survival (OS) and patient reported cosmesis (PRC) outcomes.

MATERIALS/METHODS

We searched various biomedical electronic databases for eligible randomized trials (RCTs) from date of inception to January 2023. We constructed six separate random effects frequentist network meta-analyses (NMA) to compare the effects of various PBI options using WBI as the reference; various AF-WBI options using conventional fractionated (CF) WBI as the reference and various TBB options using no TBB as the reference on IBTR and OS. The GRADE approach was used to assess the certainty of evidence. The synthesis without meta-analysis approach was pre-specified for evaluation of PRC in anticipation of various assessment and reporting methods.

RESULTS

We included 34 RCTs comprising 49,899 participants and 11 treatment options. Evidence suggests that accelerated PBI (Hazard Ratio (HR) 1.36 (95% confidence interval (CI) 0.77 - 2.41, moderate certainty), moderately hypofractionated (MHF) PBI (HR 1.38 (0.60 - 3.19), moderate certainty) and intraoperative PBI (HR 1.47 (0.81 - 2.68), low certainty) was associated with a modest but not statistically significant increase in the hazards for IBTR when compared to WBI. There was moderate certainty evidence that there were no significant differences among the accelerated ultra-hypo fractionated (AUHF) WBI (HR 0.76 (0.50 - 1.14)), MHF-WBI (HR 0.99 (0.84 - 1.16)) or UHF-WBI (HR (1.35 (0.47 - 3.92)) when compared with CF-WBI for IBTR. The effects of sequential TBB (seqTBB) (HR 0.61 (0.52 - 0.70), high certainty) and simultaneous integrated TBB (simTBB) (HR 0.77 (0.55 - 1.09), moderate certainty) on IBTR were similar when compared to no TBB. There were no significant differences in OS between PBI options and WBI, AF-WBI options and CF-WBI, TBB options and no TBB. Among the PBI vs WBI trials, MHF-PBI and APBI may be associated with fewer adverse PRC events. Among the AF-WBI vs CF-WBI trials, half of the included trials reported fewer adverse PRC events with MHF-WBI. SeqTBB and simTBB had similar adverse PRC outcome.

CONCLUSION

There were no significant differences among the PBI, AF-WBI and TBB options for IBTR and OS. PBI and AF-WBI may be associated with less adverse PRC events compared with WBI and CF-WBI respectively. There was no evidence to suggest a difference between seqTBB and simTBB for PRC outcome. This study is registered with PROSPERO CRD 42021245074.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

1019 The Surgical Skills Club: An Adaptable and Sustainable Model for Surgical Teaching

Introduction

The General Medical Council (GMC) stipulates that medical graduates should obtain competency in basic wound care. In a national review, only 24.7% of UK medical schools provided suturing training. Newly qualified doctors may be less prepared in performing basic surgical skills independently. Hence, Cambridge University Surgical Society initiated a weekly teaching programme, Surgical Skills Club (SSC).

Method

SSC covered instrument handling, knot-tying and various suturing techniques (interrupted, continuous, mattress and subcuticular), with 32 student participants. Trainees led these sessions, with tutor:student ratios at 1:5. SSC was designed to be cost-effective (£8/student); both reusable suturing pads and animal tissue were used. Glass jars were repurposed into knot-tying trainers. Participants completed questionnaires pre- and post-programme, rating confidence in skills on Likert scales; 1 (not confident) to 5 (very confident), alongside qualitative feedback.

Results

SSC was well-subscribed; most participants (88%) would highly-recommend it to peers. Receiving individualised feedback was highly valued. Students were more confident (scores 4 or 5) in skills post-programme compared to pre-programme (instrument handling: 21.9% vs 92.0%; basic knot-tying: 28.1% vs 88.0%; interrupted suturing: 50.0% vs 100%).

Conclusions

We demonstrated the effectiveness of a regular skills-teaching programme, where learning is consolidated through spaced repetition. This sustainable and accessible format can be widely adapted and implemented

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Abstract P5-03-12: Prognostic role of stem cell markers in triple-negative breast cancer (TNBC)

Introduction: Triple-negative breast cancer (TNBC) is among the most aggressive types of breast cancer with frequent recurrence and death despite chemotherapy. Studies have shown that cancer stem cells play a key role in many of the drug resistant cancers including TNBC. In this study, we report the expressions of four stem cell markers in 158 TNBC tumors.

