[Analysis of clinicopathological and molecular abnormalities of angioimmunoblastic T-cell lymphoma]

OBJECTIVE

To analyze the clinicopathological features, molecular changes and prognostic factors in angioimmunoblastic T-cell lymphoma (AITL).

METHODS

Sixty-one cases AITL diagnosed by Department of Pathology of Peking University Cancer Hospital were collected with their clinical data. Morphologically, they were classified as typeⅠ[lymphoid tissue reactive hyperplasia (LRH) like]; typeⅡ[marginal zone lymphoma(MZL)like] and type Ⅲ [peripheral T-cell lymphoma, not specified (PTCL-NOS) like]. Immunohistochemical staining was used to evaluate the presence of follicular helper T-cell (TFH) phenotype, proliferation of extra germinal center (GC) follicular dendritic cells (FDCs), presence of Hodgkin and Reed-Sternberg (HRS)-like cells and large B transformation. The density of Epstein-Barr virus (EBV) + cells was counted with slides stained by Epstein-Barr virus encoded RNA (EBER) in situ hybridization on high power field (HPF). T-cell receptor / immunoglobulin gene (TCR/IG) clonality and targeted exome sequencing (TES) test were performed when necessary. SPSS 22.0 software was used for statistical analysis.

RESULTS

Morphological subtype (%): 11.4% (7/61) cases were classified as type Ⅰ; 50.8% (31/61) as type Ⅱ; 37.8% (23/61) as type Ⅲ. 83.6% (51/61) cases showed classical TFH immunophenotype. With variable extra-GC FDC meshwork proliferation (median 20.0%); 23.0% (14/61) had HRS-like cells; 11.5% (7/61) with large B transformation. 42.6% (26/61) of cases with high counts of EBV. 57.9% (11/19) TCR⁺/IG^-, 26.3% (5/19) TCR⁺/IG⁺, 10.5% (2/19) were TCR^－/IG^－, and 5.3% (1/19) TCR^－/IG⁺. Mutation frequencies by TES were 66.7% (20/30) for RHOA, 23.3% (7/30) for IDH2 mutation, 80.0% (24/30) for TET2 mutation, and 33.3% (10/30) DNMT3A mutation. Integrated analysis divided into four groups: (1) IDH2 and RHOA co-mutation group (7 cases): 6 cases were type Ⅱ, 1 case was type Ⅲ; all with typical TFH phenotype; HRS-like cells and large B transformation were not found; (2) RHOA single mutation group (13 cases): 1 case was type Ⅰ, 6 cases were type Ⅱ, 6 cases were type Ⅲ; 5 cases without typical TFH phenotype; 6 cases had HRS-like cells, and 2 cases with large B transformation. Atypically, 1 case showed TCR^－/IG^－, 1 case with TCR^－/IG⁺, and 1 case with TCR⁺/IG⁺; (3) TET2 and/or DNMT3A mutation alone group (7 cases): 3 cases were type Ⅱ, 4 cases were type Ⅲ, all cases were found with typical TFH phenotype; 2 cases had HRS-like cells, 2 cases with large B transformation, and atypically; (4) non-mutation group (3 cases), all were type Ⅱ, with typical TFH phenotype, with significant extra-GC FDC proliferation, without HRS-like cells and large B transformation. Atypically, 1 case was TCR^－/IG^－. Univariate analysis confirmed that higher density of EBV positive cell was independent adverse prognostic factors for both overall survival (OS) and progression free survival(PFS), (P=0.017 and P=0.046).

CONCLUSION

Pathological diagnoses of ALTL cases with HRS-like cells, large B transformation or type Ⅰ are difficult. Although TCR/IG gene rearrangement test is helpful but still with limitation. TES involving RHOA, IDH2, TET2, DNMT3A can robustly assist in the differential diagnosis of those difficult cases. Higher density of EBV positive cells counts in tumor tissue might be an indicator for poor survival.

[Clinicopathological features and prognosis of anorectal melanoma: A report of 68 cases]

OBJECTIVE

To investigate the clinicopathological characteristics of anorectal mucosal melanoma (ARMM), and to evaluate the prognostic factors.

METHODS

A total of 68 primary ARMM surgical specimens from 2010 to 2018 were retrospectively studied. Slides were reviewed to evaluate pathological features. Slingluff staging method was used for staging.

RESULTS

(1) Clinical features: The median age at diagnosis in this group was 61.5 years, with a male-to-female ratio 1 ∶1.62. The most common complaint was blooding (49 cases). For anatomic site, anorectum was the prevalent (66.2%), followed by rectum (20.6%). At the time of diagnosis, 28 cases were stage Ⅰ (localized stage, 41.2%), 25 cases were stage Ⅱ (regional lymph node metastasis, 36.8%), and 15 cases were stage Ⅲ (distant metastasis, 22.1%). Five patients underwent wide local excision, the rest abdominoperineal resection, and 48 patients received adjuvant therapy after surgery. (2) Pathological features: Grossly 88.2% of the tumors were exophytic polypoid masses, with the median tumor size 3.5 cm and the median tumor thickness 1.25 cm. Depth of invasion below lamina muscularis mucosae ranged from 0-5.00 cm (median 1.00 cm). The deepest site of tumor invasion reached muscular layer in 27 cases, and perirectal tissue in 16 cases. Melanin pigmentation was absent or not obvious in 67.6% of the cases. The predominant cytology was epithelioid (45 cases, 66.2%). The rate for ulceration, necrosis, lymphovascular invasion, and perineural invasion was 89.7%, 35.3%, 55.9%, and 30.9%, respectively. The median mitotic count was 18/mm². The positive rate of S100, HMB-45 and Melan-A were 92.0%, 92.6% and 98.0%, respectively. The median of Ki-67 was 50%. The incidences of mutations within CKIT, BRAF and NRAS genes were 17.0% (9 cases), 3.8% (2 cases) and 9.4% (5 cases), respectively. (3) Prognosis: Survival data were available in 66 patients, with a median follow-up of 17 months and a median survival time of 17.4 months. The 1-year, 2-year and 5-year overall survival rate was 76.8%, 36.8% and 17.2%, respectively. The rate of lymphatic metastasis at diagnosis was 56.3%. Forty-nine patients (84.5%) suffered from distant metastasis, and the most frequent metastatic site was liver. Univariate analysis revealed that tumor size (>3.5 cm), depth of invasion below lamina muscularis mucosae (>1.0 cm), necrosis, lymphovascular invasion, BRAF gene mutation, lack of adjuvant therapy after surgery, deep site of tumor invasion, and high stage at diagnosis were all poor prognostic factors for overall survival. Multivariate model showed that lymphovascular invasion and BRAF gene mutation were independent risk factors for lower overall survival, and high stage at diagnosis showed borderline negative correlation with overall survival.

CONCLUSION

The overall prognosis of ARMM is poor, and lymphovascular invasion and BRAF gene mutation are independent factors of poor prognosis. Slingluff staging suggests prognosis effectively, and detailed assessment of pathological features, clear staging and genetic testing should be carried out when possible. Depth of invasion below lamina muscularis mucosae of the tumor might be a better prognostic indicator than tumor thickness.

[Genetic changes and biological potential of proliferative nodule in congenital pigmented nevus]

Objective: To study the genetic changes and biological potential of proliferative nodule in congenital melanocytic nevus. Methods: Whole-exome sequencing was carried out using the technique of next-generation sequencing (NGS) in order to detect the genomic alterations of two cases of proliferative nodules (PN) in congenital melanocytic nevi (CMN). Twelve cases of CMN and ten cases of malignant melanoma were used as benign and malignant controls, respectively. Mutated genes that possessed statistically significant difference between benign and malignant controls were listed, according to what benign and malignant statuses were classified and clustered. The heatmaps of clustering analyses were depicted using heatmap package. Fluorescence in situ hybridization (FISH) was also used to validate the above results. Results: Eighty-six common somatic gene mutations were detected in two samples of PN. Compared with CMN, PN had 52 more mutated genes. Furthermore, 22 of these 52 mutated genes were also detected in malignant melanoma samples. Two cases of PN fell between benign CMN and malignant melanoma in germline mutation clustering. Both cases of PN were positive in the FISH tests. Conclusions: The genetic changes of PN partially overlap with those of CMN and malignant melanoma. Therefore, although most of the PN manifest as a benign lesion clinically, it may have certain malignant potential at the genetic level, and warrant long-term monitoring and follow-up.

