Clinical significance of second-trimester 50-g glucose challenge test among Japanese women diagnosed as normoglycemic after first-trimester 75-g glucose tolerance test

OBJECTIVE

This study was performed to determine how often Japanese women diagnosed as normoglycemic on first-trimester 75-g glucose tolerance test (75gGTT) later develop gestational diabetes mellitus (GDM).

MATERIAL AND METHODS

Sixty-two women with random plasma glucose (PG) level ≥ 105 mg/dL during the first trimester and subsequent first-trimester diagnosis of normoglycemia with 75gGTT underwent 50-g glucose challenge test (50gGCT) during the second trimester. Twenty-one with a positive 50gGCT result (60-m PG ≥ 140 mg/dL) underwent second-trimester 75gGTT. First-trimester random PG levels and 75gGTT results were compared between 21 and 41 women with positive and negative 50gGCT results, respectively. Changes in immunoreactive insulin (IRI) associated with 75gGTT were determined simultaneously.

RESULTS

All 21 women with a positive 50gGCT result showed normoglycemia on second-trimester 75gGTT. Thus, none of the 62 women developed GDM. Insulin resistance increased significantly in the 21 women with 75gGTT during the first and second trimesters, as indicated by increases in homeostasis model assessment for insulin resistance (HOMA-IR) and homeostasis model assessment for β-cell function (HOMA-β) with no significant changes in preload or afterload PG levels. Neither random PG levels (116 ± 12 vs. 116 ± 12 mg/dL, respectively) nor 75gGTT results (86 ± 6 vs. 84 ± 5 mg/dL for 0-minute [0-m] PG level, 130 ± 28 vs. 131 ± 25 mg/dL for 60-m PG, and 111 ± 19 vs. 118 ± 18 mg/dL for 120-m PG, respectively) during the first trimester differed significantly between the 41 and 21 women with negative and positive second-trimester 50gGCT results, respectively.

CONCLUSION

Although insulin resistance increased in the second trimester, risk of developing GDM was < 1/62 among Japanese women in whom hyperglycemia was excluded with first-trimester GTT.

Prevalence of hyperglycaemia in singleton versus twin pregnancy

BACKGROUND

There is conflicting information regarding the risk of gestational diabetes mellitus in twin pregnancies. This study was conducted to determine whether the risk of gestational diabetes mellitus is higher in pregnant Japanese women with twin versus singleton pregnancy.

METHODS

The prevalence of gestational diabetes mellitus was studied in two different populations: 144 589 women registered with the Japan Society of Obstetrics and Gynecology (JSOG cohort) over 3 years between 2007 and 2009 in which patient selection bias was unavoidable; and 430 Japanese women who gave birth at a single centre over 5 years between 2008 and 2012 (single-centre cohort), consisting of 86 women with twins and 344 women with singletons matched for maternal age and prepregnancy body mass index. The gestational diabetes mellitus was diagnosed on the basis of the previous criteria in the JSOG cohort. The gestational diabetes mellitus was screened in a stepwise method and diagnosed on the basis of the new criteria in the single-centre cohort.

RESULTS

In the single-centre cohort, neither frequency of random glucose level ≥105 mg/dL in the first trimester [9.0% (31/344) vs 5.8% (5/86)], positive result (≥140 mg/dL) on 50 g glucose challenge test in the second trimester [26.5% (90/339) vs 26.7% (23/86)], nor women diagnosed with GDM [8.4% (29/344) vs 9.3% (8/86)] differed between the two groups. The prevalence of hyperglycaemia was higher in singleton than in twin pregnancies in the JSOG cohort (2.6% vs 1.8%, p < 0.001).

CONCLUSIONS

The risk of gestational diabetes mellitus may be similar between Japanese women with singleton and twin pregnancies. Difference in the risk of hyperglycaemia in the JSOG cohort may have been due to selection bias.

Gestational weight gain according to number of fetuses in Japanese women

AIM

It is unknown whether weekly maternal weight gain differs between Japanese women with singleton, twin, and triplet pregnancies.

METHODS

Gestational weight gain defined as net weight gain during pregnancy was analyzed in 135,036 pregnant Japanese women, including 128,838 with singletons, 5573 with twins, and 132 with triplets, who gave birth at ≥22 weeks of gestation between 2007 and 2009. Weekly weight gain was defined as follows: gestational weight gain÷[gestational week (GW) at Delivery-2].

RESULTS

Length of gestation (weeks, mean±SD) decreased significantly (38.2±2.6, 35.3±3.0, and 32.7±2.8) with increasing number of fetuses, while overall gestational weight gain (kg) was significantly smaller in women with singletons than in those with either twins or triplets (9.6±4.4 vs. 10.9±4.8 or 10.9±5.2, respectively). Thus, weekly maternal weight gain (kg/week) increased significantly with increasing number of fetuses (0.26±0.12, 0.33±0.13, and 0.35±0.16). Among women with delivery at or after GW 34, difference in gestational weight gain (kg) was prominent between the three groups (9.8±4.4, 11.4±4.7, and 13.0±5.1 for singleton, twin, and triplet pregnancies, respectively, P<0.001 between any two groups).

CONCLUSIONS

Weekly maternal weight gain increases with increasing number of fetuses. Our figures may be useful for advising Japanese women with multifetal pregnancies regarding gestational weight gain.

Clinical features of isolated gestational proteinuria progressing to pre-eclampsia: retrospective observational study

OBJECTIVES

Some women with isolated gestational proteinuria (IGP) later develop hypertension and are diagnosed with pre-eclampsia (PE). This study was performed to determine whether clinical features of such proteinuria preceding PE (P-PE) differ from those of other PE (O-PE).

DESIGN

Retrospective observational study after approval of the institutional review board of ethics.

SETTING

A single university hospital. Proteinuria was defined as a protein-to-creatinine ratio (mg/mg; P/Cr) of ≥0.27 in the spot urine specimen. IGP was defined as proteinuria in the absence of hypertension. P-PE was defined as PE in which proteinuria preceded hypertension by more than 2 days.

