Sugammadex Versus Neostigmine for Reversal of Neuromuscular Blockade in Patients With Severe Renal Impairment: A Randomized, Double-Blinded Study

BACKGROUND

Sugammadex is not advised for patients with severe renal impairment, but has been shown in a variety of other populations to be superior to neostigmine for reversal of neuromuscular blockade. The objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus reversal of cisatracurium-induced neuromuscular blockade with neostigmine results in a faster return to a train-of-four ratio (TOFR) ≥90% in patients with severe renal impairment.

METHODS

We conducted a prospective, randomized, blinded, controlled trial at a large county hospital. A total of 49 patients were enrolled. Inclusion criteria included patients age ≥18, American Society of Anesthesiologists (ASA) physical status III and IV, with a creatinine clearance <30 mL/min, undergoing general anesthesia with expected surgical duration ≥2 hours and necessitating neuromuscular blockade. Subjects received either cisatracurium 0.2 mg/kg or rocuronium 0.6 mg/kg for induction of anesthesia to facilitate tracheal intubation. Subjects were kept at moderate neuromuscular blockade during surgery and received either 2 mg/kg sugammadex or 50 µg/kg neostigmine with 10 µg/kg glycopyrrolate for reversal of neuromuscular blockade. Neuromuscular monitoring was performed with electromyography (TwitchView), and the TOFR was recorded every minute after administration of the reversal agent. The time from administration of neuromuscular reversal until the patient reached a TOFR ≥90% was recorded as the primary outcome.

RESULTS

The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min ( P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0-13.5 minutes). There were no major adverse events in either group.

CONCLUSIONS

In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.

Effect of sample length on MLU in Mandarin-speaking hard-of-hearing children

This study investigated the impact of language sample length on mean length of utterance (MLU) and aimed to determine the minimum number of utterances required for a reliable MLU. Conversations were collected from Mandarin-speaking, hard-of-hearing and typical-hearing children aged 16-81 months. The MLUs were calculated using sample sizes ranging from 25 to 200 utterances. The results showed that for an MLU between 1.0 and 2.5, 25 and 50 utterances were sufficient for reliable MLU calculations for hard-of-hearing and typical-hearing children, respectively. For an MLU between 2.5 and 3.75, 125 utterances were required for both groups. For an MLU greater than 3.75, 150 and 125 utterances were required for hard-of-hearing and typical-hearing children, respectively. These findings suggest that a greater number of utterances are required for a reliable MLU as language complexity increases. Professionals working with hard-of-hearing children should consider collecting different numbers of utterances based on the children's language complexity levels.

Decadal stability in coral cover could mask hidden changes on reefs in the East Asian Seas

Coral reefs in the Central Indo-Pacific region comprise some of the most diverse and yet threatened marine habitats. While reef monitoring has grown throughout the region in recent years, studies of coral reef benthic cover remain limited in spatial and temporal scales. Here, we analysed 24,365 reef surveys performed over 37 years at 1972 sites throughout East Asia by the Global Coral Reef Monitoring Network using Bayesian approaches. Our results show that overall coral cover at surveyed reefs has not declined as suggested in previous studies and compared to reef regions like the Caribbean. Concurrently, macroalgal cover has not increased, with no indications of phase shifts from coral to macroalgal dominance on reefs. Yet, models incorporating socio-economic and environmental variables reveal negative associations of coral cover with coastal urbanisation and sea surface temperature. The diversity of reef assemblages may have mitigated cover declines thus far, but climate change could threaten reef resilience. We recommend prioritisation of regionally coordinated, locally collaborative long-term studies for better contextualisation of monitoring data and analyses, which are essential for achieving reef conservation goals.

Multiple introductions and secondary dispersion of Tubastraea spp. in the Southwestern Atlantic

Accidental introduction through ballast water and biofouling are currently the main factors responsible for spreading non-indigenous species in the marine realm. In the Southwestern Atlantic, two scleractinian corals, Tubastraea coccinea and T. tagusensis, have been introduced by opportunistic colonization in 1980 and are now widespread along more than 3,500 km of coastline. To better understand the invasion process and the role of vectors in spreading these species, we sampled 306 and 173 colonies of T. coccinea and T. tagusensis from invaded sites, possible vectors and one native population. Analyses revealed a higher diversity of multi-locus genotypes (MLGs) on vectors, suggesting that they were contaminated prior to their arrival in the Southwestern Atlantic, and a high proportion of clones at invaded sites, with few genotypes spread over ~2,000 km. This broad distribution is most likely a result of secondary introductions through the transport of contaminated vectors. Results also suggest the occurrence of multiple invasions, mainly in the northernmost sites. In summary, clonality, secondary introductions, and multiple invasions are the main reasons for the broad spread and invasive success of Tubastraea spp. in the Southwestern Atlantic. Consequently, the correct control of vectors is the most effective approach for management and prevention of new invasions.

Application of xenogeneic anti-canine distemper virus antibodies in treatment of canine distemper puppies

OBJECTIVE

The clinical feasibility of passive immunotherapy has not been demonstrated in dogs naturally infected with canine distemper. In this study, porcine anti-canine distemper virus IgG and F(ab')₂ antibody fragments were used to treat infected puppies.

METHODS

A total of 41 naturally infected puppies (age Äsix months) exhibiting severe respiratory signs, but lacking neurological signs, were enrolled in the study. Twenty-five puppies were treated with a combination of IgG or F(ab')₂ antibody fragments (Group 1) and supportive therapy and 16 puppies received routine supportive care only (Group 2).

RESULTS

The survival rate of dogs in Group 1 (19/25; 76%) was significantly higher than that in Group 2 (5/16; 31·3%) (P<0·05). During the therapy, 8 of the 25 dogs (32%) in Group 1 developed neurological signs versus 12 of the 16 dogs (75%) in Group 2 (P<0·05). Adverse reactions were limited to elevated body temperature in dogs that received IgG antibodies.

CLINICAL SIGNIFICANCE

Porcine anti-canine distemper virus antibodies improved survival in puppies affected with canine distemper with minimal adverse effects. Therefore, this therapy could be considered for treatment of endangered animal species infected with canine distemper virus.

Abstract P4-01-05: Improving the quality of mammographic positioning

Purpose:

Optimal breast positioning is a key component to high quality screening mammograms to allow the radiologist to make the best interpretation for the patient and referring physician. In addition, the success of newer imaging techniques also depends on breast positioning. The American College of Radiology (ACR) sets the standard of what images should include by outlining 13 criteria of breast positioning. An initial audit of over 100 mammograms at our institution in 2013 found that only a mean of 33% were achieving the ACR criteria. The goal of our project was to increase the percentage of screening mammograms achieving ACR criteria to 90% by June 2015.

