[Efficacy analysis of surgical combined with postoperative adjuvant therapy for T3 gallbladder carcinoma: a multicenter retrospective study]

Objective: To explore the clinical value of adjuvant therapy in patients with T3 gallbladder cancer (GBC) who have undergone R0 resection. Methods: Clinical and pathological data from 415 patients with T3 GBC who underwent surgical treatment in 7 tertiary centers in China from January 2013 to December 2018 were collected,including 251 males and 164 females,aged (61±11)years (range: 26 to 88 years). Depending on whether to receive adjuvant therapy after radical resection,the patients were divided into the radical resection group alone (group A,n=358) and the radical resection combined with the postoperative adjuvant therapy group (group B,n=57). The general data of the two groups were matched 1∶1 by propensity score matching method,and the caliper value was 0.02.Clinicopathological characteristics,overall survival and disease-free survival of the two groups were compared.The Cox regression model was used for multivariate analysis,and patients with at least one or more independent risk factors were classified as high-risk clinicopathological subtypes. Subgroup analysis was performed to assess the clinical value of adjuvant therapy after radical resection in patients with high-risk clinicopathological subtypes. Results: After the matching,there were 42 patients in each of the two groups. The incidence of gallbladder cancer and the number of dissected lymph nodes in group B after cholecystectomy were higher than those in group A (χ2=9.224,2.570,both P<0.05). There were no significant differences in overall survival rate and disease-free survival rate between the two groups before and after matching (all P>0.05). The results of the univariate and multivariate analysis showed that CA19-9>39 U/ml,nerve invasion,tumor location (liver side or bilateral),TNM stage ⅢB to ⅣB ,poorly differentiated tumor were independent prognostic factors of overall survival and disease-free survival of patients with T3 stage gallbladder cancer (all P<0.05).Three hundred and twenty-nine patients(79.3%) had high-risk clinicopathological subtypes,and the median survival time after curative resection with and without adjuvant therapy was 17 months and 34 months respectively,and the 3-year and 5-year overall survival rates were respectively 40.0%,21.3% and 46.0%,46.0% (χ2=4.042,P=0.044);the median disease-free survival time was 9 months and 13 months,and the 3-year and 5-year disease-free survival rates were 23.4%,13.6% and 30.2%,18.2% (χ2=0.992,P=0.319). Conclusions: Postoperative adjuvant therapy following radical surgery did not yield significant improvements in the overall survival and disease-free survival rates of patients diagnosed with T3 gallbladder cancer. However, it demonstrated a significant extension in the overall survival rate for patients presenting high-risk clinicopathological subtypes.

Genomic and transcriptional heterogeneity of multifocal hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) often presents with multiple nodules within the liver, with limited effective interventions. The high genetic heterogeneity of HCC might be the major cause of treatment failure. We aimed to characterize genomic heterogeneity, infer clonal evolution, investigate RNA expression pattern and explore tumour immune microenvironment profile of multifocal HCC.

PATIENTS AND METHODS

Whole-exome sequencing and RNA sequencing were carried out in 34 tumours and 6 adjacent normal liver tissue samples from 6 multifocal HCC patients. Protein expression of Ki67, AFP, P53, Survivin and CD8 was detected by immunohistochemistry. Fluorescence in situ hybridization was carried out to validate the amplification status of sorafenib-targeted genes.

RESULTS

We deciphered genomic and transcriptional heterogeneity among tumours in each multifocal HCC patient including mutational profiles, copy number alterations, tumour evolutionary trajectory and tumour immune microenvironment profiles. Of note, sorafenib-targeted alterations were identified in the trunk of phylogenetic tree in only one out of the six patients, which may explain the relative low treatment response rate to sorafenib in clinical practice. Moreover, we demonstrated RNA expression patterns and tumour immune microenvironment profiles of all nodules. We found that RNA expression pattern was associated with Edmondson-Steiner grading. Based on the differential expression of 66 reported immune markers, unsupervised hierarchical clustering analysis of 34 nodules identified immune subsets: one low expression cluster with seven nodules and one high expression cluster with 11 nodules. CD8+ T cells were more enriched in nodules of the high expression cluster.

CONCLUSIONS

Our study provided a detailed view of genomic and transcriptional heterogeneity, clonal evolution and immune infiltration of multifocal HCC. The heterogeneity of druggable targets and immune landscape might help interpret the clinical responsiveness to targeted drugs and immunotherapy for multifocal HCC patients.

Improved quantitative assessment of HBV-associated liver fibrosis using second-harmonic generation microscopy with feature selection

BACKGROUND AND AIM

Quantitative assessments of liver fibrosis using second-harmonic generation/two-photon excited fluorescence microscopy provide greater sensitivity and accuracy than collagen proportionate area while eliminating operator-dependent variation in the staining process. In conjunction with sophisticated image analysis algorithms and feature selection, we might reduce the computation cost in future and narrow down the candidates for further clinical studies.

METHODS

We sampled a total of 244 liver specimens from patients with hepatitis B viral infections who underwent liver biopsy or liver resection at the National Taiwan University Hospital. The samples were then imaged using a Genesis (HistoIndex Pte. Ltd, Singapore) system, wherein second-harmonic generation microscopy was used to visualize collagen, and two-photon excited fluorescence microscopy was used to visualize other cell structures. We used 100 morphological features extracted from the images to assess correlations with METAVIR fibrosis scores.

RESULTS

Out of 100 quantitative measurements, 76 showed significant correlation with METAVIR scoring, thereby enabling the statistical discrimination of patients in various stages of the disease. These 76 features were also narrowed down by the nonlinear test to 10 candidate measurements, which can be further investigated in detail.

CONCLUSIONS

Our experimental results showed that the model with 10 selected features can beat the one with second-harmonic generation only, and performed equivalently well compared the model with 76 features, especially for early-stage discrimination. Features presenting significant correlation were used to fit a single combined index in order to predict pathological staging, thereby making it possible to reveal incremental progress during treatment.

Generic velpatasvir plus sofosbuvir for hepatitis C virus infection in patients with or without human immunodeficiency virus coinfection

BACKGROUND

Data are limited regarding the effectiveness and safety of generic velpatasvir plus sofosbuvir (VEL/SOF) for hepatitis C virus (HCV) in patients with or without human immunodeficiency virus (HIV) coinfection.

AIM

To evaluate the effectiveness and safety of generic VEL/SOF-based therapy for HCV infection in patients with or without HIV coinfection in Taiwan.

METHODS

Sixty-nine HIV/HCV-coinfected and 159 HCV-monoinfected patients receiving 12 weeks of generic VEL/SOF with or without ribavirin (RBV) for HCV were prospectively enrolled. The anti-viral responses and the adverse events (AEs) were compared between the two groups. The characteristics potentially related to sustained virological response 12 weeks off therapy (SVR₁₂ ) were analysed.

