Impact of new definitions of pre-eclampsia on incidence and performance of first-trimester screening

OBJECTIVE

The traditional definition of pre-eclampsia (PE) is based on the development of hypertension and proteinuria. This has been revised recently to include cases without proteinuria but with evidence of renal, hepatic or hematological dysfunction. The aim of this study was to examine the impact of new definitions of PE on, first, the incidence and severity of the disease and, second, the performance of the competing-risks model for first-trimester assessment of risk for PE.

METHODS

This was a retrospective study of 66 964 singleton pregnancies that were classified as having PE, gestational hypertension (GH) or no PE or GH, according to the traditional criteria of the International Society for the Study of Hypertension in Pregnancy (ISSHP-old), which defines PE as the presence of both hypertension and proteinuria. We reviewed the records of pregnancies with GH, and those cases with high creatinine or liver enzymes or low platelet count were reclassified as having PE, according to the new criteria of ISSHP (ISSHP-new) and the new criteria of the American College of Obstetricians and Gynecologists (ACOG). The groups of PE according to the traditional and new criteria were compared for, first, gestational age at delivery, birth-weight percentile and incidence of a small-for-gestational-age (SGA) neonate with birth weight < 10^th percentile and perinatal death, and, second, the predictive performance for preterm PE of the competing-risks model based on the combination of maternal risk factors, uterine artery pulsatility index, mean arterial pressure and serum placental growth factor at 11-13 weeks' gestation (triple test).

RESULTS

According to ISSHP-old, 1870 (2.8%) cases had PE, 2182 (3.3%) had GH and 62 912 (94.0%) had no PE or GH. The incidence of PE according to ACOG was 3.0% (2029/66 964) and ISSHP-new was 3.4% (2301/66 964). Median gestational age at delivery in the extra cases of PE according to ACOG (difference, 1.3 weeks; 95% CI, 0.71-1.71 weeks) and in the extra cases of PE according to ISSHP-new (difference, 1.5 weeks; 95% CI, 1.29-1.71 weeks) was higher than in cases with PE according to ISSHP-old (38.4 weeks). The incidence of a SGA neonate in the extra cases of PE according to ACOG (relative risk, 0.57; 95% CI, 0.42-0.79) and in the extra cases of PE according to ISSHP-new (relative risk, 0.52; 95% CI, 0.42-0.65) was lower than in the cases of PE according to ISSHP-old (33.64%). In first-trimester screening for preterm PE by the triple test, the detection rate, at a 10% false-positive rate, was 75.9% (95% CI, 70.8-80.6%) for ISSHP-old, 74.3% (95% CI, 69.2-79.0%) for ACOG and 74.0% (95% CI, 68.9-78.6%) for ISSHP-new.

CONCLUSIONS

The new definitions of PE resulted in, first, an increase in pregnancies classified as having PE but the additional cases had milder disease, and, second, a non-significant decrease in the performance of first-trimester screening for PE. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Impaired placental perfusion and major fetal cardiac defects

OBJECTIVE

To investigate the relationship between fetal congenital heart defects (CHD) and placental perfusion assessed by uterine artery pulsatility index (UtA-PI), in relation to development of pre-eclampsia (PE).

METHODS

This was a prospective screening study of singleton pregnancies at 19-24 weeks' gestation. Transvaginal ultrasound was used to measure UtA-PI and the values were converted into multiples of the normal median (MoM). Median MoM values in pregnancies with a fetus with isolated major CHD were compared to those without CHD, in relation to development of PE.