Methods:

Our breast imaging center partnered with a quality improvement (QI) team driving a radiology department-wide program on quality improvement. Team members identified 5 key causes that barred achieving the ACR criteria: disagreement on what meets criteria, not having a standard work for acquiring and reading mammograms, lack of communication between the technologist and radiologist, not having a measurement system to track performance, and lack of coaching on technologist techniques for acquiring images. Developments to address these causes included: teaching modules on what meets ACR criteria, standard work for radiologists to recall mammograms that did not meet ACR criteria, system for the technologist to document why criteria were missed, auditing system to track performance, and feedback sessions between technologists and radiologists. Over 1,700 mammograms were audited from the time period of July 2014 to March 2015.

Results:

By October 2014, the percentage of mammograms achieving all 13 of the ACR criteria was 71%, with 4 criteria that prevented reaching the 90% goal. By March 2015, 10 of the 13 ACR criteria were being sustainably met by the target goal of 90% of mammograms, better in all criteria compared to our 2013 data, and better in all but one criterion compared to published 1993 data. Table 1 demonstrates that we have been able to sustain a composite percentage of 12 of the 13 ACR criteria greater than 90% for the last 2 consecutive months.

Table 1 shows the composite percentage of mammograms achieving 12 of the 13 ACR criteria over time.2013 Baseline8/20149/201410/201411/20141/20152/20153/201564%67%77%82%83%81%95%96%The excluded, most difficult criterion (visualization of the opposite breast cleavage) has been achieved at 32% per 1993 published data; we currently achieve it at 40%. 12/2014 audits were not performed due to holidays and changes in staffing.

Conclusion:

Few institutions have published positioning data, with the most recent QI publication on breast positioning dating to 1993. We have conducted a structured process to improve quality of mammographic positioning, including revision of processes that led to poor positioning outcomes and creation of an environment to sustain our improved outcomes. Three ACR criteria continue to be problematic in reaching the 90% goal, with future investigation into whether it is actually feasible to achieve the most difficult criterion at our goal of 90%. Future work also includes assessing how the recent hire of a mammography coach to spread best practices and real-time feedback is able to further improve results and maintain the infrastructure of ongoing QI.

Citation Format: Chen CA, Strain A, Mickelsen JL, Larson DA, Jesinger RA, Botelho D, Fromholz S, Obi CN, Crawley A, Lipson JA, Ikeda DM, Cooper C, Pal S. Improving the quality of mammographic positioning. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-05.

Continuous positive airway pressure-associated cutaneous amoebiasis in an immunosuppressed patient

Organisms of the genus Acanthamoeba are environmentally ubiquitous and colonizers of the oral mucosa in humans. While largely asymptomatic in healthy persons, Acanthamoeba infection can cause disseminated disease with poor prognosis in immunosuppressed populations. Here we report a unique case of cutaneous amoebiasis associated with continuous positive airway pressure use in an immunosuppressed patient.

Genome-wide normalized score: a novel algorithm to detect fetal trisomy 21 during non-invasive prenatal testing

OBJECTIVES

Non-invasive prenatal testing for fetal trisomy 21 (T21) by massively parallel shotgun sequencing (MPSS) is available for clinical use but its efficacy is limited by several factors, e.g. the proportion of cell-free fetal DNA in maternal plasma and sequencing depth. Existing algorithms discard DNA reads from the chromosomes for which testing is not being performed (i.e. those other than chromosome 21) and are thus more susceptible to diluted fetal DNA and limited sequencing depth. We aimed to describe and evaluate a novel algorithm for aneuploidy detection (genome-wide normalized score (GWNS)), which normalizes read counts by the proportions of DNA fragments from chromosome 21 in normal controls.

METHODS

We assessed the GWNS approach by comparison with two existing algorithms, i.e. Z-score and normalized chromosome value (NCV), using theoretical approximations and computer simulations in a set of 86 cases (64 euploid and 22 T21 cases). We then validated GWNS by studying an expanded set of clinical samples (n = 208). Finally, dilution experiments were undertaken to compare performance of the three algorithms (Z-score, NCV, GWNS) when fetal DNA concentration was low.

RESULTS

At fixed levels of significance and power, GWNS required a smaller fetal DNA proportion and fewer total MPSS reads compared to Z-score or NCV. In dilution experiments, GWNS also outperformed the other two methods by reaching the correct diagnosis with the lowest range of fetal DNA concentrations (GWNS, 3.83-4.75%; Z-score, 4.75-5.22%; NCV, 6.47-8.58%).

CONCLUSION

Our results demonstrate that GWNS is comparable to Z-score and NCV methods regarding the performance of detecting fetal T21. Dilution experiments suggest that GWNS may perform better than the other methods when fetal fraction is low.

Characterization and enhanced field emission properties of IrO2-coated carbon nanotube bundle arrays

Low operating electric field and stable emission current have been achieved in IrO(2) nanocrystal-coated carbon nanotube bundle arrays (CNTBAs). Patterned vertically aligned CNTBAs were synthesized using thermal chemical vapor deposition followed by the deposition of IrO(2) nanocrystals by reactive radio-frequency magnetron sputtering using an Ir target. The structural and spectroscopic properties were characterized by field emission scanning and transmission electron microscopy, and Raman spectroscopy. The current density versus electric field measurements yielded a low turn-on field of 0.7 V microm(-1) at a current density of 0.1 microA cm(-2), a low threshold field of 2.3 V microm(-1) at a current density of 1 mA cm(-2) and a high field enhancement factor of 1 x 10(4) for the IrO(2)-coated CNTBAs. Long-term stability was also demonstrated. The enhancement of field emission characteristics is attributed to the combined effects of the geometrical structure of the IrO(2)-coated CNTBAs, and the natural conducting and enhanced resistance to oxidation properties of IrO(2).

Growth and characterization of V-shaped IrO(2) nanowedges via metal-organic vapor deposition

We report in detail the synthesis and characterization of V-shaped IrO(2) nanowedges (NWs) with an angle of 110° between the two arms. The NWs were grown on top of rutile (R) phase TiO(2) nanorods (NRs) sitting on a sapphire (SA)(100) substrate via metal-organic chemical vapor deposition (MOCVD) by using (C(6)H(7))(C(8)H(12))Ir and titanium-tetraisopropoxide (TTIP, Ti[OCH(CH(3))(2)](4)) as the source reagents. The surface morphology, structural, and spectroscopic properties of the as-deposited nanocrystals (NCs) were characterized by field emission scanning electron microscopy (FESEM), x-ray diffraction (XRD), micro-Raman spectroscopy, transmission electron microscopy (TEM), and selected-area electron diffractometry (SAED). The FESEM images and XRD patterns indicated growth of V-shaped IrO(2)(101) NWs on top of R-TiO(2) NRs. The Raman spectrum showed the nanosize induced redshift and peak broadening of the IrO(2) and rutile phase of TiO(2) signatures with respect to that of the bulk counterparts. TEM and SAED characterizations of IrO(2) NCs showed that the nanowedges were crystalline IrO(2) with a twin plane of (101) and twin direction of [Formula: see text] at the V-junction. The probable mechanisms for the formation of well-aligned IrO(2) NWs are discussed.