RESULTS

The SVR₁₂ was achieved in 67 HIV/HCV-coinfected patients (97.1%; 95% CI: 90.0%-99.2%) and in 156 HCV-monoinfected patients (98.1%; 95% CI: 94.6%-99.4%) receiving VEL/SOF-based therapy, respectively. The SVR₁₂ rates were comparable between HIV/HCV-coinfected and HCV-monoinfected patients, regardless of pre-specified baseline characteristics. One hundred twenty-two (53.5%) and seven (3.1%) patients had baseline resistance-associated substitutions (RASs) in HCV NS5A and NS5B regions, but the SVR₁₂ rates were not affected by the presence or absence of RASs. One (1.4%) and five (3.1%) patients in the HIV/HCV-coinfected and HCV-monoinfected groups had serious AEs. No patient died or discontinued treatment due to AEs. The eGFR remained stable throughout the course of treatment in HIV/HCV-coinfected patients receiving anti-retroviral therapy containing tenofovir disoproxil fumarate (TDF).

CONCLUSIONS

Generic VEL/SOF-based therapy is well-tolerated and provides comparably high SVR₁₂ rates for HCV infection in patients with and without HIV coinfection.

Fibrosis-4 index predicts cirrhosis risk and liver-related mortality in 2075 patients with chronic HBV infection

BACKGROUND

Fibrosis-4 index (FIB-4) is a surrogate marker for hepatic fibrosis in hepatitis B virus (HBV) carriers.

AIM

To investigate whether FIB-4 index stratifies the risks of adverse liver events.

METHODS

A total of 2075 treatment-naïve, noncirrhotic the patients with chronic HBV infection were included. Most of them (82.1%) were HBeAg-negative patients and their baseline FIB-4 levels were explored to stratify the risks of cirrhosis, cirrhosis-related complications and liver-related mortality.

RESULTS

During a mean follow-up period of 15.47 years, we found a higher baseline FIB-4 index was associated with increased incidence rates of cirrhosis in addition to the common host and viral factors. Patients with FIB-4 >1.29, compared to those with FIB-4 <1.29, were associated with increased risks of cirrhosis, cirrhosis-related complications and liver-related mortality with the hazard ratio (95% confidence interval) of 6.19 (4.76-8.05), 6.88, (3.68-12.86) and 7.79, (4.54-13.37) respectively. Within the first 3 years of follow-up, FIB-4 remained stable and its kinetics were consistently associated with the develoopment of adverse liver events. Furthermore, FIB-4 index of 1.29 was able to stratify all the risks of adverse liver events even in HBeAg-negative patients with a low risk of disease progression (HBV DNA <2000 IU/mL, HBsAg <1000 IU/mL and ALT <40 U/L). Only 1 patient with FIB-4 index <1.29 developed cirrhosis but not other events within 15 years of follow-up.

CONCLUSIONS

In noncirrhotic patients with chronic HBV infection, a higher FIB-4 index was associated with increased risks of adverse liver events. FIB-4 index <1.29 is useful for the prediction of the lowest risks of disease progression.

Historical epidemiology of hepatitis C virus in select countries-volume 4

Due to the introduction of newer, more efficacious treatment options, there is a pressing need for policy makers and public health officials to develop or adapt national hepatitis C virus (HCV) control strategies to the changing epidemiological landscape. To do so, detailed, country-specific data are needed to characterize the burden of chronic HCV infection. In this study of 17 countries, a literature review of published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates was conducted, and inputs were validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Hong Kong to 2.4% in Taiwan, while the largest viraemic populations were in Nigeria (2 597 000 cases) and Taiwan (569 000 cases). Diagnosis, treatment and liver transplant rates varied widely across the countries included in this analysis, as did the availability of reliable data. Addressing data gaps will be critical for the development of future strategies to manage and minimize the disease burden of hepatitis C.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm: Volume 4

Factors influencing the morbidity and mortality associated with viremic hepatitis C virus (HCV) infection change over time and place, making it difficult to compare reported estimates. Models were developed for 17 countries (Bahrain, Bulgaria, Cameroon, Colombia, Croatia, Dominican Republic, Ethiopia, Ghana, Hong Kong, Jordan, Kazakhstan, Malaysia, Morocco, Nigeria, Qatar and Taiwan) to quantify and characterize the viremic population as well as forecast the changes in the infected population and the corresponding disease burden from 2015 to 2030. Model inputs were agreed upon through expert consensus, and a standardized methodology was followed to allow for comparison across countries. The viremic prevalence is expected to remain constant or decline in all but four countries (Ethiopia, Ghana, Jordan and Oman); however, HCV-related morbidity and mortality will increase in all countries except Qatar and Taiwan. In Qatar, the high-treatment rate will contribute to a reduction in total cases and HCV-related morbidity by 2030. In the remaining countries, however, the current treatment paradigm will be insufficient to achieve large reductions in HCV-related morbidity and mortality.

Strategies to manage hepatitis C virus infection disease burden-Volume 4

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 17 countries in Africa, Asia, Europe, Latin America and the Middle East, and interventions for achieving the Global Health Sector Strategy on viral hepatitis targets-"WHO Targets" (65% reduction in HCV-related deaths, 90% reduction in new infections and 90% of infections diagnosed by 2030) were considered. Scaling up treatment and diagnosis rates over time would be required to achieve these targets in all but one country, even with the introduction of high SVR therapies. The scenarios developed to achieve the WHO Targets in all countries studied assumed the implementation of national policies to prevent new infections and to diagnose current infections through screening.

Higher lifetime chance of spontaneous surface antigen loss in hepatitis B carriers with genotype C infection

BACKGROUND

Clearance of hepatitis B surface antigen (HBsAg) indicates clinical control of hepatitis B virus (HBV) infection. However, little is known about the impact of viral genomic variations on HBsAg loss.

METHODS

We explored the association between viral genomic factors and HBsAg loss in 2121HBeAg-negative patients. HBV pre-core stop codon (1896) and basal core promoter (BCP) (1762/1764) sequences were determined in patients with HBV DNA ≥200 IU/mL (N = 1693). The effect of HBV genotype on HBsAg loss was further validated in the whole cohort of 3445 HBsAg carriers.

RESULTS

The cumulative lifetime (age 28-75 years) incidence of HBsAg loss was 50.4% in 2121 HBeAg-negative patients. We found that genotype C, but not pre-core stop codon or BCP mutants, was associated with HBsAg loss. Compared to genotype B patients, genotype C patients had higher lifetime chance of HBsAg loss, with hazard ratio of 1.8 (95% confidence interval: 1.4-2.4). Multivariable analysis showed that male sex, elevated ALT levels, lower serum HBV DNA and HBsAg levels, and genotype C infection were associated with higher chance of HBsAg loss independently. We then performed sensitivity analysis, which re-included HBeAg-positive, cirrhotic and treatment-experienced patients, and confirmed the robustness of our results in 3445 HBsAg carriers.