Design: Clinicopathological data were obtained from 158 triple negative breast cancers between 2002 and 2010. Tissue microarray was constructed and immunohistochemistry stains (IHC) for CD44 and CD24, CD 133 and ALDH1 were performed using the streptavidin-biotin method. Each set of TNBC consists of normal, ductal carcinoma in situ and invasive areas for assessment of IHC stains. Statistical analysis was done on the following parameters: Histological types, modified Bloom and Richardson grades, lymph-vascular invasion, lymph node status, tumor size, Ki67, presence of lymphocytic host response, age >50 or <50, BRCA status, prognosis (recurrence and death) and chemotherapeutic response. P values less than 0.05 were considered statistically significant.

Results: the mean age of this cohort of TNBC patients was 55 with 64% white, 13.2% black, 12.6% Asian/Pacific, 3.8% Hispanic/Latino and 1.9% other. The majority of these tumors (82.3%) were grade 3, 15.2% were grade 2, and less than 1% was grade 1. CD24, CD44 and CD133 expressions were significantly higher in TNBC than in normal breast tissues (p = 5.53 e-10, p = 1.14 e-11, p = 2.25 e-08 respectively). While both CD24 and CD133 expressions predicted poor survival (p = 0.073 and p = 0.043 respectively), neither was associated with recurrence. In contrast to CD24, CD44 and CD133 expressions, ALDH-1 expression was rare in TNBC and surrounding normal tissues. When expressed, ALDH-1 was associated with poor survival but cases were too few to reach significance. None of the four stem cell markers studied were associated with any of the conventional histopathologic features and BRCA1 or BRCA2 mutations.

Conclusions: Our study suggests that stem cell marker(s) may be prognostically important in TNBC patients. When it is fully characterized it may provide new insight in developing effective therapeutic strategies targeting stem cell related signaling pathways.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-03-12.

Multiplexed immunobead-based assay for detection of oral cancer protein biomarkers in saliva

OBJECTIVE

For clinical applications of biomarkers, there is a need for multiplex assays using high throughput platforms. The objective of this study was to determine the efficacy of Luminex Multianalyte Profiling (xMAP) technology for measurement of salivary proteins and to evaluate whether multiplex assays are as effective as single-plex assays and enzyme-linked immunosorbent assay (ELISA).

RESULTS

The average levels of interleukin-8 (IL-8) from the single-plex assay were 3313.2 +/- 3759.8 pg ml(-1) [oral squamous cell carcinoma (OSCC), n = 20] and 1061.7 +/- 1978.8 pg ml(-1) (control, n = 20). The IL-1beta average levels from the single-plex assay were 945.2 +/- 1134.8 pg ml(-1) (OSCC, n = 20) and 314.2 +/- 444.8 pg ml(-1) (control, n = 20). The average levels of IL-8 from the multiplex assay were 2834.9 +/- 3385.6 pg ml(-1) (OSCC, n = 20) and 947.3 +/- 2036.8 pg ml(-1) (control, n = 20). The IL-1beta average levels from the multiplex assay were 1013.5 +/- 1221.1 pg ml(-1) (OSCC, n = 20) and 376.3 +/- 576.3 pg ml(-1) (control, n = 20). The correlation coefficient between Luminex and ELISA assay for IL-8 (n = 19) and IL-1beta (n = 19) was 0.91 and 0.84, respectively.

CONCLUSION

Luminex xMAP single-plex and multiplex assays are as effective as ELISA assays for quantification of proteins in saliva. Both IL-8 and IL-1beta were expressed at significantly higher levels in OSCC subjects than in the matched healthy control subjects.

Growth hormone deficiency and supplementation at in-vitro fertilisation

INTRODUCTION

This study aims to evaluate the differences in oocyte stimulation, endometrial thickness, fertilisation rate and embryo quality at in-vitro fertilisation (IVF) in patients with documented growth hormone (GH) deficiency, after GH supplementation.