RESULTS

The 91 407 singleton pregnancies fulfilling the entry criteria included 206 (0.23%) with isolated major fetal CHD and 91 201 without CHD. The prevalence of PE was 4.4% in pregnancies with fetal CHD and 2.7% in those without CHD (relative risk (RR), 1.6 (95% CI, 0.84-3.04); P = 0.150); the respective values for preterm PE with delivery at < 37 weeks' gestation were 2.4% and 0.7% (RR, 3.4 (95% CI, 1.42-8.09); P = 0.006). In the total population, median UtA-PI MoM was significantly higher in those that developed PE compared to those without PE (1.22 (interquartile range (IQR), 0.94-1.57) vs 1.00 (IQR, 0.84-1.19); P < 0.0001) and, in the PE group, the median UtA-PI MoM was inversely related to gestational age at delivery (r = -0.458; P < 0.0001). The same pattern of inverse relationship between UtA-PI MoM and gestational age at delivery with PE was observed in pregnancies with and those without CHD, but, in the CHD group, compared to those without CHD, UtA-PI was significantly higher both in pregnancies with and in those without PE.

CONCLUSIONS

In pregnancies both with and without fetal CHD that develop PE, impedance to flow in the UtAs is increased and this increase is particularly marked in those with preterm PE. The prevalence of preterm PE is more than three times higher in pregnancies with than those without fetal major CHD, and the prevalence of major CHD in pregnancies with preterm PE is also more than three times higher than in those without PE. However, > 97% of pregnancies with fetal CHD do not develop preterm PE and > 99% of pregnancies with preterm PE are not associated with fetal CHD. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

ASPRE trial: incidence of preterm pre-eclampsia in patients fulfilling ACOG and NICE criteria according to risk by FMF algorithm

OBJECTIVE

To report the incidence of preterm pre-eclampsia (PE) in women who are screen positive according to the criteria of the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG), and compare the incidence with that in those who are screen positive or screen negative by The Fetal Medicine Foundation (FMF) algorithm.

METHODS

This was a secondary analysis of data from the ASPRE study. The study population consisted of women with singleton pregnancy who underwent prospective screening for preterm PE by means of the FMF algorithm, which combines maternal factors and biomarkers at 11-13 weeks' gestation. The incidence of preterm PE in women fulfilling the NICE and ACOG criteria was estimated; in these patients the incidence of preterm PE was then calculated in those who were screen negative relative to those who were screen positive by the FMF algorithm.

RESULTS

A total of 34 573 women with singleton pregnancy delivering at ≥ 24 weeks' gestation underwent prospective screening for preterm PE, of which 239 (0.7%) cases developed preterm PE. At least one of the ACOG criteria was fulfilled in 22 287 (64.5%) pregnancies and the incidence of preterm PE was 0.97% (95% CI, 0.85-1.11%); in the subgroup that was screen positive by the FMF algorithm the incidence of preterm PE was 4.80% (95% CI, 4.14-5.55%), and in those that were screen negative it was 0.25% (95% CI, 0.18-0.33%), with a relative incidence in FMF screen negative to FMF screen positive of 0.051 (95% CI, 0.037-0.071). In 1392 (4.0%) pregnancies, at least one of the NICE high-risk criteria was fulfilled, and in this group the incidence of preterm PE was 5.17% (95% CI, 4.13-6.46%); in the subgroups of screen positive and screen negative by the FMF algorithm, the incidence of preterm PE was 8.71% (95% CI, 6.93-10.89%) and 0.65% (95% CI, 0.25-1.67%), respectively, and the relative incidence was 0.075 (95% CI, 0.028-0.205). In 2360 (6.8%) pregnancies fulfilling at least two of the NICE moderate-risk criteria, the incidence of preterm PE was 1.74% (95% CI, 1.28-2.35%); in the subgroups of screen positive and screen negative by the FMF algorithm the incidence was 4.91% (95% CI, 3.54-6.79%) and 0.42% (95% CI, 0.20-0.86%), respectively, and the relative incidence was 0.085 (95% CI, 0.038-0.192).

CONCLUSION

In women who are screen positive for preterm PE by the ACOG or NICE criteria but screen negative by the FMF algorithm, the risk of preterm PE is reduced to within or below background levels. The results provide further evidence to support the personalized risk-based screening method that combines maternal factors and biomarkers. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Correction: Temporal Patterns of Influenza A and B in Tropical and Temperate Countries: What Are the Lessons for Influenza Vaccination?

