Polyamine depletion enhances oil body mobilization through possible regulation of oleosin degradation and aquaporin abundance on its membrane

Oil body (OB) mobilization, a crucial event associated with early seedling growth, is delayed in response to salt stress. Previous reports suggest that careful regulation of polyamine (PA) metabolism is essential for salt stress tolerance in plants. Many aspects of PA-mediated regulation of metabolism have been uncovered. However, their role in the process of OB mobilization remains unexplored. Interestingly, the present investigations reveal a possible influence of PA homeostasis on OB mobilization, while implicating complex regulation of oleosin degradation and aquaporin abundance in OB membranes in the process. Application of PA inhibitors resulted in the accumulation of smaller OBs when compared to control (-NaCl) and the salt-stressed counterparts, suggesting a faster rate of mobilization. PA deficit also resulted in reduced retention of some larger oleosins under controlled conditions but enhanced retention of all oleosins under salt stress. Additionally, with respect to aquaporins, a higher abundance of PIP2 under PA deficit both under control and saline conditions, is correlated with a faster mobilization of OBs. Contrarily, TIP1s, and TIP2s remained almost undetectable in response to PA depletion and were differentially regulated by salt stress. The present work, thus, provides novel insights into PA homeostasis-mediated regulation of OB mobilization, oleosin degradation, and aquaporin abundance on OB membranes.

Polyamine homeostasis modulates plasma membrane- and tonoplast-associated aquaporin expression in etiolated salt-stressed sunflower (Helianthus annuus L.) seedlings

Salt stress adversely affects plants by causing osmotic and ionic imbalance. Cellular osmotic adjustment occurs by modulation of water fluxes. Polyamines (PAs) are often advocated to be involved in osmoregulation during stressful conditions, and thus, they serve as potential "osmolytes." Aquaporins (AQPs), the water-transporting channels, are expected to play crucial roles in osmoregulation. Present investigations on etiolated sunflower seedlings demonstrate a possible correlation between PA homeostasis and maintenance of water balance, as a function of modulation of the abundance of two major AQP subfamilies: PIP2 (plasma membrane intrinsic protein 2) and TIP1 (tonoplast intrinsic protein 1). Salt stress (120 mM NaCl) restricts growth of sunflower seedlings and induces reduction in relative water content (RWC). This accompanies enhanced abundance of PIP2s and TIP1s in seedling roots and that of TIP1s in cotyledons, as revealed by Western blot analysis of AQP isoforms and also their imaging by confocal laser scanning microscopy (CLSM). Raising seedlings in the presence of 500 μM of DFMA (DL-α-difluoromethylarginine) or DFMO (DL-α-difluoromethylornithine), which are potent inhibitors of PA biosynthesis enzymes (arginine decarboxylase (ADC) and ornithine decarboxylase (ODC), respectively), significantly promotes root extension, irrespective of NaCl stress, and results in further lowering of salt-induced reduction in RWC in roots and cotyledons. This correlates with enhanced accumulation of both PIP2s and TIP1s in seedling roots, but not in cotyledons. Present work, therefore, implicates PA homeostasis in the maintenance of water status of sunflower seedlings, possibly via regulation of abundance and distribution of AQP isoforms associated with the plasma membrane and tonoplast.

Nitric oxide modulates polyamine homeostasis in sunflower seedling cotyledons under salt stress

Free polyamine (PA) titers in plants may be regulated through reversible conjugate formation and/or through modulation of their synthesis, transport and degradation. PA signaling involves the well-acknowledged signaling molecule, nitric oxide (NO), which functions in diverse biological processes. Present investigations demonstrate the influence of salt stress (120 mM NaCl) and exogenous NO donor (250 µM Diethylenetriamine, DETA) on PA homeostasis of 2 d old, etiolated sunflower (Helianthus annuus L.) seedling cotyledons as a long-distance signaling response. Significantly enhanced intracellular spermine (Spm) accumulation was observed in seedling cotyledons under salt stress and in response to NO donor, the increase being more pronounced in seedlings treated with NO, evidently as a result of upregulation of the PA biosynthetic enzymes - arginine decarboxylase (ADC) and S-adenosylmethionine decarboxylase (SAMDC) - as revealed by Western blot and confocal imaging (CLSM). Moreover, salt stress induced the activity of polyamine oxidase (PAO), a PA catabolic enzyme, while NO lowered its activity in salt-stressed seedling cotyledons. NO, thus, appears to assist the seedlings in adapting to salt stress by positively regulating PA homeostasis through regulation of PA distribution between free, conjugated and bound forms, increased accumulation of PA biosynthetic enzymes and lowering the rate of PA catabolism.

The chemical, genetic and immunological basis of idiosyncratic drug–induced liver injury

Idiosyncratic drug reactions can be extremely severe and are not accounted for by the regular pharmacology of a drug. Thus, the mechanism of idiosyncratic drug–induced liver injury (iDILI), a phenomenon that occurs with many drugs including β-lactams, anti-tuberculosis drugs and non-steroidal anti-inflammatories, has been difficult to determine and remains a pressing issue for patients and drug companies. Evidence has shown that iDILI is multifactorial and multifaceted, which suggests that multiple cellular mechanisms may be involved. However, a common initiating event has been proposed to be the formation of reactive drug metabolites and covalently bound adducts. Although the fate of these metabolites are unclear, recent evidence has shown a possible link between iDILI and the adaptive immune system. This review highlights the role of reactive metabolites, the recent genetic innovations which have provided molecular targets for iDILI, and the current literature which suggests an immunological basis for iDILI.

