Viper bite during pregnancy: case report

Viper bites in pregnant women have rarely been reported thus far. Moreover, there is no consensus regarding the treatment of such cases. In this paper, the authors report the successful treatment of viper bite during pregnancy without using antivenom.

Leiomyosarcoma of the broad ligament: a case report with CT and MRI images

Primary leiomyosarcoma of the broad ligament is a very rare and highly malignant gynecological tumor. The authors report a 61-year-old postmenopausal woman with signs and symptoms of malignant ovarian tumor. Preoperative magnetic resonance imaging (MRI) was interpreted as being suspicious for malignant tumors, such as an ovarian cancer or a leiomyosarcoma of the broad ligament, so laparotomy was performed. Macroscopically, the tumor was revealed with a 18 x 13.7 x 9.5 cm degenerated, multiple cystic part and solid whitish part arising from broad ligament which on histopathology proved to be leiomyosarcoma. To the best of the authors' knowledge, primary leiomyosarcoma of the broad ligament has been documented in 21 reports or so, and no imaging findings are available. Here the authors present the MRI findings of primary leiomyosarcoma of the broad ligament.

Whipple disease diagnosed with PCR using formalin-fixed paraffin-embedded specimens of the intestinal mucosa

We herein present the case of a 54-year-old Japanese woman with Whipple disease diagnosed with polymerase chain reaction (PCR) using formalin-fixed paraffin-embedded (FFPE) specimens. The patient complained of weight loss, diarrhea and arthralgia. An endoscopic examination revealed swollen villi in the duodenum and ileum. Pathology demonstrated the presence of numerous macrophages filled with diastase-resistant PAS-positive particles. PCR using FFPE specimens amplified a fragment of 16S rDNA from Tropheryma whipplei. After the administration of ceftriaxone followed by trimethoprim/sulfamethoxazole, no signs of recurrence were observed for two years. The use of FFPE specimens for PCR should be considered for the prompt diagnosis and prevention of disease progression.

Cortactin, an actin binding protein, regulates GLUT4 translocation via actin filament remodeling

Insulin regulates glucose uptake into fat and skeletal muscle cells by modulating the translocation of GLUT4 between the cell surface and interior. We investigated a role for cortactin, a cortical actin binding protein, in the actin filament organization and translocation of GLUT4 in Chinese hamster ovary (CHO-GLUT4myc) and L6-GLUT4myc myotube cells. Overexpression of wild-type cortactin enhanced insulin-stimulated GLUT4myc translocation but did not alter actin fiber formation. Conversely, cortactin mutants lacking the Src homology 3 (SH3) domain inhibited insulin-stimulated formation of actin stress fibers and GLUT4 translocation similar to the actin depolymerizing agent cytochalasin D. Wortmannin, genistein, and a PP1 analog completely blocked insulin-induced Akt phosphorylation, formation of actin stress fibers, and GLUT4 translocation indicating the involvement of both PI3-K/Akt and the Src family of kinases. The effect of these inhibitors was even more pronounced in the presence of overexpressed cortactin suggesting that the same pathways are involved. Knockdown of cortactin by siRNA did not inhibit insulin-induced Akt phosphorylation but completely inhibited actin stress fiber formation and glucose uptake. These results suggest that the actin binding protein cortactin is required for actin stress fiber formation in muscle cells and that this process is absolutely required for translocation of GLUT4-containing vesicles to the plasma membrane.

VIP and calcitonin-producing pancreatic neuroendocrine tumor with watery diarrhea: clinicopathological features and the effect of somatostatin analogue

CONTEXT

Pancreatic neuroendocrine tumor (pNET) secretes various peptide hormones; however, calcitonin hypersecretion is rare. Its clinicopathological significance and treatment is still controversial.

CASE REPORT

A 43 year-old Japanese man presented severe watery diarrhea and a large mass in the pancreatic tail. Blood concentration of VIP was elevated to 649 pg/mL (reference range: 0-100 pg/mL), and calcitonin to 66,700 pg/mL (reference range: 15-86 pg/mL). There was no tumor in other endocrine organs. The resected tumor was composed of 80% calcitonin-positive cells and 10% VIP-positive cells. After the operation, the levels of VIP and calcitonin were decreased to 44 and 553 pg/mL, respectively, and diarrhea was improved. The mRNA of somatostatin receptor (SSTR) subtypes 2, 3 and 5 in the tumor tissue were increased 22.8, 25.1, and 37.0-fold of those of normal pancreas, respectively. At 19 months after the operation, blood calcitonin was again raised to 3,980 pg/mL, and metastatic tumors were found in the liver. With the treatment of long-acting somatostatin analogue, calcitonin was reduced to 803 pg/mL. The patient does not present endocrine symptom, and the size of the metastatic tumors appears stable.

CONCLUSION

From the world literature to date, co-secretion of VIP and calcitonin was documented in only 10 cases of pNET including the current case. Although VIP is a primary cause of diarrhea in these cases, high level of calcitonin may also influence on the clinical symptoms. Somatostatin analogue suppresses the levels of VIP and calcitonin, and the control proliferation is also expected when tumor cells express SSTRs.

Weekly paclitaxel/5-fluorouracil followed by platinum retreatment for patients with recurrent ovarian cancer: a single institution experience

PURPOSE

Since the prognosis of recurrent ovarian cancer patients is still poor, we need to establish a useful treatment strategy to achieve their long-term survival. We treated recurrent ovarian cancer patients with weekly paclitaxel (PTX)/5-fluorouracil (5-FU) followed by platinum retreatment to investigate its clinical efficacy in a preliminary manner.