[This corrects the article DOI: 10.1371/journal.pone.0152310.].

Abstract P4-02-03: FDG PET/CT for early monitoring of response to neoadjuvant chemotherapy in breast cancer patients

Introduction: Neoadjuvant chemotherapy (NAC), initially used only for locally advanced breast cancer, is now commonly used in patients with operable but large breast cancer or unfavorable tumor/breast size index because increases the chances of performing breast conservative surgery (BCS) instead of mastectomy in this group of patients.

Patients and Methods: This is a prospective unicenter trial. FDG PET/CT were performed in 40 patients at baseline and after the second cycle of NAC. The level and relative changes in standardized uptake value (SUV) of FDG uptake were assessed regarding their ability to predict histopathologic response.

Pathologic complete response (pCR) was defined as no malignant cells (no invasive ductal carcinoma and no ductal carcinoma in situ) identifiable in sections from the site of the tumor in the breast and in the axillary lymph node.

Results: This prospectively study analyzed forty patients undergoing NAC, all female, age ranged 27–64 years (mean 41.0 years and median 38 years), all tumors were invasive ductal carcinoma, histological tumor grade 1, 2 and 3 were present respectively at 5%, 38.5% and 100% of the sample and nuclear grade 2 and 3 were present respectively at 12.5% and 87.5%. Estrogen receptor was positive in 60% of patients and the progesterone receptor was positive in 47.5% of patients. Her 2 was overexpressed in 12 patients (30%). Phenotype in this sample had the following distribution: 12.5% luminal A (5 patients), 50% Luminal B (20 patients: 14 patients with Ki-67&gt; 14% and 6 cases with HER 2 overexpression), 15 % HER 2 (6 patients) and cases triple negative 9 (22.5%). size of the primary tumor ranged from 4.10 cm to 12.0 cm (mean 7.10 cm). The size of the primary tumor ranged from had a mean of 6.7 cm and a median of 6.0 cm. This group showed great uniformity in relation to primary chemotherapy. NAC with cyclophosphamide and adriamycin were administered to 38 patients. In this study, pCR was obtained in 12 patients (30%). Baseline FDG SUV referring to pCR group was 11.26 and 7.26 in non-pCR group (p = 0.04). FDG SUV after second cycle was 2.73 in pCR group and 4.64 in non-pCR group (p = 0.048). When analyzing ΔSUV (difference between baseline SUV and SUV after second cycle), pCR group had a mean reduction of 81.58% and non-pCR group had a mean reduction of 81.58% (p = 0.001). Receiver operating curve analyses were performed to deter mine optimal differentiation cut-off values of ΔSUV for differentiation of pCR and non-pCR. After two courses of NAC the optimal cutoff value to early differentiation between pCR from non-pCR were 59,1% in decrease of SUV. The sensitivity and specificity were 64,3% and 100,0%, respectively.

Conclusion: The optimum role of FDG PET in predicting the response of breast cancers to neoadjuvant chemotherapy is still not clearly defined and the SUV cut-off needs to be validated. FDG-PET allows for prediction of treatment response by the level of FDG uptake in terms of SUV at baseline and after two cycles of chemotherapy and FDG-PET may be helpful for individual treatment stratification in breast cancer patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-02-03.