METHODS

This was a retrospective analysis of 20 cases of patients who were pregnant and had GH supplementation during IVF at the Singapore General Hospital between 1993 and 2003. All these patients had previously failed IVF due to poor stimulation, poor egg quality, poor fertilisation at intracytoplasmic sperm injection (ICSI) or failed implantation, and they had documented GH deficiency. These initial cycles were compared with their subsequent IVF cycles with GH supplementation. A non-parametric test was used for statistical analysis.

RESULTS

Embryo quality, determined by scoring the embryos on Day two using morphology, improved significantly after supplementation of GH (p-value is less than 0.001, median embryo score increased from 10.7 to 16). There was also a statistically significant increase in the fertilisation rate for those patients who had ICSI. There was no statistical difference in the number of oocytes retrieved or in the mean endometrial thickness with GH.

CONCLUSION

This study implies that GH supplementation may improve embryo quality in selected patients with GH deficiency. Its role in improving fertilisation rate at ICSI merits further research and evaluation.

Risk behaviours and benign prostatic hyperplasia

OBJECTIVE

To identify risk factors for benign prostatic hyperplasia (BPH).

SUBJECTS AND METHODS

Medical history data, including reported urological conditions and treatments, and risk factor data were collected from 34 694 participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, a randomized controlled trial designed to evaluate methods for the early detection of cancer.

RESULTS

Asian men had the lowest risks (odds ratio, 95% confidence interval) for nocturia (0.7, 0.5-0.9), physician-diagnosed BPH (0.3, 0.2-0.5) and transurethral prostatectomy (TURP, 0.2, 0.1-0.6), while risks for Whites and Blacks were similar for most measures of BPH. Greater alcohol intake was associated with decreased nocturia (P trend = 0.002), BPH (P trend < 0.001) and TURP (P trend < 0.001). Current tobacco use was associated with decreased nocturia (0.8, 0.7-0.9), BPH (0.7, 0.6-0.8) and TURP (0.6, 0.4-0.8) but dose-response patterns were weak.

CONCLUSION

Asian-Americans have the lowest risk of clinical BPH. Alcohol and possibly cigarettes are related to a lower risk for BPH.

Relationship of demographic and clinical factors to free and total prostate-specific antigen

OBJECTIVES

To characterize the role of demographic and clinical parameters in the measurements of prostate-specific antigen (PSA), free PSA (fPSA), and percent free PSA (%fPSA).

METHODS

This was a cohort study of volunteers to a randomized screening trial. A central laboratory determined PSA and fPSA for the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. A baseline evaluation of free and total PSA was done for 7183 white, black, Asian, Hispanic, and other male volunteers, aged 55 to 74 years. Comparisons were made across racial and ethnic groups and across a set of clinical parameters from a baseline questionnaire.

RESULTS

The median levels of serum PSA were less than 2.1 ng/mL in each age-race grouping of the study participants. The levels of free and total PSA were higher in black (n = 868, 12%) participants than in white (n = 4995, 70%) and Asian (n = 849, 11.8%) participants. Individuals who identified themselves as ethnically Hispanic (n = 339, 4.7%) had median PSA levels higher than whites who were not Hispanic. The free and total PSA levels increased with age, particularly among men 70 to 74 years old. However, the %fPSA levels showed less variation among the four racial groups or by age. The free and total PSA levels were higher among those who had a history of benign prostatic disease.

CONCLUSIONS

Demographic (age and race/ethnicity) and clinical (history of benign prostatic disease) variables had a moderate effect on the measures of PSA and fPSA and very little effect on %fPSA.