CONCLUSION

Genotype C infection, compared to genotype B, is associated with a higher lifetime chance of HBsAg loss in Asian HBV carriers.

Efficient delayed fluorescence via triplet-triplet annihilation for deep-blue electroluminescence

Four 2-(styryl)triphenylene derivatives (TSs) were synthesized for deep-blue dopant materials. By using a pyrene-containing compound, DMPPP, as the host, the TS-doped devices exhibited significant delayed fluorescence via triplet-triplet annihilation, providing the highest quantum efficiency of 10.2% and a current efficiency of 12.3 cd A(-1).

In vivo proton MRS of normal pancreas metabolites during breath-holding and free-breathing

AIM

To characterize normal pancreas metabolites using in vivo proton magnetic resonance spectroscopy ((1)H MRS) at 3T under conditions of breath-holding and free-breathing.

MATERIALS AND METHODS

The pancreases of 32 healthy volunteers were examined using (1)H MRS during breath-holding and free-breathing acquisitions in a single-voxel point-resolved selective spectroscopy sequence (PRESS) technique using a 3T MRI system. Resonances were compared between paired spectra of the two breathing modes. Furthermore, correlations between lipid (Lip) content and age, body-mass index (BMI), as well as choline (Cho) peak visibility of the normal pancreas were analysed during breath-holding.

RESULTS

Twenty-nine pairs of spectra were successfully obtained showing three major resonances, Lip, Cho, cholesterol and the unsaturated parts of the olefinic region of fatty acids (Chol+Unsat). Breath-hold spectra were generally better, with higher signal-to-noise ratios (SNR; Z=-2.646, p=0.008) and Cho peak visible status (Z=-2.449, p=0.014). Correlations were significant between spectra acquired by the two breathing modes, especially for Lip height, Lip area, and the area of other peaks at 1.9-4.1ppm. However, the Lip resonance was significantly different between the spectra of the two breathing modes (p<0.05). In the breath-holding spectra, there were significant positive correlations between Lip peak height, area, and age (r=0.491 and 0.521, p=0.007 and 0.004), but not between Lip peak area and BMI. There was no statistical difference in Cho resonances between males and females. The Lip peak height and area were significantly higher in the Cho peak invisible group than in the Cho peak visible group (t=2.661 and 2.353, p=0.030 and 0.043).

CONCLUSION

In vivo(1)H MRS of the normal pancreas at 3T is technically feasible and can characterize several metabolites. (1)H MRS during breath-holding acquisition is superior to that during free-breathing acquisition.

The clinical significance of occult hepatitis B transfusion in Taiwan--a look-back study

OBJECTIVES

A look-back study was conducted to determine the clinical significance of occult hepatitis B virus (HBV) blood transfusion in an HBV hyperendemic area.

AIM

To improve the blood transfusion safety.

BACKGROUND

Occult HBV is transmissible through blood transfusion in HBV-naÏve recipients. However, its impact on recipients with prevalent HBV infection in HBV hyperendemic areas is unclear.

METHODS/MATERIALS

In 2006, 12 occult HBV blood donors were found from 10 824 repository samples by nucleic acid testing. The 74 corresponding recipients were identified and their pre- and post-transfusion clinical information was gathered, and the living recipients were recalled for follow-up. From the available archival sera, the HBV DNA was examined and sub-genomic sequences between paired donor and recipient were compared using polymerase chain reaction-based assays.

RESULTS

Among the 74 recipients, 18 were still alive and 12 returned to our clinic. From the available serological profiles, 76% of recipients had ongoing or recovered HBV infection before transfusion. Only 24 recipients had available post-transfusion serological profiles and none seroconverted to be hepatitis B surface antigen (HBsAg) positive. Moreover, except for the prior HBsAg carriers, the recipients' HBV DNA levels after transfusion were low (<20 IU/mL). One recipient had identical HBV surface gene sub-genomic sequence (384 nucleotides) to his donor. After transfusion, no recipient developed post-transfusion hepatitis (PTH) and the clinical outcome was good.

CONCLUSION

In HBV hyperendemic areas, occult hepatitis B transfusion might not lead to HBsAg carriage or PTH. The risk of transfusion-transmitted HBV infection was probably lower than that in non-endemic areas because most recipients had already experienced HBV infection.

Expression of distinct alpha 1-adrenoceptor phenotypes in the iris of pigmented and albino rabbits

BACKGROUND AND PURPOSE

The expression of multiple pharmacological phenotypes including alpha(1L)-adrenoceptor has recently been reported for alpha(1)-adrenoceptors. The purpose of the present study was to identify alpha(1)-adrenoceptor phenotypes in the irises of pigmented and albino rabbits.

EXPERIMENTAL APPROACH

Radioligand binding and functional bioassay experiments were performed in segments or strips of iris of pigmented and albino rabbits, and their pharmacological profiles were compared.

KEY RESULTS

[(3)H]-silodosin at subnanomolar concentrations bound to intact segments of iris of pigmented and albino rabbits at similar densities (approximately 240 fmol x mg(-1) protein). The binding sites in the iris of a pigmented rabbit were composed of a single component showing extremely low affinities for prazosin, hydrochloride [N-[2-(2-cyclopropylmethoxyphenoxy)ethyl]-5-chloro-alpha,alpha-dimethyl-1H-indole-3-ethamine hydrochloride (RS-17053)] and 5-methylurapidil, while two components with high and low affinities for prazosin, RS-17053 and 5-methylurapidil were identified in irises from albino rabbits. In contrast, specific binding sites for [(3)H]-prazosin were not clearly detected because a high proportion of non-specific binding and/or low affinity for prazosin occurred. Contractile responses of iris dilator muscle to noradrenaline were antagonized by the above ligands, and their antagonist affinities were consistent with the binding estimates at low-affinity sites identified in both strains of rabbits.

CONCLUSIONS AND IMPLICATIONS

A typical alpha(1L) phenotype with extremely low affinity for prazosin is exclusively expressed in the iris of pigmented rabbits, while two distinct phenotypes (alpha(1A) and alpha(1L)) with high and moderate affinities for prazosin are co-expressed in the iris of albino rabbits. This suggests that a significant difference in the expression of phenotypes of the alpha(1)-adrenoceptor occurs in the irises between the two strains of rabbits.

Operative laparoscopy for unruptured ectopic pregnancy in a caesarean scar

Eight women diagnosed by transvaginal ultrasonography with unruptured caesarean scar pregnancy underwent operative laparoscopy as an alternative treatment to laparotomy. The ultrasonographic diagnosis of caesarean scar pregnancy was confirmed in all women at laparoscopy. None of the women required conversion of the procedure to laparotomy. The total operative time ranged from 75 to 120 minutes. The total blood loss was limited, ranging from 50 to 200 ml. All women tolerated the operation well and had uneventful recoveries. Our results show that in the hands of a well-trained operator, laparoscopy appears to be a reasonable alternative for the management of an unruptured caesarean scar pregnancy.