METHODS

Sixteen patients with recurrent ovarian cancer, pretreated with taxane and platinum, were treated with weekly paclitaxel (PTX)/5-fluorouracil (FU). PTX (80 mg/m2) on day 1, 8, and 15 was combined with a bolus injection of 5-FU (500 mg/m2) on day 2, 9, and 16. Chemotherapy was given every four weeks. Patients with stable disease or progressive disease were subsequently retreated with a platinum-containing regimen. Response was evaluated by RECIST criteria or CA125 criteria. Toxicities were evaluated according to the National Cancer Institute-common toxicity criteria (NCI-CTC) version 3.

RESULTS

Among five patients with sensitive disease, one of four patients with measurable tumor and one without measurable tumor responded to weekly PTX/5-FU. Among 11 patients with resistant disease, none of five patients with measurable tumor and three of six patients without measurable tumor responded to weekly PTX/5-FU. Overall objective response rate by weekly PTX/5-FU was 31.3% (5/16). Among 16 patients, 13 patients who showed no response or progressive disease (three with sensitive disease, ten with resistant disease) received platinum retreatment after weekly PTX/5FU. All three patients with sensitive disease and three of ten patients with resistant disease revealed response to platinum retreatment. Overall objective response rate by platinum retreatment after weekly PTX/5-FU was 46.2% (6/13).

CONCLUSIONS

Weekly PTX/5FU followed by platinum retreatment could be a useful treatment strategy for recurrent ovarian cancer patients. We need to establish the standard treatment strategy for recurrent ovarian cancer patients with a poor prognosis.

A phase I study of modified irinotecan (CPT-11) plus cisplatin (CDDP) [m-IP] against paclitaxel/carboplatin [TC] -resistant and recurrent ovarian cancer

13015

Background: CPT-11/CDDP is effective regimen for ovarian cancer. Particularly against ovarian cancer resistant to prior chemotherapy, a 40% response rate was reported (Sugiyama T Cancer Letters, 1998). However, every 4 weeks treatment with CPT-11 day 1, 8, and 15, administration on day 15 was skipped in about 60% due to toxicity, and the relative dose intensity of IP was 66.7% in non-small cell lung cancer (Saito H Am J Clin Oncol 2006). We planed Phase I study, in consideration of the effect of prior chemotherapy in TC-resistant ovarian cancer, a modified CPT-11 (day 1, 8) and CDDP (day 1) for every 4 weeks treatment (m-IP). The aim of this study conducted to examine the dose limiting toxicity (DLT), to evaluate the maximum tolerated dose (MTD), and define the recommended dose (RD) for a phase II study. Methods: Patients with TC-resistant ovarian cancer having a PS 0–1, age 30–75 years, normal organ functions, and written informed consent. CPT-11 was administered intravenously over 90 minutes on day 1 and day 8, plus CDDP was day 1, repeated every 4 weeks. The dose escalation schedule was defined: Doses of CPT-11/CDDP (mg/m2) were 60/60 at level 1, 70/60 at level 2 and 70/70 at level 3. DLT were determined as Grade 4 hematological toxicity and = Grade 3 non-hematological toxicity occurred, and when dosing on day 8 was delayed for more than 8 days due to toxicity. Results: Nine patients were enrolled (level 1/2/3: 3/3/3). DLTs, at level 1 and 2, no patients developed. At level 3, grade 3 nausea and vomiting and delayed treatment on day 8 due to anorexia, were observed in all of 3 patients. Therefore, MTD was determined to be level 3 and RD was determined to be level 2 (CPT-11: 70mg/m2, CDDP: 60mg/m2). Major =Grade 3 toxicities observed were leukopenia, neutropenia, nausea, and vomiting. No Grade 4 hematological toxicities were observed. Diarrhea was mild. Antitumor effect at RD was observed in 1 patient with CR, 1 patient with PR and 1 patient with PD. Conclusions: The MTD of m-IP was CPT-11 70mg/m2 and CDDP 70mg/m2 (level 3), the RD was CPT-11 70mg/m2 and CDDP 60mg/m2 (level 2). Preliminary response are promissing associated with tolerable toxicity for TC-resistant and recurrent ovarian cancer. A Phase II study is currently conducted.

No significant financial relationships to disclose.

A validation study of a scoring system to estimate the risk of lymph node metastasis for patients with endometrial carcinoma for tailoring the indication of lymphadenectomy

5040

Background: The present standard treatment for cases with endometrial cancer is surgical staging including lymphadenectomy. Elimination of lymphadenectomy will not be approved of unless strict condition are met. Our aim is to verify whether a preoperative scoring system to estimate the risk of lymph node metastasis (LNM) in endometrial carcinoma is clinically useful for tailoring the indication of lymphadenectomy. Methods: This study was carried out on 211 patients with endometrial carcinoma for whom volume index, serum CA125 level, tumor grade/histology were preoperatively confirmed. LNM score was set up using these three risk factors as reported in our previous study (Am J Obstet Gynecol 2003). We analyzed whether these factors remain still valid in a different cohort of patients. Based on the LNM score before a validation study was started, the estimated rate of lymph node metastasis (para-aortic lymph node metastasis) in a low risk group was 3.4% (0.0%), an intermediate group 7.7% (5.8%), a high risk group 44.4% (30.6%) and an extremely high risk group 70.0% (50.0%). Results: Volume index, serum CA125 level, and tumor grade/histology, were found to be independent risk factors for LNM in the cohort of this validation study. The actual rate of lymph node metastasis (para-aortic lymph node metastasis) in a low risk group was 3.2% (1.0%), an intermediate group 15.3% (11.9%), a high risk group 30.2% (23.8%) and an extremely high risk group 78.6% (57.1%). Conclusions: LNM frequencies increased in proportion to the impact of the LNM score and the actual rate of lymph node metastasis for each score was quite consistent with the estimated rate of lymph node metastasis.Our LNM score for patients with endometrial carcinoma is useful.

No significant financial relationships to disclose.