[A comparison between the revision of Atlanta classification and determinant-based classification in acute pancreatitis]

Objective: To compare the performance of the revision of Atlanta classification (RAC) and determinant-based classification (DBC) in acute pancreatitis. Methods: Consecutive patients with acute pancreatitis admitted to a single center from January 2001 to January 2015 were retrospectively analyzed. Patients were classified into mild, moderately severe and severe categories based on RAC and were simultaneously classified into mild, moderate, severe and critical grades according to DBC. Disease severity and clinical outcomes were compared between subgroups. The receiver operating curve (ROC) was used to compare the utility of RAC and DBC by calculating the area under curve (AUC). Results: Among 1 120 patients enrolled, organ failure occurred in 343 patients (30.6%) and infected necrosis in 74 patients(6.6%). A total of 63 patients (5.6%) died. Statistically significant difference of disease severity and outcomes was observed between all the subgroups in RAC and DBC (P<0.001). The category of critical acute pancreatitis (with both persistent organ failure and infected necrosis) had the most severe clinical course and the highest mortality (19/31, 61.3%). DBC had a larger AUC (0.73, 95%CI 0.69-0.78) than RAC (0.68, 95%CI 0.65-0.73) in classifying ICU admissions (P=0.031), but both were similar in predicting mortality(P=0.372) and prolonged ICU stay (P=0.266). Conclusions: DBC and RAC perform comparably well in categorizing patients with acute pancreatitis regarding disease severity and clinical outcome. DBC is slightly better than RAC in predicting prolonged hospital stay. Persistent organ failure and infected necrosis are risk factors for poor prognosis and presence of both is associated with the most dismal outcome.

[Expression of CD137 in tumor cells of Hodgkin lymphoma from Northern China and its application in pathological differential diagnosis]

目的

明确CD137在北方地区经典型霍奇金淋巴瘤（cHL）中的表达，探讨其作为cHL辅助病理鉴别诊断新指标的可能应用价值。

方法

收集54例cHL患者资料，以55例伴有“HRS样细胞”的非cHL患者为对照。在病理组织标本中选取“HRS细胞”或“HRS样细胞”丰富的区域制作组织芯片；以“HRS细胞”或“HRS样细胞”为观察对象，cHL组应用CD30、CD15、CD20、PAX5、CD3免疫组织化学染色；同时对两组患者标本进行CD137（BBK-2）抗体免疫组织化学染色及采用EBV编码的小RNA（EBER）原位杂交法检测EBV感染状态。

结果

54例cHL患者均为淋巴结内原发，中位年龄45.5（22.0~68.0）岁；男女比例1.7∶1；对照组患者结内54例，结外（皮肤）1例，中位年龄50.0（12.0~81.0）岁；男女比例1.9∶1。54例cHL患者均表达CD30，HRS细胞主要诊断相关免疫标志物CD30、CD15、CD20、CD3阳性表达率依次为100.0%、70.4%、18.5％和0，可见PAX5弱至中等强度表达，阳性率70.4%；EBV感染阳性率25.9%（对照组阳性率21.8%）。cHL组CD137阳性率57.4%，对照组阳性率14.5%，差异有统计学意义（P<0.001）。将cHL组及对照组按照患者年龄（≥60/<60岁）、性别、有无EBV感染、组织学亚型以及主要诊断相关标志物的表达与否进行分组，CD137阳性率差异均无统计学意义（P值均> 0.05）。以2013年为界进行分组，2013年前后两组cHL患者的CD137阳性率差异有统计学意义（39.4%对85.7%，P=0.001），对照组差异无统计学意义（12.5％对16.1%，P=0.705）；2013以后存档的标本中cHL组与对照组患者CD137阳性率差异有统计学意义（85.7％对16.1%，P<0.001）。

结论

通过研究初步证实北方地区大多数cHL患者的HRS细胞表达CD137，而对照组患者“HRS样细胞”CD137阳性率较低。保存期3年以内较保存期3年以上的cHL患者标本CD137阳性率高，更适于进行CD137免疫组织化学染色检测。CD137有望作为辅助cHL病理鉴别诊断的新指标。

[TNFAIP3 deletion status in classical Hodgkin lymphoma and its relation to Epstein-Barr virus]

Objective: To investigate the TNFAIP3/A20 abnormalities and its association with Epstein-Barr virus (EBV) in classical Hodgkin lymphoma (CHL). Methods: Formalin-fixed, paraffinembedded tissue blocks of 54 CHL patients were collected and subjected to the construction of tissue microarray (TMA) for further analyses. EBV status was evaluated by in situ hybridization (ISH) for EBER1/2 and immunohistochemistry (IHC) with anti-LMP-1 antibody. Fluorescence in situ hybridization (FISH) and IHC were performed to determine the copy number alterations of TNFAIP3 and A20 protein expression respectively. Results: The concordance rate of IHC for LMP-1 and ISH for EBER1/2 was100%, and 25.9% (14/54) cases were identified with EBV infection. Immunohistochemistry analysis demonstrated 27.8% (15/54) cases with A20 expression deficiency. Of the 54 cases tested for A20 expression, 49 cases were simultaneously analyzed by FISH, which showed 10 (20.4% ) cases harboring TNFAIP3 deletion. However, discrepancy was observed between the results of A20 by IHC and TNFAIP3 deletion by FISH. Only 1 case with TNFAIP3 deletion demonstrated complete loss of A20 immunoreactivity. In addition, comparison of the frequency of either A20 expression loss or TNFAIP3 deletion between EBV-positive and-negative cases did not reveal any significance (P>0.05). Conclusion: TNFAIP3 deletion could be observed in both EBV-positive and - negative CHL cases. A20 expression by IHC could not confirm TNFAIP3 deletion by FISH, which might be related to the technical issues.

[Expression of epidermal growth factor receptor mutation specific antibodies in lung adenocarcinoma: evaluation of sensitivity, specificity and relationship to histologic subtypes]

OBJECTIVE

To evaluate the expression of epidermal growth factor receptor (EGFR) mutation specific antibodies in invasive lung adenocarcinomas, and their sensitivity, specificity, as well as relationship to histological subtypes.

METHODS

Immunostaining with EGFR mutation-specific antibodies, del E746-A750 in exon 19 and L858R in exon 21, was performed in tissue microarrays of 884 cases of resection specimens to study the relationship between the immunophenotypes and morphologic subtypes. The sensitivity and specificity of the stains were compared with gene mutations detected by amplified refractory mutation system-polymerase chain reaction (ARMS-PCR).

RESULTS

Of the 884 cases, the expression of del E746-A750 in exon 19 was 3+ , 2+ , 1+ and 0 in 7 cases (0.79%), 38 cases (4.30%), 129 cases (14.59%) and 710 cases (80.32%), respectively. For L858R in exon 21, 3+ , 2+ , 1+ and 0 staining were seen in 82 cases (9.28%), 93 cases (10.52%), 82 cases (9.28%) and 627 cases (70.93%), respectively. For both antibodies, positive expression (1+ or more) was mainly observed in lepidic, acinar and papillary predominant subtypes, and rarely seen in solid subtype or invasive mucinous adenocarcinoma (P=0.014 and 0.016). If 1+ to 3+ expression was set as positive, the specificity of exon 19/exon 21 reached 98.59%/92.98%, while the sensitivity was relatively lower (62.86%/88.89%). If 2+ to 3+ expression was read as positive, the specificity and sensitivity were 99.30%/97.37% and 25.71%/74.60% for exon 19/exon 21. If only 3+ expression was considered positive, the specificity was 100.0% for both antibodies, with a low sensitivity (8.57% for exon 19 and 34.92% for exon 21). Of the 18 cases with E746-A750 del in exon 19 based on molecular detection, the sensitivity of immunohistochemistry for exon 19 was 88.89% if a positive cutoff value ≥1+ was used; in contrast, of the 8 cases harboring other deletions in exon 19, only two cases were positive as 1+ .