PARTICIPANTS

All of 10 and 18 consecutive women with P-PE and O-PE, respectively, who gave birth between January 2008 and August 2013.

RESULTS

Proteinuria appeared earlier (at 30.2±3.0 vs 35.3±4.3 weeks, p=0.001), the P/Cr level was greater at birth (7.28±2.14 vs 3.19±2.49, p<0.001), net maternal weight gain during the last antenatal 1 week was greater (3.1±1.8 vs 1.3±1.7 kg, p=0.023) and length of pregnancy was shorter (32.5±1.9 vs 36.1±3.6 weeks, p=0.001) in women with P-PE than in O-PE. The duration of IGP was 10.0±5.9 days (range 3-20), and the time interval until delivery after diagnosis of PE was 6.1±8.2 days (range 0-23) in 10 women with P-PE. The P/Cr levels at birth were significantly inversely correlated with the antenatal lowest antithrombin activity and fibrinogen levels among the 28 women with PE.

CONCLUSIONS

Women with P-PE were likely to exhibit greater proteinuria in the urine, greater water retention in the interstitial space and more enhanced coagulation-fibrinolysis, thus suggesting that they may constitute a more severe form of PE than women with O-PE do.

Differentiation of acute fatty liver of pregnancy from syndrome of hemolysis, elevated liver enzymes and low platelet counts

As proposed criteria (Swansea criteria) for the diagnosis of acute fatty liver of pregnancy (AFLP) do not include antithrombin (AT) activity, diagnosis of AFLP may be delayed. The aim of this review is to underscore problems in the differential diagnosis of AFLP and the syndrome of hemolysis, elevated liver enzymes and low platelet counts (HELLP syndrome) and to facilitate prompt diagnosis of AFLP. Published works dealing with liver dysfunction in pregnancy, HELLP syndrome and AFLP were reviewed. AFLP and HELLP syndrome shared common clinical, laboratory, histological and genetic features, and differential diagnosis between them was often difficult. However, HELLP syndrome was likely to occur in patients with hypertension, but AFLP occurred often in the absence of hypertension. In addition, AFLP was exclusively associated with pregnancy-induced antithrombin deficiency (PIATD). Approximately 50% of patients with AFLP did not have thrombocytopenia at presentation. As the Swansea criteria for AFLP did not include PIATD, diagnosis of AFLP was delayed until manifestation of life-threatening complications; 60% of women were admitted to intensive care and 15% to a specialist liver unit. In conclusion, incorporation of AT activity of less than 65% into the diagnostic criteria for AFLP may facilitate suspicion and prompt diagnosis of AFLP, decrease uncertainty regarding the diagnosis of AFLP, and contribute to better investigation and understanding of the process leading to the development of liver dysfunction.

Accumulation ofDendrobium superbum (orchidaceae) fragrance in the rectal glands by males of the melon fly,Dacus cucurbitae

4-(4-Hydroxyphenyl)-2-butanone was characterized from flowers of the orchidDendrobium superbum as a specific attractant factor for the male melon fly,Dacus cucurbitae. The male flies compulsively licked the flower surface and sequestered the compound in significant quantities in their rectal glands. The compound was detected within 6 hr after ingestion and was retained for more than six days in the rectal gland sacs.

Association of NT-proBNP with plasma renin activity and plasma aldosterone concentration in women with singleton pregnancy

OBJECTIVE

To determine the association of the N-terminal fragment of precursor protein brain-type natriuretic peptide (NT-proBNP) levels with plasma renin activity (PRA) and plasma aldosterone concentration (PAC) in singleton pregnancies.

DESIGN

Serum NT-proBNP levels, PRA and PAC were determined in 215 blood specimens from 139 women with singleton pregnancies, including 34 and 105 women who did and did not develop hypertensive disorders in pregnancy, respectively. Twenty-five blood specimens were obtained from 25 women who later developed hypertension (systolic BP⩾140mmHg and/or diastolic BP⩾90mmHg), but were normotensive at the time of blood sampling.

RESULTS

The serum NT-proBNP levels [pg/ml, median (range), 32 (5-142)] did not change in normotensive women, but increased significantly to 97 (23-436) after the development of hypertension (D/H). The PRA [ng/ml/h, median (range), 7.1 (1-20)] did not change in normotensive women, but decreased significantly to 1.9 (1-16) after D/H. PAC (pg/ml) increased significantly from 397 (94-1750) to 667 (123-2010) between the 2nd and 3rd trimesters in normotensive women. However, as PAC of hypertensive women did not change significantly before and after D/H, PAC [293 (116-1720)] after D/H was significantly lower than that [667 (123-2010)] of the 3rd trimester in the normotensive women. The serum levels of NT-proBNP were significantly and negatively correlated with both PRA and PAC.

CONCLUSIONS

The renin-angiotensin-aldosterone system is suppressed in pregnant women with cardiac conditions associated with higher NT-proBNP levels.

Changes in d-dimer levels in pregnant women according to gestational week

We performed a retrospective review of medical charts regarding blood d-dimer levels determined cross-sectionally by the latex agglutination assay in 1952 samples from 1185 women to determine changes in d-dimer levels according to the stage of pregnancy. Three of 17 women in whom further investigations were performed were found to have clinical venous thromboembolism (VTE). The median and 95th percentile values of d-dimer (μg/mL) in the 1182 women without clinical VTE, 0.54 and 2.41 at gestational week (GW) 4-13, increased gradually to 1.22 and 5.03 at GW 14-27, 1.81 and 6.18 at GW 28-35, and 2.13 and 5.85 at GW 36-42, respectively. A total of nine women (0.76%), including three women with clinical VTE, exhibited a d-dimer level >14.0μg/mL, which was well above the 99th percentile for any stage of pregnancy. Thus, 3 (33%) of the nine with a d-dimer level >14μg/mL developed clinical VTE, while none of the remaining 1176 women with a d-dimer level ⩽14μg/mL developed clinical VTE. Although further prospective studies are required, our results suggested that there is a certain cut-off d-dimer value that would allow us to differentiate between pregnant women with and without clinical VTE.