Use of surgical sealant in debulking surgery for advanced ovarian carcinoma--case report

Haemostatic sealants are frequently used in gynaecological surgery. Several commercial products are available with similar mechanisms of action and chemical structure. We report the use of Floseal in a laparotomy for ovarian cancer to achieve haemostasis. This is the first reported case with the successful use of Floseal in gynaecological oncology.

Liver resection for metastases arising from recurrent granulosa cell tumour of the ovary--a case series

Ovarian granulosa cell tumours (GCT) occur rarely and represent 2-3% of all ovarian tumours. Regarded as tumours with low malignant potential and renowned for late recurrences, these tumours occasionally metastasize to the liver. We present our experience with three patients who underwent secondary cytoreductive surgery including liver resection for recurrence of the disease resulting in greatly improved quality of life and disease-free interval.

Use of serum progesterone measurements to reduce need for follow-up in women with pregnancies of unknown location

OBJECTIVE

To assess the efficacy of a progesterone-based algorithm for the management of women with pregnancies of unknown location (PULs) and explore the feasibility of developing a single-visit strategy in those with a low risk of requiring medical intervention.

METHODS

All clinically stable women in whom pregnancy could not be identified on ultrasound scan were managed by a pre-defined protocol based on measurement of serum progesterone and beta-human chorionic gonadotropin (beta-hCG). Intervention in the form of surgery or medical treatment with methotrexate was offered to all women with persistent or worsening symptoms and non-declining serum beta-hCG. Decision-tree analysis was used to develop a protocol for the management of women with resolving pregnancies who are at low risk of requiring medical intervention.

RESULTS

1110 women were included in the data analysis: normal intrauterine pregnancy was diagnosed in 248 (22.3%; 95% CI, 19.9-24.8) women. 761 (68.6%; 95% CI, 65.8-71.3) abnormal pregnancies resolved spontaneously on expectant management, while the remaining 101 (9.1%; 95% CI, 7.4-10.8) women with abnormal pregnancies required some form of medical intervention. Intervention rates in patients presenting with initial serum progesterone levels of <or= 20 nmol/L and <or= 10 nmol/L, were 3.9% (95% CI, 2.4-5.4) and 2.1% (95% CI, 0.9-3.3), respectively. In women presenting with progesterone <or= 10 nmol/L and beta-hCG < 450 IU/L, the intervention rate was 1.3% (95% CI, 0.2-2.5).

CONCLUSION

Women with PULs with progesterone <or= 10 nmol/L at presentation are at low risk of requiring medical intervention and may not benefit from attending routine follow-up visits.

A comparative study of the risk of malignancy index and the ovarian crescent sign for the diagnosis of invasive ovarian cancer

OBJECTIVE

To compare the value of the risk of malignancy index (RMI) and the ovarian crescent sign (OCS) in the diagnosis of ovarian malignancy.

METHODS

This was a prospective observational study of women with ultrasonographic diagnosis of an ovarian cyst. The RMI was calculated in all cases using a previously published formula (RMI = U (ultrasound score) x M (menopausal status) x serum CA125 (kU/L)). A value > 200 was considered to be diagnostic of ovarian cancer. The OCS was defined as a rim of visible healthy ovarian tissue in the ipsilateral ovary. Its absence was taken as being diagnostic of invasive cancer.

RESULTS

A total of 106 consecutive women were included in the study, of whom 92 (86.8%) had a benign ovarian tumor, five (4.7%) had borderline lesions and nine (8.5%) had an invasive ovarian cancer. The absence of an OCS diagnosed invasive ovarian cancer with a sensitivity of 100% (95% CI, 70-100%), specificity of 93% (95% CI, 86-96%), positive predictive value (PPV) of 56%, negative predictive value (NPV) of 100% and positive likelihood ratio (LR+) of 13.86 (95% CI, 6.79-28.29). This compared favorably with a sensitivity of 89% (95% CI, 57-98%), specificity of 92% (95% CI, 85-96%), PPV of 50%, NPV of 99% and LR+ of 10.78 (95% CI, 5.34-21.77), which were achieved using RMI > 200 (P < 0.01).

CONCLUSIONS

The RMI and the OCS are useful tests for discriminating between invasive and non-invasive ovarian tumors. The application of these tests in a sequential manner might improve the overall accuracy of ovarian cancer diagnosis.

Risk of malignancy index for referral of ovarian cancer cases to a tertiary center: does it identify the correct cases?