Calcium phosphate transfection

This unit contains two methods of calcium phosphate-based eukaryotic cell transfection, protocols that can be used for both transient and stable transfections. In the protocols, plasmid DNA is introduced to monolayer cell cultures via a precipitate that adheres to the cell surface. The Basic Protocol uses a HEPES-buffered solution to form a calcium phosphate precipitate that is directly layered onto the cells. In the alternate high-efficiency method, a BES-buffered system is used that allows the precipitate to form gradually in the medium and is then dropped onto the cells. The alternate method is particularly efficient for stable transformation of cells with circular plasmid DNA, and may be helpful with linear or genomic DNA. Both methods of transfection require very high-quality plasmid DNA, which can be prepared as described in the second Support Protocol. Transfection efficiency in some cell lines can be increased by shocking the cells with glycerol or dimethyl sulfoxide (DMSO) as described in the first Support Protocol.

Calcium phosphate transfection

This unit presents two methods of calcium phosphate-based eukaryotic cell transfection that can be used for both transient and stable transfections. In these protocols, plasmid DNA is introduced to monolayer cell cultures via a precipitate that adheres to the cell surface. A HEPES-buffered solution is used to form a calcium phosphate precipitate that is directly layered onto the cells. For some cells, shocking the cells with glycerol or DMSO improves transfection efficiency. In the alternate high-efficiency method, a BES-buffered system is used that allows the precipitate to form gradually in the medium and then drop onto the cells. While the alternate method is particularly efficient for stable transformation of cells with circular plasmid DNA, both protocols yield similar results for transformation with linear plasmid or genomic DNA, or for transient expression.

Growth and characterization of well-aligned densely-packed rutile TiO(2) nanocrystals on sapphire substrates via metal-organic chemical vapor deposition

Well-aligned densely-packed rutile TiO(2) nanocrystals (NCs) have been grown on sapphire (SA) (100) and (012) substrates via metal-organic chemical vapor deposition (MOCVD), using titanium-tetraisopropoxide (TTIP, Ti(OC(3)H(7))(4)) as a source reagent. The surface morphology as well as structural and spectroscopic properties of the as-deposited NCs were characterized using field-emission scanning electron microscopy (FESEM), transmission electron microscopy (TEM), selected-area electron diffractometry (SAED), x-ray diffraction (XRD) and micro-Raman spectroscopy. FESEM micrographs reveal that vertically aligned NCs were grown on SA(100), whereas the NCs on the SA(012) were grown with a tilt angle of ∼33° from the normal to substrates. TEM and SAED measurements showed that the TiO(2) NCs on SA(100) with square cross section have their long axis directed along the [001] direction. The XRD results reveal TiO(2) NCs with either (002) orientation on SA(100) substrate or (101) orientation on SA(012) substrate. A strong substrate effect on the alignment of the growth of TiO(2) NCs has been demonstrated and the probable mechanism for the formation of these NCs has been discussed.

Comparison between 'in vivo' and 'in vitro' methods for evaluating tumor angiogenesis using cervical carcinoma as a model

The role of angiogenesis in tumorigenesis is widely accepted. Therefore, it is mandatory to develop a clinically useful method for assessing tumor angiogenesis. This study was designed to compare the 'in vivo' and 'in vitro' methods for assessing angiogenesis and to evaluate their clinical application using cervical carcinoma as a model. Ninety women with stages IB-IIA cervical carcinoma exhibiting visible cervical tumors by transvaginal ultrasound were enrolled in this study. All patients underwent radical abdominal hysterectomy and pelvic lymph node dissection. Vascularity index (VI) was assessed by power Doppler ultrasound and a quantitative image processing system. The microvessel density (MVD) of the excised tumors was immunohistochemically assessed. Both the enzyme immunoassay and immunohistochemistry methods were performed for assessing the protein levels of vascular endothelial growth factor (VEGF) in tumor tissues. Significantly higher VI, MVD and cytosol VEGF concentrations were detected in tumors with deep stromal invasion (>or=1/2 thickness) (11.43 +/- 7.25 vs. 5.87 +/- 6.81, P < 0.001; 53.0 vs. 37.0, P = 0.006, 550.0 vs. 86.0 pg/mg, P < 0.001), lymphatic invasion (12.21 +/- 7.89 vs. 6.86 +/- 6.29, P < 0.001; 53.0 vs. 40.0, P = 0.038; 930.0 vs. 110.0 pg/mg, P = 0.002), and pelvic lymph node metastasis (17.15 +/- 8.58 vs. 7.83 +/- 6.41, P < 0.001; 54.0 vs. 39.0, P = 0.02; 964.0 vs. 131.0 pg/mg, P = 0.002). VEGF-rich tumors detected by immunohistochemistry also revealed higher VI (12.26 +/- 7.96 vs. 8.05 +/- 7.62, P = 0.012), MVD (53.0 vs. 37.5, P = 0.01) and cytosol VEGF levels (745.0 vs. 98.0 pg/mg, P = 0.002). The relationships between VI values, MVD values and cytosol VEGF concentrations were linear (VI vs. MVD, r = 0.38, P < 0.001; VI vs. VEGF, r = 0.78, P < 0.001; MVD vs. VEGF, r = 0.29, P = 0.006). As revealed by the receiver operating characteristic (ROC) curve analysis, VI is better than MVD and VEGF in predicting lymph node metastasis. In conclusion, there is histological, molecular and clinical evidence supporting VI as a useful 'in vivo' indicator of tumor angiogenesis, particularly for predicting lymph node metastases in cervical carcinomas.

Identification and characterization of bone morphogenetic protein 2/4 gene from the starfish Archaster typicus

A bone morphogenetic protein 2/4 (BMP2/4) gene has been cloned from the starfish, Archaster typicus, for the purpose of investigating the expression pattern of the BMP4 gene in echinoderm embryos which do not produce micromeres. The isolated gene (named AtBMP2/4) contained two exons that encoded the entire coding region. The deduced AtBMP2/4 protein sequence contained 509 amino acids. Sequence comparison showed that it shared high amino acid similarity with sea urchin BMP2/4 and Xenopus BMP2 and BMP4. Northern blot analyses indicated that AtBMP2/4 mRNA initially appears at the blastula stage and has a maximal expression level at the gastrula stage. Whole-mount in situ hybridization revealed that AtBMP2/4 mRNA is expressed in the archenteron, coelomic vesicles, and ectodermal cells of gastrula stage embryos. The observed spatial distribution pattern vastly differs from that of sea urchin SpBMP2/4, which is expressed mainly in the oral ectoderm region of the mesenchyme blastula and early gastrula embryos.