CONCLUSIONS

Both the EGFR mutation specific antibodies del E746-A750 in exon 19 and L858R in exon 21 demonstrate high specificity and relatively low sensitivity, and are mostly expressed in lepidic, acinar and papillary predominant subtypes, but rarely in solid subtype or invasive mucinous adenocarcinoma. For cases with 3+ expression, a mutational statue for EGFR is likely. For the 2+ positive cases, the accuracy to predict mutation almost reaches 90%, but molecular detection for confirmation is desirable. For the 1+ and negative cases, DNA-based test is essential to avoid false negativity.

Effects of weight bearing and non-weight bearing exercises on bone properties using calcaneal quantitative ultrasound

OBJECTIVE

This study was designed to investigate bone properties using heel quantitative ultrasound (QUS) in young adults participating in various sports.

METHODS

A cross sectional study was performed on Chinese male students (n = 55), aged 18-22 years. Subjects with previous fractures or suffering from any diseases known to affect bone metabolism or taking any medication with such an effect, were not included. The subjects were categorised according to their main sporting activities, including soccer (n = 15) (a high impact, weight bearing exercise), dancing (n = 10) (a low impact, weight bearing exercise), and swimming (n = 15) (non-weight bearing exercise). A sedentary group acted as controls (n = 15). A reproducibility study of the velocity of sound (VOS) and the broadband ultrasound attenuation (BUA) measurement was performed and analysed using the intraclass correlation coefficient (ICC).

RESULTS

There was good intra-investigator and inter-investigator agreement (ICC > or = 0.8; p < 0.05) in the measurement of BUA and VOS. No significant differences in BUA and VOS (p > 0.05) were found between the dominant and non-dominant heel. Soccer players (137 +/- 4.3 dB/MHz; 1575 +/- 56 m/s; 544.1 +/- 48.4) and dancers (134.6 +/- 3.7 dB/MHz; 1538 +/- 46 m/s; 503.0 +/- 37.0) had significantly higher BUA, VOS, and stiffness index (SI) scores (p < 0.05), respectively, than swimmers (124.1 +/- 5.1 dB/MHz; 1495 +/- 42 m/s; 423.3 +/- 46.9) and the sedentary control group (119.9 +/- 6.1 dB/MHz; 1452 +/- 41 m/s; 369.9 +/- 46.4). A trend of a significant linear increase with the weight bearing and high impact exercise was revealed in all QUS parameters (p < 0.05).

CONCLUSION

This cross sectional study indicated that regular participation in weight bearing exercise in young people might be beneficial for accruing peak bone mass and optimising bone structure.

Regional differences in trabecular BMD and micro-architecture of weight-bearing bone under habitual gait loading--a pQCT and microCT study in human cadavers

This study used both multi-slice pQCT and microCT to investigate regional changes in bone mineral density and structural parameters in the ultradistal tibia and in the mid-femoral neck under habitual gait loading. Twenty cadavers with 2 females and 18 males aged 70.8 +/- 8.5 were used in this study. Seventy-two cylindrical bone cores with 5 mm in diameter and 10 mm in length from the anterior/posterior and superior/inferior regions were obtained from ultradistal tibia and mid-femur neck, respectively, so that their differences in terms of volumetric trabecular bone mineral density (tBMD) as well as micro-architectural parameters could be studied. The results showed that the mean volumetric tBMD at both the organ (including the bone marrow spaces) and tissue levels (excluding the bone marrow spaces) were a 49.2% and 28.3%, respectively, lower in the anterior bone cores than in the posterior bone cores from the ultradistal tibia (P < 0.01). MicroCT measurements on BV/TV, BS/TV, Tb.N, Tb.Th, and DA were found to be on average of 33.5%, 23.6%, 9.1%, 18.0%, and 14.6%, respectively, lower in the anterior trabecular bone cores (P < 0.001), while Tb.Sp and SMI were 12.5% and 29.3%, respectively, higher in the anterior trabecular bone cores (P < 0.01). No significant difference in micro-architectural parameters was found in the trabecular bone cores obtained from mid-femoral neck, except that the mean DA of the inferior bone cores was significantly higher by 30.1% than that of the superior bone cores (P = 0.01). A statistically significant linear relationship with the correlation coefficient, ranging from 0.37 to 0.94 and -0.62 to -0.85, respectively, was shown between the tBMD at the organ level and all of the micro-architectural parameters (P < 0.05). We suggest that dynamic loading changes during the striking of the heel in normal gait, as well as the peaks of the hip joint reaction force occur during the heel strike and before toe off positions in the lifetime of the subject may account for such regional differences in BMD and micro-architecture. The findings from the correlation study also suggest that, apart from BMD, the micro-architecture may exhibit adaptation in response to such excessive loading.

Regional differences in cortical bone mineral density in the weight-bearing long bone shaft--a pQCT study

This study used a multislice peripheral quantitative computed tomography (pQCT) to measure volumetric BMD (vBMD) and cortical thickness for investigating regional adaptation in lower tibial shaft in 72 healthy postmenopausal women aged 47-60. Tomographic slices were analysed on four distinct cortical regions: the anterior, posterior, medial and lateral cortical wall. One-way analysis of variance (ANOVA) test was used to compare the vBMD in the four regions. The results showed that the posterior cortex had the highest vBMD (1923 +/- 135.3 mg/cm(3)), significantly (P < 0.001) higher than the anterior cortex (1805 +/- 110.6 mg/cm(3)), medial cortex (1863 +/- 103.6 mg/cm(3)) and lateral cortex (1815 +/- 111.6 mg/cm(3)); whereas there was no significant difference (P > 0.05) between the medial and lateral cortices located near the neutral plane of bending. The anterior cortex had the greatest thickness (2.56 +/- 0.47 mm), significantly (P < 0.001) greater than that of the posterior cortex (2.11 +/- 0.27 mm), medial cortex (2.20 +/- 0.39 mm) and lateral cortex (2.03 +/- 0.29 mm). The vBMD of the posterior cortex was a significant 6.5% higher than that of the anterior cortex (P < 0.001); whereas the anterior cortical thickness was a significant 21.3% greater than that of the posterior cortex (P < 0.001). There was no linear relationship found between cortical vBMD and cortical thickness measured at the four cortical regions (r = 0.086, P > 0.05). In conclusion, the regional differences, with higher vBMD found in posterior cortex, might be a result of mechanical adaptation, which caused the posterior cortex to sustain higher compressive loading than the anterior tensile cortex during the landing phase in the gait cycles of individuals. Nevertheless, regional geometric adaptation in anterior cortical thickness might be adapted to accommodate for the reduced vBMD and to reduce the bending stress in this region.

Interphase FISH--assisted second-trimester termination of a trisomy 21 fetus in an IVF-ET twin pregnancy. A case report

BACKGROUND

When confronting a dizygotic pregnancy with one fetus affected with chromosomal aberrations, most couples would opt for selective termination of the affected twin.

CASE

Routine genetic amniocentesis was performed for an in vitro fertilization-embryo transfer twin pregnancy at 18 weeks' gestation due to advanced maternal age. After two weeks, cytogenetic analysis revealed that both twins were male and one was affected with trisomy 21. At that time, ultrasound examination could not tell them apart with certainty. With the aid of interphase fluorescence in situ hybridization (FISH), we had no trouble locating the affected twin and performed feticide successfully with an intracardiac potassium chloride injection. At 37 weeks of gestation, a normal male was delivered along with a macerated trisomy 21 fetus.

CONCLUSION

In a dizygotic twin pregnancy discordant for chromosome aberrations, when ultrasound cannot distinguish the affected twin, performing interphase FISH with an appropriate chromosome probe proves very useful in quickly and accurately locating the chromosomally abnormal twin for selective termination.