Tissue specificity of lymphocyte migration into sheep gingival tissue

T cells show a bias in their migration pathways: some migrate preferentially to peripheral lymph nodes, some to mucosal tissues and some to peripheral tissues such as skin. The aim here was to determine the types of T cells that migrate preferentially into inflamed gingival tissue and compare this migration to that found in inflamed subcutaneous and mucosal tissues. The experiments were designed so that the simultaneous 3 h localization of two, differentially radiolabelled, lymphocyte populations (subcutaneously and mucosally derived) into sites of purified protein derivative/bacillus Calmette-Guerin-induced, delayed-type hypersensitivity, inflammatory lesions in skin, bowel and gingiva in the sheep model could be compared. The relative migration of two populations in each of the tissues was expressed as a ratio of the radioactivity of intestinal/subcutaneous lymphocytes recovered from that tissue. From nine experiments, the ratios [mean+/-S.E.M. (n)] for skin, bowel and gingiva were 0.53+/-0.02 (84), 1.98+/-0.11 (85), and 0.73+/-0.05 (29), respectively. These findings suggest that inflammation in skin and gingiva favoured the localization of subcutaneously derived lymphocytes (ratio significantly <1, P<0.025), while in bowel, the localization of intestinally derived lymphocytes was favoured (ratio significantly >1, P<0.025). Statistical analysis demonstrated that the relative localization of the two lymphocyte populations to the gingival lesions differed significantly from that for inflamed skin and bowel lesions (P<0.05). When tumour necrosis factor-alpha was used as a non-antigenic inflammatory agent to induce lymphocyte migration into skin and gingiva, a similarly greater increase in the localization of subcutaneously derived lymphocytes was detected, but the relative localization of lymphocytes was not significantly different between the two tissues. Therefore, it appears that there is tissue specificity in the migration of lymphocytes into the inflamed gingival tissues and that antigen is required for distinct tissue-specific lymphocyte traffic to occur.

Cyclosporine A inhibits lymphocyte migration into ovine peripheral nerve allografts

Lymphocyte migration into nerve allografts was measured to estimate the cyclosporine A (CsA) dose required to suppress rejection. Twelve outbred sheep received daily subcutaneous CsA at 0, 5, 10, or 15 mg/kg/day for 2 weeks prior to implantation of multiple heterotopic subcutaneous nerve grafts. Lymphocyte migration was determined after 7 days by an intravenous pulse of autologous 111indium-labeled lymphocytes and subsequent quantitation of gamma radioactivity in nerve tissue (CPM/g, mean +/- SEM). Measurement by radioimmunoassay revealed a dose-dependent increase in blood cyclosporine levels. Lymphocyte migration into autografts (404+/-44) was significantly less than migration into allografts (16,554+/-2,049), in control animals (P < 0.01). A dose-dependent inhibition of lymphocyte migration into nerve allografts was observed with counts of 7,662+/-1,692, 4,083+/-1,112, and 1,561+/-232 in sheep receiving 5, 10, or 15 mg/kg/day of CsA, respectively. Daily CsA administration produced effective blood levels and immunosuppression sufficient to inhibit lymphocyte migration into nerve allografts.

Analysis of the complementary determining region III of the immunoglobulin heavy chain locus in acute lymphoblastic leukemia in Chilean children

We have analyzed the sequence of 40 VDJ rearrangements of the immunoglobulin heavy chain gene locus on 32 unselected children from Chile with precursor B cell ALL at diagnosis. Rearrangements were derived by PCR with VH gene family-specific primers and sequenced directly. The number of VDJ rearrangements, and the pattern of VH, DH and JH gene usage was identical to the one reported by groups from developed countries. CDR3 regions represented an unbiased repertoire; VH to JH joinings were in frame in 36% of cases. Absent N nucleotides in the DJ border, suggestive of fetal origin of ALL, were seen in 9/40 rearrangements but they did not correlate with younger age. More than one rearrangement was sequenced in six patients, representing independent events with no signs of clonal evolution. One patient was analyzed at first bone marrow relapse showing persistence of one rearrangement and evolution of a second one which conserved the DJ border. The subset of B cell precursors which suffer malignant transformation to ALL appear to be common in different parts of the world.