Design of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial

The objectives of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial are to determine in screenees ages 55-74 at entry whether screening with flexible sigmoidoscopy (60-cm sigmoidoscope) can reduce mortality from colorectal cancer, whether screening with chest X-ray can reduce mortality from lung cancer, whether screening men with digital rectal examination (DRE) plus serum prostate-specific antigen (PSA) can reduce mortality from prostate cancer, and whether screening women with CA125 and transvaginal ultrasound (TVU) can reduce mortality from ovarian cancer. Secondary objectives are to assess screening variables other than mortality for each of the interventions including sensitivity, specificity, and positive predictive value; to assess incidence, stage, and survival of cancer cases; and to investigate biologic and/or prognostic characterizations of tumor tissue and biochemical products as intermediate endpoints. The design is a multicenter, two-armed, randomized trial with 37,000 females and 37,000 males in each of the two arms. In the intervention arm, the PSA and CA125 tests are performed at entry, then annually for 5 years. The DRE, TVU, and chest X-ray exams are performed at entry and then annually for 3 years. Sigmoidoscopy is performed at entry and then at the 5-year point. Participants in the control arm follow their usual medical care practices. Participants will be followed for at least 13 years from randomization to ascertain all cancers of the prostate, lung, colorectum, and ovary, as well as deaths from all causes. A pilot phase was undertaken to assess the randomization, screening, and data collection procedures of the trial and to estimate design parameters such as compliance and contamination levels. This paper describes eligibility, consent, and other design features of the trial, randomization and screening procedures, and an outline of the follow-up procedures. Sample-size calculations are reported, and a data analysis plan is presented.

Direct intrauterine fetal therapy in a case of bronchopulmonary sequestration associated with non-immune hydrops fetalis

Bronchopulmonary sequestration associated with non-immune hydrops fetalis is generally recognized as a uniformly fatal fetal condition without fetal surgical intervention. We describe here the first case of such a condition treated successfully with direct intrauterine fetal therapy using digoxin and frusemide.

The inhibitory effects of pravastatin on natural killer cell activity in vivo and on cytotoxic T lymphocyte activity in vitro

BACKGROUND

We have reported that heart transplant recipients treated with pravastatin demonstrate decreases in the incidence of clinically severe acute rejection episodes, the incidence and progression of transplant coronary vasculopathy, and natural killer cytotoxicity. These patients also exhibited a significant improvement in 1-year allograft survival. Because of these clinical findings suggesting an immunosuppressive effect of pravastatin unique to transplant recipients and the unclear role of natural killer cells in allograft rejection, we postulated that pravastatin may exert its immunomodulatory effect by acting with cyclosporine to alter T lymphocyte function.

METHODS

Twenty patients randomized into an ongoing trial of pravastatin after heart transplantation were monitored serially for natural killer cell cytotoxicity. In a separate experiment, lymphocytes isolated from normal volunteers were treated with various combinations of pravastatin and cyclosporine and tested for cytotoxic T lymphocyte toxicity in a one-way mixed lymphocyte reaction.

RESULTS

Pravastatin-treated heart transplant recipients exhibited a decrease in natural killer cell cytotoxicity (9.8% mean natural killer cell cytotoxicity vs 22.1% in the control group, p < 0.01). In the one-way mixed lymphocyte reaction with blood obtained from control subjects, there was a synergistic inhibition of cytotoxic T lymphocyte activity when the cells were cultured in a combination of pravastatin and cyclosporine (20.3% mean cytotoxicity of target cells vs 41.4% in the control group, p < 0.01).

CONCLUSIONS

Pravastatin exerts an immunosuppressive effect in heart transplant recipients as expressed by a reduction in rejection and natural killer cell cytotoxicity. Pravastatin and cyclosporine act synergistically to reduce cytotoxic T lymphocyte activity. This synergistic effect of pravastatin and cyclosporine may explain why this immunosuppressive effect is unique to transplant recipients.

Early fetal blood sampling--another available option for early prenatal diagnosis

Fourteen cases had early fetal blood sampling (FBS) performed between 13 and 18 weeks gestation in the Antenatal Diagnostic Centre, National University Hospital, Singapore from Jan 1988 to December 1994. The indications were: a) ultrasound abnormality (n = 6), b) hydrops (n = 1), c) screening for blood disorders (n = 2), d) amnio results inconclusive or to confirm abnormal amnio results (n = 5). This article analyses retrospectively the early FBS procedure and its outcome. There were no procedure related fetal losses in this study. The reliable rapid results obtained following the procedure enabled the obstetrician to counsel the couple regarding the current pregnancy and advise them accordingly for the subsequent pregnancy. Thus we found it useful not only in our patients but also for patients from overseas who get their results within a week to plan their stay.