Effects of caesarean section on serum levels of NT-proBNP

OBJECTIVE

To determine the effects of delivery by caesarean on serum levels of N-terminal fragment of precursor protein brain-type natriuretic peptide (NT-proBNP).

METHODS

Serum NT-proBNP levels were determined longitudinally at 24 and 36 weeks of gestation (GW) and on post-partum day 3 and month 1 (PPD3 and PPM1, respectively) in 78 women with normotensive singleton pregnancies. Thirty-nine women underwent caesarean delivery. Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were determined on PPD3. Effects of maternal demographic characteristics on NT-proBNP levels were also analysed.

RESULTS

NT-proBNP levels (pg/ml) either in pregnancy or on PPM1 did not differ between women with vaginal and caesarean deliveries (44 ± 24 vs 41 ± 30, 24 GW; 37 ± 22 vs 29 ± 22, 36 GW; 43 ± 28 vs 39 ± 24, PPM1, respectively). Levels on PPD3 were significantly higher (94 ± 105 vs 247 ± 186, P < 0.0001) in women with caesarean delivery. Among women with caesarean delivery, a larger rise of NT-proBNP on PPD3 occurred in nulliparous than in multiparous women (319 ± 232 vs 185 ± 107, P = 0.023), while no rise occurred among multiparous women with vaginal delivery (108 ± 115 vs 47 ± 27). NT-proBNP levels on PPD3 were significantly and negatively correlated with PRA, PAC and maternal weight loss after childbirth on PPD3. These 3 variables on PPD3 were significantly lower in women undergoing caesarean than vaginal delivery (0.8 ± 0.4 vs 1.9 ± 1.4 ng/ml/h for PRA; 70 ± 38 vs 136 ± 88 pg/ml for PAC; 2.7 ± 1.2 vs 4.3 ± 1.1 kg for weight loss, each P < 0.0001).

CONCLUSIONS

The transient post-partum rise in serum NT-proBNP may reflect transient volume overload after parturition and is remarkable in nulliparous women, especially after caesarean section.

Clinical significance of proteinuria determined with dipstick test, edema, and weekly weight gain ⩾500g at antenatal visit

OBJECTIVE

To determine how urine dipstick test, edema, and/or excessive weight gain (EWG, defined as ⩾500g/week) at antenatal visits predict significant proteinuria (defined as a protein-to-creatinine ratio [P/Cr, mg/mg] ⩾0.27) and preeclampsia.

METHODS

Data from 3279 antenatal visits between 30 and 36weeks of gestation were studied in 783 women with singleton pregnancies. In 24 preeclamptic pregnancies, data from 89 antenatal visits at and before diagnosis of preeclampsia were used. Spot P/Cr was determined in women with repeated positive dipstick test results in two successive antenatal visits or in those with a positive dipstick test result tested in the presence of hypertension.

RESULTS

Proteinuria on dipstick test, edema, and EWG appeared often in both women with and without preeclampsia; 66.7% vs. 27.7%, 83.3% vs. 44.1%, and 91.7% vs. 81.6%, respectively. However, repeated positive dipstick test results in two successive antenatal visits yielded sensitivity of 45.5%, specificity of 95.2%, and positive and negative predictive values of 30.0% and 97.4%, respectively, for detection of significant proteinuria and corresponding figures of 33.3%, 94.1%, 14.0%, and 98.0% for prediction of preeclampsia.

CONCLUSION

Repeated positive dipstick test results in two successive antenatal visits warrant a need for a confirmation test of significant proteinuria.

Changes in hemoglobin F levels in pregnant women unaffected by clinical fetomaternal hemorrhage

BACKGROUND

Complete automation of high-performance liquid chromatography (HPLC) for determination of hemoglobin F (%Hb F) and hemoglobin A1c (%Hb A1c) levels has made this procedure available in many clinical laboratories. However, the physiological changes in %Hb F during pregnancy and the effects of physiological and supraphysiological levels of %Hb A1c on measurement of %Hb F have not been studied extensively.

METHODS

Simultaneous determination of %Hb F and %Hb A1c was conducted in 490 blood samples obtained before (n=21), during the 1st (n=150), 2nd (n=116), and 3rd (n=192) trimesters of pregnancy, and postpartum (n=11) from 357 women, including 60 women with hyperglycemia but unaffected by clinical fetomaternal hemorrhage, by HPLC.

RESULTS

Mean (SD) Hb F levels were 0.71% (0.25%) before pregnancy. The value of 0.82% (0.47%) during the 1st trimester decreased significantly to 0.66% (0.35%) during the 2nd trimester and to 0.58% (0.38%) during the 3rd trimester. The level was 0.62% (0.31%) approximately one year after delivery. Thus, %Hb F was highest during the 1st trimester of pregnancy. The effects of varied %Hb A1c levels on %Hb F measurements were clinically negligible.

CONCLUSIONS

The data presented in this work may be used as reference intervals of %Hb F determined with HPLC during pregnancy.

Antithrombin activity, platelet count, hemoglobin concentration and hematocrit value determined immediately before vaginal delivery among healthy women

AIMS

To determine the normal reference values for antithrombin (AT) activity, platelet count (Plt), hemoglobin concentration (Hb), and hematocrit value (Ht) immediately before vaginal delivery among healthy pregnant women with singleton pregnancies and to determine association of these blood parameters with fetal growth.

METHODS

A complete blood count was performed and the AT activity was examined in 300 consecutive women admitted to hospital at > or = gestational week 36 for labor pains and/or the rupture of fetal membranes. All the women were normotensive and had singleton pregnancies, and none of the women had proteinuria, a weekly weight gain > or = 0.5 kg, or other specific complications upon admission. All the women attempted a vaginal delivery.

RESULTS

The medians (5th-95th percentile) were 90% (71-110%) for AT activity, 234x10(9)/L (150-337x10(9)/L) for Plt, 11.0 g/dL (9.5-12.8 g/dL) for Hb, and 34.0% (30.4-38.6%) for Ht. Women with an Hb value of > or = the median (11.0 g/dL) gave birth to significantly smaller infants than their counterparts.