Functional properties of an agouti signaling protein variant and characteristics of its cognate radioligand

Agouti signaling protein (ASIP), the human (h) homolog of agouti, is an endogenous melanocortin peptide antagonist. To date, characterization of this protein has been performed with recombinant protein only and without the availability of an ASIP/agouti radioligand. In this report we describe the functional characteristics of a chemically synthesized truncated ASIP variant, ASIP-[90-132 (L89Y)], and the binding characteristics of its cognate radioligand, (125)I-ASIP-[90-132 (L89Y)]. Similar to full-length recombinant ASIP/agouti, ASIP-[90-132 (L89Y)] was a potent inhibitor of alpha-melanocyte-stimulating hormone cAMP generation at the cloned human melanocortin receptor (hMCR) subtypes hMC1R and hMC4R. It also displayed a lesser degree of inhibition at the hMC3R and hMC5R. However, ASIP-[90-132 (L89Y)] was found to be less potent than full-length recombinant ASIP and, surprisingly, only exhibited weak inhibitory activity at the hMC2R. In competition binding assays with the radioligand (125)I-ASIP-[90-132 (L89Y)], ASIP-[90-132 (L89Y)] displayed a hierarchy of binding affinity that roughly paralleled its rank order of inhibitory potency at the various MCR subtypes, i.e., hMC1R approximately hMC4R > hMC3R approximately hMC5R > hMC2R. Structure-activity studies revealed that ASIP-[90-132 (L89Y)] possessed greater pharmacological potency than either the further truncated ASIP variants ASIP-(116-132) or cyclo(CRFFRSAC). Interestingly, the latter molecules were both weak agonists at the hMC1R. These studies further support the concept that ASIP/agouti inhibits melanocortin action by directly binding to target MCRs and provide additional insight into the structural requirements for maximal inhibitory potency.

Ultrasonographic features of pseudotumorous form of ascariasis

We report the ultrasonographic findings of a 60 year old woman with pseudotumorous form of ascariasis. Real-time ultrasonographic examination using a curved array transducer revealed grossly thickened small bowel loops, multiple small circular deposits throughout the peritoneal cavity, and a moderate amount of ascites. The English literature on the different forms of abdominal ascariasis is reviewed. Specific signs, which include the 'strip' sign, the 'four-lines', 'inner tube', or 'double tube' sign, the 'bull's eye' or 'target' sign, a 'worm mass' or 'spaghetti-like' appearance, and the 'zig-zag' sign can be present in any form of abdominal ascariasis, as they represent the image of the Ascaris worms visualized under ultrasonographic examination. However, the non-specific signs are not peculiar to A. lumbricoides infections, but are results of secondary changes due to A. lumbricoides infections in the corresponding organs.

Intramedullary osteosclerosis: imaging features in nine patients

PURPOSE

To determine the conventional radiographic, computed tomographic (CT), magnetic resonance (MR) imaging, scintigraphic, and histologic features of intramedullary osteosclerosis and to review the clinical features.

MATERIALS AND METHODS

Nine female patients with leg pain and imaging features indicative of intramedullary sclerosis were seen during a 25-year period. None of the patients had a history of trauma or infection, familial bone disease, or related abnormal laboratory findings. Imaging studies included radiography (n = 9), CT (n = 4), MR imaging (n = 5), and skeletal scintigraphy (n = 5). Histologic correlation was available in five patients.

RESULTS

Sixteen bone lesions (midtibia, n = 14; distal fibula, n = 1; and proximal femur, n = 1) were evident. Both lower extremities were involved in seven patients, and a single extremity was involved in two. Intramedullary sclerosis was present, as was cortical thickening, mainly in the diaphysis of the long bones, without extensive periosteal reaction or soft-tissue involvement. Findings at bone scintigraphy were positive in all lesions. Histologic analysis showed nonspecific changes of markedly sclerotic bone with a variable degree of mineralization and maturity.

CONCLUSION

Intramedullary osteosclerosis is a distinct disorder that typically affects the diaphysis of one or both tibiae in women. Characteristic imaging findings, when coupled with clinical information, allow precise diagnosis.

Stigma of mental illness

BACKGROUND

Psychiatric patients carry the additional burden of stigma.

METHODS

The views of 300 psychiatric out-patients and day-patients and 100 mental health workers concerning stigma were sought. The control group comprised 50 cardiac out-patients.

RESULTS

A fair proportion of patients with schizophrenia or depression perceived that stigma had a negative effect on their self-esteem, relationships and job opportunities. The majority felt a need for an increase in public awareness of mental illness. In contrast, the cardiac patients reported very little stigmatization.

CONCLUSIONS

The diagnostic label of mental illness may render the person vulnerable to stigmatization. Possible causes of stigma and ways of reducing stigma are discussed.

Subject-domain approach to the study of air pollution effects on schoolchildren's illness absence

In this paper, the authors propose a new statistical modeling technique, the subject-domain approach, which is theoretically proven to be equivalent to the time-domain approach in detecting an association between exposure and response with time trends. The authors use an empirical data set from a school absence monitoring study conducted during the 1994-1995 school year in Taiwan to demonstrate this subject-domain approach's application to environmental epidemiologic studies. Because the subject-domain models can control the influential personal confounding factors in the models, they show greater statistical power than the traditional time-domain approaches in determining the relation between air pollution and illness absences. The authors' models found that the schoolchildren's risks of illness absence were significantly related to acute exposures to nitrogen dioxide and nitrogen oxides with a 1-day lag (p < 0.01) at levels below the World Health Organization's guidelines. By contrast, the authors could not detect significant associations between air pollution and schoolchildren's absenteeism using time-domain approaches. Such findings imply that the models built on subject domain may be a general solution to the problem of the ecologic fallacy, which is commonly encountered in environmental and social epidemiologic studies.

Short-term effect of ozone on the pulmonary function of children in primary school

The objective of this study was to evaluate the short-term effect of ambient air pollution on the pulmonary function of schoolchildren. We sampled 941 children in primary school in three communities in Taiwan (Sanchun, Taihsi, and Linyuan). The nearby stations of the Taiwan air quality monitoring network provided the hourly ambient concentrations of sulfur dioxide, carbon monoxide, ozone, particulate matter < or = to 10 microm in aerodynamic diameter, and nitrogen dioxide. Spirometry was performed once for each sampled child. We also obtained the status of indoor air pollution and chronic respiratory disease history by using a structured questionnaire. Multivariate linear model analysis was used to evaluate pulmonary function effects of each pollutant in addition to determinants of indoor air pollution and meteorologic conditions. We found a significantly negative association of peak O(3) concentration on the day before spirometry with individual forced vital capacity and forced expiratory volume in 1 sec. The decrease in children's lung function can occur at peak hourly O(3) concentrations < 80 ppb. The slope of lung function decrease for Taiwanese children is approximately 1 mL/ppb for peak hourly O(3) exposure.

Determinants of parental decisions on 'drop out' from cancer treatment for childhood cancer patients

Little is known about the psychosocial process of parental decisions on 'drop out' from cancer treatment for paediatric patients in Taiwan. This study, based on structured in-depth interviews, attempted to document the determinants of parental decisions on drop out. A total of 19 parents of paediatric cancer patients who dropped out from a cancer treatment for at least a month within 3 years since first treatment were interviewed. Content analysis of qualitative data revealed six categories of determinants associated with parental decisions: suffering severe pain from medical treatments and adverse side-effects; desire for better and less painful treatments; adverse effect of other patients' experiences; searching for possible explanations for disease after prolonged denial of diagnosis; lack of empathy from health care professionals; and misinterpretation of improved prognostics. These findings reflected the deficiency of psychological and emotional support for parents from health care professionals prior to and during cancer treatment.

Effects of music listening on depressed women in Taiwan

This study investigated the physiological and psychological effects of music listening on depressed women in Taiwan. Through the use of a pretest-posttest, control group, experimental design, the heart rate, respiratory rate, blood pressure, and immediate mood states before and after a music/sound intervention were measured in 30 women. Quantitative data were analyzed descriptively and with t tests. A qualitative questionnaire was administered to participants to elicit information related to the subjective experience of music/sound listening. Significant posttest differences were found in experimental group participants' heart rates, respiratory rates, blood pressure, and tranquil mood states. Significant posttest differences also were found in control group participants' heart rates and tranquil mood states. The results support the use of music listening as a body-mind healing modality for depressed women.