Altered perlecan expression in placental development and gestational diabetes mellitus

The proteoglycan perlecan is involved in cell signaling, regulation of growth factor activity, and maintenance of basement membranes. This study aims to investigate the expression of perlecan during placental development and whether hyperglycemia of gestational diabetes mellitus induces the alteration of perlecan expression in placenta. Immunohistochemistry, immunoprecipitation/sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and quantitative real-time PCR were carried out to study the placental perlecan expression at different trimesters of pregnancies and in gestational diabetes mellitus. The perlecan protein was mainly immunolocalized in the trophoblast and vessel basement membranes with some staining in the villous stroma of placental villus. Perlecan was also found to co-localize with laminin and collagen IV in the basement membranes of placenta. The protein and mRNA levels of placental perlecan were significantly decreased as the gestational age increased. However, a significant increase in perlecan expression was observed in the third trimester placentas with gestational diabetes mellitus compared to the gestational age-matched controls. Furthermore, trophoblast cells cultured in a high glucose (30 mM) medium and a high osmotic pressure medium (5.6 mM glucose and 24.4 mM mannitol) showed increased perlecan expression compared to cells cultured in the low glucose (5.6 mM) regular medium. These alterations of perlecan expression may be associated with the structural changes of placenta during maturation. The metabolic effect of high glucose and high osmotic pressure of gestational diabetes mellitus may contribute to the increased perlecan expression of diabetic placentas.

Decreased placental GCM1 (glial cells missing) gene expression in pre-eclampsia

Pre-eclampsia is a multisystem disorder of pregnancy associated with elevated blood pressure, proteinuria, and complex biochemical disturbances. The mammalian homologue of the glial cells missing (GCM) gene, GCM1, is selectively expressed in the placenta. GCM1 expression has been shown to affect placental branching and vasculogenesis, abnormalities of which may result in the development of pre-eclampsia. In this study immunohistochemistry, Western blot, and quantitative real-time PCR were used to investigate GCM1 expression at different gestational ages and in pre-eclampsia. Of 36 placentae without pre-eclampsia (ranged from 5-40 weeks of gestation), the level of GCM1 expression was relatively constant before late third trimester. The immunoreactivity of GCM1 protein and the level of GCM1 mRNA were not significantly different during normal pregnancy until 37 weeks of gestation, when the level of GCM1 expression was reduced significantly. Furthermore, significant reductions in GCM1 protein and mRNA were observed in pre-eclamptic placentae compared with gestational age-matched controls. Our results suggest that GCM1 is a distinct transcription factor involved in placental disease and altered expression of the GCM1 gene may contribute to the etiology of pre-eclampsia.

A conservative surgical treatment of cervical pregnancy with active bleeding - uterine artery ligation and cervicotomy

Cervical pregnancy complicated with massive bleeding usually results in abdominal hysterectomy, and thus the patient loses her fertility potential. Conservative management to control active hemorrhaging as well as to preserve reproductive function is necessary for women who desire more children. We present four patients with cervical pregnancy, complicated by life threatening hemorrhage, who were successfully treated with uterine artery ligation and cervicotomy. Subsequently, one patient had two successful term pregnancies delivered by cesarean section.

The synergistic effect of thrombopoietin in erythropoiesis with erythropoietin and/or IL-3 and myelopoiesis with G-CSF or IL-3 from umbilical cord blood cells of full-term neonates

The authors sought to determine whether recombinant human thrombopoietin (TPO) acts synergistically with other cytokines on burst-forming unit-erythroid (BFU-E)-derived and colony-forming unit-granulocyte/macrophage (CFU-GM)-derived colony formations from cord blood. Cord blood nonadherent mononuclear cells (MNC) from normal full-term neonates were cultured in a methylcellulose system. When cultured with 5 x 10(4) MNC/mL, erythropoietin (EPO) 2 U/mL, interleukin-3 (IL-3) 50 ng/mL, and/or TPO 400 ng/mL (experiment 1), the addition of TPO to EPO gave rise to more BFU-E-derived colonies (p = .002). The addition of TPO to EPO + IL-3 gave rise to more BFU-E-derived colonies (p = .006) also. TPO synergizes erythropoiesis from cord blood. When cultured with IL-3 50 ng/mL, granulocyte colony-stimulating factor (G-CSF) 25 ng/mL, and/or TPO 400 ng/mL, the addition of TPO to IL-3 gave rise to more CFU-GM-derived colonies (p = .002). The addition of TPO to G-CSF gave rise to more CFU-GM-derived colonies (p = .002) also. TPO synergizes myelopoiesis from cord blood. Thus, TPO has synergistic effects on both erythropoiesis and myelopoiesis from cord blood. In the identical conditions of culture, cord blood had significantly greater BFU-E-derived or CFU-GM-derived colony formation than bone marrow (in a previous report by the authors) did. When cultured under conditions similar to those of experiment 1, but with 1 x 10(4) cord blood MNC/mL and TPO 100 ng/mL (experiment 2), results similar to those in the experiment 1 also revealed that TPO has synergistic effects on erythropoiesis and myelopoiesis from cord blood. In every individual assay, the numbers of BFU-E-derived or CFU-GM-derived colonies in experiment 1 were significantly higher than those in experiment 2.

Microsatellite alterations in exfoliated cervical epithelia deoxyribonucleic acid as a marker for high-grade dysplasia

OBJECTIVE

The purpose of this study was to evaluate the feasibility of the use of deoxyribonucleic acid microsatellite alterations in cervical epithelia in the prediction of high-grade dysplasia and to compare it with a strategy based on human papillomavirus testing.

STUDY DESIGN

Our prospective study subjects were from a cohort of 498 women with minimally abnormal Papanicolaou test results including atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion who had documented repeated Papanicolaou and human papillomavirus tests. Of these, 52 eligible patients having conizations or hysterectomies as their histologic outcomes were subjected to tests of loss of heterozygosity on a panel of 5 microsatellites (D3S1110, THRB, D3S1228, D6S291, D3S1289) within the deoxyribonucleic acid of exfoliated cervical epithelia. These genetic alterations were analyzed through fluorescence polymerase chain reaction by comparison of allele ratios of exfoliated cells with those of normal control tissue. Predictive values for high-grade cervical dysplasia and cancer between this deoxyribonucleic acid marker and human papillomavirus status were compared.

RESULTS

With the use of loss of heterozygosity in at least one locus for predicting high-grade cervical neoplastic lesion, the sensitivity, specificity, positive predictive value, and negative predictive value were 96.7%, 59.1%, 76.3%, and 92.9%, which were superior to those of the human papillomavirus test (80%, 59.1%, 72.7%, and 92.9%). As a triage for atypical squamous cells of undetermined significance, its sensitivity and negative predictive value were up to 100%.