CONCLUSIONS

A considerable number of healthy women exhibit a reduced AT activity and/or platelet count immediately before delivery. Hemoconcentration evidenced by a raised Hb value adversely effects on infant growth. Our data may be helpful when considering the normal ranges of these blood parameters for healthy parturient women.

Characteristics of insulin secretion patterns in Japanese women with overt diabetes and gestational diabetes defined according to the International Association of Diabetes and Pregnancy Study Groups criteria

AIM

To characterize patterns of insulin secretion in women with overt diabetes and gestational diabetes (GDM) defined by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria.

MATERIAL AND METHODS

A total of 228 Japanese women were examined retrospectively. All 228 women had a positive 50-g glucose challenge test (GCT) result at 25.2±1.2weeks of gestation and underwent a 75-g glucose tolerance test (GTT) at 27.4±1.8weeks of gestation. The immunoreactive insulin levels were determined during the GTT in four groups of pregnant women: five with overt diabetes, 20 with GDM according to both the previous Japan Society of Gynecology and Obstetrics (JSOG) and current IADPSG criteria (traditional GDM group), 43 with GDM according to only the IADPSG criteria (new GDM group), and 160 with non- GDM, but with a positive GCT result.

RESULTS

Attenuated and slow rise in plasma insulin in concert with prolonged hyperglycemia were characteristic in women with overt diabetes, compared with women with GDM in whom excessive insulin secretion in the presence of hyperglycemia was characteristic. The new GDM group did not differ significantly from the traditional GDM group with respect to scores of such indices as the insulinogenic index, the homeostasis model assessment for insulin resistance, and the quantitative insulin sensitivity check index.

CONCLUSION

Women with overt diabetes have both an impaired capacity for insulin secretion and elevated insulin resistance, while women with GDM exhibit a maintained insulin secretory capacity with an elevated insulin resistance.

Risk factors for postpartum hypertension in women with twin pregnancies

OBJECTIVE

Which physical findings and blood parameters predict postpartum hypertension remain to be studied in women with twin pregnancies.

METHODS

The antenatal systolic and diastolic blood pressures (SBP and DBP, respectively), and 16 laboratory variables were investigated in 150 normotensive women who gave birth to twins.

RESULTS

When the median values of the 18 continuous variables were used as cut-off values, an SBP>120 mm Hg (relative risk [95% confidence interval], 2.81 [1.94-4.08]), a DBP>70 mm Hg (2.42 [1.68-3.49]), an aspartate aminotransferase level>18 U/L (2.22 [1.55-3.19]), and a uric acid level>5.3 mg/dL (1.68 [1.20-2.36]) were independent risk factors for postpartum hypertension.

CONCLUSIONS

Antenatal blood pressure measurements and a laboratory work-up may be useful clinically for predicting postpartum hypertension in women with twin pregnancies.

Do uterotrophic drugs increase the risk of fatal hemorrhagic brain stroke?

OBJECTIVE

To evaluate whether uterotrophic agents increase the risk of fatal hemorrhagic brain stroke.

METHODS

Between 1991 and 1992, there were 230 maternal deaths among 2,420,000 pregnant women in Japan and the causes of these deaths was investigated in 1994. Using information provided in this report, we identified 35 women who died from or were assumed to die from hemorrhagic brain stroke. We assumed that 93% of women would have tried vaginal delivery. The risk of fatal hemorrhagic brain stroke after uterotrophic agent use was calculated according to the assumption that 5.0-40% of women received uterotrophic agents.

RESULTS

Use of uterotrophic agents for induction/augmentation of labor was confirmed in five (14.3%) of the 35 women who died from hemorrhagic brain stroke. The incidence of fatal brain stroke after the use of uterotrophic agents was only significantly higher than that for spontaneous hemorrhagic brain stroke if these agents were administered in ≤ 6.0% of women.

CONCLUSIONS

Because more than 6.0% of women received uterotrophic agents, these agents are unlikely to increase the risk of fatal hemorrhagic brain stroke.

Change in the number of patients after the adoption of IADPSG criteria for hyperglycemia during pregnancy in Japanese women

AIMS

To assess how the number of Japanese pregnant women with hyperglycemia changes after the adoption of the criteria proposed by the IADPSG.

METHODS

The study subjects comprised 228 Japanese women with a plasma glucose level ≥ 7.8 mmol/L on a glucose challenge test and who subsequently underwent a glucose tolerance test among 1038 women with singleton pregnancies. Gestational diabetes mellitus (GDM) is currently diagnosed using the JSOG criteria in Japan.

RESULTS

Of the 228 women, all 25 women with GDM and an additional 43 women without GDM according to the JSOG criteria were classified as having hyperglycemia according to the IADPSG criteria, resulting in an increase of patients with hyperglycemia from 2.4% (25/1038) to 6.6% (68/1038). The number of infants with a birthweight ≥ 3600g was significantly larger among the 43 women with newly diagnosed GDM than among the 160 women who remained normoglycemic (14% [6/43] vs. 3.8% [6/160], p = 0.02). The calculated number of patients requiring treatment for a reduction of one infant with a birthweight ≥ 3600 g was at least 9.8 for women with newly diagnosed GDM.

CONCLUSION

The IADPSG criteria increase the number of patients by at least 2.7-fold but may be cost-effective with respect to the resulting reduction in macrosomia.

Natural killer, natural killer T, helper and cytotoxic T cells in the decidua from sporadic miscarriage

PROBLEM

The aim of this cohort study was to assess natural killer (NK) cell and natural killer T (NKT) cell populations and cytokine expressions of helper T (Th) and cytotoxic T (Tc) cells in the decidua of sporadic miscarriage (MS) and induced abortion (IA).

METHODS

The deciduae were obtained from consecutive 40 women whose pregnancies ended in the first trimester MS, and the fetal chromosome karyotypes were analyzed. The cell populations were measured by flow cytometry.