Adverse effect of air pollution on respiratory health of primary school children in Taiwan

This study is a part of the Study On Air Pollution and Health In Taiwan (SOAP&HIT), an ongoing research project involving cooperation of several universities in Taiwan. In this study, the objective was to evaluate the effects of ambient air pollution on respiratory symptoms and diseases of school children, in addition to considering indoor air pollution. Six communities were selected: one community located in a rural area (Taihsi), two in urban areas (Keelung and Sanchung), and the other three in petrochemical industrial areas (Toufen, Jenwu, and Linyuan). We sampled 5,072 primary school students in six communities from the main study population of SOAP&HIT. Respiratory health was assessed by evaluation of the children's respiratory symptoms and diseases using a parent-completed questionnaire. Data were analyzed using logistic regression analysis to compute odds ratios of adverse effect. The school children in the urban communities had significantly more respiratory symptoms (day or night cough, chronic cough, shortness of breath, and nasal symptoms) and diseases (sinusitis, wheezing or asthma, allergic rhinitis, and bronchitis) when compared with those living in the rural community. However, only nasal symptoms of children living in the petrochemical communities were more prevalent than in those living in the rural community. Although the association with ambient air pollution is suggestive, the cross-sectional study cannot confirm a causal relationship; thus further studies are needed.

Management of major complications in laparoscopically assisted vaginal hysterectomy

We reviewed 722 laparoscopically assisted vaginal hysterectomies performed between March 1991 and March 1996 at our institute, looking at the management of major complications. The indications for hysterectomy included adenomyosis, myoma uteri, intractable menorrhagia, endometriosis, and severe pelvic adhesion. During 1 to 6 years' follow-up, there were 12 (1.7%) major complications, comprising six bladder injuries, one iliac artery perforation, two bowel injuries, two cases of partial intestinal obstruction, and one pelvic abscess. Four complications were repaired successfully by laparotomy, six were repaired laparoscopically or vaginally, and two were treated conservatively. All the cases with visceral injuries were detected intraoperatively, therefore, adequate repair operations could be performed uneventfully. Early detection and treatment allow complications to be resolved more easily.

Pregnancy after intracytoplasmic injection of immotile sperm. A case report

BACKGROUND

With the advent of intracytoplasmic sperm injection (ICSI), fertilization and pregnancy have been reported in complete asthenozoospermia. The major problem with the use of immotile sperm for ICSI has been differentiating between live and dead sperm. We successfully selected live sperms with the hypoosmotic swelling test, and a twin pregnancy resulted after intracytoplasmic injection of completely immotile sperm.

CASE

A 32-year-old woman and her 36-year-old husband had had primary infertility for four years. Evaluation of the couple showed complete asthenozoospermia of the husband. Ovulation in the wife was successfully stimulated with clomiphene citrate, follicle-stimulating hormone and human menopausal gonadotropin. We selected the viable sperm with the hypoosmotic swelling test. ICSI was then performed. After assisted hatching, we transferred four embryos on the third day after oocyte retrieval. Intrauterine twin pregnancy was confirmed by ultrasonography four weeks later. The healthy infants, free of anomalies, were born on the 36th gestational week.

CONCLUSION

The hypoosmotic swelling test is a simple method of selecting immotile and viable sperm for use in ICSI.

New approaches in laparoscopically assisted radical vaginal hysterectomy

BACKGROUND

To illuminate our new approaches in laparoscopically assisted radical vaginal hysterectomy.

METHODS

Twenty-four women underwent laparoscopically assisted radical vaginal hysterectomies during the period from March 1994 to May 1995 in our institute. Indications for this surgery, including cervical carcinoma stage 1A to 2A, were the same as for abdominal radical hysterectomy. The procedure was performed under general endotracheal anesthesia through means of the technique of videolaparoscopy. Two new approaches were recruited in these procedures including using middle upper abdomen as the primary trocar site and using ureteral stent or illuminator as a ureter marker.

RESULTS

All of these patients completed the procedures without exception. The mean hospital stay was 8.2 +/- 3.2 days. The average blood loss was 540 +/- 210 ml with a range from 100 to 1800 ml. Operating time was from 220 to 420 minutes with a mean time of 325 minutes. In all cases pelvic lymphadenectomy was performed without exception, yielding an average of 13.2 macroscopic nodes. Two of them metastatic lymph nodes were noted. No ureteral injury occurred after using the ureteral stent as a marker.

CONCLUSIONS

In this preliminary result, using middle upper abdomen as the primary trocar site could provide the surgeon with a wider and familiar visual angle, thus making the pelvic or para-aortic lymphadenectomy much easier. Moreover, using the ureteral illuminator as a marker during unroofing the ureter laparoscopically is helpful to prevent the ureteral injury and facilitating the procedures in laparoscopically radical hysterectomy.

The effect of human papillomavirus infection on sperm cell motility

OBJECTIVE

To investigate the presence of human papillomavirus (HPV) in human sperm cells and to evaluate potential effects of HPV on the sperm functions.

DESIGN

A descriptive clinical study.

PATIENT(S)

Specimens of semen were collected from 24 randomly selected patients who attended the fertility clinics at Chang Gung Memorial Hospital.

MAIN OUTCOME MEASURE(S)

The presence of HPV DNA and RNA were examined by polymerase chain reaction. Semen quality and sperm cell function were analyzed by computer-aided autoanalyzer.

RESULT(S)

Human papillomavirus type 16 DNA and RNA were found in 6 (25%) and 2 (8%) of the sperm cells specimens, respectively. Human papillomavirus type 18 DNA and RNA were present in 11 (46%) and 5 (21%) of the same sperm cells specimens, respectively. Incidence of asthenozoospermia among patients infected with either HPV was significantly higher than in those without HPV in their sperm cells (75% versus 8%). Although performance of curvilinear velocity, straight-line velocity, and mean amplitude of lateral head displacement was significantly lower in HPV-infected specimens, the differences of linearity, beat cross frequency, and straightness were not statistically significant.

CONCLUSION(S)

These results suggest that human papillomavirus can be found in human sperm cells and that certain HPV-specific genes are actively transcribed. Sperm motility parameters seem to be affected by the presence of HPV in the sperm cells, and also the incidence of asthenozoospermia may be associated with HPV infection.

Sertoli-Leydig cell tumour in an infertile patient after stimulated ovulation

A 36 year-old infertile female developed a stage IV (FIGO) ovarian carcinoma consisting of a poorly differentiated Sertoli-Leydig cell tumour after receiving one course of ovulation induction with follicle stimulating hormone (FSH), human menopausal gonadotrophin (HMG) and human chorionic gonadotrophin (HCG) followed by gonadotrophin-releasing hormone analogue (GnRHa). The patient died of liver metastasis and hepatic failure 4 1/2 months after first diagnosis, despite aggressive treatment consisting of debulking surgery and aggressive adjuvant chemotherapy.

The outcome of in vitro fertilization and embryo transfer therapy in women with endometriosis failing to conceive after laparoscopic conservative surgery

STUDY OBJECTIVE

To compare the outcome of in vitro fertilization and embryo transfer (IVF-ET) after laparoscopic surgery in women with endometriosis with that of patients with tubal factor infertility.

DESIGN

Retrospective survey of hospital and office charts using a computerized worksheet.

SETTING

Lin-Kou medical center of Chang Gung Memorial Hospital.

PATIENTS

Sixty-seven women with minimal to mild or moderate to severe endometriosis. Women with tubal factor infertility without other associated disorders (60 cycles) made up the control group.

INTERVENTIONS

Seventy-five consecutive cycles of IVF-ET were performed in these patients who failed to conceive after laparoscopic conservative surgery.

MEASUREMENTS AND MAIN RESULTS

The concentration of serum estradiol on the day of human chorionic gonadotropin (hCG) injection, the day of hCG injection, clinical pregnancy rates per transfer, number of follicles larger than 14 mm, number of embryos transferred, and implantation rate were not significantly different between women with endometriosis and those with tubal factor infertility. The number of oocytes retrieved and number fertilized were decreased, and the basal level of follicle-stimulating hormone on cycle day 3 was higher in women with both degrees of endometriosis. Women in both endometriosis groups received more follicle-stimulating hormone and human menopausal gonadotropin than those with tubal factor infertility.