CONCLUSION

The promising results on determining microsatellite alteration in dysplastic lesions might imply that it is possible to detect the earliest changes by potential molecular markers with exfoliated cervical epithelial cells.

Involvement of apoptosis during deciduomal regression in pseudopregnant hamsters effect of progesterone

We determined whether fragmentation of genomic DNA, apoptosis, occurs during deciduomal regression in pseudopregnant hamsters and the effect of progesterone on the apoptotic processes. Artificially induced deciduoma were obtained on different days of pseudopregnancy and separated into mesometrial and antimesometrial tissues. The deciduomal cell cycle progression and population profiles of both sides were compared by flow cytometry. The proportion of sub-G1 peak, which was correlated with the apoptotic cells, were about 10% on day 8 and reached to 40% in both tissues on day 10. Exogenous progesterone treatment by daily injection (2 mg; s.c.) on and after day 8 reduced the percentage of low molecular weight DNA in both tissues on day 10 and day 12 as compared to the nontreated control one, respectively. The appearance of DNA ladder was also delayed at least 24 h by progesterone administration. The intensity of DNA fragmentation was more pronounced in antimesometrial deciduoma. In situ 3'-end labeling of apoptotic cells further substantiated the apoptotic process. The apoptotic cells first appeared in the luminal region in antimesometrial deciduoma on day 8 and spreaded all over the entire deciduomal tissue on day 10. Progesterone treatment stimulated deciduomal proliferating cell nuclear antigen (PCNA) expression, maintained deciduoma until day 14 and retarded the differentiation and regeneration of the uterine epithelium.

Mutation analysis of the putative tumor suppressor gene PTEN/MMAC1 in cervical cancer

OBJECTIVE

PTEN/MMAC1, a candidate tumor suppressor gene located at chromosome 10q23.3, was recently identified and found to be homozygously deleted or mutated in several different types of human tumors. The aim of this study is to determine whether PTEN/MMAC1 is a target for 10q loss of heterozygosity in cervical cancer.

METHOD

We examined 50 primary cervical carcinoma specimens using a PCR-based assay followed by SSCP and direct sequencing. The genomic DNA was also confirmed by Southern blot analysis.

RESULTS

All specimens except one, which has a 7-base deletion, showed a negative result. Among them, 30 randomly selected cases and their paired noncancerous tissue were further screened using nested RT-PCR. Six of 30 cervical cancerous tissues had aberrant transcripts. However, 4 of the matched noncancerous tissues also had aberrant transcripts. Southern blot analysis of the entire genomic DNA did not reveal any evidence of gene alteration.

CONCLUSIONS

Sequence abnormalities in the PTEN/MMAC1 gene were only detected in 1 of 50 cervical cancers analyzed indicating that aberrant PTEN/MMAC1 function is an uncommon event in the development of cervix cancers. However, similar to studies with the TSG101 gene, screening for aberrant transcripts of PTEN/MMAC1 with nested RT-PCR may detect transcripts, which, although they vary from the normal size, may not be related to oncogenesis as they are also frequently found in normal tissues of the same patient.

Is modified in situ vaginal wall sling operation the treatment of choice for recurrent genuine stress incontinence?

PURPOSE

We evaluate objectively the results of a modified in situ vaginal wall sling operation for recurrent genuine stress incontinence and whether it is a substitute for the traditional sling procedure.

MATERIALS AND METHODS

A total of 23 patients with urodynamically proved recurrent genuine stress urinary incontinence were recruited in this study. Patients were treated with a modified needle urethropexy technique using an island of in situ vaginal skin as a sling to support the bladder neck and urethra. Surgical outcome was evaluated subjectively and objectively at a median of 15 months. A total of 42 patients who underwent a traditional polytetrafluoroethylene sling operation served as controls.

RESULTS

The cure rate of the vaginal wall sling operation was 34.8% by objective assessment, which was lower than that of the traditional sling procedure (88.1%, p <0.05). The subjective success rate demonstrated the same results (vaginal sling 60.9% versus traditional sling 92.9%, p <0.05). The risk factors for operation failure were lower maximal urethral pressure, lower urethral closing pressure, narrow vaginal capacity and previous anterior colporrhaphy or a Stamey operation (all p <0.05). In 3 cases suburethral epithelial inclusion cysts were specific complications of the operation. There was no prolonged urinary retention or urethral erosion.

CONCLUSIONS

Based on our results, we do not believe that the vaginal wall sling operation should be recommended for all recurrent genuine stress urinary incontinence cases and especially not for those with factors predictive of surgical failure. Further studies are needed to investigate and clarify the possible causes of failure.

Injection therapy for stress incontinence in women

Periurethral bulking agents have been used to treat intrinsic sphincter deficiency for decades. Currently available agents include polytetrafluoroethylene, glutaraldehyde cross-linked collagen, autologous fat and silicone microimplants. Polytetrafluoroethylene has never been approved by the United States Food and Drug Administration for periurethral injection because of the risk of particle migration. Early results have reported subjective cure rates of up to 95% with collagen injections. However, collagen may cause allergic reactions and long-term results are still awaited. Periurethral fat injection has a reported success rate ranging from 23% to 65%. It is simple and avoids the use of foreign materials, but the main disadvantage relates to the variability of resorption and connective tissue replacement. Silicone microimplants need further study to evaluate their efficacy and safety. The best material has not yet been defined. Long-term studies are still necessary to define the optimal injectable agent.

Analysis of TSG101 tumour susceptibility gene transcripts in cervical and endometrial cancers

Carcinoma of the uterine cervix is a common malignancy among women that has been found to show loss of heterozygosity in the chromosome 11p. Recent studies have localized the TSG101 gene in this region, and also demonstrated a high frequency of abnormalities of this gene in human breast cancer. To determine the role of the TSG101 gene in the carcinogenesis of cervical and uterine carcinoma, 19 cases of cervical carcinoma and five cases of endometrial carcinoma, as well as nearby non-cancerous tissue from the same patients, and 16 blood samples from healthy persons as normal control were analysed by Southern blot analysis of genomic DNA, reverse transcription of the TSG101 mRNA followed by PCR amplification and sequencing of the products. We found that abnormal transcripts of the TSG101 gene were common both in cancerous or non-cancerous tissues of the uterus and cervix and in normal peripheral mononuclear cells. There was no genomic deletion or rearrangement in spite of the presence of abnormal transcripts, and no definite relationship between the abnormal transcripts and HPV infection was found. Although the frequency of abnormal transcripts was higher in cancerous than in non-cancerous tissue, normal peripheral mononuclear cells also had abnormal transcripts. Given these findings, the role of the TSG101 gene as a tumour-suppressor gene should be re-evaluated. Because some aberrant transcripts could be found at the first PCR reaction, we suggest that the aberrant transcripts might be the result of imperfect minor splicesome products.