Incidence of chromosomal abnormalities in 153 pregnancies with ultrasound detected fetal abnormalities

One hundred and fifty-three patients with fetal abnormalities diagnosed on ultrasound were karyotyped between January 1992 and December 1993. There were 19 (12.4%) fetuses with chromosomal abnormalities. The risk of chromosomal aberrations in the malformed fetuses were increased in the presence of intrauterine growth retardation (15.4%), oligohydramnios (20%) and polyhydramnios (25%). Fetal karyotyping is thus essential in the management of such pregnancies.

The role of transvaginal ultrasonography and colour Doppler imaging in the detection of ectopic pregnancy

OBJECTIVE

To assess the use of transvaginal ultrasound and colour Doppler imaging in the detection of ectopic pregnancy.

MATERIALS AND METHODS

Seventy-one patients with suspected ectopic pregnancies had transvaginal sonography and colour Doppler imaging performed and 61 ectopic pregnancies were confirmed at surgery. Various ultrasound features on transvaginal B mode scanning were noted and the resistance index of peritrophoblastic flow in the adnexal masses computed.

RESULTS

The use of transvaginal B mode imaging alone in the diagnosis of ectopic pregnancy achieved a sensitivity of 98% and a positive predictive value of 86%. The mean gestational age at time of diagnosis was 6 weeks 5 days (range 4 weeks to 13 weeks 2 days). The use of transvaginal colour flow imaging did not increase detection rates of ectopic pregnancy. The mean RI values for patients with or without ectopic pregnancy were almost identical.

CONCLUSION

Colour Doppler imaging failed to improve on the results of transvaginal B mode sonography in the detection of ectopic pregnancy.

Management of non-immune hydrops: 8 years' experience

During a period of 8 years (1985-92), 100 fetuses were diagnosed to have non-immune hydrops on the basis of ultrasonographic findings and absence of rhesus isoimmunization. Both the mother and the fetus were thoroughly evaluated by a set protocol that included a detailed fetal abnormality scan with echocardiography and fetal blood sampling. A cause for non-immune hydrops could be identified in 81% of the fetuses. Cardiovascular abnormalities (23%) and alpha(1)-thalassemia (22%) were almost equally common etiological factors in the South-East Asian population under investigation. A chromosomal abnormality was detected in 10% of the fetuses with non-immune hydrops. Twenty-six fetuses were found to be suitable for in utero therapy. In utero therapy included one or more of the following: (1) fetal intravascular blood transfusion; (2) direct fetal drug therapy; and (3) fetal pleuroamniotic shunting. Eighteen of the 26 babies (69.2%) were alive and well at 1 month after delivery. It is concluded that in well-selected cases appropriate in utero fetal therapy can lead to significant improvement in fetal salvage.

The effect of pravastatin on acute rejection after kidney transplantation--a pilot study

Hyperlipidemia is an important complication of kidney transplantation affecting up to 74% of recipients. HMG-CoA reductase inhibitors are reported to provide safe and effective treatment for this problem. A recent study suggests that pravastatin, an HMG-CoA reductase inhibitor, also decreases the incidence of both clinically severe acute rejection episodes and natural killer cell cytotoxicity after orthotopic heart transplantation. We have performed a prospective randomized pilot study of the effect of pravastatin on these same parameters after cadaveric kidney transplantation. Graft recipients were randomized to receive pravastatin after transplantation or no pravastatin (24 patients in each group) in addition to routine cyclosporine and prednisone immunosuppression. Lipid levels, acute rejection episodes and serial natural killer cell cytotoxicities were followed for 4 months after the transplant. At the end of the study period, pravastatin had successfully controlled mean total cholesterol levels (202.6 +/- 9.3 vs. 236.5 +/- 11.9 mg/dl, P < 0.02), LDL levels (107.9 +/- 6.6 vs.149.6 +/- 10.7 mg/dl, P < 0.002), and triglyceride levels (118.8 +/- 14.2 vs. 157.2 +/- 13.8 mg/dl, P < 0.05). In addition, the pravastatin-treated group experienced a reduction in the incidence of biopsy-proven acute rejection episodes (25% vs. 58%, P = 0.01), the incidence of multiple rejections episodes (P < 0.05), and the use of both pulse methylprednisolone (P = 0.01) and OKT3 (P = 0.02). Mean natural killer cell cytotoxicity was similarly reduced (11.3 +/- 1.6 vs. 20.0 +/- 2.0% lysis of K562 target cells, P < 0.002). These data suggest that pravastatin exerts an additional immunosuppressive effect in kidney transplant recipients treated with cyclosporine-based immunosuppression.