Characterization of adnexal masses to identify patients with malignant ovarian tumors preoperatively for referral to a cancer center for treatment has been extensively studied. A simple algorithm called "risk of malignancy index" (RMI) reported by Jacobs incorporated the serum CA125 level, menopausal status, and ultrasound morphologic features. This algorithm has subsequently been tested on retrospective and prospective data with encouraging results. However, these studies did not include cases that had had both their serum CA125 measurements and ultrasound examinations from a diverse range of laboratories and sonographers. The purpose of this study was to determine the effectiveness of the RMI algorithm for identifying cases of ovarian malignancy presenting at cancer units for subsequent referral to a cancer center. All cases of suspected ovarian malignancy referred to the Northern Gynaecological Oncology Centre (NGOC) during an 18-month period were identified from the NGOC database. A case note review was performed, and the following data were extracted: patient demographics, the referring physician and the operating surgeon, ultrasound morphology, serum CA125 levels, and menopausal status. All patients had their ultrasound performed by sonographers at the peripheral unit according to local protocols. A total of 182 patients with a pelvic mass were referred to the center for surgery. A total of 24% patients had benign tumors, 6% had tumors of borderline malignancy, and 70% had invasive tumors. A total of 145 cases had an RMI >200; 125 of these had ovarian or peritoneal cancers. An RMI >200 had a sensitivity of 88.5% for diagnosing invasive lesions. The overall sensitivity of this algorithm for diagnosing all borderline, invasive ovarian, or primary peritoneal lesions was 87.4%, and the positive predictive value was 86.8%. Our data confirm the effectiveness of the RMI algorithm in clinical practice for the identification and subsequent referral to cancer centers of cases of potential ovarian malignancy. We therefore recommend its continued use.

Prevalence of high-grade CIN following mild dyskaryotic smears in different age groups

OBJECTIVE

The new guidelines of the British Society of Colposcopy and Cervical Pathology suggest that women should be offered colposcopy after only one mildly dyskaryotic smear. This is expected to generate increased workload for the colposcopy clinics, at least in the short term. The main objective of this study was to estimate the incidence of high-grade cervical intraepithelial neoplasia (CIN) in women with mildly dyskaryotic smears and investigate whether there is any variation in different age groups. The rationale was to determine whether we could reduce the burden on colposcopy services by prioritizing the mild dyskaryotic referrals by age, as we hypothesized that high-grade CIN is less frequent in younger women.

METHODS

The study sample included all women who were referred for colposcopy with a cervical smear suggesting mild dyskaryosis (with or without koilocytosis) from April 2000 to March 2003.

RESULTS

We studied 510 women. They were divided into three age groups (<20, 20-25 and >25 years). The overall prevalence of high-grade CIN (CIN II and III) was 28.7%. The positive predictive value of a mildly dyskaryotic smear for high-grade CIN was similar in all groups.

CONCLUSIONS

Our results show that we are not in a position to prioritize our referrals by age group and reduce the initial pressure for colposcopies. We are also concerned that with the implementation of the new guidelines, a significant number of women <25 years will be carrying high-grade CIN for more than 5 years before they are first screened.

Risk of malignancy index for referral of ovarian cancer cases to a tertiary center: does it identify the correct cases?

Characterization of adnexal masses to identify patients with malignant ovarian tumors preoperatively for referral to a cancer center for treatment has been extensively studied. A simple algorithm called “risk of malignancy index” (RMI) reported by Jacobs incorporated the serum CA125 level, menopausal status, and ultrasound morphologic features. This algorithm has subsequently been tested on retrospective and prospective data with encouraging results. However, these studies did not include cases that had had both their serum CA125 measurements and ultrasound examinations from a diverse range of laboratories and sonographers. The purpose of this study was to determine the effectiveness of the RMI algorithm for identifying cases of ovarian malignancy presenting at cancer units for subsequent referral to a cancer center. All cases of suspected ovarian malignancy referred to the Northern Gynaecological Oncology Centre (NGOC) during an 18-month period were identified from the NGOC database. A case note review was performed, and the following data were extracted: patient demographics, the referring physician and the operating surgeon, ultrasound morphology, serum CA125 levels, and menopausal status. All patients had their ultrasound performed by sonographers at the peripheral unit according to local protocols. A total of 182 patients with a pelvic mass were referred to the center for surgery. A total of 24% patients had benign tumors, 6% had tumors of borderline malignancy, and 70% had invasive tumors. A total of 145 cases had an RMI >200; 125 of these had ovarian or peritoneal cancers. An RMI >200 had a sensitivity of 88.5% for diagnosing invasive lesions. The overall sensitivity of this algorithm for diagnosing all borderline, invasive ovarian, or primary peritoneal lesions was 87.4%, and the positive predictive value was 86.8%. Our data confirm the effectiveness of the RMI algorithm in clinical practice for the identification and subsequent referral to cancer centers of cases of potential ovarian malignancy. We therefore recommend its continued use.

Expectant management of miscarriage—prediction of outcome using ultrasound and novel biochemical markers

BACKGROUND

The aim of this study was to examine the value of various ultrasound and biochemical parameters for the prediction of successful expectant management of miscarriage.

METHODS

This was a prospective observational study. Clinically stable women with an ultrasound diagnosis of miscarriage were offered expectant management. In all cases, gestational age, size of retained products of conception, serum HCG, progesterone, 17-hydroxyprogesterone, insulin growth factor-binding protein 1 (IGFBP-1), inhibin A and inhibin pro alpha-C RI levels were recorded. Follow-up continued until resolution of the pregnancy. Clinical data, ultrasound findings and biochemical markers were analysed using univariate analysis and decision tree analysis.

RESULTS

Fifty-four women underwent expectant management of miscarriage. Thirty-seven (69%) had successful expectant management and 17 (31%) required surgery. The size of retained products, serum HCG, progesterone, inhibin A and inhibin pro alpha-C RI were all significantly different in those pregnancies that resolved spontaneously (P<0.05). Serum inhibin A was the best predictor of a complete miscarriage.