Drug design with a new transition state analog of the hydrated carbonyl: silicon-based inhibitors of the HIV protease

BACKGROUND

Silicon is the element most similar to carbon, and bioactive organosilanes have therefore been of longstanding interest. Design of bioactive organosilanes has often involved a systematic replacement of a bioactive molecule's stable carbon atoms with silicon. Silanediols, which are best known as unstable precursors of the robust and ubiquitous silicone polymers, have the potential to mimic an unstable carbon, the hydrated carbonyl. As a bioisostere of the tetrahedral intermediate of amide hydrolysis, a silanediol could act as a transition state analog inhibitor of protease enzymes.

RESULTS

Silanediol analogs of a carbinol-based inhibitor of the HIV protease were prepared as single enantiomers, with up to six stereogenic centers. As inhibitors of this aspartic protease, the silanediols were nearly equivalent to both their carbinol analogs and indinavir, a current treatment for AIDS, with low nanomolar K(i) values. IC(90) data from a cell culture assay mirrored the K(i) data, demonstrating that the silanediols can also cross cell membranes and deliver their antiviral effects.

CONCLUSIONS

In their first evaluation as inhibitors of an aspartic protease, silanediol peptidomimetics have been found to be nearly as potent as currently available pharmaceutical agents, in enzyme and cell protection assays. These neutral, cell-permeable transition state analogs therefore provide a novel foundation for the design of therapeutic agents.

Steady-state and time-resolved fluorescence studies on wild type and mutant chromatium vinosum high potential iron proteins: holo- and apo-forms

Detailed circular dichroism (CD), steady-state and time-resolved tryptophan fluorescence studies on the holo- and apo- forms of high potential iron protein (HiPIP) from Chromatium vinosum and its mutant protein have been carried out to investigate conformational properties of the protein. CD studies showed that the protein does not have any significant secondary structure elements in the holo- or apo- HiPIP, indicating that the metal cluster does not have any effect on formation of secondary structure in the protein. Steady-state fluorescence quenching studies however, suggested that removal of the iron-sulfur ([Fe(4)S(4)](3+)) cluster from the protein leads to an increase in the solvent accessibility of tryptophans, indicating change in the tertiary structure of the protein. CD studies on the holo- and apo- HiPIP also showed that removal of the metal prosthetic group drastically affects the tertiary structure of the protein. Time-resolved fluorescence decay of the wild type protein was fitted to a four-exponentials model and that of the W80N mutant was fitted to a three-exponentials model. The time-resolved fluorescence decay was also analyzed by maximum entropy method (MEM). The results of the MEM analysis agreed with those obtained from discrete exponentials model analysis. Studies on the wild type and mutants helped to assign the fast picosecond lifetime component to the W80 residue, which exhibits fast fluorescence energy transfer to the [Fe(4)S(4)](3+) cluster of the protein. Decay-associated fluorescence spectra of each tryptophan residues were calculated from the time-resolved fluorescence results at different emission wavelengths. The results suggested that W80 is in the hydrophobic core of the protein, but W60 and W76 are partially or completely exposed to the solvent.

The anti-apoptotic role of interleukin-6 in human cervical cancer is mediated by up-regulation of Mcl-1 through a PI 3-K/Akt pathway

Interleukin-6 (IL-6), a multifunctional cytokine, has recently been implicated in human cervical cancer, though the mechanism remains elusive. This study demonstrates that the anti-apoptotic protein Mcl-1 and IL-6 was concomitantly expressed in human cervical cancer tissues and cell lines, but not in normal cervix tissues. Upon IL-6 treatment, Mcl-1, but not other Bcl-2 family members, was rapidly up-regulated peaking at 4-8 h in human cervical cancer C33A cells. Supporting this observation, using anti-IL-6 or anti-IL-6 receptor antibody to interrupt the IL-6 autocrine loop in SiHa cells significantly reduced cellular level of Mcl-1. This study hypothesizes that the expression of Mcl-1 in cervical cancer cells is regulated by IL-6. The matter of which signaling pathways transduced by IL-6 is responsible for the Mcl-1 up-regulation is further investigated herein. Blocking the STAT3 or MAPK pathway with dominant-negative mutant STAT3F or the MEK inhibitor PD98059 failed to inhibit IL-6-mediated Mcl-1 expression. Meanwhile, the IL-6-induced Mcl-1 up-regulation was effectively abolished by treatment with PI 3-K inhibitors, LY294002. Additionally, overexpression of dominant-negative (dn) Akt in C33A cells could inhibit the IL-6-induced increase of Mcl-1. Finally, overexpression of IL-6 in C33A cells caused a markable resistance to apoptosis induced by doxorubicin or cisplatin. Transient transfection of IL-6-overexpressed cells with a mcl-1 antisense vector, leading to the attenuation of their apoptosis-resistant activity. In conclusion, the data herein suggest that IL-6 regulated the mcl-1 expression via a PI 3-K/Akt-dependent pathway that may facilitate the oncogenesis of human cervical cancer by modulating the apoptosis threshold.

Phase I clinical trial of curcumin, a chemopreventive agent, in patients with high-risk or pre-malignant lesions

Curcumin (diferuloylmethane), a yellow substance from the root of the plant Curcuma longa Linn., has been demonstrated to inhibit carcinogenesis of murine skin, stomach, intestine and liver. However, the toxicology, pharmacokinetics and biologically effective dose of curcumin in humans have not been reported. This prospective phase-I study evaluated these issues of curcumin in patients with one of the following five high-risk conditions: 1) recently resected urinary bladder cancer; 2) arsenic Bowen's disease of the skin; 3) uterine cervical intraepithelial neoplasm (CIN); 4) oral leucoplakia; and 5) intestinal metaplasia of the stomach. Curcumin was taken orally for 3 months. Biopsy of the lesion sites was done immediately before and 3 months after starting curcumin treament. The starting dose was 500 mg/day. If no toxicity > or = grade II was noted in at least 3 successive patients, the dose was then escalated to another level in the order of 1,000, 2,000, 4,000, 8,000, and 12,000 mg/day. The concentration of curcumin in serum and urine was determined by high pressure liquid chromatography (HPLC). A total of 25 patients were enrolled in this study. There was no treatment-related toxicity up to 8,000 mg/day. Beyond 8,000 mg/day, the bulky volume of the drug was unacceptable to the patients. The serum concentration of curcumin usually peaked at 1 to 2 hours after oral intake of crucumin and gradually declined within 12 hours. The average peak serum concentrations after taking 4,000 mg, 6,000 mg and 8,000 mg of curcumin were 0.51 +/- 0.11 microM, 0.63 +/- 0.06 microM and 1.77 +/- 1.87 microM, respectively. Urinary excretion of curcumin was undetectable. One of 4 patients with CIN and 1 of 7 patients with oral leucoplakia proceeded to develop frank malignancies in spite of curcumin treatment. In contrast, histologic improvement of precancerous lesions was seen in 1 out of 2 patients with recently resected bladder cancer, 2 out of 7 patients of oral leucoplakia, 1 out of 6 patients of intestinal metaplasia of the stomach, I out of 4 patients with CIN and 2 out of 6 patients with Bowen's disease. In conclusion, this study demonstrated that curcumin is not toxic to humans up to 8,000 mg/day when taken by mouth for 3 months. Our results also suggest a biologic effect of curcumin in the chemoprevention of cancer.