CONCLUSIONS

The outcome of IVF-ET in patients with endometriosis after laparoscopic surgery did not differ from that in the group with tubal factor infertility, but the former required more ampules of gonadotropin to achieve the same response. The advantages of laparoscopic surgery in women with endometriosis should be probably correlated with success of IVF-ET.

Life table analysis of pregnancy rates in women with moderate or severe endometriosis comparing danazol therapy after carbon dioxide laser laparoscopy plus electrocoagulation or laparotomy plus electrocoagulation versus danazol therapy only

STUDY OBJECTIVE

To assess the effectiveness, in terms of pregnancy rates, of isotopic 13CO2 laser laparoscopy versus traditional laparoscopy or laparotomy in the treatment of infertile women with moderate or severe endometriosis.

DESIGN

Prospective 5-year study.

SETTING

Medical school-affiliated hospital.

PATIENTS

Three hundred nine infertile women with moderate to severe endometriosis.

INTERVENTIONS

The patients were treated with one of four options: operative laparoscopy with the 13carbon dioxide (13CO2) laser vaporization and/or resection, operative laparoscopy with simple electrocoagulation and sharp dissection, laparotomy with electrocoagulation and sharp dissection, and medical treatment with danazol. Estimated cumulative pregnancy rates using life table analyses were indicators of treatment of success and compared among treatments. A subgroup of 192 women considered to have endometriosis as the only infertility factor was also evaluated.

MEASUREMENTS AND MAIN RESULTS

Pregnancy rates in the laparoscopy group were equal to or higher than those of the laparotomy group, for both the entire population and the endometriosis-only subset. When the CO2 laser was used as an adjuvant option, the rates were better, especially in patients with advanced disease and with endometriosis as the only infertility factor.

CONCLUSION

In women with endometriosis as the only infertility factor, laparoscopic surgery with the 13CO2 laser was more effective than nonlaser treatment.

Efficacy of isotopic 13CO2 laser laparoscopic evaporation in the treatment of infertile patients with minimal and mild endometriosis: a life table cumulative pregnancy rates study

STUDY OBJECTIVE

To assess the efficacy of 13CO2 laser laparoscopy in treating infertile women with minimal to mild endometriosis according the American Fertility Society classification in terms of pregnancy rates.

DESIGN

Prospective study.

SETTING

Medical school-affiliated hospital.

PATIENTS

One hundred seventy-six women whose infertility was associated with minimal or mild endometriosis diagnosed by laparoscopy.

INTERVENTIONS

The patients were treated with one of four methods: 49 underwent operative laparoscopy with newly developed 13CO2 laser vaporization and/or resection; 45 were treated by operative laparoscopy with simple monopolar electrocoagulation; 43 who had undergone only diagnostic laparoscopy did not receive any treatment; and 39 received danazol 800 mg/day for 3 months after diagnostic laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Estimated cumulative pregnancy rates using life table analyses were indicators of treatment of success and compared among the treatments. A subgroup of 111 patients considered to have endometriosis as the only major infertility factor were also evaluated and compared among treatment options. Pregnancy rates in the CO2 laser laparoscopy group were significantly higher than in the other three groups and in endometriosis-only subset.

CONCLUSIONS

Advanced laparoscopic surgery with the CO2 laser can be more efficient than other modalities in treating infertile women with minimal to mild endometriosis in terms of pregnancy rates. It appears that in experienced hands, laser laparoscopy has more favorable results than the other treatments.

Preferential retention of the E6 and E7 regions of the human papilloma virus type 18 genome by human sperm cells

OBJECTIVE

To determine if sperm cells differentially take up or retain different regions of human papilloma virus (HPV) type 18 genome.

DESIGN

A descriptive clinical study.

SETTING

A major medical center affiliated with a medical college.

PATIENTS

Twenty-three randomly selected patients who attended Fertility Clinics at the Chang Gung Memorial Hospital. Semen specimens were obtained from volunteered patients who attended fertility clinics at the Chang Gung Memorial Hospital.

MAIN OUTCOME MEASURE

The presence of various regions of HPV type 18 genome in sperm cells was determined by polymerase chain reaction.

RESULTS

Among 23 sperm specimens that were positive for HPV type 18 DNA by polymerase chain reaction, the upstream regulatory region, E6, E7, E1, and L1 regions or open region frames were detected in 4 (17%), 7 (30%), 19 (83%), 5 (22%), and 1 (4%) specimens, respectively. The differential display of the presence of various regions of the HPV type 18 genome was not the result of different amplification and detection efficiencies of these DNA fragments.

CONCLUSION

These results suggest that the oncogenic portion of HPV DNA is present in spermatozoa. Furthermore, the E6 and E7 regions of the viral genome preferentially were taken up and/or retained by the human sperm cells.

Reconsideration of testicular biopsy and follicle-stimulating hormone measurement in the era of intracytoplasmic sperm injection for non-obstructive azoospermia?

To determine the possibility of finding motile spermatozoa and spermatids in patients with high serum follicle stimulating hormone (FSH) and spermatogenetic disorders proven by pathology, 100 cases of male infertility were reviewed. Of these, 71 patients were found to have non-obstructive azoospermia or severe primary spermatogenetic disorders, and 20 had obstructive azoospermia. A prospective study of the most recent 51 cases was conducted. Multiple testicular tissue biopsies were examined by a pathologist and a well-trained gynaecological technician. The findings of spermatozoa, spermatids and serum FSH concentrations were compared among six different histological groups. It was concluded that 51.2% of the non-obstructive azoospermic and failed spermatogenetic patients had spermatids and even motile 'shaking' spermatozoa and should be re-evaluated. In the non-obstructive azoospermic patients here, almost all the motile spermatozoa and spermatids were found in patients with a serum FSH concentration of < 30 mIU/ml. It is suggested that a testicular biopsy should be conducted in every case of non-obstructive azoospermia and spermatogenetic disorder, even in those patients with elevated serum FSH concentrations.

The effects of Vero cell co-culture on human zygotes resulting from in vitro fertilization and oocytes following subzonal insemination

A variety of co-culture systems have been devised to enhance the human embryo development in vitro. Vero cells were selected because they can be highly controlled and are easy to handle. To evaluate the embryotrophic effects of Vero cell monolayers, when they were co-cultured with human in vitro fertilized zygotes or subzonal inseminated oocytes. Total 1695 two-pronuclear embryos resulting from in vitro fertilization were cultured with Vero cells or medium alone for 24 hours. Similarly, sixty-six two-pronuclear embryos resulted from subzonal insertion of sperm (SUZI) with co-culture starting immediately following SUZI were compared with fifty-two two-pronuclear embryos resulted from SUZI, without co-culture. The numbers of blastomere and morphology of embryos were compared between the co-culture group and control group using student's t-test. Cell numbers in each embryo were greater in the IVF/co-culture group than in the control group (4.01 +/- 1.32 vs. 3.86 +/- 1.45, p < 0.05). The rates of poor quality embryo with major fragmentation were lower in the co-culture group than in the control group(11.5% vs. 19.9%, p < 0.001, for IVF embryos; 9% vs. 27%, p < 0.005, for SUZI oocytes). Co-culture SUZI oocytes on Vero cells prior to fertilization did not positively influence embryo cleavage, but improved embryo quality. We conclude that Vero cells can enhance human embryo development; however, the period for one-day or two-day co-culture is too short to provide a maximal support. Short term co-culture did not increase implantation rates. Immediate co-culture following SUZI might somewhat rescue the microinseminated oocytes. However, a longer duration of co-culture is necessary to exert the maximal effects on embryo development and implantation.

Comparison of hysterosalpingography and hysteroscopy in female infertility

STUDY OBJECTIVE

To determine the diagnostic value of hysterosalpingography (HSG) and diagnostic hysteroscopy in infertility evaluations.

DESIGN

Comparative 2-year study.

SETTING

Outpatient infertility clinic of a tertiary medical center.

PATIENTS

Two hundred sixteen women being investigated for infertility.