CONCLUSION

This study shows that novel biochemical markers may be used to predict the likelihood of successful expectant management of miscarriage.

Expectant management of tubal ectopic pregnancy: prediction of successful outcome using decision tree analysis

OBJECTIVE

To establish whether a decision tree based on a combination of clinical, morphological and biochemical parameters could be constructed to help in the selection of women with tubal ectopic pregnancies for expectant management.

METHODS

This was a prospective observational study in a tertiary referral early pregnancy unit in an inner city teaching hospital. The study group consisted of 179 women with ultrasound diagnosis of ectopic pregnancy. Demographic, clinical and ultrasound data were recorded in each case at the initial visit. In addition all women had a blood sample taken for the measurements of serum beta-human chorionic gonadotropin (beta-hCG) and progesterone. Clinically stable women with non-viable pregnancies and no signs of hematoperitoneum were managed expectantly on an outpatient basis until their serum beta-hCG declined to <20 IU/L. Women who developed pelvic pain during follow-up and those with non-declining serum beta-hCG were offered surgery.

RESULTS

A total of 107/179 (59.8%) tubal ectopics were considered suitable for expectant management. Ectopic pregnancy resolved spontaneously in 75/107 (70%) women, which was 41.9% of the total number of tubal ectopics. Maternal age, initial serum beta-hCG and progesterone were all significantly different in pregnancies that resolved spontaneously compared to those requiring surgery (P < 0.05). Initial serum beta-hCG level was the best predictor of the outcome of expectant management. These differences enabled a construction of a four-level decision tree to estimate the likelihood of successful expectant management.

CONCLUSIONS

There are significant differences in demographic, ultrasound and biochemical findings between spontaneously resolving ectopics and those requiring treatment. Decision tree analysis may be used as a guide to estimate the probability of successful expectant management in individual cases.

Results from an ultrasound-based familial ovarian cancer screening clinic: a 10-year observational study

OBJECTIVES

To assess the use of transvaginal sonography as a screening test for familial ovarian cancer and, secondarily, to determine the value of a family history of malignant disease and the potential role of serum CA 125 levels in the screening procedure.

METHODS

Two thousand five hundred self-referred women were studied at the Ovarian Screening Clinic at King's College Hospital, London. These symptom-free women with at least one close relative who had developed ovarian cancer were studied prospectively. Each woman was scanned for the presence of a persistent ovarian lesion and a sample of peripheral blood was taken for the retrospective analysis of serum CA 125. Women with a positive screen result were referred for surgical investigations; those with a negative result but considered to be at high risk were rescreened. The main outcome measures were findings at surgery, the histological classification of ovarian lesions, and cancer reported at follow-up.

RESULTS

The women were aged 17 to 78 (mean, 48) years; 65% were premenopausal, 26% were postmenopausal and 9% had undergone hysterectomy. Seven hundred and thirty-eight women (29.5%) had a family history of multiple site cancers and 279 (11.2%) reported cancer specific to the ovary. There were 4231 screenings (2500 first screens, 998 second screens and 733 third or higher order screens). One hundred and four screens gave a positive result (2.5%); 11 cancers were detected (seven (64%) at stage I, four of which were of borderline malignancy). One additional cancer was reported within 12 months of the last scan and classified as a false-negative screen result. Eight cancers (including two peritoneal) were reported at follow-up (> 1-9 years after the last scan). All these women presented at an advanced stage (stage III). Fifteen of 20 cancers occurred in premenopausal women. The overall sensitivity of ultrasound screening was 92% (95% confidence interval, 76-100); the specificity was 97.8%. The prior odds of any woman having a screen-detectable ovarian malignancy during the study period were 1 : 207. The posterior odds subsequent to a positive screen result were 1 : 8.5 (1 : 12.7 at Screen 1; 1 : 3.7 at Screen 2; 1 : 3.0 at subsequent screens); the value was 1 : 11.4 for women with one family relative with ovarian cancer and 1 : 5.0 for women with the site-specific ovarian cancer syndrome. The prior use of a decision level for serum CA 125 >or= 20 U/mL would have reduced the number of women undergoing sonography by 78%; seven of the 12 cancers (58%) would have been detected (63% of all stage I disease, 75% of invasive stage I disease). An alternative cut-off value of 35 U/mL would have resulted in a detection rate of 33%.

CONCLUSIONS

Transvaginal sonography can effectively detect intraovarian cancer and tumors of borderline malignancy in women with a family history of the disease. Screening efficacy is related to the type of family history. The level of serum CA 125 can be used to select women for sonography, but the detection rate for early cancers would be reduced.

Prediction of early pregnancy viability in the absence of an ultrasonically detectable embryo

OBJECTIVE

To identify clinical, ultrasound and biochemical parameters that may allow prediction of pregnancy viability in women without a detectable embryo on ultrasound examination.

METHODS

This was a prospective observational study of pregnant women with an ultrasound finding of a gestational sac measuring < 20 mm mean diameter without a visible embryo. Women's age, menstrual dates, clinical symptoms (pain and bleeding), mean gestational sac diameter and measurements of serum beta-human chorionic gonadotropin and progesterone were recorded in all cases. All women were managed expectantly until the pregnancy viability was established conclusively based on clinical and ultrasound findings. All parameters were tested by univariate analysis and then analyzed in a stepwise procedure to form a logistic regression model for predicting pregnancy viability.