Interleukin-6 in cervical cancer: the relationship with vascular endothelial growth factor

OBJECTIVE

Interleukin-6 (IL-6), a central proinflammatory cytokine, has been implicated in cervical cancer, though its role remains elusive. This study was an attempt to elucidate the role of IL-6 in the pathogenesis of cervical cancer, with particular emphasis on tumor angiogenesis.

METHODS

Cytosolic IL-6, vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF) levels were determined via enzyme immunoassay in 60 FIGO stage IB-IIA cervical cancer patients. Immunohistochemical staining in tissue sections was performed to analyze the distributions of IL-6 and IL-6 receptors. Meanwhile, human papillomavirus (HPV) DNA was detected by polymerase chain reaction-based survey. In vitro studies of two cervical cancer cell lines, C33A and SiHa, for the interaction between IL-6 and VEGF were also performed.

RESULTS

Consistently higher expression of IL-6 and VEGF was evident in cancerous tissues than in adjacent noncancer tissues in early-stage cervical cancer patients (P < 0.01). After recombinant human IL-6 was added, VEGF was induced in a time- and dose-dependent manner in cervical cancer cell line C33A. Correspondingly, interrupting the IL-6 autocrine machinery with either anti-IL-6 or anti-IL-6 receptor antibody markedly reduced the expression of VEGF at the transcriptional level in SiHa cells. Significantly higher levels of IL-6 in cancer tissues were observed in patients older than 45 (P < 0.01), patients with tumors >2 cm (P < 0.01), patients with oncogenic HPV-16 or -18 infections (P < 0.01), and patients with squamous cell carcinoma (P = 0.02). Patients with a deeper stromal invasion, vaginal invasion, lymphovascular emboli, or lymph node metastasis appeared to have higher intratumoral IL-6 levels, although the differences were statistically insignificant.

CONCLUSIONS

Substantially high microenvironmental IL-6 levels promote tumor angiogenesis and the development of cervical cancer. Thus, inhibition of the biological activity of IL-6 may be potentially beneficial.

Polymorphisms of GA/GT microsatellite loci from Anguilla japonica

Six novel microsatellite loci, containing (GA)(15\N17) or (GT)(10\N19) perfect tandem repeats, were isolated and characterized for the catadromous eel Anguilla japonica. The allelic size of the 6 loci ranged from 79 to 226 bp in length. All loci were polymorphic with a mean number of 14.7 alleles per locus and a mean heterozygosity of 0.67, suggesting higher polymorphism than that of freshwater and anadromous fishes, but lower than that of marine fishes. Genotype diversity of the 6 loci ranged from 0.22 to 0.61 with a mean value of approximately 0.5. Cross-species amplification showed that 5 of the 6 microsatellite primers proved to be useful in addressing questions of population genetics for all Anguilla species.

Regulation of G proteins by covalent modification

Heterotrimeric G protein alpha,beta, and gamma subunits are subject to several kinds of co- and post-translational covalent modifications. Among those relevant to G protein-coupled receptor signaling in normal cell function are lipid modifications and phosphorylation. N-myristoylation is a co-translational modification occurring for members of the G(i) family of Galpha subunits, while palmitoylation is a post-translational modification that occurs for these and most other Galpha subunits. One or both modifications are required for plasma membrane targeting and contribute to regulating strength of interaction with the Gbetagamma heterodimer, effectors, and regulators of G protein signaling (RGS proteins). Galpha subunits, including those with transforming activity, are often inactive when unable to be modified with lipids. The reversible nature of palmitoylation is intriguing in this regard, as it lends itself to a regulation integrated with the activation state of the G protein. Several Galpha subunits are substrates for phosphorylation by protein kinase C and at least one is a substrate for phosphorylation by the p21-activated protein kinase. Phosphorylation in both instances inhibits the interactions of these subunits with the Gbetagamma heterodimer and RGS proteins. Several Galpha subunits are also substrates for tyrosine phosphorylation. A Ggamma subunit is phosphorylated by protein kinase C, with the consequence that it interacts more tightly with a Galpha subunit but less well with an effector.

Cytosol vascular endothelial growth factor in endometrial carcinoma: correlation with disease-free survival

OBJECTIVE

The aim of this study was to evaluate whether vascular endothelial growth factor (VEGF) could be a marker for disease-free survival in endometrial carcinoma patients.

METHODS

Fifty-three patients with endometrial carcinoma undergoing surgery were enrolled. Clinical and pathologic items were recorded. Cytosol VEGF was quantified by enzyme immunoassay. The microvessel density (MVD) of the excised tumors was immunohistochemically assessed. The relationship among MVD, cytosol VEGF concentration of the tumor tissues, and clinicopathologic parameters was analyzed. The risk factors influencing clinical outcome were tested.

RESULTS

Higher cytosol VEGF concentrations and MVD values were noted in tumors with advanced stage (more than stage I) (917 versus 125 pg/mg, P = 0.03; 94.1 +/- 37.8 versus 60.8 +/- 38.9, P = 0.008), lymphovascular emboli (917 versus 102 pg/mg, P = 0.001; 94.4 +/- 33.2 versus 62.4 +/- 40.7, P = 0.009), and lymph node metastasis (1032 versus 95 pg/mg, P < 0.001; 116.5 +/- 30.8 versus 56.7 +/- 33.3, P < 0.001). The cytosol VEGF and MVD showed a positive linear correlation (VEGF versus MVD, r = 0.41, P = 0.003). Grade 3 tumor and overexpressed cytosol VEGF (> 800 pg/mg) are independent risk factors for recurrence. There was a trend that patients with grade 1 or 2 tumors and normal-expressed VEGF had the highest probability of disease-free survival, and patients with grade 3 tumors and overexpressed cytosol VEGF had the poorest probability of disease-free survival.

CONCLUSIONS

Cytosol VEGF had a good correlation with the disease progression and metastasis in endometrial carcinoma, and it might also be an independent prognostic factor for disease-free survival of endometrial carcinoma patients.