RESULTS

No significant differences in NK cell or NKT cell percentages were found among MS with normal chromosome karyotype (MSNK, n = 14), MS with abnormal karyotype (MSAK, n = 26) and IA (n = 14). Interferon (IFN)-gamma(+) cell percentage and interleukin (IL)-4(+)/tumor necrosis factor (TNF)-alpha(+) ratio of Th cells in MS groups were increased, while IL-4(+) cell percentage, IL-4(+)/IFN-gamma(+) and IL-4(+)/TNF-alpha(+) ratios of Tc cells in MS groups were decreased as compared with those in IA. No significant difference in these parameters between MSNK and MSAK was found.

CONCLUSIONS

These results suggested that Tc1 predominance existed in the decidua of MS. Th1 predominance was not found in MSNK.

Topological factors in placental surface arteries correlate with neonatal birth weight

OBJECTIVES

There has been no study concerning association between topological factors of placental vascularization and neonatal growth in humans. The aim of study was to assess whether any network index of placental surface arteries was associated with neonatal birth weight.

MATERIALS AND METHODS

Twenty-six placentas were randomly selected between 34 and 41 weeks of gestational ages. Placental weights ranged 385 to 770 g; and neonatal weights ranged 1960 to 3680 g. After visualization of placental surface arteries by a milk injection method, network indices including the number of nodes, network density, network diameter, average distance of nodes, and the degree centralization were determined. These network indices and placental weights were compared with neonatal birth weights.

RESULTS

The number of nodes, network density, network diameter, average distance of nodes, and the degree centralization were found to be as follows (Mean +/- SD); 84.7 +/- 29.3, 0.0262 +/- 0.0088, 15.8 +/- 2.77, 7.83 +/- 1.13, 0.0263 +/- 0.0091, respectively. We found that neonatal birth weights correlated with the number of nodes of placental surface arteries (correlation coefficient R = 0.40) and placental weights (R = 0.52) both. However, the number of nodes of placental surface arteries was not associated with the placental weights or the gestational age.

CONCLUSIONS

We for the first time found that a topological factor, i.e., the number of nodes of placental surface arteries correlated with neonatal growth. There was no correlation between numbers of nodes and placental weights. This suggests that the number of nodes affects fetal growth independent of placental weights. A topological factor of placental vascularization might significantly affect fetal growth in utero and determine risks of vascular diseases in their future lives.

Association between preterm birth and vaginal colonization by mycoplasmas in early pregnancy

To examine the association between colonization by two newly classified species of genital ureaplasmas (Ureaplasma parvum and U. urealyticum) in early pregnancy and subsequent late abortion or preterm birth at <34 weeks of gestation, four species of genital mycoplasmas--Mycoplasma genitalium, M. hominis, U. parvum, and U. urealyticum--as well as Chlamydia trachomatis and Neisseria gonorrhoeae were examined by PCR-based methods in a prospective cohort study of 877 women with singleton pregnancies at <11 weeks of gestation. Antibiotics were used only in cases in which C. trachomatis and/or N. gonorrhoeae was detected. Multivariate logistic-regression analysis was used to assess independent risk factors after taking maternal low body weight and past history of preterm birth into account. M. genitalium, M. hominis, U. parvum, U. urealyticum, C. trachomatis, and N. gonorrhoeae were detected in 0.8%, 11.2%, 52.0%, 8.7%, 3.2%, and 0.1% of these 877 women, respectively. Twenty-one (2.4%) women experienced late abortion or preterm birth at <34 weeks of gestation. Three factors-detection of U. parvum in the vagina (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1 to 8.5); use of antibiotics, such as penicillin and cefatrizine, for incidental inflammatory complications before 22 weeks of gestation (OR, 4.2; 95% CI, 1.6 to 10.0); and past history of preterm birth (OR, 10.4; 95% CI, 2.7 to 40.5)-were independently associated with late abortion and preterm birth. In conclusion, vaginal colonization with U. parvum, but not U. urealyticum, is associated with late abortion or early preterm birth.

No difference in natural killer or natural killer T-cell population, but aberrant T-helper cell population in the endometrium of women with repeated miscarriage

BACKGROUND

The aim of this study was to assess the natural killer (NK) cell and natural killer T (NKT) cell populations and cytokine expression of T-helper (Th) cells in the endometrium of women who suffered from unexplained repeated miscarriage (RM).

METHODS

The percentages of NK cells, NKT cells and CD4(+) cells expressing intracellular interferon (IFN)-gamma, interleukin (IL)-4 and tumour necrosis factor (TNF)-alpha were measured by flow cytometry in the endometrium of 20 RM women and 17 fertile control women in the mid-luteal phase of the menstrual cycle.

RESULTS

No significant differences in CD56(+) NK cell or CD3(+)CD4(-)CD8(-)Valpha24(+)Vbeta11(+) NKT cell percentages were found between RM and control women. However, in RM women compared with control women, the percentages of CD3(+) cells (mean 40.3 versus 56.5%), CD4(+)IFN-gamma(+) cells (28.4 versus 39.5%) and CD4(+)TNF-alpha(+) cells (32.9 versus 45.8%) were significantly lower. The Th1/Th2 cell balance in RM women did not differ from that of controls.

CONCLUSIONS

Immunodystrophism detected as diminution of the Th cell population rather than Th1 predominance, NK cell or NKT cell accentuation in the endometrium might underlie the pathophysiology of unexplained RM. This finding provokes an additional controversy on the Th1/Th2 balance concerning RM aetiology.

Allograft inflammatory factor-1 regulates trinitrobenzene sulphonic acid-induced colitis

The expression of allograft inflammatory factor-1 (AIF-1) in 2,4,6-trinitrobenzene sulphonic acid (TNBS)-induced colitis, a model for T helper 1 (Th1) type disease, was investigated in BALB/c mice. The AIF-1 expression was significantly increased in the colitis lesion compared to that in the normal colon. We then prepared AIF-1 transgenic mice (Tgm) with the BALB/c background that express high levels of AIF-1 in lymphoid tissues and the colon. When AIF-1 Tgm were administrated TNBS, the TNBS-induced colitis was ameliorated compared with that in non-transgenic littermates. The amelioration of colitis was associated with the low expression of interleukin-1beta in the colon. The present findings suggest that AIF-1 regulates Th1-type inflammatory responses.