RESULTS

One hundred and eighteen (59%) women had a normal intrauterine pregnancy and 82 (41%) had a miscarriage. Stepwise analysis showed that three diagnostic parameters (maternal age, gestational sac diameter and serum progesterone) contributed significantly to the predictive power of the logistic model. With this model, at a cut-off value of 10% probability, the diagnosis of viable pregnancy was made with a sensitivity of 99.2% (95% CI, 95.8-99.97) and specificity of 70.7% (95% CI, 61.3-78.9).

CONCLUSION

The use of a logistic regression model allows prediction of pregnancy viability when an embryo cannot be visualized on ultrasound scan.

Analysis of the protection afforded by annexin 1 in ischaemia-reperfusion injury: focus on neutrophil recruitment

Ischaemia-reperfusion injury underlies many of the most important cardiovascular diseases such as myocardial infarction, thrombotic stroke, embolic vascular occlusions and peripheral vascular insufficiency. Neutrophils feature prominently in this inflammatory component of post-ischaemic injury. Experimental therapies, shown to reduce neutrophil-mediated ischaemia-reperfusion injury include neutrophil depletion, direct inhibitors of neutrophil activators, antibodies against neutrophil adhesion molecules and the endothelial adhesion molecules. However, aside from these approaches, it is increasingly recognised that glucocorticoids are potent inhibitors of neutrophil-mediated injury. The anti-inflammatory actions of glucocorticoid include the activation of classical cytoplasmic receptors leading to changes in gene transcription as well as the induction of regulatory proteins, such as annexin 1. Annexin 1 is a potent inhibitor of neutrophil extravasation in vivo. Administration of the annexin 1 or peptides derived from its N-terminal domain, reduce neutrophil extravasation in models of acute inflammation. In addition, as reviewed by this article, annexin 1 protects against ischaemia-reperfusion in the heart and mesenteric microcirculation, as well as in multiple organ failure associated with splanchnic ischaemia-reperfusion. Such findings would suggest annexin 1 is a novel anti-inflammatory agent with a potential for the treatment of cardiovascular pathologies associated with neutrophil activation and recruitment.

Splanchnic ischaemia-reperfusion injury: mechanistic insights provided by mutant mice

Reperfusion of ischaemic tissues often leads to microvascular dysfunction that is manifested as impaired endothelium-dependent dilation of arterioles, enhanced fluid filtration and leucocyte plugging in capillaries, and the trafficking of leucocytes and plasma protein extravasation in postcapillary venules. Efforts to define the mechanisms that underlie these microvascular responses to ischaemia and reperfusion have largely relied on pharmacological agents and monoclonal antibodies. Gene-targeting technology has been applied to the production of transgenic and knockout mice that are rapidly gaining acceptance as tools for mechanistic studies of ischaemia-reperfusion (I/R) injury that obviate some of the concerns (e.g. specificity) raised about previously employed experimental strategies. This review summarizes some of our efforts to apply gene-targeted mice to the study of I/R injury in the splanchnic vascular bed. A role for endothelial cell adhesion molecules (CAMs) and reactive oxygen metabolites is supported by results from mutant mice. Low density lipoprotein receptor mice also reveal that the microvascular and inflammatory responses to I/R are greatly exaggerated during chronic hypercholesterolaemia. The wide variety of mutant mice that have been produced for inflammation-related research makes this experimental strategy particularly promising for mechanistic investigations of the tissue responses to I/R.

Prospective evaluation of three different models for the pre-operative diagnosis of ovarian cancer

OBJECTIVE

To test the accuracy of the risk of malignancy index, the revised risk of malignancy index and Tailor's regression model to diagnose malignancy in women with known adnexal masses.

DESIGN

Prospective collaborative study.

SETTING

Gynaecology Assessment Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London.

SAMPLE

Sixty-one women with known adnexal masses were examined pre-operatively. Women were recruited from three South London hospitals.

METHODS

The demographic, biochemical and sonographic data recorded for each patient included: age; menopausal status; CA125 levels; tumour volume; ultrasound characteristics; and Doppler blood flow analysis (peak and mean blood velocities, the pulsatility and resistance indices). The diagnosis of malignancy was made for each woman using all three models and the results compared with the final histopathological diagnosis.

RESULTS

Thirty-eight women had benign tumours and 23 had ovarian cancer. Women with malignant tumours were significantly older than those with benign masses. There were also significant differences in CA125 levels, locularity, presence of papillary proliferations and ascites between the two groups. Tailor's regression model achieved a 43% sensitivity and 92% specificity in the diagnosis of malignancy. This compared with a 74% sensitivity and 92% specificity with the risk of malignancy model, and a 74% sensitivity and 89% specificity with the revised risk of malignancy model.

CONCLUSION

When applied prospectively all three diagnostic models performed less accurately than originally reported, despite clinical signs of malignancy being present in many cases. It is likely that their accuracy would be even less in a population of women in whom there was a substantial clinical uncertainty. Intra-tumoral blood velocity and CA125 levels were the best individual parameters for discrimination between benign and malignant tumours.