Urodynamic study on postsurgical bladder function in cervical cancer treated with systematic nerve-sparing radical hysterectomy

The objective of this study was to assess the postsurgical bladder function by urodynamic study in patients with cervical cancer treated with nerve-sparing radical hysterectomy. A total of 27 consecutive patients were included in the study. Of the 27 patients, autonomic nerves had been completely preserved at least on one side in 22 patients (group A), and autonomic nerves could not be successfully preserved in five patients (group B). In group A, there was no significant difference in compliance at the moment of strong desire to void, maximum flow rate, and residual urine volume between before the operation and at 12 months after the operation. However, abdominal pressure at maximum flow had significantly increased in patients of group B than of group A. Detrusor contraction pressure at maximum flow had significantly decreased in patients of group B than of group A. Bladder sensation was diminished in three cases (60%) of group B but preserved in all the patients of group A. Although it is still preliminary, our surgical technique described in this report is thought to be effective for preservation of bladder function. For further evaluation of the efficacy of nerve-sparing radical hysterectomy in terms of quality of life and survival of patients, a prospective randomized trial needs to be performed.

Intracytoplasmic immunoglobulin crystals in follicular lymphoma

We report a case of follicular lymphoma with crystal inclusions. Swollen lymph nodes taken from the left neck of a 53- year-old Japanese woman were replaced by follicular proliferation of atypical centroblastic and centrocytic cells with intracytoplasmic crystal inclusions. The crystals were confined to lymphoma cells and were not found in histiocytes. Lymphoma cells were positively immunostained with lambda light chain and mu heavy chain, but the crystals were only weakly so. In situ hybridization of light chains disclosed a monoclonal expression of lambda light chain mRNA in lymphoma cells. The crystals had a periodic linear substructure with about 5-nm intervals. The worldwide literature reports 8 cases, including the current case of non-Hodgkin's lymphoma with crystals confined to the neoplastic cells. The cases did not accompany paraproteinemia and crystal-storing histiocytosis and appear to follow a favorable clinical outcome.

Increased apoptosis of human fetal membranes in rupture of the membranes and chorioamnionitis

Apoptosis is thought to participate pathophysiologically in the rupture of human fetal membranes (ROM). The aim of this study was to assess apoptosis of the amnion and the chorion in relation to ROM and chorioamnionitis (CAM). The amnion and chorion at the position of the cervical os and fundus of the uterus were obtained from 44 patients. Apoptotic DNA fragmentation was densitometrically determined, and the relative ratio was used for the quantitative evaluation. Among patients without CAM, the relative ratios of apoptosis in the amnion from patients with ROM were higher than those in patients without ROM (P< 0.05). Among patients without ROM, the apoptotic levels in the amnion from patients with CAM were higher than those in patients without CAM (P< 0.05). These were the cases with the amnion at the position of cervical os and fundus, but not with the chorion. The highest ratio of apoptosis was seen in the amnion from patients with CAM and ROM. Among patients with ROM and no CAM, the apoptotic levels at the cervical os in the amnion (P=0.059) and chorion (P< 0.05) was higher than those at the fundus. The increased apoptosis of human fetal membranes was related to ROM and CAM. Apoptosis plays a role in the pathophysiology of ROM.

NK cell activity and subsets in women with a history of spontaneous abortion. Cause, number of abortions, and subsequent pregnancy outcome

OBJECTIVE

The aim of this study was to assess the role of NK cells in nonpregnant women with a history of spontaneous abortion.

STUDY DESIGN

113 nonpregnant women with a history of spontaneous abortion were assessed for peripheral NK cell activity and percentage of NK cell subsets, in relation to the cause of abortions, the number of spontaneous abortions, and subsequent pregnancy outcome (n = 56).

RESULTS

Neither NK cell activity nor subsets showed a significant difference in relation to the cause or number of spontaneous abortions. NK cell activity in nonpregnant women who later experienced subsequent abortion with normal chromosomes (n = 10) (mean +/- SD: 42.8 +/- 15.8%) was relatively higher than that in women with subsequent live birth (control, n = 39) (32.1 +/- 13.7%) (p = 0.099). NK cell activity in women who later experienced subsequent abortion with abnormal chromosomes (n = 7) (28.7 +/- 21.4%) was the same as the level in the control.

CONCLUSION

Peripheral NK cell activity or subsets during nonpregnant status were not related to the cause or number of previous spontaneous abortions. A relation between preconceptional NK cell activity and later experiencing abortion with normal chromosomes should be further studied.

Effects of losartan in combination with or without exercise on insulin resistance in Otsuka Long-Evans Tokushima Fatty rats

Hypertension often complicates type 2 diabetes mellitus, and angiotensin converting enzyme inhibitor treatment has been shown to improve insulin resistance in such cases. However, the effect of angiotensin II type-1 (AT(1)) receptor antagonists on insulin resistance is still controversial. To gain further information on this effect, we examined the effect of losartan on insulin resistance in Otsuka Long-Evans Tokushima Fatty (OLETF) rats, a model of type 2 diabetes mellitus. Losartan administration alone lowered systolic blood pressure, but did not improve oral glucose tolerance test or insulin resistance in OLETF rats. However, the administration of losartan with exercise significantly improved both systolic blood pressure and insulin resistance relative to control OLETF rats. On the other hand, losartan treatment, regardless of exercise, increased glucose uptake in excised soleus muscle and fat cells. To explore the beneficial effect of losartan on skeletal muscle glucose uptake, we examined intracellular signaling of soleus muscle. Although Akt activity and glucose transporter type 4 (GLUT4) expressions were not affected by losartan with or without exercise, extracellular signal-regulated kinase (ERK1/2) and p38 mitogen-activated protein (MAP) kinase activities were increased by both interventions. These results indicate that angiotensin AT(1) receptor antagonist improved local insulin resistance, but not systemic insulin resistance. These findings may explain the controversy over the effect of angiotensin AT(1) receptor antagonists on insulin resistance in clinical use. The enhancing effect of angiotensin AT(1) receptor antagonist on skeletal muscle glucose uptake may be attributable to MAP kinase activation or other mechanisms rather than phosphatidylinositol 3-kinase activation.