The use of the lipophilic fluorochrome CM-DiI for tracking the migration of lymphocytes

In this study we examined the new cell dye CM-DiI for tracking the migration of lymphocytes from blood to lymph. This lipophilic marker intercalates in the plasma membrane like the PKH dyes and older DiI derivatives. The stability and intensity of staining achieved with these dyes is better than most other fluorochromes or radioisotopes, yet they are poorly soluble in aqueous solutions, which can make staining difficult, and they are not fixable in tissue sections. CM-DiI is reported to have increased water solubility and it can be fixed using traditional aldehyde fixatives, making it feasible to detect labeled cells in histological sections. To determine the suitability of CM-DiI as a lymphocyte marker, a labeling protocol was developed. We tested the ability of stained cells to recirculate in vivo. Following the intravenous injection of CM-DiI positive cells, their recovery in lymph over 40 h was comparable to that of cells labeled with other fluorochromes or radioisotopes. The kinetics of recirculation were also very similar, as labeled cells were detectable in lymph within 4 h of injection, and the peak percentage of labeled cells in lymph was generally observed between 20-30 h. We also confirmed that CM-DiI is retained in the lymphocyte membrane following routine paraffin processing. Thus CM-DiI does not appear to alter the process of lymphocyte recirculation, and it should be a useful marker for tracking these cells.

t(1;5)(q23;q33) in a patient with high-risk B-lineage acute lymphoblastic leukemia

The t(1;5)(q23;q33) is a rare genetic anomaly that was reported previously in two infants with a myeloproliferative disorder and eosinophilia and in one adult patient with acute nonlymphocytic leukemia (ANLL). A 13-year-old boy with high-risk early pre-B acute lymphoblastic leukemia (ALL) who presented to our institution carried the t(1;5)(q23;q33). He had an initial blast count of 230 X 10(9)/L and responded poorly to prednisone. Complete remission (CR) was achieved, and he had a bone marrow (BM) relapse 3 months after despite intensive consolidation therapy. He underwent allogeneic BM transplantation (BMT) from a human leukocyte antigen (HLA)-identical siblings in early relapse with total body irradiation (TBI) and cyclophosphamide conditioning. He had a short second CR with a central nervous system (CNS) relapse on day + 106 after BMT. Two of the previously reported patients also did not respond to chemotherapy. The t(1;5)(q23;q33) appears to be a rare lineage nonspecific anomaly related to hematologic malignancies that are resistant to current therapy.

The exit of lymphocytes and RBCs from the peritoneal cavity of sheep

The purpose of this study was to compare the exit rates and migration pathways of 51Cr-labeled lymphocytes from the peritoneal cavity into the blood with those of a non-motile cell population, 111In-RBCs, in order to determine whether lymphocytes actively migrate from the peritoneal cavity. Radiolabeled cells were infused into the peritoneal cavity and multiple samples of lymph draining from the peritoneal cavity and/or blood were obtained, then the animal was sacrificed and various tissues were harvested and assayed for radioactivity. The recovery of 51Cr-lymphocytes from the mesenteric nodes was not significantly different from that of nodes anatomically distant from the cavity, so it is unlikely that large numbers of lymphocytes migrate across the mesothelial lining of the cavity and into the mesenteric lymphatics. However, the caudal mediastinal node contained about 18-fold more 51Cr-lymphocytes and 473 times as many 111In-RBCs, confirming the importance of this node in the drainage of cells and fluid from the cavity. The hepatic node also appears to receive cells directly from the peritoneal cavity. We also calculated the recovery of labeled cells at the end of the experiment (T = 40 h), and found that the recovery of 51Cr-lymphocytes (3.87 +/- 1.29% ID) in the blood was much lower than that of 111In-RBCs (35.28 +/- 5.02% ID). This difference can be attributed mainly to the traffic of labeled lymphocytes out of the blood rather than the selective retention of lymphocytes within the peritoneal cavity. Cannulation of the caudal mediastinal efferent lymphatic and the thoracic duct, which drain the peritoneal cavity, revealed approximately a 3-fold higher cumulative recovery of 111In-RBCs than 51Cr-lymphocytes over 6 h. However, by 40 h the percentage of labeled RBCs and lymphocytes remaining in the cavity was not significantly different. While 51Cr-lymphocytes may leave the peritoneal cavity at a slower rate than 111In-RBCs, both cell populations appear to exit solely via lymphatic vessels.