Direct fetal therapy for hydrops secondary to congenital atrioventricular heart block

BACKGROUND

The outcome for the fetus with hydrops fetalis secondary to complete congenital heart block is almost uniformly poor. Transplacental fetal therapy with inotropic drugs may be unreliable in the hydropic fetus. We describe our experience of direct fetal therapy with digoxin and furosemide in three cases.

CASES

In the first two cases, fetal hydrops secondary to congenital heart block was detected at 33 and 31 weeks. Direct fetal therapy with digoxin and furosemide was given and the mothers received digoxin concurrently. The neonates were born normally at 35 weeks and 33 weeks; one required ventricular pacing, but both are currently alive and well. In the third case, fetal hydrops was detected at 24 weeks, when furosemide was used alone for direct fetal therapy. The mother developed chorioamnionitis at 29 weeks and was delivered by cesarean; the infant died of cardiac failure after 48 hours.

CONCLUSION

Initial direct fetal therapy with digoxin and furosemide followed by transplacental treatment with digoxin and direct fetal therapy with diuretics might improve the perinatal salvage of hydropic fetuses with congenital heart block. Treatment must be individualized because development of infection and preterm labor might defeat the objective.

Role of transvaginal ultrasound color flow imaging and Doppler waveform analysis in differentiating between benign and malignant ovarian tumors

This study was undertaken to assess the usefulness of ultrasound color flow imaging and Doppler waveform analysis in differentiating between benign and malignant ovarian tumors. From 1991 to 1993, 146 patients with 156 ovarian tumors underwent transvaginal scanning with color flow imaging and Doppler waveform analysis prior to surgery. All the ovarian tumors were removed surgically and confirmed histologically. The sensitivity and specificity of color flow imaging in identifying malignant ovarian tumors was 76.5% and 68%, respectively. Positive and negative predictive values were 40% and 91.2%, respectively. The addition of Doppler waveform analysis failed to produce statistically better results. Seven of the eight cases of ovarian cancer were missed by color Doppler. There were no solid areas present and malignancy was not suspected. Both modalities also failed to identify any case of ovarian cancer presenting as a simple cyst.

Effect of pravastatin on outcomes after cardiac transplantation

BACKGROUND

Hypercholesterolemia is common after cardiac transplantation and may contribute to the development of coronary vasculopathy. Pravastatin, a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, has been shown to be effective and safe in lowering cholesterol levels after cardiac transplantation. Cell-culture studies using inhibitors of HMG-CoA reductase have suggested an immunosuppressive effect.

METHODS

Early after transplantation, we randomly assigned consecutive patients to receive either pravastatin (47 patients) or no HMG-CoA reductase inhibitor (50 patients).

RESULTS

Twelve months after transplantation, the pravastatin group had lower mean (+/- SD) cholesterol levels than the control group (193 +/- 36 vs. 248 +/- 49 mg per deciliter, P < 0.001), less frequent cardiac rejection accompanied by hemodynamic compromise (3 vs. 14 patients, P = 0.005), better survival (94 percent vs. 78 percent, P = 0.025), and a lower incidence of coronary vasculopathy in the transplant as determined by angiography and at autopsy (3 vs. 10 patients, P = 0.049). There was no difference between the two groups in the incidence of mild or moderate episodes of cardiac rejection. In a subgroup of study patients, intracoronary ultrasound measurements at base line and one year after transplantation showed less progression in the pravastatin group in maximal intimal thickness (0.11 +/- 0.09 mm, vs. 0.23 +/- 0.16 mm in the control group; P = 0.002) and in the intimal index (0.05 +/- 0.03 vs. 0.10 +/- 0.10, P = 0.031). In a subgroup of patients, the cytotoxicity of natural killer cells was lower in the pravastatin group than in the control group (9.8 percent vs. 22.2 percent specific lysis, P = 0.014).

CONCLUSIONS

After cardiac transplantation, pravastatin had beneficial effects on cholesterol levels, the incidence of rejection causing hemodynamic compromise, one-year survival, and the incidence of coronary vasculopathy.