Endothelial nitric oxide synthase gene (NOS3) variant and hypertension in pregnancy

Hypertension in pregnancy (HP), including preeclampsia, is known to be a multifactorial disease. Recently, a Glu298Asp variant of the endothelial nitric oxide synthase gene (NOS3) was identified as being associated with coronary spasm and myocardial infarction, whereas it has been reported that endothelial nitric oxide synthase plays a role in HP. We therefore performed an association study of the Glu298Asp variant with HP among 152 HP patients and 335 normal pregnant control individuals, in the context of other risk factors before pregnancy. The frequency of the variant GA+AA NOS3 genotypes was significantly higher in the patients (0.23) than in the controls (0.12) (P < 0.01). Multivariate analysis revealed that family history of hypertension, TT genotype of the angiotensinogen gene (AGT), GA+AA NOS3 genotype, and prepregnancy body mass index > or = 24 were independent potent risk factors, after adjustment for maternal age and parity. The odds ratios of the factors were 2.7, 2.3, 2.2, and 2.1, respectively. Our results suggested that the Asp298 of NOS3 is a potent, independent risk factor for HP.

Persistent detection of alfa-fetoprotein in the vagina without overt preterm premature rupture of the membranes. Clinical and chemical characterizations

OBJECTIVES

The objectives of this study were to clinically characterize and seek risk factors for the patients with persistently detected alfa-fetoprotein (AFP) in the vagina without showing overt preterm premature rupture of the membranes (PROM).

STUDY DESIGN

The cohort study was undertaken using vaginal-cervical specimens collected consecutively between 21 and 40 weeks of gestation from 25 consenting women. Demographic, obstetric, neonatal, and laboratory data from patients with persistent positive results of AFP kit tests without showing overt leakage of amniotic fluid were compared to those from controls. Cervical levels of interleukin-1 alpha, interleukin-1 beta, interleukin-6, interleukin-8, and granulocyte elastase were measured by immunoassay, and the uterine cervix was assessed by transvaginal ultrasonography. Statistical analysis involved Fisher's exact test and Mann-Whitney U test.

RESULTS

The incidence of overt preterm PROM was significantly higher in the patients with persistently detected AFP in preterm (3 in 4 cases) than in controls (3 in 21 controls). At sampling before determination of persistently detected AFP, patients with persistently detected AFP had significantly higher cervical levels of interleukin-6 and significantly shorter cervical length than controls.

CONCLUSIONS

Patients with persistently detected AFP in the vagina without showing overt preterm PROM have the risk of overt preterm PROM. Increased levels of interleukin-6 in cervical specimens and short cervical length may be risk factors for the occurrence of persistent detection of AFP in the preterm.

[Anesthesia for electroconvulsive therapy during pregnancy--a case report]

We experienced anesthetic management for ECT in a patient with psychiatric disease during the third trimester of pregnancy. The 24 year-old patient had been on oral antipsychotics prescribed to treat schizophrenia for ten years. Her signs and symptoms deteiorated during pregnancy in spite of increased doses of antipsychotics. With tocolytic agent administered intravenously, anesthesia was induced by intravenous thiamylal immediately followed by intravenous suxamethonium for muscle relaxation. Alternative current was applied on both side of the head after the sufficient anesthesia had been obtained. The patient received intermittent mandatory ventilation by breathing mask with 100% oxygen during the procedure. Along with monitoring of maternal hemodynamic variables and arterial oxygen saturation (Spo2), fetal heart rate and uterine contraction were recorded by cardiotocogram throughout the procedure. At the first two treatments, the patient showed neither significant uterine contraction nor fetal heart rate changes. At the third treatment, continuous uterine contraction refractory to tocolysis was recorded for six minutes, resulting in fetal bradycardia. At the sixth treatment, general anesthesia was induced and maintained by sevoflurane in oxygen followed by suxamethonium for muscle relaxation. The uterine contraction was remarkably diminished and fetal heart rate remained unchanged during the procedure. In conclusion, inhalation anesthesia is beneficial for ECT in the last stage of pregnancy to reduce uterine contraction by potential uterine relaxation effect of anesthetics.

High NK cell activity in early pregnancy correlates with subsequent abortion with normal chromosomes in women with recurrent abortion

PROBLEM

The aim of this study was to assess the role of natural killer (NK) cells in pregnant women with a history of recurrent spontaneous abortion (RSA).

METHOD OF STUDY

Consecutive 66 pregnant women with a history of RSA were prospectively assessed for peripheral NK cell activity, percentage of the NK cell subsets, and subsequent pregnancy outcome.

RESULTS

NK cell activity in women with subsequent live birth (group I) at 4-5 gestational weeks (GW) (mean +/- SD, 32.5 +/- 12.31%) significantly decreased at 6-7 GW (28.1 +/- 12.1%) and at 8 9 GW (28.0 +/- 11.8%). NK cell activity in women with subsequent abortion with normal chromosomes (group II) at 6 7 GW (41.2 +/- 19.0%) was significantly higher than that in group I women, while NK cell activity at 6-7 GW in women with subsequent abortion with abnormal chromosomes (group III) was the same as the level in group I women.

CONCLUSIONS

High NK cell activity at 6-7 GW correlates with subsequent abortion with normal chromosomes.