Stroke complicating pregnancy and the puerperium

BACKGROUND

The role of nonobstetric factors, such as stroke, in maternal mortality has become of increasing importance because maternal deaths resulting directly from obstetric causes are decreasing. Strokes contribute to high mortality and morbidity, and are severe complications during pregnancy and puerperium. The objective of this study was to investigate the maternal outcome of patients with complications of stroke during pregnancy and puerperium. The causes, incidence and essential management of stroke are also reviewed.

METHODS

During the 10-year period from January, 1986, to January, 1996, women who suffered from stroke during pregnancy, or up to six weeks postpartum, and were discharged from our hospital were identified. Stroke was defined as the abrupt onset of a focal neurologic syndrome that consisted of hemorrhagic and ischemic central nervous system events. All were assessed using computerized tomography or magnetic resonance imaging. Neurologists reviewed each case from the medical records.

RESULTS

Thirteen women who had had a stroke during pregnancy or puerperium were identified. Nine of these women had intracerebral hemorrhage and four had ischemic strokes. During this 10-year period, approximately 85,321 women gave birth at the Mackay Memorial Hospital, and the incidence of stroke was approximately 1 in 6,500 pregnancies. Among the nine cases of hemorrhagic strokes, three women had preeclampsia and one had gestational diabetes mellitus. Mortality from strokes was 38%, and 63% of survivors had residual neurologic deficits; 46% of the strokes occurred during the puerperium.

CONCLUSIONS

Stroke during pregnancy and puerperium causes high mortality and morbidity. Early diagnosis and adequate treatment cannot be overemphasized, as prompt and proper management is beneficial for outcome. The same meticulous care provided during the antepartum and intrapartum periods should be continued into the puerperium.

High-grade endometrial stromal sarcoma in a 10-year-old girl: case report

Endometrial stromal sarcomas occur primarily in perimenopausal women and are quite uncommon in children. We report a case of high-grade endometrial stromal sarcoma in a 10-year-old girl, who initially experienced lower abdominal pain on voiding. After a series of examinations, surgical treatment was performed, including an extended total hysterectomy with bilateral salpingo-oophorectomy, bilateral pelvic lymph node sampling, and partial omentectomy. Adjuvant radiotherapy and hormonal therapy followed, however, the abdominal tumor recurred 9 months later. Invasion of the right lobe of the liver with compression of the inferior vena cava and pleural effusion was noted. The patient then received prolonged oral etoposide therapy. The treatment stabilized the tumor size and relieved her symptoms for 4 months. She finally succumbed to the disease as a result of distant metastasis.

Accuracy of frozen section diagnosis in gynecology

OBJECTIVE

A retrospective study was undertaken to evaluate the accuracy of frozen section diagnosis in gynecological surgery.

METHODS

We compared the results of 792 consecutive gynecological frozen section diagnoses with their final diagnoses from January 1991 to June 1996. Slides for which the frozen section diagnosis was uncertain or incompatible with the final diagnosis were reviewed by an attending pathologist to determine the possible causes.

RESULTS

A total of 299 ovarian, 390 lymph node, 56 uterine lesions, and 77 other tissue samples were obtained. The frozen section diagnosis was compatible with the final diagnosis in 97.5% of cases. The sensitivity for nonbenign lesions was 90.9%, and the specificity was 99.5%. There were no false positives or overestimated cases; 1.3% of cases were falsely negative, 0.4% underestimated the degree of malignancy, and 0.9% were uncertain. Possible causes for incompatible or uncertain frozen section diagnoses were analyzed. The accuracy of frozen section diagnoses for ovarian, lymph node, uterine, and other tissues was also evaluated. Frozen section was found to identify correctly 13 of 17 ovarian malignancies metastaic from other organs, 14 of 15 germ cell malignancies, and 3 of 4 dysgerminomas. The low sensitivity in ovarian borderline malignancy was due to the even lower sensitivity in its mucinous subgroup. The relationship between section numbers and accuracy of frozen section diagnosis in mucinous ovarian tumors was assessed.

CONCLUSIONS

Frozen section diagnosis in gynecology is sufficiently accurate for clinical use, with a low false negative rate and an even lower false positive rate. Most incompatible frozen section diagnoses occurred in ovarian lesions, especially in mucinous ovarian tumors. Performing multiple sections (at least one section for every 10 cm in diameter) is recommended in the frozen section diagnosis of mucinous ovarian tumors.

Impact of reverse end-diastolic flow velocity in umbilical artery on pregnancy outcome after the 28th gestational week

BACKGROUND

The aim of this study was to discuss pregnancy outcome in chromosomally and structurally normal fetuses having reverse end-diastolic flow velocity (REDFV) on Doppler umbilical artery velocimetry (DUAV) in the third trimester.

METHODS

DUAV was performed in the high risk pregnancy antepartum fetal surveillance. We excluded gestational age less than 28 weeks, multiple pregnancies, and chromosomal or congenital anomalies. Thirty cases were categorized as having REDFV The pregnancy outcome was investigated in these cases.

RESULTS

There were three stillbirths and 12 neonatal deaths, resulting in a perinatal mortality rate of 50%. Twenty-eight patients (93.3%) had complications with preeclampsia (20 of severe degree and eight moderate). Cesarean section was performed on 24 patients (80%) due to acute fetal distress. The mean gestational age at delivery was 31.8+/-3.2 weeks. The mean diagnosis-to-delivery interval was 10+/-8.2 hours. The average birth weight was 970+/-270 gm, 28 (93.3%) were found to be below the 10th percentile of ideal birth weight. An umbilical artery pH less than 7.2 at delivery was found in 12 of 18 examined cases (66.7%). Twelve out of 15 placentae (80%) showed significant infarcts on pathological examination. All newborns (100%) needed admission to the neonatal intensive care unit.

CONCLUSIONS

REDFV on DUAV represents an ominous and severe fetal condition with an adverse pregnancy outcome, especially in conditions associated with preeclampsia and/or intrauterine growth retardation. Intensive and frequent surveillance and aggressive management at the appropriate time would improve perinatal outcome.

Analysis of FHIT transcripts in cervical and endometrial cancers

Carcinoma of the uterine cervix is a common malignancy, and many affected women, have been found to exhibit loss of heterozygosity (LOH) in the chromosome 3p region. Recent studies have localized the FHIT (fragile histidine triad) gene in this region and also demonstrated a high frequency of abnormalities of this gene in various cancers. To determine the role of the FHIT gene in cervical and uterine carcinomas, 16 cases of cervical carcinoma and 7 cases of endometrial carcinoma, as well as nearby non-cancerous tissues in these patients, were analyzed by reverse transcription of the FHIT mRNA followed by polymerase chain reaction amplification and sequencing of the products. In this study, 13 of 16 cervical cancers and 4 of 7 endometrial cancers displayed abnormal FHIT transcripts, including a lack of 2 or more exons of the FHIT gene, the insertion of several bases in the deletion junctions, and a 282 bp deletion from cDNA 171 to 452, resulting in a frameshift. Moreover, 5 of 16 matched non-cancerous tissues from the cervical cancer patients and 4 of 7 non-cancerous tissues from endometrial cancer patients also showed the presence of abnormal transcripts lacking 3 or more exons of the FHIT gene. Only 1 of 23 paired samples exhibited LOH. Our results suggest that the abnormal transcript of the FHIT gene is common in both normal and tumor tissues of the uterus and cervix. We also checked for HPV infection in these samples and found no definite relationship between the abnormal transcript and human papillomavirus infection.