Role of adhesion molecules in vascular regulation and damage

The trafficking of leukocytes within the microcirculation is critical for normal immune surveillance of tissues. The process of leukocyte recruitment is tightly regulated by the sequential expression and activation of specific adhesion molecules on the surface of leukocytes and endothelial cells. These adhesion molecules mediate distinct steps in the recruitment of leukocytes in the microcirculation. The selectins mediate leukocyte rolling, whereas glycoproteins belonging to the integrin and immunoglobulin supergene families enable leukocytes to firmly adhere and emigrate in venules. The leukocyte-endothelial cell adhesion that is mediated by these adhesion molecules has been shown to alter the function of endothelial cells in all segments of the vasculature (ie, in arterioles, capillaries, and venules). Diseases such as ischemia-reperfusion, hypertension, and atherosclerosis exhibit vascular changes that are characteristic of acute or chronic inflammatory responses. These vascular alterations are associated with, and influenced by, changes in the avidity and density of adhesion molecules on the surface of either endothelial cells, leukocytes, or both. The activation and increased expression of these adhesion glycoproteins have been attributed to excessive production of cytokines and oxidants. The risk factors for cardiovascular disease, particularly diabetes mellitus and hypercholesterolemia, appear to sensitize the microvasculature to these inflammatory stimuli, thereby rendering tissues more vulnerable to the deleterious effects of ischemia and reperfusion. These findings raise the possibility of applying therapeutic strategies that are directed against adhesion molecules for the management of some cardiovascular diseases.

Dexamethasone inhibition of leucocyte adhesion to rat mesenteric postcapillary venules: role of intercellular adhesion molecule 1 and KC

BACKGROUND

A previous study showed that the glucocorticoid dexamethasone, at doses of 100 microg/kg and above, inhibited leucocyte adhesion to rat mesenteric postcapillary venules activated with interleukin 1beta (IL-1beta), as assessed by videomicroscopy.

AIMS

To identify whether the adhesion molecule, intercellular adhesion molecule 1 (ICAM-1), or the chemokine KC could be targeted by the steroid to mediate its antiadhesive effect.

METHODS

Rat mesenteries were treated with IL-1beta (20 ng intraperitoneally) and the extent of leucocyte adhesion measured at two and four hours using intravital microscopy. Rats were treated with dexamethasone, and passively immunised against ICAM-1 or KC. Endogenous expression of these two mediators was validated by immunohistochemistry, ELISA, and the injection of specific radiolabelled antibodies.

RESULTS

Dexamethasone greatly reduced IL-1beta induced leucocyte adhesion, endothelial expression of ICAM-1 in the postcapillary venule, and release of the mast cell derived chemokine KC. Injection of specific antibodies to the latter mediators was also extremely effective in downregulating (>80%) IL-1beta induced leucocyte adhesion.

CONCLUSIONS

Induction by IL-1beta of endogenous ICAM-1 and KC contributes to leucocyte adhesion to inflamed mesenteric vessels. Without excluding other possible mediators, these data clearly show that dexamethasone interferes with ICAM-1 expression and KC release from mast cells, resulting in suppression of leucocyte accumulation in the bowel wall, which is a prominent feature of several gastrointestinal pathologies.

A comparison of methods for preoperative discrimination between malignant and benign adnexal masses: the development of a new logistic regression model

OBJECTIVE

The aim of this study was to assess the complementary use of ultrasonographic end points with the level of circulating CA 125 antigen by multivariate logistic regression analysis algorithms to distinguish malignant from benign adnexal masses before operation.

STUDY DESIGN

One hundred ninety-one patients aged 18 to 93 years with overt adnexal masses were examined by transvaginal ultrasonography with color Doppler imaging and 31 variables were recorded. The end points were the histologic classification of the tumor and the areas under the receiver-operator characteristic curves of alternative algorithms.

RESULTS

One hundred forty patients had benign tumors and 51 (26.7%) had malignant tumors: 31 primary invasive tumors (37% International Federation of Gynecology and Obstetrics stage I), 5 tumors of borderline malignancy (100% International Federation of Gynecology and Obstetrics stage I), and 15 tumors were metastatic and invasive. The most useful variables for the logistic regression analysis were the menopausal status, the serum CA 125 level, the presence of >/=1 papillary growth (>3 mm in length), and a color score indicative of tumor vascularity and blood flow. The optimized procedure had a sensitivity of 95.9% and a specificity of 87.1%. The area under the receiver-operator characteristic curve was significantly higher (P <.01) than the corresponding values from the independent use of serum CA 125 levels or indexes of tumor form or vascularity.

CONCLUSION

Regression analysis of a few complementary variables can be used to accurately discriminate between malignant and benign adnexal masses before operation.

Sonographic prediction of malignancy in adnexal masses using an artificial neural network

OBJECTIVE

To generate a neural network algorithm which computes a probability of malignancy score for pre-operative discrimination between malignant and benign adnexal tumours.

DESIGN

A retrospective analysis of previously collected data. Information from 75% of the study group was used to train an artificial neural network and the remainder was used for validation.

SETTING

The Gynaecological Ultrasound Research Unit at King's College Hospital, London.

POPULATION

Sixty-seven women with known adnexal mass who had been examined using transvaginal B-mode ultrasonography and colour Doppler imaging with pulse spectral analysis immediately before surgery. The excised masses were classified histologically as benign (n = 52) or malignant (n = 15), of which three were borderline.