Combined use of magnetic resonance imaging, CA 125 assay, histologic type, and histologic grade in the prediction of lymph node metastasis in endometrial carcinoma

OBJECTIVE

The aim of this study was to predict retroperitoneal lymph node metastasis during the preoperative examination of patients with endometrial carcinoma and to determine whether lymphadenectomy must be performed.

STUDY DESIGN

This study was carried out on 214 patients with endometrial carcinoma. Preoperative evaluators were volume index, depth of myometrial invasion (as assessed by magnetic resonance imaging), serum CA 125 level, histologic type, and histologic grade. With the use of receiver operating characteristic curves, cutoff values of volume index and serum CA 125 levels were determined. The relationships of these evaluators with pelvic lymph node metastasis were investigated by multivariate analysis with a logistic regression model. The relationships of these evaluators with para-aortic lymph node metastasis were investigated in the same way.

RESULTS

Histologic type, volume index, histologic grade, and serum CA 125 level were found to be independent risk factors for pelvic lymph node metastasis; serum CA 125 level and volume index were found to be independent risk factors for para-aortic lymph node metastasis. Among 110 cases with no risk factors for pelvic lymph node metastasis, pelvic lymph node metastasis was observed in 4 cases (3.6%). On the other hand, only 1 case of 128 cases (0.7%) with no risk factors for para-aortic lymph node metastasis actually had metastasis.

CONCLUSION

Careful consideration of the possibility of the elimination of the requirement of retroperitoneal lymphadenectomy is needed in cases with no risk factors for lymph node metastasis. However, our results suggest that para-aortic lymphadenectomy may not be necessary in cases with no risk factors for para-aortic lymph node metastasis.

(4E)-dehydrocitrals [(2E,4E)- and (2Z,4E )-3,7-dimethyl-2,4,6-octatrienals] from acarid mite Histiogaster sp. A096 (Acari: Acaridae)

A mixture of two monoterpenes was obtained as the opisthonotal gland secretion from unidentified Histiogaster sp. A096 (Acari: Acaridae), and their structures were elucidated to be (4E)-dehydrocitrals [(2E,4E)- and (2Z,4E)-3,7-dimethyl-2,4,6-octatrienals] by GC/MS, GC/FT-IR, UV and 1H-NMR spectra. Both isomers of (4E)-dehydrocitral prepared by syntheses in 4 steps from 3-methyl-2-butenal with 34.2% yields (based on the ylide) were separated by column chromatography into the (2E,4E)- and (2Z,4E)-3,7-dimethyl-2,4,6-octatrienal. Mass spectra together with GC retention times of the purified natural (4E)-dehydrocitrals were identical with those of synthetic (2E,4E)-3,7-dimethyl-2,4,6-octatrienal and (2Z,4E)-3,7-dimethyl-2,4,6-octatrienal. The geometry at the 2-C position of both synthetic (4E)-dehydrocitrals was confirmed by NOESY analyses. This is the first identification of (4E)-dehydrocitrals from the animal kingdom.

The relationship between a leaf-rolling moth (Dactylioglypha tonica) and fungi covering the cocoon

To discover the relationship between a leaf-rolling moth and the fungi densely covering its cocoons, the rolled nest leaves were collected in two districts in Japan and antibacterial properties of the fungi were examined. Cocoons and fungi isolated from the nest were classified into 5 categories by the growth stages of the insects, and 7 categories based on taxonomic properties and pigment productivity, respectively. The dominant genus was Penicillium in each location. However, the composition of the fungal categories was different and seemed to depend on their circumstances. From all cocoons with larvae, the strains that belonged to the same fungal category and produced the same antibiotic (deoxyherqueinone) were isolated. From these results, the species-specific relationship between the insect and fungi or fungal products was considered to be not extremely tight, and it was suggested the period of the larval spinning of the cocoon is a key stage of this unique relationship.

Clinicopathological study of mucinous gastric carcinoma

BACKGROUND AND AIMS

Mucinous gastric carcinoma (MUC) is relatively a rare subtype of gastric carcinoma, and there has been considerable controversiy over the prognosis of this type of carcinoma. In this study we tried to analyze the clinicopathological differences between MUC and other types of gastric carcinoma (non-MUC) and determine whether MUC is associated with a worse prognosis than non-MUC.

MATERIAL AND METHODS

We reviewed 645 patients with pathologically confirmed gastric cancer who underwent gastrectomy in our facility during the period from 1975 through 1997. Among them, 20 patients (3.1%) had gastric carcinoma with (MUC), and 625 patients had it without extracellular mucin (non-MUC). In addition, we classified MUC into two groups (well-differentiated type; 7 cases and poorly differentiated type; 9 cases) and analyzed the differences between them.

RESULTS

The MUC tumors were more often located in the lower and the upper third of the stomach (MUC: 55% and 25%, non-mUC: 41% and 18%, respectively). The patients with MUC had more serosal invasion (t3 plus t4; MUC: 45%, non-MUC: 18%), more-invasive carcinoma (Type 3 plus 4; MUC: 60%, non-MUC: 36%) and more lymph-node involvement (MUC: 45%, non-MUC: 38%) than the patients with non-MUC. The patients with MUC were more advanced in stage at the time of diagnosis (Stage III plus IV; MUC: 50%, non-MUC: 26%) and had a higher peritoneal dissemination rate (MUC: 30%, non-MUC: 12%) and a lower curability rate (MUC: 60%, non-MUC: 78%) than the patients with non-MUC. The mean size of tumors in MUC (7.4 cm) was larger than that of non-MUC (5.5 cm). Therefore, the overall 5-year survival rate for MUC patients (33%) was lower than that for non-MUC patients (64%). There were no significant differences between well-differentiated and poorly differentiated subtypes of MUC except for the curability and peritoneal dissemination rates.