Carcinosarcoma of ovary associated with previous radiotherapy

Carcinosarcoma is a rare neoplasm which, in the female genital tract, arises mainly in the endometrium. Although the pathogenesis remains obscure, there is an apparent association between pelvic irradiation and uterine sarcomas. There have been sporadic case reports of the development of carcinosarcomas of the cervix, vagina, and extragenital areas, but not of the ovary, after previous pelvic irradiation. We describe a case of ovarian carcinosarcoma arising in a 74-year-old female who had pelvic irradiation 33 years previously. Exploratory laparotomy showed a 25 x 18 x 9 cm left ovarian tumor with adjacent organ invasion including peri-uterine serosa and rectum. The patient was treated by optimal cytoreduction, followed by chemotherapy with adriamycin and cisplatin. However, acute hepatitis caused by reactivation of hepatitis B virus infection developed just before the fifth course of chemotherapy. She died of hepatic failure two weeks later.

Vascular endothelial growth factor and prognosis of cervical carcinoma

OBJECTIVE

To evaluate vascular endothelial growth factor (VEGF) as a marker for predicting lymph node metastasis and an independent prognostic factor of early-stage cervical carcinoma.

METHODS

One hundred thirty-five women with stage IB-IIA cervical carcinoma had radical abdominal hysterectomies and pelvic lymph node dissections. Intratumoral cytosol VEGF concentrations were assayed with enzyme immunoassay. Histopathologic items and cytosol VEGF-influencing clinical outcomes were compared.

RESULTS

Twenty-two women (16.3%) who had disease recurrence had higher levels of cytosol VEGF (1020 versus 112 pg/mg protein, P <.001) than those without recurrence. Using a cutoff value of 400 pg/mg protein resulted in best sensitivity of 75%, best specificity of 70%, positive predictive value of 41%, and negative predictive value of 92%. Only overexpressed cytosol VEGF (hazard ratio 6.44, P <.001) was an independent prognostic factor of disease-free survival. The overexpressed cytosol VEGF (hazard ratio 4.50, P =.021) and positive lymphovascular emboli (hazard ratio 4.11, P =.045) were independent prognostic factor of overall survival.

CONCLUSION

Cytosol VEGF might be a biomarker for the status of pelvic lymph nodes in early-stage cervical carcinoma and an independent prognostic indicator of its outcome.

Strategies for amplification by polymerase chain reaction of the complete sequence of the gene encoding nuclear large subunit ribosomal RNA in corals

The nearly complete nuclear large subunit ribosomal RNA (LSU rRNA) gene in corals was amplified by primers designed from polymerase chain reaction (PCR) strategies. The motif of the putative 3'-terminus of the LSU rRNA gene was sequenced and identified from intergenic spacer (IGS) clones obtained by PCR using universal primers designed for corals. The 3'-end primer was constructed in tandem with the universal 5'-end primer for the LSU rRNA gene. PCR fragments of 3500 bp were amplified for octocorals and non- Acropora scleractinian corals. More than 80% of the Acropora LSU rRNA gene (3000 bp) was successfully amplified by modification of the 5'-end of the IGS primer. Analysis of the 5'-end of LSU rDNA sequences, including the D1 and D2 divergent domains, indicates that the evolutionary rate of the LSU rDNA differs among these taxonomic groups of corals. The genus Acropora showed the highest divergence pattern in the LSU rRNA gene, and the presence of a long branch of the Acropora clade from the other scleractinian corals in the phylogenetic tree indicates that the evolutionary rate of Acropora LSU rDNA might have accelerated after divergence from the common ancestor of scleractinian corals.

Angiogenesis of endometrial carcinomas assessed by measurement of intratumoral blood flow, microvessel density, and vascular endothelial growth factor levels

OBJECTIVE

To evaluate the relationship between blood flow in the tumor assessed by color Doppler ultrasound, microvessel density, and vascular endothelial growth factor levels in endometrial carcinoma.

METHODS

Forty-nine patients undergoing surgery for endometrial carcinoma were enrolled. Transvaginal color Doppler ultrasound was performed preoperatively and the lowest resistance index (RI) in the tumor was recorded for analysis. Vascular endothelial growth factor in the tumor was quantified by enzyme immunoassay. The microvessel density of the excised tumor was assessed immunohistochemically. The relationships between the corresponding RI, microvessel density, and vascular endothelial growth factor level of the tumor tissues and clinical and pathologic parameters were analyzed.

RESULTS

Significantly lower RIs were noted in tumors of stage II or greater (0.37 compared with 0.50, P <.001), of high histologic grade (grade 3) (0.34 compared with 0.49, P =.004), with deep myometrial invasion (one-half depth or greater) (0.39 compared with 0.49, P =.002), with lymphovascular emboli (0.38 compared with 0.49, P <.001), or with lymph node metastasis (0.30 compared with 0.49, P <.001) compared with stage I tumors and tumors of histologic grade 1 or 2, with superficial myometrial invasion, without lymphovascular emboli, or with no lymph node metastasis. Increased vascular endothelial growth factor levels and microvessel density (x200 field) also were detected in tumors of stage II or greater (975 compared with 129 pg/mg, P =.014; and 88 compared with 61, P =.018, respectively), with lymphovascular emboli (1138 compared with 120 pg/mg, P =.002; and 86 compared with 63, P =.023), or with lymph node metastasis (1011 compared with 95 pg/mg, P <.001; and 98 compared with 61, P =. 019). Resistance index, microvessel density, and vascular endothelial growth factor levels in the tumor showed linear correlations (RI compared with microvessel density: r = -.32, P =. 03; RI compared with vascular endothelial growth factor levels: r = -.40, P =.004; microvessel density compared with vascular endothelial growth factor levels: r =.36, P =.011).

CONCLUSION

Blood flow assessed by color Doppler ultrasound has histologic and biologic correlations with angiogenesis and vascular endothelial growth factor levels and might play an important role in predicting tumor progression and metastasis in endometrial carcinoma.

Altering expression of alpha3beta1 integrin on podocytes of human and rats with diabetes

The adhesion molecule integrin alpha3beta1 is the major receptor of podocyte to the glomerular capillary basement membrane (GBM). Since progressive alteration of the glomerular extracellular matrix (ECM) compartment leading to GBM thickening is common in diabetic nephropathy, we investigated the cellular distribution of alpha3beta1 integrin in podocytes of patients with diabetic nephropathy and streptozotocin-induced diabetic rats, and we evaluated the effects of high glucose on the cultured rat podocytes. Both human and rat kidneys were stained using the immunoelectron microscopy and immunoperoxidase technique with mouse monoclonal antibodies to human integrin alpha3 subunit. The results showed that both the number of immunogold particles and the staining of integrin alpha3 subunit on podocytes were weaker in patients with diabetic nephropathy than those of control kidneys. The staining of alpha3 on podocytes in the poorly-controlled diabetic rats was also weaker after one and three months of hyperglycemia. However, the staining was identical to controls in rats with only one week of hyperglycemia. High glucose (25 mM) but not streptozotocin in vitro suppressed the alpha3 expression of cultured rat podocytes. Our results demonstrated that the expression of integrin alpha3beta1 on podocytes was suppressed in both human and rats with diabetes, possibly due to the effects of hyperglycemia, and the suppression became more severe with the duration of diabetes.