A new simplified method of gene typing

SSP-PCR (sequence-specific primer) DNA typing was performed in Terasaki trays using 1.5 microliters of DNA, and the ethidium-stained PCR product was measured by direct fluorometric reading. Elimination of the gel electrophoresis step greatly simplified the SSP method. 17 serological DR specificities were discriminated for 239 DNA samples utilizing the new method, standard SSP, sequence-specific oligonucleotide probe (SSOP), and restriction fragment length polymorphism (PCR-RFLP). Results showed 98% concordance between the SSP-PCR assay and conventional methods. DRB1 alleles were determined by PCR-RFLP in 59 samples, by SSP in 110 samples, and by consensus (all methods) in the remaining samples.

Direct detection of PCR products for HLA class II typing

Direct detection of the PCR, or DD-PCR is proposed as an efficient method for performing PCR assays. Following the PCR reaction, ethidium homodimer dye is added to the reaction mixture and read by fluorescence. The dye step circumvents the necessity of running reactions on agarose gel electrophoresis, which is the current standard. This simple modification should find wide application for assays utilizing the PCR reaction. Here we show the ready detection of HLA class II polymorphism.

Fetal blood sampling and its complications related to the indications for fetal blood sampling

A prospective study on fetal blood sampling (FBS) was conducted in the Fetomaternal Medicine Division of the Department of Obstetrics and Gynaecology at the National University Hospital, Singapore. FBS was performed on 159 occasions in 156 women between January, 1988 and December, 1991. The aim of this study was to identify the factors that were associated with an adverse outcome following the procedure. Twenty four abnormal pregnancies were terminated; of the remaining 132 desired pregnancies the overall pregnancy loss was 44 (33.3%), which included those within 2 weeks and those after 2 weeks of the procedure and neonatal deaths. Fetal loss occurring within 2 weeks of the procedure is considered a procedure-related loss which occurred in 19 (14.3%) of the 132 pregnancies. When the fetal loss occurred within 2 weeks of the procedure 89% had a major abnormality on ultrasonographic scanning. The conclusion from our study is that the risks of FBS were increased in abnormal pregnancies, most likely due to the underlying pathology.

A new microcellular cytotoxicity test based on calcein AM release

We present a microtest for cell-mediated immunity, based on the use of the Tarasaki tray and calcein AM vital dye. The number of target cells needed has been reduced to 500 per test with a corresponding tenfold reduction in the number of effector cells needed. Results were read at the rate of 1 second per test using a fluorimeter attached to a microscope. Each reaction was also confirmed visually with the use of ethidium bromide as a counterstain for dead cells. The calcein AM dye used to stain the living cells was shown to have a low spontaneous leakage rate--less than 15% in 4 hours at 37 degrees C. Dilutions of targets stained by calcein AM had a linear relationship with measured fluorescence values. NK cells, LAKs, and CTLs were readily detectable by this microtest. Quantitation of killing and kinetic analysis was readily performed with this test system. A significant positive correlation to 51Cr-release results was found. We conclude that the microtest should find wide application in studies of cell-mediated immunity.

The role of IgA anti-HLA class I antibodies in kidney transplant survival

The unusually high 88% one-year cadaver kidney graft survival rate in patients with IgA nephropathy (IgAN) prompted us to investigate the influence of IgA anti-HLA class I antibodies on subsequent graft survival. We found that patients with various original diseases with IgA antibodies to the HLA molecule had high 91% one-year graft survival compared with 58% one-year survival for those who did not have preformed IgA antibodies against the HLA molecule prior to transplantation (P < 0.0005). The IgA antibodies were detected by reaction with class I HLA molecules isolated by capture with monoclonal antibody and detected with an enzyme-linked immunosorbent assay. In contrast, IgG antibodies to the HLA molecule resulted in a lower one-year graft survival rate (74%) than in those patients without IgG antibodies (87%) (p = 0.08). IgA antibodies to the HLA molecule, when present, tended to react at a high frequency on a random lymphocyte panel. These findings suggest that sensitization resulting in IgA anti-HLA antibodies may counteract the deleterious effect of an IgG antibody response in clinical kidney transplantation.