INTERVENTIONS

An HSG was followed by a diagnostic hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

The HSGs were interpreted as normal in 79 (36.9%) women and as showing some abnormalities of the uterine cavity in 135 (63.1%). In the former group, 51 patients had a normal uterine cavity, but 28 had abnormal findings on hysteroscopy, a false negative rate of 35.4%. Of 135 women with an abnormal HSG, hysteroscopy found a normal uterine cavity in 21, a false positive rate of 15.6%. The sensitivity of HSG was 80.3% in revealing intrauterine abnormality and its specificity was 70.1%. Although some abnormalities were identified by both methods in 114 women, findings of both procedures were similar in only 88 (77.2%). In 75 (35.0%), the findings of HSG differed from those of hysteroscopy. In only 139 (65%) patients were the findings (normal and abnormal) similar for both methods.

CONCLUSIONS

We advocate hysteroscopy in the investigation of female infertility for its accuracy, safety, simplicity, and convenience.

Laparoscopic Removal of a Large Leiomyoma Using Airlift Gasless Laparoscopy

Some discrepancies still exist with regard to the efficacy of laparoscopic removal of large symptomatic leiomyomas. In our experience, when performing myomectomy, airlift gasless laparoscopy has several advantages. First, a small incision can be made, through which conventional surgical instruments (endoscopic equipment is not required) are inserted and the myomectomy is efficiently performed. Second, the large excised leiomyoma can be cut into strips easily with a conventional long knife and removed through a small abdominal incision. Third, sutures can be placed easily, and the surgeon can place fingers through a small surgical wound to palpate the organ and tie the knot directly. Fourth, high-pressure irrigation and large-volume suction devices can be used without fear of decompressing the pneumoperitoneum. Finally, the potential risks of metabolic and hemodynamic instability due to carbon dioxide insufflation to establish pneumoperitoneum are avoided.

Laparoscopic myomectomy of large symptomatic leiomyoma using airlift gasless laparoscopy: a preliminary report

Despite the expanding role of laparoscopic surgery in many gynaecological fields, some discrepancies still exist regarding the efficacy of laparoscopic myomectomy in treating patients with large symptomatic leiomyoma. In this report, a better operative procedure and the results of treatment are evaluated. Patients (n = 14) presenting with infertility, menorrhagia, pressure symptoms or pelvic mass associated with a large leiomyoma were managed with laparoscopic myomectomy using airlift gasless laparoscopy. Uterine size ranged from 14 to 24 weeks gestational age and the weight of the myoma ranged from 246 to 669 g (mean 454); operative time ranged from 78 to 165 min (mean 104) and blood loss from 90 to 580 ml (mean 201). No major complication occurred during the operation or follow-up. All except one patient were discharged within 72 h of the operation and resumed normal activity within 1 week. When myomectomy is indicated, the airlift gasless laparoscopic approach appears to offer a better alternative to abdominal or pneumoperitoneum laparoscopic surgery in selected cases. Airlift gasless laparoscopy has several advantages: (i) small abdominal incisions and minimal endoscopic equipment are required; (ii) the excised leiomyomata mass can be easily cut into strips and removed through the small abdominal incision; (iii) the uterine defect can be more efficiently repaired using easily performed suture techniques; (iv) high-pressure irrigation and large-volume suction devices can be used without fear of decompressing the pneumoperitoneum; and (v) the potential risk of metabolic and haemodynamic derangements during pneumoperitoneum laparoscopy are obviated. Gasless laparoscopy also has some disadvantages. The exposure obtained with gasless laparoscopy is not as good, under some circumstances, as that achieved by pneumoperitoneum. For patients who are thin, and even those with moderate obesity, the exposure obtained with airlift mechanical suspension is adequate; however, morbidly obese patients with previous abdominal surgery with suspected pelvic adhesions can incur some problems during the operation because of a poor operative field.

Insulin-like growth factor-binding proteins produced by Vero cells, human oviductal cells and human endometrial cells, and the role of insulin-like growth factor-binding protein-3 in mouse embryo co-culture systems

Co-culturing embryos on helper cells can mimic the in-vivo environment, thereby enhancing embryo development in vitro. Insulin-like growth factors (IGF) and their binding proteins (IGFBP) also enhance embryo development. To investigate the kinds of IGFBP produced by various cell monolayers and the effects of IGFBP-3 on mouse embryo co-culture systems, 2-cell ICR mouse embryos were cultured in either human tubal fluid medium alone or in the presence of Vero cells, human oviductal cells or endometrial cells. The helper cells were analysed immunohistochemically to investigate the types of IGFBP produced by various cell monolayers. The concentrations of IGF-I and IGFBP-3 in media obtained from the culture of embryos alone, cells alone or cells plus embryos were determined by radioimmunoassays. On day 7, more blastocysts hatched in the co-culture groups (73% in the Vero cell group, 76% in the endometrial cell group and 74% in the oviductal cell group) than in the control group (43%) (P < 0.0001). The results of immunohistochemistry revealed that (i) all three cell groups produced a lot of IGFBP-1, -2 and -3, but only a little of IGFBP-4 and -5; and (ii) IGFBP-1, -2, and -3 were present in blastocysts in either the presence or absence of helper cells. The IGF-I secreted by cell monolayers or embryos was undetectable (detection limit 0.83 microg/l). The IGFBP-3 concentrations in media obtained from co-cultured embryos and cells were significantly higher than in media without embryos (median values in oviductal cell culture medium, 165 versus 127 microg/l, P = 0.04; median values in endometrial cell culture medium, 277.5 versus 183.5 microg/1, P = 0. 0002; median values in Vero cell culture medium, 219 versus 120 microg/l, P = 0.011). Although IGFBP-3 concentration in the medium that contained embryos alone was undetectable by radioimmunoassay (detection limit 1.1 microg/l), immunohistochemistry demonstrated the presence of IGFBP-3 in the embryos. Co-culture in systems in which there was an increased production of IGFBP-3 led to an improved development of mouse embryos. IGFBP can improve the binding of IGF to cell surface receptors of target tissue, and thus enhance the effect of limited IGF concentrations in promoting embryo development in a co-culture system. We conclude that Vero cells, human endometrial cells and oviductal cells produce IGFBP-1, -2, -3, -4 and -5. IGFBP-3 may play a role in embryotrophic potential by either regulating the action of IGF or directly enhancing embryo development.

Human papillomavirus deoxyribonucleic acid and ribonucleic acid in seminal plasma and sperm cells

OBJECTIVE

To investigate the possible presence and expression of human papillomavirus viruses (HPV) in human plasma and sperm cells.

DESIGN

Controlled clinical study.

SETTING

A major medical center affiliated with a medical college.

PATIENTS

Twenty-four randomly selected patients who attended Fertility Clinics at the Chang Gung Memorial Hospital.

INTERVENTIONS

Specimens of semen were collected from volunteered patients

MAIN OUTCOME MEASURE

The presence of HPV types 16 and 18 DNA and RNA sequences were examined by polymerase chain reaction.

RESULTS

Human papillomavirus type 16 E6 and E7 DNA and RNA sequences were found in two and zero seminal plasma specimens, respectively, and in six and two sperm cells specimens, respectively. Deoxyribonucleic acid and RNA sequences of HPV type 18 were found in eight and two seminal specimens and in 11 and 5 sperm cells specimens, respectively.

CONCLUSION

These results seem to suggest that HPV cannot only infect human sperm cells, certain HPV genes are expressed actively in infected sperm cells. The virus-infected sperm cells conceivably can behave as vectors or carriers for the transmission of HPV, to sexual partner during sexual contact, to fetuses through fertilized eggs, or both.

Coculture of human spermatozoa with reproductive tract cell monolayers can enhance sperm functions better than coculture with Vero cell monolayers

PURPOSE

In order to develop a better system for support of human sperm function in vitro, we conducted studies to evaluate whether reproductive tract cells are better than non-reproductive tract cells as an adjunt in that regard.

METHODS

Human spermatozoa were cocultured with Vero cells, with human oviduct cells and endometrial cells, and without cells (control) for either 1, 4, or 24 hr. Sperm motility was then analyzed with a computer-aided sperm analyzer (CASA-Hamiliton Thron, HTM IVOS Motility Analyzer). Aliquots of spermatozoa incubated for 24 hr were also stained with Hoechst 33258 and FITC-PNA to evaluate the status of acrosome in live cells.