CONCLUSIONS

The overall survival rate for patients with MUC was worse than that for patients with non-MUC. The poor prognosis was correlated with more advanced stage at diagnosis and more frequent serosal invasion. These results suggest the need to diagnose patients with MUC in the early stage of cancer and that in the case of the advanced stage, wide excision of the surrounding tissues and aggressive lymph-node dissection will be needed.

Outbreak of Chinese herb nephropathy in Japan: are there any differences from Belgium?

OBJECTIVE

The purpose of this article was to study and clarify the features of Chinese herb nephropathy (CHN) in Japan.

PATIENTS AND METHODS

The subjects consisted of patients diagnosed as having CHN in Saiseikai Nakatsu Hospital and of those reported in the literature in Japan. We investigated the clinical and histological features of CHN patients in Japan and compared them with the Belgian cases.

RESULTS

The remarkable differences were as follows: (1) high prevalence in males compared with Belgian cases, (2) Fanconi syndrome was found in most cases, (3) no patients had malignant tumors in the urinary tract. In addition, the ascribed Chinese medicines in Japan were divided into three groups: 'Tenshin-toki-shigyaku-ka-gosyuyu-syokyo-to', 'Boui-ougi-to', and others.

CONCLUSION

CHN in Japan has some characteristics distinguished from Belgian nephropathy. One hypothesis is a susceptibility to aristolochic acids (AAs), which is considered to be a causative agent, may be different among races. Another is that there could be some other toxic substances affecting the clinical findings although they are not identified at present. Further studies must be undertaken to clarify these differences.

An antibiotic from Penicillium sp. covering the cocoon of the leaf-rolling moth, Dactylioglypha tonica

An antibiotic-producing Penicillium sp. strain was isolated from cocoons of the leaf-rolling moth, Dactylioglypha tonica. An antibacterial compound was isolated from the cultured broth, and the chemical structure of the principle was determined by spectroscopic data to be a derivative of isocoumarincarboxylate.

The characteristic pattern of aminoaciduria in patients with aristolochic acid-induced Fanconi syndrome: could iminoaciduria be the hallmark of this syndrome?

BACKGROUND

In Japan the patients with Chinese herbs nephropathy (CHN), aristolochic acids-(AAs) associated renal failure, often present Fanconi syndrome. The aim of this study was to investigate the pattern of aminoaciduria in patients with AAs-induced Fanconi syndrome and to clarify whether it is different from other Fanconi syndromes reported in the literature.

SUBJECTS AND METHODS

The subjects consisted of 4 patients with Fanconi syndrome due to AAs. We studied biochemical data and urinary excretion of amino acids in the 4 patients. Amino acids in their urine were analyzed by high performance liquid chromatography (HPLC).

RESULTS

Three out of 4 patients showed in common very increased excretion ofproline, hydroxyproline and citruline. Last patient showed the very increased levels of proline and valine. Regarding glycine, which is considered to belong to the same group as imino acid and to be shared with high-affinity transport system ofproline, there was not very increased excretion.

CONCLUSION

These findings suggest that AAs would predominantly affect the low-affinity transport system of proline in the brushborder membrane of proximal tubules because the low-affinity system is considered not to be shared with glycine transport.

A dihydroxy-gamma-lactone as an oviposition stimulant for the swallowtail butterfly, Papilio bianor, from the rutaceous plant, Orixa japonica

The oviposition response of the Rutaceae-feeding swallowtail butterfly, Papilio bianor, was induced by a methanolic extract from leaves of its major host, Orixa japonica. Several components were responsible for this oviposition response. One of the stimulants was isolated and identified as (-)-2-C-methyl-D-erythrono-1,4-lactone. The compound was inactive alone, but elicited oviposition behavior when mixed with other fractions.

A putative binding protein for lipophilic substances related to butterfly oviposition

A unique protein of 23 kDa (Jf23) was found in the tarsus of the female swallowtail butterfly, Atrophaneura alcinous. Jf23 has 38% identity with a bilin-binding protein, which was found in the cabbage butterfly, Pieris brassicae, and which has two consensus sequences in common with the members of the lipocalin family, suggesting that it is a binding protein for lipophilic ligands. Western blot analysis showed that Jf23 was expressed only in the female, and not in the male. Electrophysiological response of the female tarsi was stimulated by methanolic extract of their host plant, Dutchman's pipe (Aristolochia debilis). The stimulated response was depressed by the presence of Jf23 antiserum. These results suggest that Jf23 is one of the chemosensory signaling proteins, which plays one or more roles in female butterfly oviposition.

Chinese herb nephropathy in Japan presents adult-onset Fanconi syndrome: could different components of aristolochic acids cause a different type of Chinese herb nephropathy?

BACKGROUND

We encountered two cases of Chinese herb-induced Fanconi syndrome in Japan. One component of the chinese medicine was "Kan-mokutsu" (Aristolochia manshuriensis) in which aristolochic acids (AAs) were detected.

METHODS

Renal biopsy showed flattening of proximal tubular epithelial cells and paucicellular interstitial fibrosis without glomerular lesions, all of which were in accordance with Chinese herb nephropathy (CHN). To date, many cases of CHN have been reported mainly as progressive renal failure in western countries.

RESULTS

However, our cases were different from those in that they presented Fanconi syndrome. The detected AAs in our cases consisted of aristolochic acid (AA)-I, II and D. In contrast, in Belgium, the incriminated agent was Aristolochia fangchi which consisted of AA-I, B, C, and aristolactum.

CONCLUSION

These findings could indicate that different components of AAs could cause different clinical lesions, or that the amount of ingested AAs might reflect clinical pictures, that is to say, our patients took lower volume of Chinese herbs and might be in an early stage of CHN. Furthermore, it is likely that susceptibility to this substance may be different among races. CHN would include two clinical aspects: subacute renal failure and adult-onset Fanconi syndrome. It is important to bear in mind that CHN could present Fanconi syndrome.