Development and characterization of a novel anti-fucosylated antigen monoclonal antibody YB-2 and its usefulness in the immunohistochemical diagnosis of colorectal cancer

A novel monoclonal antibody, YB-2 was obtained after immunization of mice with fucosylated antigens isolated from human saliva. The antibody was demonstrated to react with Y (Fuc alpha 1-->2Gal-beta 1-->4[Fuc alpha 1-->3]GlcNAc beta),Leb (Fuc alpha 1-->2Gal beta 1-->3[Fuc alpha 1-->4]GlcNAc beta) and H type 2 (Fuc alpha 1-->2Gal-beta 1-->4GlcNAc beta) antigens, but not with H type 1 (Fuc alpha 1-->2Gal beta 1-->3GlcNAc beta), Lea (Gal beta 1-->3[Fuc alpha 1-->4]GlcNAc beta), X (Gal beta 1-->4[Fuc alpha 1-->3]GlcNAc beta) or with non-fucosylated antigens. Inhibition assays of YB-2 antibody with such reactive antigens showed that YB-2 antibody preferentially reacted with Y antigen. Formalin-fixed and paraffin-embedded sections prepared from normal and malignant colorectal tissues were examined immunohistochemically with YB-2. The positive rates of staining with YB-2 antibody were 88.6% in malignant and 12.0% in normal tissues. The expression of fucosylated antigens detected by YB-2 antibody seemed to be correlated with survival among patients with primary colorectal cancer. Therefore, YB-2 antibody could be useful as an immunochemical tool for diagnosis and evaluation of the prognosis of colorectal cancer.

In vitro studies to explain high renal allograft survival in IgA nephropathy patients

The pretransplant sera of 27 IgA nephropathy (N) kidney transplant patients were investigated for antibodies to the HLA molecule, together with 104 sera from non-IgA N patients and 60 controls. IgA antibodies to HLA were found in 61% of IgA N patients and 2% of non-IgA N patients. IgA N patients with IgA antibodies to HLA had a 100% 2-year cadaver donor graft survival rate compared with 70% in those without IgA antibodies. Patients with IgG antibodies to HLA without accompanying IgA antibodies had the worst graft survival rates. We propose that IgA anti-HLA contributes to the high kidney graft survival in IgA N patients by blocking IgG antibodies or inhibiting cellular immune response.

A case report: vesico-rectal fistula with ano-urethral atresia

Vesico-rectal fistula is a rare congenital abnormality causing severe early second trimester oligohydramnios. Prenatal diagnosis of such a case is reported here. Ultrasound diagnosis could be aided by transabdominal amnio-infusion and, if necessary, fetal intraperitoneal saline installation. In a karyotypically normal fetus with normal somatic growth, demonstration of normal fetal kidneys together with a functioning urinary bladder, in presence of severe oligohydramnios, is very suggestive of the diagnosis. Since pulmonary hypoplasia is the major cause of neonatal mortality in these cases, restoration of normal amniotic fluid volume by serial amnio-infusion was attempted. Although amnio-infusion is an important diagnostic aid in the evaluation of severe midtrimester oligohydramnios, the role of multiple therapeutic amnio-infusion in improving lung growth remains to be evaluated.

Umbilical artery blood flow in intra-uterine growth retarded fetuses and fetal outcome: a study of 102 cases

The 102 fetuses diagnosed by ultrasound to be asymmetrically growth-retarded had blood flow velocity waveforms of the umbilical artery studied. Sixty-two cases had normal blood flow, 28 had abnormal blood flow but with present end-diastolic flow, 8 had absent end-diastolic flow, and 4 had reversal of end-diastolic flow. Comparison was made between the blood flow status and other biophysical methods of antenatal surveillance and perinatal outcome. There is a strong correlation between abnormal blood flow and abnormalities detected by other biophysical methods of antenatal surveillance. Our study shows that fetuses with severe blood flow impairment tend to be more severely growth-retarded and to be delivered earlier. Our results also show abnormal blood flow to be associated with a poor perinatal outcome. Those fetuses with severe impairment of blood flow suffered a high incidence of operative delivery for fetal distress, acidosis at birth, perinatal mortality and morbidity. The association between abnormal blood flow and the 5-minute Apgar score is significant only in those with the severest impairment of blood flow. Our results are in close agreement with similar studies recorded in the literature.