RESULTS

Significant differences (P < 0.05) between the oviduct cell and the control groups after 24 hr were evident in the curvilinear velocity (VCL) (81.4 +/- 13.4 vs 60.0 +/- 14.1 microns/sec) and amplitude of lateral head displacement (ALH) (5.2 +/- 0.6 vs 4.1 +/- 0.5 microns). The incidence of acrosome reaction of live sperm was significantly higher in the endometrial cell group than in the controls (25.4 +/- 9.9 vs 6.6 +/- 2.4%; P < 0.001).

CONCLUSIONS

Coculture with human reproductive tract cells seems to improve some functional parameters of human spermatozoa. Coincubation with such cell lines, especially oviduct cells, might be a feasible approach to optimization of human spermatozoa for assisted fertilization using subfertile or frozen-thawed samples. We think coincubating human spermatozoa with a human reproductive tract cell line, especially oviduct cells, might be a feasible approach in preparing human spermatozoa for assisted fertilizatioin in subfertile and frozen-thawed semen samples.

Improved sperm recovery rate with Percoll gradient method in intrauterine insemination

The purpose of this study was to compare the different sperm manipulation methods on the recovery rate of motile sperm that was collected to use in the intrauterine insemination. Three hundred and thirty-five IUI (intrauterine insemination) cycle from a total of 963 treatment cycles was performed for non-peritoneal factor infertility couples. The sperm separation methods were swim-up, swim-down and Percoll gradient (since Mar. 1992). We compared the different sperm preparation methods in normal and abnormal semen analysis group. Our results show that in the abnormal semen samples (oligospermic approximately, asthenospermic approximately), the Percoll gradient method is superior to the swim-up and swim-down methods on the recovery of a higher number of total, motile and active motile spermatozoa (p < 0.05), even though the sperm quality before preparation was rather poorer than the samples prepared by the other two methods. The pregnancy rate in both groups are not statistically significant. We conclude that the Percoll gradient is an improved method for semen manipulation as it allows greater recovery of sperm with higher motility in intrauterine insemination.

Management of urinary bladder injuries in laparoscopic assisted vaginal hysterectomy

BACKGROUND

To illustrate our experience and evolution in management of urinary bladder injury in laparoscopically assisted vaginal hysterectomy.

METHODS

Four hundred and twenty-two women underwent laparoscopically assisted vaginal hysterectomy with or without adnexectomy during the period March 1991-September 1994. The indicators for hysterectomy included adenomyosis, myoma uteri, intractable menorrhagia, endometriosis and severe pelvic adhesion. There are six cases of urinary bladder injuries resulting from our 422 cases of laparoscopically assisted vaginal hysterectomy.

RESULTS

The first two cases of urinary bladder injuries were repaired through exploratory laparotomy. The third case was repaired through laparoscopic intracorporeal suture. The technique of the automatic linear stapler through laparoscopy was used in case 4. The last two cases were repaired vaginally. All these patients recovered well after primary repair with an indwelling catheter for five to seven days regardless of the method of repair. The operation time for repairing the injuries is shortest in vaginal approach.

CONCLUSIONS

The urinary bladder injury is one of the most common complications associated with laparoscopically assisted vaginal hysterectomy. Early detection and treatment enable complications to be overcome easily. As the laparoscopist acquires further experience in dealing with these complications, the urinary bladder injury may be managed laparoscopically. However, vaginal approach may be an easier way in dealing with this complication. Thus, most laparotomy or high technique laparoscopically repair could be avoided.

The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa

PURPOSE

The purpose of this study was to evaluate the relationship between the total motile sperm count and the success of IUI treatment cycles with postwashed husband spermatozoa in couples with infertility in a large patient population.

PATIENTS

When 939 couples underwent 1375 cycles of IUI with varying etiologies of infertility which included male factor, endometriosis, tubal factor, ovulatory dysfunction, uterine factor, cervical factor, and unexplained infertility, the results were 207 pregnancies.

RESULTS

The overall pregnancy rate per cycle was 15.1% (207/1375). The total motile sperm count were significantly increased in the pregnant group than the nonpregnant group (38.7 x 10(6) versus 28.6 x 10(6); P < 0.001). There was a trend toward an increased success rate with increased total motile sperm count. Significance was reached when the total motile sperm count exceeded 5 x 10(6). Life table analysis was performed and the curve representing a cumulative chance of pregnancy calculated from our data reached 72%.

CONCLUSIONS

Our findings suggest that a final postwashed total motile sperm count used for IUI may be considered predictive of the success for pregnancy and allow couples to be informed of the chances of success.

Results of modified laparoscopically assisted neovaginoplasty in 18 patients with congenital absence of vagina

Construction of a neovagina using pelvic peritoneum via a laparoscopically assisted approach was used in 18 patients with congenital absence of the vagina. A better operative procedure is reported, which was modified from our preliminary technique, and the results of treatment are evaluated. Pelvic peritoneum was used for construction of a vagina, replacing a laparotomy by a minimally invasive laparoscopic approach. During follow-up, the advantages of our procedures are: (i) minimal likelihood of 'poor take' or later contraction because an autograft peritoneal epithelial line is used; (ii) minimal short and long term care is required; (iii) the technique is simple in experienced hands and has all the well-recognized benefits of minimal invasive surgery; (iv) the average length of neovagina is adequate and patency and depth can be maintained with minimal dilatation; (v) the neovagina, with epithelial lining resembling that of a normal vagina, facilitates comfortable sexual intercourse; (vi) the procedure is unaccompanied by dyspareunia or scarring, which are frequently associated with other techniques; (vii) less emotional stress and better cosmetic and economic benefits are noted.

The imaging diagnosis of hepatic schistosomiasis japonicum sequelae

We reviewed the ultrasound (US) and computed tomography (CT) examinations of the liver in 21 patients with hepatic schistosomiasis japonicum (HSJ), to assess the role of imaging in its diagnosis. Thirteen patients had histopathological evidence of hepatic ova deposition. A 'network' pattern was present in 14 of 17 (82%) patients on US, and 'turtle-back' calcification in 11 of 13 (85%) patients on non-contrast CT (NCCT). The combination of US and NCCT was positive for HSJ in all nine patients subjected to both investigations. These findings are specific for HSJ and we discuss how they differ from the imaging findings reported in hepatic Schistosoma mansoni (HSM). We conclude that the sequelae of HSJ infection create an imaging diagnosis. Although an uncommon incidental finding at liver imaging, the combined US and CT appearances are so characteristic that in the majority of patients biopsy can potentially be avoided.

Laparoscopic repair of bowel herniation through previous cannula insertion sites

Operative laparoscopy frequently requires large cannulas below or above the umbilicus, which may result in unusual complications such as small bowel herniation through these insertion sites. Three women experienced small bowel herniation through cannula incision sites, either extraumbilically or paraumbilically, after major laparoscopic surgery. Two patients who had undergone laparoscopic myomectomy developed small bowel herniation through the 12-mm extraumbilical cannula site on postoperative days 7 and 8, respectively. In the first woman, the nontender, palpable, and reducible herniation healed spontaneously, with no episode of herniation during follow-up. The second patient required laparoscopic reduction of the herniated loop and repair of the fascial defect. The last woman had undergone laparoscopic-assisted vaginal hysterectomy and developed small bowel herniation through an unrecognized fascial defect paraumbilically 3 days postoperatively. Intended repair by laparoscopy was changed to laparotomy due to extensive and incarcerated bowel herniation.

Ureteral injury during laparoscopically assisted radical vaginal hysterectomy

We report on a case of ureteral injury during laparoscopically radical hysterectomy to treat a patient with a stage IA2 carcinoma of the uterine cervix. The advantage of laparoscopically radical hysterectomy is the prevention of the identification and dissecting of the ureter from a vaginal approach, the main problem in the Schauta technique. However, ureteral injury may still occur while resecting the cardinal ligament without good visualization of the ureter during a vaginal procedure. Because the ureter was well identified and freed laparoscopically, a vaginal approach after uterine removal may be an option for treatment. Moreover, using the ureteral stent as a marker during a modified Schauta technique is helpful in the prevention of ureteral injury during laparoscopically assisted radical vaginal hysterectomy.