Glycosides of 14,15-seco- and 13,14:14,15-disecopregnanes from the roots of Tylophora tanakae

Five new glycosides of 14,15-seco- and 13,14:15-diseco-type pregnanes, including a new pregnane, 2 alpha-hydroxyhirundigenin, were isolated, in addition to one known glycoside, cynatratoside B, from the roots of Tylophora tanakae Maxim. Their structures were elucidated by spectral and chemical means.

A sclerosant with astringent properties developed in China for oesophageal varices: comparison with ethanolamine oleate and polidocanol

BACKGROUND

Xiao zhi ling (XZL), which consists of Chinese nutgalls and aluminium potassium sulphate, is used as a local injection for the treatment of internal haemorrhoids in China. It is also used for endoscopic sclerotherapy of oesophageal varices. To date, however, it has not been compared with other sclerosants with regard to its safety and efficacy.

METHODS

In the present study, the effect on the endothelium and the haemolytic and thrombosing effects of XZL were compared with those of 5% ethanolamine oleate and 1% polidocanol, using an endothelial cell line and red blood cells taken from rats and the dorsal marginal ear vein of rabbits. In addition, XZL was injected into the area surrounding varices in rats and its efficacy was studied endoscopically and histologically.

RESULTS

Xiao zhi ling reduced the size of varices in rats after causing severe damage in the injected region. Compared with the other two sclerosants, however, XZL had little effect on the endothelium and was the least haemolytic compound. Furthermore, XZL did not cause thrombosis in the injected vein of a rabbit.

CONCLUSIONS

These results suggest that XZL is another type of sclerosant with astringent rather than detergent properties. This compound should be used to treat oesophageal varices by paravariceal injection in smaller doses than 5% ethanolamine oleate and 1% polidocanol.

Esophageal varices in rat models of liver cirrhosis

Animal models resembling the human situation are very useful to investigate human disease. However, there has been no evidence of esophageal varices in rats with liver cirrhosis. In the present study, to determine whether intrahepatic portal hypertension produced by liver cirrhosis induces esophageal varices in rats, the esophagus was examined endoscopically in rat models of liver cirrhosis. All rats given carbon tetrachloride or thioacetamide and six of seven rats given a choline-deficient diet had esophageal varices or venous dilatation after 16 weeks of treatment, although the varices in one rat given carbon tetrachloride and in two rats given a choline-deficient diet were reduced from weeks 16 to 18. These findings suggest that timing is important when studying esophageal varices in rat models of liver cirrhosis. It is concluded that certain models of liver cirrhosis in rats could be used as models of esophageal varices due to intrahepatic portal hypertension.

[Traditional remedy-induced Chinese herbs nephropathy showing rapid deterioration of renal function]

A 19-year-old female was referred to our hospital for azotemia and anemia. She had been taking a health food for atopic dermatitis for about three years. Urinalysis showed proteinuria, glycosuria and microscopic hematuria. Generalized aminoaciduria was observed. Moreover, severe anemia, azotemia, hypokalemia and hypophosphatemia were also observed. Renal biopsy specimen disclosed hypocellular interstitial fibrosis and degeneration of the proximal tubular epithelial cells. No remarkable changes were observed in the glomeruli. Aristolochic acid was detected in the health food. From these findings, she was diagnosed as having Chinese herbs nephropathy (CHN). Although consumption of the food intake was stopped, her renal function deteriorated rapidly. Previously, we reported that certain kinds of Chinese herbal drugs contain aristolochic acid and that the drugs should be prohibited if aristolochic acid is identified. However, we experienced a patient of CHN arising from traditional remedy, which was not proved to be safe. It should be awared that health foods may contain aristolochic acid.

Trypsin inhibitor activity in commercial soybean products in Japan

The effect of trypsin inhibitor (TI) in soybean on the prevention of cancer has been reported in animal studies. However, the actual intake of active TI in daily life is not known. In this experiment we measured TI activity in various soybean products and the effects of some factors of processing on the TI activity. Average TI activity in whole soybean was 4,819 U/100 g, and the average percentages of remaining activity in products against that of whole soybean were momen-tofu 2.5%, yose-tofu 3.4%, kinugoshi-tofu 4.3%, jyuten-tofu 7.9%, soymilk 13.0%, natto 0.7%, soy sauce 0.8% and miso 0.3%. By heating soymilk at 100 degrees C, TI activity decreased to 11% at 10 min and 5% at 20 min. After heating soymilk in a water-bath for 15 min at 75 and 100 degrees C, TI activity decreased to 35 and 12%, respectively. The TI activity of tofu was proportional to the remaining whey. The effects of chemicals used for the coagulation of soy protein and foam-removal on TI activity were little. The results suggest that soybean products retain 2.5-12.5% TI activity of the whole soybean and that humans are consuming some active TI in their daily lives.

[Chinese herbs nephropathy in the Kansai area: a warning report]

In 1993, Vanherweghem and his associates reported cases of rapidly progressive renal interstitial fibrosis in young women who were administered a slimming regimen including Chinese herbs. Subsequently, similar cases have been reported. In Japan, especially in the Kansai area, several cases of Chinese herbs nephropathy have already been reported. We experienced a patient suffering from Chinese herbs nephropathy (CHN), and further detected aristolochic acids from the Chinese herbs taken by the patient. Aristolochic acids are known to be causative agents of CHN. The danger of CHN should be noted as soon as possible and drugs containing aristolochic acids should be prohibited.

The pheromone system of the male danaine butterfly, Idea leuconoe

Male Idea leuconoe butterflies release a complex mixture of volatiles from their pheromone glands (hairpencils) during courtship. The pheromone components geranyl methyl thioether (2), viridifloric beta-lactone (3) and 6-hydroxy-4-dodecanolide (10) have been synthesized for the first time. Therefore, the structural assignment of these new natural products could be proved. Related 7-hydroxy-5-alkanoides are also present in the extract. The volatiles are embedded in a lipidic, matrix with more than 150 components. This matrix consists of alkanes, alkenes, 2,5-dialkyltetrahydrofurans, secondary alkanols and alkenols as well as alkanones and alkenones. Several regioisomers of the oxidized hydrocarbons occur. The elucidation of double bond positions has been performed by MS using DMDS adducts.