Massive intravenous immunoglobulin treatment in pregnancy complicated by Guillain-Barré Syndrome

A pregnant woman developed acute demyelinating poly-neuropathy (Guillain-Barré syndrome (GBS)) in the 28th week of gestation (GW) after flu-like infection. Hypertension, liver dysfunction, and a decrease in consciousness level developed at 29GW. Blood chemical analysis revealed increased levels of liver enzymes GOT 247 IU/l and GPT 624 IU/l. Viral serological study showed a positive test for Epstein-Barr virus IgM. Weakness of bilateral facial muscles and limbs, a loss of tendon reflexes, and generalized paresthesia were detected by neurologic examinations. Over the course of 5 days, a massive dose (100g) of intravenous immunoglobulin (MIVIg) was infused in 30GW. An average manual muscle testing score by the Medical Research Council method and peak flow value began to be significantly restored during and after MIVIg infusions. Values of the liver enzymes gradually decreased, and improvement of the muscle weakness and dysbasia was observed. Her pregnancy normally ended in spontaneous vaginal delivery of a healthy infant in 37GW. This is the first report confirming the efficacy of MIVIg, without plasmapheresis, in GBS-complicated pregnancy.

Insulin response patterns contribute to different perinatal risks in gestational diabetes

The aim of this study was to evaluate the insulin dynamics of patients with gestational diabetes mellitus (GDM) and to compare perinatal outcomes according to the insulin response patterns. Twenty-two out of 925 consecutive women examined were diagnosed as having GDM. One hundred and ten women who experienced a normal pregnancy were used as controls. Plasma glucose levels and insulin responses were evaluated by a 2-hour 75-gram oral glucose tolerance test (OGTT). Immunoreactive insulin (IRI), the area under the curve (AUC) of glucose (AUCg) and insulin (AUCi), and the insulinogenic index (II = DeltaIRI 30 min/DeltaBS 30 min) were measured. The GDM patients were divided into three subgroups, consisting of hyper-, normo- and hypoinsulinemic groups, according to the mean +/- 2 SD of the AUCi obtained from the controls. Clinical and laboratory findings were compared among the GDM subgroups and controls. The GDM patients showed impaired insulin secretion to glucose stimuli, with low plasma insulin levels (at 30 min) and reduced insulin/glucose ratios (at 30 and 60 min) early in the 75-gram OGTT. The II and AUCi/AUCg values of GDM patients were reduced as compared with those of controls. These reduced insulin responses were remarkable in hypo- and normoinsulinemic GDM patients, but were not detected in hyperinsulinemic GDM patients. The number of babies large for their gestational age in normo- and hypoinsulinemic GDM patients was significantly higher than that in hyperinsulinemic GDM patients or controls. Hyperinsulinemic GDM patients had a high frequency of pregnancy-induced hypertension (40%). The body mass index prior to pregnancy of hyperinsulinemic GDM patients was significantly higher than that of normoinsulinemic GDM patients or controls. It was demonstrated that not only insulin secretion, but also perinatal clinical characteristics, differed among the GDM subgroups. The heterogeneity of the disease was thus confirmed.

Prognostic significance of combined conventional and immunocytochemical cytology for peritoneal washings in endometrial carcinoma

BACKGROUND

Noncancerous cells simulating adenocarcinoma cells may interfere with the analysis of peritoneal cytology (PC) in patients with endometrial carcinoma. Immunocytochemistry (ICC) may improve the diagnosis of PC.

METHODS

PC slides from 115 patients with endometrial carcinoma were reviewed. Suspicious or positive cell clusters were recovered with a cell transfer method and were subjected to ICC for MOC-31, cytokeratin 5/6, and p53. Conventional Papanicolaou staining and ICC results were compared directly on the same cells.

RESULTS

By combined conventional and immunocytochemical PC (CONV-ICC-PC), cytodiagnosis was positive in 18 of 115 patients (15.7%) and suspicious in 3 of 115 patients (2.6%). According to a multivariate Cox regression analysis of patients with tumors confined to the uterus that included grade, myometrial invasion, cervical involvement, and CONV-ICC-PC, only CONV-ICC-PC was an independent prognostic factor (P < 0.05). A multivariate analysis for all of the patients studied that compared CONV-ICC-PC with staging variables revealed that only peritoneal metastasis (P < 0.0001) and lymph node metastasis (P < 0.01) were independent prognostic factors. When peritoneal metastases were excluded, CONV-ICC-PC (P < 0.01) and lymph node metastasis (P < 0.0025) were the independent prognostic factors. By cell transfer and p53 immunostaining in samples from 14 patients with malignant cells in their peritoneal washings, no deaths occurred among 5 patients with negative p53, whereas 5 of 9 patients with positive p53 died of disease at the time of data analysis.

CONCLUSIONS

MOC-31 immunostaining improves the diagnosis of PC in endometrial carcinoma. Positive PC is an important prognostic factor for patients with endometrial carcinoma confined to the uterus. The p53 positive cells in PC have possible prognostic significance.

Antisense GLUT-1 protects mesangial cells from glucose induction of GLUT-1 and fibronectin expression

A stable clone of rat mesangial cells expressing antisense GLUT-1 (i.e., MCGT1AS cells) was developed to protect them from high glucose exposure. GLUT-1 protein was reduced 50%, and the 2-deoxy-[(3)H]glucose uptake rate was reduced 33% in MCGT1AS. MCLacZ control cells and MCGT1 GLUT-1-overexpressing cells were used for comparisons. In MCLacZ, 20 mM D-glucose increased GLUT-1 transcription 90% vs. no increase in MCGT1AS. Glucose (8 mM) and 12 mM xylitol [a hexose monophosphate (HMP) shunt substrate] did not stimulate GLUT-1 transcription. An 87% replacement of the standard 8 mM D-glucose with 3-O-methylglucose reduced GLUT-1 transcription 80%. D-Glucose (20 mM) increased fibronectin mRNA and protein by 47 and 100%, respectively, in MCLacZ vs. no increases in MCGT1AS. Fibronectin synthesis was elevated 48% in MCGT1 and reduced 44% in MCGT1AS. We conclude that 1) transcription of GLUT-1 in response to D-glucose depends on glucose metabolism, although not through the HMP shunt, and 2) antisense GLUT-1 treatment of mesangial cells blocks D-glucose-induced GLUT-1 and fibronectin expression, thereby demonstrating a protective effect that could be beneficial in the setting of diabetes.