Periurethral fat injection in the treatment of recurrent genuine stress incontinence

PURPOSE

We evaluated the efficacy, safety and mechanism of periurethral fat injection in the treatment of recurrent genuine stress incontinence.

MATERIALS AND METHODS

Periurethral fat injections were performed in 26 patients for the treatment of recurrent genuine stress incontinence. A complete urogynecological study, including a 1-hour pad test, urodynamic studies and chain urethrocystography were done in each case and were repeated at least 3 months after operation. Each patient was followed for at least 12 months.

RESULTS

Of 26 patients 13 (50%) were dry after operation and 4 (15.4%) showed improvement and were satisfied with the results of the operation, giving a total success rate of 65.4%. There were 6 cases of immediate postoperative minor complications (23%). Average volume of injected fat was 14.8 +/- 4.8 cc, which did not affect the success rate. Preoperative and postoperative chain urethrocystographic values for bladder neck descent in reference to the pubosacral tip line showed no statistical difference between successfully and unsuccessfully treated groups. Urodynamic studies in all cases showed no differences relating to operation. However, minimal urethral resistance increased from 0.122 +/- 0.061 to 0.205 +/- 0.134 (p = 0.023) in the treatment success group. This change was not demonstrated in the treatment failure group.

CONCLUSIONS

Periurethral fat injection for the treatment of recurrent genuine stress incontinence is a simple technique that works by the increment of urethral resistance. It has an acceptable success rate without financial outlay for the injected material.

Fluorescence in situ hybridization (FISH) as a method to detect aneuploid cells

OBJECTIVES

To test the sensitivity and specificity of various FISH probes for detecting male and aneuploid cells and to determine the percentage of fetal cells that must be present in a sample in order to use the probes for prenatal diagnosis.

METHODS

Adult human lymphocytes were cultured and harvested. Twelve different proportions of male to female cells and 5 different proportions of trisomy 21 cells and trisomy 18 cells in euploid cells were prepared for FISH. Alpha-satellite DYZ1 was applied to detect the male cells. Chromosome 21/Down syndrome critical region cosmid and D13Z1/D21Z1 alpha-satellite probes were applied to detect trisomy 21 cells. The D18Z1 alpha-satellite probe was used to detect trisomy 18 cells.

RESULTS

DYZ1 detected male cells reliably in concentrations as low as 2%. Both D18Z1 and chromosome 21/Down syndrome critical region cosmid probes could detect aneuploid cells at reasonably achievable concentrations. However, the D13Z1/D21Z1 probe was not sensitive below concentrations of 50%.

CONCLUSIONS

FISH is an alternative technique for noninvasive prenatal diagnosis. The sensitivity and specificity of FISH probes may play a crucial role in the accuracy of prenatal diagnosis.

Prospective comparison of laparoscopic and traditional colposuspensions in the treatment of genuine stress incontinence

OBJECTIVE

To compare prospectively the results of laparoscopic and traditional colposuspensions in the treatment of genuine stress incontinence and to evaluate the efficacy, technique, and functional and anatomical changes after these two procedures.

MATERIALS AND METHODS

Ninety-two patients with urodynamically proven genuine stress incontinence participated in this study, with 46 patients randomly allocated to laparoscopic colposuspension, and the other 46 patients to the traditional procedures. All patients had repeat studies at least 3 months after operation.

RESULTS

The bladder neck position was significantly elevated after operation either at rest or during straining in both groups (all p < 0.001), but it was higher in the traditional group than the laparoscopy group during straining (p < 0.05). Comparison of urodynamics before and after operation in both groups showed significantly increased minimal urethral resistance and improved pressure transmission ratios at the proximal urethra (Q2). The blood loss was less in the laparoscopy group. The duration of bladder drainage after laparoscopic colposuspension was shorter, and was not affected by subsequent laparotomy. The operative time was almost the same. The success rate of the laparoscopy group was lower than that of the traditional group (80.4% vs. 95.6%, p = 0.044). The complication rates were 10.8% and 17.4% respectively.

CONCLUSION

Laparoscopic colposuspension is an effective method for the treatment of GSI, as documented by anatomical and functional assessments. However, the success rate is still lower than for the traditional procedure.

Applicability of perineal sonography in anatomical evaluation of bladder neck in women with and without genuine stress incontinence

Thirty-seven patients with proven genuine stress incontinence (GSI) underwent ultrasound study to evaluate the bladder neck position relative to the symphysis pubis. Sixty-five continent women including 40 parous and 25 nulliparous women were recruited as a control group. Several parameters were found to be statistically different between incontinent and control groups (P < 0.01). If 28 degrees or 13 mm were used as the cut-off point for rotational angle (RA) and descent of bladder neck (DBN), the sensitivity, specificity, and positive and negative predictive values were 78.0%, 76.9%, 64.3%, and 33.3%, respectively. The specificity and positive predictive value for GSI increased to 83.1% and 67.6% if these two parameters were used together. Perineal sonography is valuable in assessing anatomic change of the bladder neck, but it is not a sensitive tool for predicting GSI.

Cervical cancer in young women in Taiwan: prognosis is independent of papillomavirus or tumor cell type

The objective of this study was to address the hypotheses that younger patients with cervical cancer have a uniquely worse clinical outcome and/or are more likely to have adverse tumor cell types or specific human papillomaviruses (HPV). Cases of stage Ib-IIa cervical cancer among women 35 years of age or younger (82) and over 35 (54) were analyzed and compared with respect to the following: (1) histologic type (squamous vs nonsquamous), (2) human papillomavirus (HPV) type via polymerase chain reaction, and (3) clinical parameters, including tumor size, nodal metastases, and recurrence/persistence. Patients 35 years of age or younger had a survival similar (71.2% vs 72.4%) to that of older women from the same institution. In the younger group, outcome was not correlated with the presence or absence of HPV or HPV type. Nonsquamous carcinomas, including adenocarcinoma and small cell carcinoma, were strongly associated with HPV18, were more prevalent in the younger group, and had a slightly higher risk of recurrence/persistence; however, these differences were not significant and 71% of the recurrences were squamous cell carcinomas. Thus, in young Taiwanese women with stage Ib-IIa cervical cancer, the majority of deaths cannot be attributed to a specific HPV type or unique tumor morphology.