METHODS

The variables that were put into the artificial neural network were: age, menopausal status, maximum tumour diameter, tumour volume, locularity, the presence of papillary projections, the presence of random echogenicity, the presence of analysable blood flow velocity waveforms, the peak systolic velocity, time-averaged maximum velocity, the pulsatility index, and resistance index. Histological classification, categorised as benign or malignant, was the output result.

RESULTS

A variant of the back propagation method was selected to train the network. The overall architecture of the network with the best performance contained an input layer with four variables (age, time-averaged maximum velocity, papillary projection score and maximum tumour diameter), a hidden layer with three units and an output layer with one. The sensitivity and specificity at the optimum diagnostic decision value for the artificial neural network output (0.45) were 100% (95% CI 78.2%-100%) and 98.1% (95% CI 89.5%-100%), respectively. These values were significantly better than those obtained from the independent use of the resistance index, pulsatility index, time-averaged maximum velocity or peak systolic velocity at their optimum decision values (P < 0.01).

CONCLUSION

Artificial neural networks may be used on clinical and ultrasound derived end-points to accurately predict ovarian malignancy. There is a need for a prospective evaluation of this technique using a larger number of patients.

Comparison of transvaginal color Doppler imaging and color Doppler energy for assessment of intraovarian blood flow

OBJECTIVE

To investigate any systematic differences in the analysis of blood flow velocity waveforms derived by color Doppler imaging and color Doppler energy examination of corpora lutea and adnexal tumors, to test whether the accuracy for diagnosing ovarian malignancy differs between end points derived by color Doppler imaging and color Doppler energy, and to compare the reproducibility of flow velocity waveform analysis obtained by both methods.

METHODS

Fifty-six asymptomatic women with presumed corpora lutea and 67 women with known adnexal masses were included in the study. They all were examined using transvaginal sonography with color Doppler imaging and color Doppler energy. Pulsed Doppler sonography was used to obtain flow velocity waveforms to determine the pulsatility index (PI), resistance index (RI), peak systolic velocity, and time-averaged maximum velocity. The tumors were classified retrospectively according to histologic criteria.

RESULTS

There were 52 women with benign, three with borderline, and 12 with malignant ovarian tumors. Repeated-measures analysis of variance revealed no systematic differences in the values of all four measurements performed under color Doppler imaging and color Doppler energy for all cases of corpora lutea and adnexal tumors (PI: P=.153, RI: P=.197, peak systolic velocity: P=.355, time-averaged maximum velocity: P=.159). All cases of borderline and malignant tumors had detectable pulsatile blood flow with color Doppler imaging and color Doppler energy. Forty-two (80.8%) of the benign tumors had flow detectable with color Doppler imaging, compared with 40 (76.9%) with color Doppler energy (P=.480). Analysis of receiver operating characteristic curves showed a marginal but nonsignificant improvement in diagnostic performance with color Doppler energy compared with color Doppler imaging for all four measurements (PI: P=.182, RI: P=.178, peak systolic velocity: P=.254, time-averaged maximum velocity: P=.238). The intraclass correlation coefficients for all four measurements were superior with color Doppler imaging compared with color Doppler energy.

CONCLUSION

Flow velocity waveform analysis and diagnostic accuracy for ovarian malignancy are not significantly different between color Doppler imaging and color Doppler energy. Examinations with color Doppler imaging appear to be more reproducible than those with color Doppler energy.

Lipocortin 1 protects against splanchnic artery occlusion and reperfusion injury by affecting neutrophil migration

Splanchnic artery occlusion and reperfusion (SAO/R) shock was induced in rats by clamping both the superior mesenteric artery and the celiac trunk for 45 min, followed by release of the clamp (60-min reperfusion). Following this reperfusion period, rats developed a fall in mean arterial blood pressure, associated with a significant increase in tissue myeloperoxidase (MPO) activity in the intestine and a marked histologic injury to the distal ileum. Treatment of rats with a lipocortin-1 (LC1)-derived N-terminal peptide, peptide Ac(2-26), dose-dependently (0.125-0.5 mg/kg s.c.) reduced the progressive fall in blood pressure and prevented the infiltration of neutrophils into the reperfused intestine (reduced MPO activity). The LC1 peptide also reduced the degree of ischemia/reperfusion injury in the bowel as evaluated by histologic examination. The glucocorticoid dexamethasone (0.1 mg/kg s.c., -1 h) also produced a marked improvement in SAO/R shock (i.e., maintained mean arterial blood pressure and reduced tissue MPO activity), and this was reversed by pretreatment with two different antisera raised against the LC1 pharmacophore. Peptide Ac(2-26) (0.5 mg/kg s.c., -30 min) reduced (>60%) the extent of IL-1beta-induced cell emigration and significantly attenuated (approximately 45%) the number of adherent leukocytes in the rat mesenteric vascular bed, as assessed by video microscopy. These results suggest that LC1 inhibits neutrophil migration and accumulation into reperfused tissues, thereby ameliorating the outcome of SAO/R shock.