Identification of a cis-acting element and a novel trans-acting factor of the human insulin receptor gene in HepG2 and rat liver cells

The liver is a major target organ of insulin and is important for glucose homeostasis. We analyzed the tissue specific regulation of the insulin receptor gene in the liver by studying the cis-acting element and trans-acting factor of the human insulin receptor gene in human hepatoma cell line, HepG2 cells. In the chloramphenicol acetyl transferase (CAT) assay with chimeric plasmids containing various deletions and insertions of the human insulin receptor promoter/CAT gene, a HepG2 cell specific cis-acting element was identified between nt -592 to -577 of the promoter. In electrophoretic mobility shift assay and UV cross-link analysis, a 35-kDa nuclear protein that bound to 5'-TCCCTCCC-3' (nt -588 to -581) sequence was identified in HepG2 cells as well as in rat hepatocytes. This nuclear protein, designated as hepatocyte-specific transcription factor of the insulin receptor gene (HTFIR), might play an important role in tissue-specific expression of the insulin receptor gene in the liver.

Recurrent Pregnancy Loss: Etiology of Thrombophilia

Congenital and acquired thrombophilia are associated with an increased risk of pregnancy-associated venous thrombosis and fetal loss. Two hundred eighty-nine patients with a history of recurrent spontaneous abortion were subjected to screening examinations for the etiology of these abortions. Endocrine abnormality (28.0%), uterine abnormality (10.4%), autoimmune diseases (1.4%), antiphospholipid antibody syndrome (4.5%), and balanced type chromosome translocation (4.2%) were found as underlying causes of recurrent abortions, and the remaining 55.0% of the 289 patients were classified as having an unexplained etiology. Congenital thrombophilia such as protein C (PC) deficiency, protein S (PS) deficiency, antithrombin deficiency, and factor V Leiden mutation was not frequently detected; only one patient had PS deficiency. A reduced factor XII activity was found at a frequency of 4.2%. The frequency of methylene tetrahydrofolate reductase gene C677T mutation in recurrent aborters (0.38) was the same as that found in a fertile control group. Although the prevalence of anti-beta2-glycoprotein I antibody (abeta2-GPI) syndrome was very low (1.7%), patients with a high titer of immunoglobulin G (IgG) class abeta2-GPI, despite anticoagulation therapy, experienced severe fetomaternal complications in subsequent pregnancies. The rate (13.8%) of positive tests for serum IgA class abeta2-GPI in patients with unexplained etiology was higher than that in the controls (0%) (P < .05). We conclude that congenital thrombophilia is rare in Japanese patients who had experienced consecutive spontaneous abortions.

Prenatal diagnosis of agnathia-holoprosencephaly: three-dimensional imaging by helical computed tomography

We report a case of agnathia-holoprosencephaly which was prenatally diagnosed based on helical computed tomography (CT) images obtained at 23 weeks of gestation. Ultrasound examination first showed the presence of alobar holoprosencephaly, but the facial structures were not clearly detailed. However, three-dimensional imaging by helical CT precisely demonstrated the most striking feature of agnathia: absence of the mandible. This technique provided us valuable information that contributed to the in utero diagnosis. In utero helical CT is a useful examination tool for the diagnosis of osteogenic abnormalities.

Postpartum thyroid dysfunction in women with normal thyroid function during pregnancy

OBJECTIVE

The aim of this study was to establish the risk of postpartum thyroid dysfunction (PPTD) in women who had normal thyroid function during pregnancy and no history of thyroid disease.

DESIGN

Four thousand and twenty-two consecutive pregnant women were screened for thyroid function and antithyroid antibody. Among women with normal thyroid function during pregnancy and no history of thyroid disease, thyroid function were assessed in 131 of 388 antithyroid antibody positive (Group I) and 1030 of 3503 antibody negative (Group II) women at 1 and 3 months postpartum. In Group I women who experienced PPTD, the frequency of later manifestation of Hashimoto's disease was compared according to titres of antithyroid antibodies.

MEASUREMENTS

Blood samples in early pregnancy, and at 1 month and 3 months postpartum were obtained using the dried blood spot method. Levels of fT4 were measured by RIA, TSH by fluoroimmunoassay or ELISA, antimicrosome antibody (AMC) and antithyroglobulin antibody (ATG) by indirect agglutination reactions.

RESULTS

The prevalence of PPTD at 1 month and 3 months postpartum were found to be 6.9% and 21.3% in Group I, and 5.3% and 4.7% in Group II, respectively. The prevalence of PPTD was significantly higher at 3 months postpartum in Group I (P<0.05). 27.3% of women with PPTD in Group I were later found to have Hashimoto's disease and 9.1% manifested hypothyroidism without goitre. A high AMC titre (> or = 25600) at 3 months postpartum in women with PPTD was related to the manifestation of Hashimoto's disease. AMC titres of PPTD women and women who developed Hashimoto's disease were significantly higher than those of control women who did not experience PPTD.

CONCLUSION

A high prevalence of PPTD was found in women with antithyroid antibodies who were euthyroid during pregnancy. Prolonged follow-up of the subsequent thyroid function may be needed in women who experience PPTD and/or show a high titre of antithyroid antibody.