Regulation of galpha i palmitoylation by activation of the 5-hydroxytryptamine-1A receptor

Nearly all alpha subunits of heterotrimeric GTP-binding regulatory proteins (G proteins) are palmitoylated at cysteine residues near the N terminus. A regulated cycle of palmitoylation could provide a mechanism for modulating G protein signaling by affecting protein interactions and localization of the subunit. In the present studies we utilized both [(3)H]palmitate incorporation and pulse-chase techniques to address the dynamics of alpha(i) palmitoylation in Chinese hamster ovary cells. Both techniques demonstrated a dose- and time-dependent change in [(3)H]palmitate labeling of alpha(i) upon activation of stably expressed 5-hydroxytryptamine-1A receptors by the agonist (+/-)-2-dipropylamino-8-hydroxy-1,2,3, 4-tetrahydronaphthalene hydrobromide (DPAT), with an EC(50) of approximately 10 nm. For the incorporation assay, DPAT elicited an approximate doubling in labeling at the earliest time point measured. For the pulse-chase assay, DPAT promoted a significant loss of radiolabel almost equally as fast. These data demonstrate that the exchange of palmitate on alpha(i) is increased upon stimulation of 5-hydroxytryptamine-1A receptors through the combined processes of depalmitoylation and palmitoylation. These results provide the basis for extending the concept of regulated exchange of palmitate beyond G(s) and provide a framework for exploring the specific functional attributes of the palmitoylated and depalmitoylated forms of subunit.

Laparoscopic cystectomy of a twisted, benign, ovarian teratoma in the first trimester of pregnancy

Adnexal torsion is an unusual, but serious complication in pregnancy. The treatment is surgical, but this may increase the risk of pregnancy loss in the first trimester. The use of laparoscopic surgery, which is less invasive than traditional laparotomy, has been limited by diagnostic and technical difficulties including determination of ovarian tumor nature and spillage of cyst contents intraoperatively. A 25-year-old woman in her 11th week of pregnancy had acute severe left lower-abdominal pain, which was diagnosed as left ovarian teratoma with torsion. She underwent emergency laparoscopic surgery with unwinding of the twisted fallopian tube and ovary and cystectomy of the teratoma. The patient subsequently delivered a full-term baby, without complications. Accurate ultrasound and cytologic diagnoses along with copious intraoperative warm, normal saline irrigation were likely contributing factors to the successful outcome of this case.

Neural and local effects of hypoxia on cardiovascular responses to obstructive apnea

Obstructive sleep apnea (OSA) acutely increases systemic (Psa) and pulmonary (Ppa) arterial pressures and decreases ventricular stroke volume (SV). In this study, we used a canine model of OSA (n = 6) to examine the role of hypoxia and the autonomic nervous system (ANS) in mediating these cardiovascular responses. Hyperoxia (40% oxygen) completely blocked any increase in Ppa in response to obstructive apnea but only attenuated the increase in Psa. In contrast, after blockade of the ANS (20 mg/kg iv hexamethonium), obstructive apnea produced a decrease in Psa (-5.9 mmHg; P < 0.05) but no change in Ppa, and the fall in SV was abolished. Both the fall in Psa and the rise in Ppa that persisted after ANS blockade were abolished when apneas were induced during hyperoxia. We conclude that 1) hypoxia can account for all of the Ppa and the majority of the Psa response to obstructive apnea, 2) the ANS increases Psa but not Ppa in obstructive apnea, 3) the local effects of hypoxia associated with obstructive apnea cause vasodilation in the systemic vasculature and vasoconstriction in the pulmonary vasculature, and 4) a rise in Psa acts as an afterload to the heart and decreases SV over the course of the apnea.

Universal Primers for Amplification of Mitochondrial Small Subunit Ribosomal RNA-Encoding Gene in Scleractinian Corals

We describe the construction of polymerase chain reaction primers designed to amplify a portion of the mitochondrial (mt) small subunit ribosomal (SSU) RNA-encoding genes in scleractinian corals. Combinations of cloning and sequencing show that the amplified fragments are between 694 and 896 bp in length. Alignment of the amplified DNA sequences to the published mt SSU rRNA genes of Metridium senile and Sarcophyton glaucum indicates several conserved regions among actiniarian, corallimorpharian, octocorallian, and scleractinians, suggesting this primer set can successfully amplify over 80% of the mt SSU rDNA region of scleractinian corals. Surveys of sequence variation and estimation of the rate of evolution show an extremely slow divergence of the SSU rRNA gene in the family Acroporidae.

Effects of arousal and sleep state on systemic and pulmonary hemodynamics in obstructive apnea

During obstructive sleep apnea (OSA), systemic (Psa) and pulmonary (Ppa) arterial pressures acutely increase after apnea termination, whereas left and right ventricular stroke volumes (SV) reach a nadir. In a canine model (n = 6), we examined the effects of arousal, parasympathetic blockade (atropine 1 mg/kg iv), and sleep state on cardiovascular responses to OSA. In the absence of arousal, SV remained constant after apnea termination, compared with a 4.4 +/- 1.7% decrease after apnea with arousal (P < 0.025). The rise in transmural Ppa was independent of arousal (4.5 +/- 1.0 vs. 4.1 +/- 1.2 mmHg with and without arousal, respectively), whereas Psa increased more after apnea termination in apneas with arousal compared with apneas without arousal. Parasympathetic blockade abolished the arousal-induced increase in Psa, indicating that arousal is associated with a vagal withdrawal of the parasympathetic tone to the heart. Rapid-eye-movement (REM) sleep blunted the increase in Psa (pre- to end-apnea: 5.6 +/- 2.3 mmHg vs. 10.3 +/- 1.6 mmHg, REM vs. non-REM, respectively, P < 0.025), but not transmural Ppa, during an obstructive apnea. We conclude that arousal and sleep state both have differential effects on the systemic and pulmonary circulation in OSA, indicating that, in patients with underlying cardiovascular disease, the hemodynamic consequences of OSA may be different for the right or the left side of the circulation.