[Prolymphocytic leukemia, description of 2 cases]

We present the clinical and laboratory features of 2 patients with B prolymphocytic leukemia. Both are females of the fifth and seventh decade of life. One had the classical clinical picture of massive splenomegaly and a high white cell count, with characteristic prolymphocytes, and the other was asymptomatic, with a low white cell count. The cells were positive to B cell lineage reagents with strong surface immunoglobuline (Ig) and unreactive to T cell antibodies. Analysis of Ig genes at the DNA level demonstrated that both cases had heavy-chain gene rearrangements, confirming the B-cell origin. These are the first patients of prolymphocytic leukemia described in Chile.

Decorin, a chondroitin/dermatan sulfate proteoglycan is under neural control in rat skeletal muscle

Proteoglycans (PGs) are abundant components of the extracellular matrices (ECM) of skeletal muscle. We have previously found that the synthesis of skeletal muscle PGs present at the ECM increase after denervation. The experiments reported here were undertaken to identify which PG(s) increase after denervation of rat leg muscles. Incorporation of radioactive sulfate demonstrated the presence of a chondroitin/dermatan sulfate PG of 70-90 kDa in the skeletal muscle ECM, which increased after denervation. The PG has a core protein of 39-45 kDa after treatment with chondroitinase ABC. Antibodies against rat decorin, a chondroitin/dermatan sulfate PG synthesized by various cell types, specifically immunoprecipitated this PG from a mixture of PGs. Immunocytolocalization of this PG indicated that the chondroitin/dermatan sulfate PG accumulates at the perimysium of skeletal muscle after denervation. Finally, Northern blot analysis indicated an increase of muscle transcripts for decorin after denervation. The data reported here suggest that a chondroitin/dermatan sulfate PG present at the skeletal muscle ECM, very similar if not identical to decorin, increases after denervation.

The proteoglycan decorin is synthesized and secreted by differentiated myotubes

Proteoglycans (PGs) are important components of the skeletal muscle extracellular matrix (ECM). Skeletal muscles are composed of muscle fibers and mononucleated cells. The latter are known to synthesize and secrete several PGs. Rat skeletal muscle ECM contains a chondrotin/dermatan sulfate PG which was immunoprecipitated by antibodies against rat decorin. The synthesis and secretion of PGs by a mouse cell line was analyzed during in vitro differentiation. PGs were characterized by biochemical and immunological techniques including immunocytolocalization experiments. At least three different PGs are synthesized and secreted by differentiated myotubes: a 220 to 460 kDa heparan sulfate, a 250 to 310 kDa chondroitin/dermatan sulfate, and a 75 to 130 kDa chondroitin/dermatan sulfate. This latter PG was specifically immunoprecipitated with antibodies against rat fibroblast decorin. Indirect immunocytolocalization analysis revealed that decorin was localized inside the cells, with a strong reaction around the nuclei. During differentiation the relative proportions of some PGs changed. Thus, a decrease in the relative proportion of the heparan sulfate PG was observed, whereas a significant increase in the relative proportion of decorin was detected. No change in the large chondroitin/dermatan PG was seen during the differentiation process. The possible cell sources of decorin found in rat skeletal muscle ECM are discussed.

Isolation and characterization of rat skeletal muscle proteoglycan decorin and comparison with the human fibroblast decorin

1. The extracellular matrix (ECM) of rat skeletal muscle contains several proteoglycans (PGs). The more abundant correspond to a chondroitin/dermatan sulfate PG or decorin. 2. Decorin isolated from rat skeletal muscle ECM has a smaller molecular size than human fibroblast decorin. 3. The difference in size is mainly due to the glycosaminoglycan (GAG) chain length rather than the core protein size. 4. Peptide analysis of trypsin treated decorins shows at least three peptides with the same electrophoretic mobility.