AMP-Activated protein kinase is activated by the stimulations of G(q)-coupled receptors

The AMP-activated protein kinase (AMPK) functions as a metabolic sensor that monitors cellular AMP and ATP levels. Platelet-activating factor (PAF) activates endogeneous AMPKalpha1 in Chinese hamster ovary cells expressing the PAF receptor coupled with both G(i) and G(q), but its activity was not inhibited after treatment with islet-activating protein. Norepinephrine and bradykinin also activated AMPKalpha1 in cells expressing the G(q)-coupled alpha(1b)-adrenergic receptor and bradykinin receptor, respectively. Stimulations of the G(i)-coupled alpha(2A)-adrenergic receptor, fMet-Leu-Phe receptor, prostaglandin EP3alpha receptor, and G(s)-coupled beta(2)-adrenergic receptor did not activate AMPKalpha1. AMPKalpha1 thus is activated specifically by stimulation of G(q)-coupled receptors. G(q)-coupled receptors transmit the signal for GLUT4 translocation and glucose uptake through an insulin-independent pathway. However, direct activation of AMPKalpha1 with treatment of 5-aminoimidazole-4-carboxamide-1-beta-d-ribofuranoside did not trigger GLUT4 translocation nor stimulate glucose uptake in our cells. Thus, activation of AMPKalpha1 via G(q) is not sufficient to trigger GLUT4 translocation or stimulate glucose uptake.

Prevention of lymphocyst formation following systematic lymphadenectomy

BACKGROUND

The occurrence of pelvic lymphocysts is an important complication following systematic lymphadenectomy for gynecological malignancies. We employed a procedure to prevent vaginal shortening following radical hysterectomy and we examined whether this procedure could be effective in preventing pelvic lymphocyst formation.

METHODS

We studied the incidence of lymphocysts in 190 patients with 84 cervical cancers, 74 endometrial cancers and 32 ovarian cancers, using computed tomographic examination at 3 and 6 months subsequent to the surgery. The surgery included radical hysterectomy and a procedure to prevent vaginal shortening (101), modified radical hysterectomy (79) and simple hysterectomy (7), with systematic lymphadenectomy.

RESULTS

There was a significant difference in the incidence of pelvic lymphocysts between cervical cancer (4.8%) and ovarian cancer (18.8%). The postoperative incidence of lymphocyst formation in patients undergoing radical hysterectomy with the procedure to prevent vaginal shortening (5.9%) was significantly lower than in those who underwent modified radical hysterectomy (15.2%).

CONCLUSION

Our procedure to prevent vaginal shortening could be effective in preventing not only the shortening of the vagina but also the occurrence of pelvic lymphocysts in patients undergoing radical hysterectomy with systematic lymphadenectomy for gynecological malignancies.

Factor XII deficiency in women with recurrent miscarriage

Congenital thrombophilia is known to cause significant maternal complications, and possibly has an adverse effect on normal fetal development. The aim of this study was to assess the prevalence of factor XII (FXII) deficiency in women with a history of recurrent miscarriage. Two hundred and forty-one consecutive Japanese women with a history of two or more recurrent miscarriages were prospectively assessed for their etiology by conventional screening methods. Seven women were found to have reduced FXII activity (19. 2-46.1%) and prolonged activated partial thromboplastin time (33. 3-51.3 s). Of these 7 women, 6 had experienced early pregnancy losses, while 1 woman had experienced repeated mid-trimester fetal losses with coincidental gestational thrombocytopenia. In 241 women with a history of recurrent miscarriage, the prevalence of FXII deficiency was 2.9%.

Prevention of vaginal shortening following radical hysterectomy

We describe a surgical procedure and post-operative management for the prevention of vaginal shortening following radical hysterectomy. A total of 452 patients who underwent hysterectomies were examined prospectively depending on the operation method. This study showed that our procedure was effective in the prevention of vaginal shortening following radical hysterectomy. Preservation of the ovaries appeared to be important in preventing vaginal shortening, and post-operative hormone replacement therapy was not as effective as the preservation of the ovaries. The effect of external irradiation on vaginal shortening was not conspicuous in the case that the ovaries were preserved.

Novel mutation (E113X) of antithrombin III gene (AT3) in a woman with gestational recurrent thrombosis

A 35-year-old Japanese woman with a low level (42-54%) of blood antithrombin (AT) III, experienced two induced abortions due to deep venous thrombosis at 8 weeks of gestation (GW) and cerebral thrombosis at 10 GW. The present pregnancy was successfully managed with intravenous administration of AT III (6,000-8,000 U/wk). Analysis of polymerase chain reaction (PCR)-single strand conformation polymorphism (SSCP) for exons 3A and 4 of the AT III gene (AT3) using her DNA revealed extra expansion bands with altered migration. The DNA sequencing demonstrated novel mutations in exon 3A of AT3: a G to T substitution at nucleotide position 5333 in codon GAG for Glu 113, causing a stop codon (E113X), and an A to T substitution at position 5338 in codon AAA for Lys 114, forming Asn (K114N). These novel mutations, especially E113X, in AT3 may be related to recurrent thrombosis in the pregnancy.

Gi-mediated translocation of GLUT4 is independent of p85/p110alpha and p110gamma phosphoinositide 3-kinases but might involve the activation of Akt kinase