Lipocortin 1 protects against splanchnic artery occlusion and reperfusion injury by affecting neutrophil migration

Splanchnic artery occlusion and reperfusion (SAO/R) shock was induced in rats by clamping both the superior mesenteric artery and the celiac trunk for 45 min, followed by release of the clamp (60-min reperfusion). Following this reperfusion period, rats developed a fall in mean arterial blood pressure, associated with a significant increase in tissue myeloperoxidase (MPO) activity in the intestine and a marked histologic injury to the distal ileum. Treatment of rats with a lipocortin-1 (LC1)-derived N-terminal peptide, peptide Ac(2-26), dose-dependently (0.125-0.5 mg/kg s.c.) reduced the progressive fall in blood pressure and prevented the infiltration of neutrophils into the reperfused intestine (reduced MPO activity). The LC1 peptide also reduced the degree of ischemia/reperfusion injury in the bowel as evaluated by histologic examination. The glucocorticoid dexamethasone (0.1 mg/kg s.c., -1 h) also produced a marked improvement in SAO/R shock (i.e., maintained mean arterial blood pressure and reduced tissue MPO activity), and this was reversed by pretreatment with two different antisera raised against the LC1 pharmacophore. Peptide Ac(2-26) (0.5 mg/kg s.c., -30 min) reduced (&gt;60%) the extent of IL-1beta-induced cell emigration and significantly attenuated (approximately 45%) the number of adherent leukocytes in the rat mesenteric vascular bed, as assessed by video microscopy. These results suggest that LC1 inhibits neutrophil migration and accumulation into reperfused tissues, thereby ameliorating the outcome of SAO/R shock.

Ultrasound screening for congenital uterine anomalies

The aim of this study was to investigate the prevalence of congenital uterine anomalies in 1046 women attending gynaecological ultrasound clinics for a variety of indications. Using three-dimensional ultrasound, anomalies were found in 55 women (5.4%), including 32 (3.1%) with an arcuate uterus and 23 (2.3%) with major anomalies. The prevalence of uterine anomalies was similar to the findings in women undergoing elective sterilisation, but lower than in studies of women with recurrent miscarriage.

Dexamethasone inhibits leukocyte emigration in rat mesenteric post-capillary venules: an intravital microscopy study

The effect of subcutaneous administration of dexamethasone (DEX) on interleukin-1beta(IL-1beta, 20 ng i.p., - 2 h) and platelet-activating factor (PAF, 100 nM in superfusion) -induced leukocyte interaction with the endothelium of rat mesenteric post-capillary venules was studied. DEX produced a dose-dependent inhibition of IL-1beta-induced leukocyte extravasation in the rat mesenteric vascular bed, with a calculated ED5o of 40 microg/kg and a maximal effect of 80-100% inhibition at 0.1 mg/kg. IL-1beta-induced cell adhesion to post-capillary venules was only partially inhibited by the steroid, with a calculated ED50 of 480 microg/kg and a maximal effect of 40-60% inhibition. Furthermore, the steroid inhibited leukocyte emigration, but not adhesion, caused by superfusion of the mesenteric vascular bed with PAF. A doubling of leukocyte emigration time (from 226 to 552 s) was observed after treatment of rats with DEX. Administration for 5 days of a dose of 10 microg/kg DEX (which was inactive when given as a single injection) resulted again in a selective inhibition of IL-1beta-induced leukocyte emigration, without effect on cell adhesion. These data demonstrate a preferential susceptibility of the leukocyte emigration process to the inhibitory action of DEX.

Sonographic prediction of malignancy in adnexal masses using multivariate logistic regression analysis

The aim of the study was to assign a probability of malignancy for any patient with an adnexal tumor by the application of multivariate logistic regression analysis to variables recorded at the time of pelvic sonography. Sixty-seven women with known adnexal masses were examined using transvaginal B-mode and color Doppler imaging. For each patient the variables included: (1) age, (2) maximum tumor diameter, (3) tumor volume, (4) unilocularity (presence (0) or absence(1)), (5) papillary projections (presence (1) or absence (0)), (6) random echogenicity (presence (1) or absence (0)), (7) highest peak systolic velocity (PSV), (8) time-averaged maximum velocity (TAMXV), (9) pulsatility index (PI) and (10) resistance index (RI). The TAMXV, PI and RI were those associated with the highest PSV. These ten independent variables and the final histological diagnosis for each patient (the dependent variable) were used for the regression analysis. Approximately 75% of the entire dataset was randomly selected for generating the regression model. The remaining 25% was used as the testing set for cross-validation of the model. In the entire dataset there were 52 women with benign, three with borderline and 12 with invasive ovarian tumors. Regression analysis on the ten variables resulted in the retention of only 'age', 'papillary projection score' and 'TAMXV' as significantly contributing to predicting the presence or absence of malignancy. The probability of malignancy for any patient was given by solving the equation: Probability = 1/(1 + e-z) where e is the base value for natural logarithms and z = (0.1273 x Age) + (0.2794 x TAMXV) + (4.4136 x Papillary projections score) - 14.2046. Cross-validation of the model on the test set of data gave a 100% sensitivity and specificity. However, for the entire dataset the best sensitivity and specificity were 93.3 and 90.4%, respectively, at a cut-off value of 25% probability of malignancy. In conclusion, multivariate logistic regression analysis enables the calculation of probability of malignancy for any patient with a known adnexal mass. The accuracy of this prediction appears to be better than that of morphological or Doppler criteria when the latter are used independently. The value of this model needs to be tested prospectively.