A concealed penis mimicking penile agenesis in an infant with trisomy 13

Penile agenesis results from failure in the development of the genital tubercle and is rarely associated with chromosomal abnormalities. We report on an echographic prenatal diagnosis of penile agenesis associated with trisomy 13. At birth, the contour of the penile shaft and the glans could not be seen. However, a careful palpation allowed us to determine that the penile shaft was concealed and normal in size, rather than penile agenesis being present. To our knowledge, a concealed penis associated with trisomy 13 has not previously been described.

Functional impairment of bronchoalveolar lavage phospholipids in early Pneumocystis carinii pneumonia in rats

Surfactant abnormalities may contribute to the impairment of gas exchange observed in Pneumocystis carinii pneumonia. Analysis of rat bronchoalveolar lavage (BAL) lipid extracts from normal controls, steroid controls, trimethaprim-sulfamethoxazole (TMP-SMX) controls, TMP-SMX/P. carinii pneumonia controls, and P. carinii pneumonia animals reveal similar total phospholipid and total protein levels. However, there was a marked reduction in phosphatidylglycerol (PG) from the BAL of P. carinii pneumonia rats as compared with control animals, with a decrease from 4.91 +/- 1.29 nmol/mg protein to 0.46 +/- 0.57 nmol/mg protein (p<0.05) and a decrease, as a percent of total phospholipids, from 7.7% +/- 0.88% to 0.91% +/- 0.59% (p<0.001). Furthermore, in vitro surface activities of BAL lipid extracts from control and P. carinii pneumonia rats revealed minimum surface tension increases from 9.38 +/- 1.71 mN/m in controls to 16.36 +/- 0.83 mN/m in P. carinii pneumonia rats (p<0.05) and likewise maximum surface tension increases from 22.14 +/- 4.34 mN/m to 38.57 +/- 2.07 mN/m (p<0.01). Of interest, the surface activity of PG-deficient P. carinii pneumonia BAL lipid extracts is completely restored to that of normal controls by the addition of exogenous PG. These findings suggest that a functionally abnormal surfactant occurs in P. carinii pneumonia and that this may account, in part, for the impairment of gas exchange observed in this disorder.

Acute pancreatitis in pregnancy

BACKGROUND

Discuss the course of acute pancreatitis in pregnant patients and demonstrate that most attacks of pancreatitis in pregnancy are mild.

METHODS

This article is a retrospective case series study. Eight patients with acute pancreatitis during pregnancy were seen in referral-based obstetric practice at our department in the last 5 years. Five of them had either gallstones or hyperlipidemia. Two patients had both gallstones and hyperlipidemia. One patient was lost to follow-up at 33 weeks gestation. The others were followed at least one month post-partum. Conservative treatment was instituted for pancreatitis and a fat-restricted diet was instituted for hyperlipidemia.

RESULTS

There was no maternal mortality and only one fetal death. Acute pancreatitis occurred in both primipara and multipara patients. Preterm labor or preeclampsia may occur in pregnancy complicated by acute pancreatitis. Most patients experience relief from the pancreatitis soon after delivery. Two patients underwent cesarean section, one was due to fetal distress and the other was elective.

CONCLUSIONS

Early diagnosis and treatment is of utmost importance. Gallstones and/or hyperlipidemia seems to have a specific link with acute pancreatitis in pregnancy. Although acute pancreatitis is a rare complication of pregnancy, we present evidence that both maternal and fetal mortality can be minimized if appropriately treated.

Mini-catheter used for bladder drainage following stress-incontinence surgery and the factors relating to drainage failure

OBJECTIVES

To determine the most effective length for the mini-catheter and to discuss factors relating to drainage failure.

METHODS

Prospective study of a No. 8 silastic feeding tube for bladder drainage omits the necessity of additional catheterization for measuring residual urine. This two-part study in which 146 patients took part, first, determined the suitable length for insertions for the perforated portion and the imperforated portion; then, gauged the effectiveness of the mini-catheter with desired proportions.

RESULTS

Drainage is better when the imperforated portion is at least 5 cm in length (p = 0.0129). The length of the perforated portion, on the other hand, has less impact of the resultant drainage provided that its length does not exceed 5 cm. Beyond this length, an obstruction often occurs. There were 2 obstructions (1.3%) induced by blood clot as well as 9 patients (5.8%) who suffered from one, or more, complications attributed to the mini-catheter for reasons other than the length of insertion.

CONCLUSIONS

When care is taken in creating a mini-catheter of the proper proportions, it offers many advantages and very few complications to gynecologists and patients alike.

Laparoscopic para-aortic lymph node sampling in the staging of invasive cervical carcinoma: including a comparative study of 21 laparotomy cases

OBJECTIVES

To assess the efficacy and risks of laparoscopic para-aortic lymph node sampling compared with standard laparotomy in staging cervical carcinoma.

METHODS

From August 1993 through July 1994, 38 patients with biopsy-proven invasive cervical carcinoma (24 early and 14 advanced invasive cancers) were entered into the study. This was a prospective study of laparoscopic para-aortic lymphadenectomy in invasive cervical carcinoma, with patients serving as their own controls. Video laparoscopic lymph node sampling was performed. In patients with early invasive cancer, the nodes were sent for frozen section and, if negative, laparotomy was performed to look for any residual nodes. Radical hysterectomy was performed immediately if residual nodes were negative. Patients with either nodal metastasis on frozen section or with advanced cancer underwent para-aortic lymphadenectomy only. The operative technique was also evaluated.

RESULTS

Laparoscopy required an average of 77 min (S.D. 40), with an average blood loss of 116 ml (S.D. 321). The average number of nodes was 15 (S.D. 7). At subsequent laparotomy the average number of residual nodes found was 0.4 (S.D. 0.9) and none showed metastasis. One vena cava laceration and one ureteral injury required immediate repair, and two patients were too obese to undergo laparoscopy.

CONCLUSIONS

Laparoscopic para-aortic lymph node sampling is a less invasive, reliable method for staging invasive cervical carcinoma and can substitute for traditional open procedures. The incidence of risks with this method appears to be low.

Pathogenesis and host response in Pneumocystis carinii pneumonia

Pneumocystis carinii (PC) pneumonia is recognized as the leading cause of opportunistic pulmonary infections in immunocompromised hosts during the past decade. Although much remains unknown about pathogenesis and host response in PC, recent years, studies of PC have provided us with an increasing base of knowledge about this organism and its relationship to the host. These studies have led to a better understanding of mechanisms of PC attachment and injury to host cells. New information about the interaction of PC with pulmonary surfactant provides insight about the pathophysiology of PC pneumonia. The interplay of the organism, host inflammatory cells, release of cytokines, generation of toxic metabolites, and involvement of both cellular and humoral immunity is complex, but understanding the pathogenesis of PC pneumonia is necessary in order to develop new therapies for this disorder.