Activation of phosphoinositide 3-kinase (PI-3K) is essential for insulin-stimulated translocation of GLUT4 and glucose transport in insulin target tissues. A novel p110gamma PI-3K was reported to be activated by G(i)-coupled receptors via Gbetagamma subunits. We asked whether the stimulation of G(i)-coupled receptors would trigger GLUT4 translocation and glucose uptake by the activation of Gbetagamma-dependent p110gamma PI-3K. We find that this translocation and glucose uptake can be induced by the ligand stimulation of G(i)-coupled alpha(2A) adrenergic receptor and fMet-Leu-Phe receptor in cells stably expressing these receptors. The noradrenaline ('noradrenaline')- and fMet-Leu-Phe-stimulated GLUT4 translocations were abolished by pretreatment with pertussis toxin. Pretreatment with wortmannin or genistein also inhibited the G(i)-mediated GLUT4 translocation. On ligand stimulation of these two kinds of G(i)-coupled receptor, although there was a slight increase in PtdIns(3,4,5)P(3) production, activation of either the p85/p110alpha PI-3K or Gbetagamma-dependent p110gamma PI-3K was not observed even in Chinese hamster ovary cells stably overexpressing exogenous p101/p110gamma. The G(i)-mediated GLUT4 translocation was accompanied by activation of the serine-threonine kinase Akt; the inhibitory effects of pertussis toxin, wortmannin and genistein on G(i)-mediated GLUT4 translocation paralleled their inhibitory effects on Akt activation. In contrast, the activation of some other G(i)-coupled receptors, such as prostaglandin EP3alpha receptor and platelet-activating factor receptor, did not cause either pertussis-toxin-sensitive translocation of GLUT4myc or activation of Akt kinase. These results indicate that the ligand stimulation of some G(i)-coupled receptors triggers GLUT4 translocation that occurs independently of p85/p110alpha-type and p110gamma-type PI-3Ks but might involve the activation of Akt kinase.

Overexpression of wild-type Akt1 promoted insulin-stimulated p70S6 kinase (p70S6K) activity and affected GSK3 beta regulation, but did not promote insulin-stimulated GLUT4 translocation or glucose transport in L6 myotubes

We have developed a simple, direct and sensitive method to detect GLUT4 on the cell surface. Using this system, we found that PI3-kinase plays a key role in the signaling pathway of insulin-stimulated GLUT4 translocation. One of the down stream effectors of PI3-kinase is serine-threonine kinase Akt (protein kinase B, RAK-PK), but the involvement of Akt in insulin-stimulated GLUT4 translocation is controversial. To investigate whether Akt1 regulates insulin-stimulated GLUT4 translocation and glucose uptake in L6 myotubes, we established L6 myotubes stably expressing c-myc epitope-tagged GLUT4 (GLUT4myc) and mouse wild type (WT) Akt1. We found that overexpression of WT Akt1 promoted insulin-stimulated p70S6 kinase (p70S6K) activity and increased the basal activity of GSK3 beta, but did not promote insulin-stimulated GLUT4 translocation or glucose uptake. These data supported the result that Akt is not a main signaling molecule to transmit the signal of insulin-stimulated GLUT4 translocation or glucose uptake from insulin-activated PI3-kinase.

Activation of G-protein coupled fMLP or PAF receptor directly triggers glucose transporter type 1 (GLUT1) translocation in Chinese hamster ovary (CHO) cells stably expressing fMLP or PAF receptor

The chemoattractants, fMLP and PAF, stimulate glucose uptake in phagocytes to obtain an energy source for host defense. Glucose uptake in phagocytes is mainly regulated via glucose transporter type 1 (GLUT1). To examine molecular mechanisms of facilitated glucose uptake in response to fMLP or PAF, we established CHO cells stably expressing fMLP or PAF receptor with c-myc epitope tagged GLUT1 which could immunologically detect GLUT1 on the cell surface. In the CHO cells, both fMLP and PAF directly triggered GLUT1 translocation from the intracellular pool to the cell surface, and stimulated glucose uptake. Therefore, in phagocytes, we propose that fMLP and PAF also trigger GLUT1 translocation to stimulate glucose uptake as an energy source for host defense.

Increased in situ expression of nitric oxide synthase in human colorectal cancer

There is growing evidence that nitric oxide (NO) has an important role in tumor growth. However, information on the expression of NO synthase (NOS) in colorectal cancers is scanty. We therefore investigated the distribution and expression of NOS in human colorectal cancers. The expression of three types of NOS, inducible (iNOS), endothelial (eNOS) and neuronal (nNOS), was examined by immunohistochemistry in 25 cases of colorectal cancer. The expression of iNOS was also investigated at the mRNA level using the reverse transcriptase polymerase chain reaction (RT-PCR) in 6 cases. Correlations were made between iNOS expression and the histopathological findings. Immunoreactive iNOS was detected in the tumor cells in 22 cases (88%) with diffuse cytoplasmic reactions. Expression of iNOS-mRNA detected by RT-PCR in three tumor tissues was over five-fold that in normal mucosa. Intensified immunoreactivity of iNOS was associated with vascular invasion. iNOS expression did not correlate with pathological staging, tumor size, lymph node metastasis, p53 expression or tumor vessel density. Immunoreactive eNOS stained more strongly in the endothelial cells of microvessels within and around the tumor than in the areas remote from the tumor. There is enhanced expression of iNOS and eNOS in human colorectal cancers, which may correlate with tumor growth and vascular invasion.

Passive immune thrombocytopenia in neonates of mothers with idiopathic thrombocytopenic purpura: incidence and risk factors

The aim of this study was to evaluate risk factors for occurrence of neonatal passive immune thrombocytopenia (PIT) in pregnancy complicated by idiopathic thrombocytopenic purpura (ITP). We studied 63 pregnant women with ITP and the 66 neonates retrospectively. Neonatal platelet counts were compared with maternal platelet counts, platelet-associated gamma G immunoglobulin (PAIgG) values, and the presence of antiplatelet antibody in the maternal circulation, history of previous PIT, maternal treatments for ITP, and other maternal or neonatal factors. PIT (platelet counts <100 x 10(3)/microL) was observed in 9 (14.3%) of 63 pregnancies. Presence of circulating antiplatelet antibody in maternal blood, splenectomy prior to pregnancy, and history of previous PIT were observed more frequently with statistical significance in patients giving birth to neonates who developed PIT. No effect on occurrence of PIT was found by the administration of corticosteroids or immunoglobulin. Splenectomy prior to pregnancy was found by logistic regression analysis to be a single significant variable (p = 0.021, odds ratio 7.20, confidence intervals: 1.35 to 38.3) among the risk factors for PIT.