N-Myristoylation and betagamma play roles beyond anchorage in the palmitoylation of the G protein alpha(o) subunit

Many of the alpha subunits of heterotrimeric GTP-binding regulatory proteins (G proteins) are palmitoylated, a modification proposed to play a key role in the stable anchorage of the subunits to the plasma membrane. Palmitoylation of alpha subunits from the G(i) family is preceded by N-myristoylation, which alone or together with betagamma probably supports a reversible interaction of the alpha subunit with membrane as a prerequisite to the eventual incorporation of palmitate. Previous studies have not addressed, however, the question of whether membrane association alone, carried out through N-myristoylation, interaction with betagamma, or other events, is sufficient for palmitoylation. We report here for alpha(o) that it is not. We found that N-myristoylation is required for palmitoylation at least in part because it supports events subsequent to membrane attachment. Mutants of alpha(o) designed to target the subunit to membrane without an N-myristoyl group are unable to be palmitoylated as evaluated by incorporation of [(3)H]palmitate. Mutants of alpha(o) unable to interact normally with betagamma yet still attach to membrane demonstrate that betagamma, in contrast, is not required for palmitoylation. betagamma becomes necessary, however, when the N-myristoyl group is absent. Our results suggest that N-myristoylation and betagamma, while almost certainly relevant to the reversible interaction of alpha(o) with membrane, also play at least partly overlapping, post-anchorage roles in palmitoylation.

Synthesis of 9Z,11E-octadecadienoic and 10E,12Z-octadecadienoic acids, the major components of conjugated linoleic acid

Linoleic acid was efficiently converted into the two major components of conjugated linoleic acid, 9Z,11E-octadecadienoic (1a) and 10E,12Z-octadecadienoic acid (1b) using either the superbase (n-butyllithium/potassium tert-butoxide) or by simply refluxing with KOH in 1-butanol. In turn, 1a and 1b were separated from each other using the lipase from Aspergillus niger via stereoselective esterification in 1-butanol. This enzyme has a preference for the 9Z,11E isomer, 1a, and has excellent selectivity. This method has allowed the ready preparation of gram quantities of 1a and 1b in their highly purified forms, which are not readily accessible by current methods.

Serum vascular endothelial growth factor in epithelial ovarian neoplasms: correlation with patient survival

OBJECTIVE

To investigate the relationship between serum vascular endothelial growth factor (VEGF) and clinicopathological factors and to determine whether VEGF is an independent prognostic factor of ovarian cancer patients.

METHODS

Fifty-six women with International Federation of Gynecology and Obstetrics stages I to IV epithelial ovarian cancer undergoing surgery were enrolled. Clinical and pathologic items were recorded. Pretreatment VEGF serum samples of the 56 women were measured by an enzyme-linked immunosorbent assay. The results were correlated to clinical data. The histopathologic items and serum VEGF influencing clinical outcome were evaluated comparatively.

RESULTS

The median VEGF serum level in ovarian cancer patients was 458.7 pg/mL. The 75% quatile was defined as the cutoff level. Elevated vascular endothelial growth factor serum levels before therapy correlated significantly with poorer disease-free survival (DFS) (log rank test, P = 0.001) and overall survival (OS) (log rank test, P < 0.001) on all of the 56 patients. Besides, significantly reduced DFS (log rank test, P = 0.001) and OR (log rank test, P = 0.006) were also observed on 40 patients with residual disease less than 2 cm. High histologic grade (RR = 2.24 for DFS; RR = 2.38 for OS) and elevated serum VEGF levels (RR = 3.34 for DFS; RR = 4.47 for OS) are the prognostic factors on the 56 ovarian carcinoma patients by multivariate analyses. The advanced surgical staging (RR = 3.28 for DFS; RR = 3.84 for OS), high histologic grade (RR = 2.55 for DFS; RR = 2.44 for OS), and elevated serum VEGF levels (RR = 5.62 for DFS; RR = 5.37 for OS) are the prognostic factors for 40 ovarian carcinoma patients with residual disease less than 2 cm by multivariate analyses.

CONCLUSIONS

Pretreatment VEGF serum levels might be regarded as an additional factor in predicting the outcome of ovarian cancer patients. It also could provide prognostic information in clinically relevant subsets, such as those of residual disease less than 2 cm. Anti-angiogenic therapy, if is available, might be a new treatment modality for ovarian cancer patients with poor prognosis predicted by VEGF and other clinical parameters.

Sea urchin TgBMP2/4 gene encoding a bone morphogenetic protein closely related to vertebrate BMP2 and BMP4 with maximal expression at the later stages of embryonic development

We have cloned a gene fragment (named TgBMP2/4) that encodes a protein homologous to vertebrate bone morphogenetic protein (BMP) 2 and BMP4 in the sea urchin Tripneustes gratilla. This peptide sequence contains 204 amino acids with 7 conserved cysteine residues at the C-terminus of the coding region and a cluster of basic amino acids that may serve as a signal for proteolytic cleavage. Sequence comparison and phylogenetic analyses reveal that TgBMP2/4 is closely related to vertebrate BMP2 and BMP4 as well as to amphioxus BMP2/4, with similarity levels ranging from 90% to 94% at the mature C-terminal domain. Northern blot analyses show that a 6.3-kb TgBMP2/4 mRNA appears first at the mesenchyme blastula stage and increases to a maximal level at the gastrula and pluteus stages. This expression pattern is different from that of a BMP2/4-related gene previously found in sea urchin.

Vascular endothelial growth factor in cervical carcinoma

OBJECTIVE

To quantitate vascular endothelial growth factor of cervical carcinoma and elucidate its clinical correlation.

METHODS

Intratumoral protein levels of vascular endothelial growth factor were measured in 104 cervical cancer patients and in 30 cervical tissue specimens of benign gynecologic diseases as controls. The concentrations were correlated with clinical and pathologic characteristics.

RESULTS

The median concentrations of vascular endothelial growth factor in cervical cancer tissues were higher than those in benign cervical tissues (180.0 versus 0.0 pg/mg of protein, P < .001). Tumors larger than 4 cm (1030.0 versus 118.0 pg/mg of protein, P < .001) and with deep stromal invasion (364.0 versus 111.0 pg/mg of protein, P = .016) had higher levels than those smaller than 4 cm or with superficial stromal invasion. Higher levels were also found in tumors with lymphovascular emboli (568.0 versus 118.0 pg/mg of protein, P = .006), parametrial invasion (582.0 versus 117.0 pg/mg of protein, P = .04), and pelvic lymph node metastasis (759.5 versus 121.0 pg/mg of protein, P = .002) than in those without. The protein levels of vascular endothelial growth factor correlated positively with tumor sizes (r = 0.340, P < .001). Tumors with overexpressed VEGF were larger (3.35 +/- 1.17 versus 2.13 +/- 1.28 cm, P < .001) and had higher incidence of deep stromal invasion (20 of 57 versus 6 of 47, P = .009), lymphovascular emboli (15 of 33 versus 11 of 71, P = .011), parametrial invasion (15 of 32 versus 11 of 72, P = .002), and lymph node metastasis (10 of 20 versus 16 of 84, P = .004).

CONCLUSION

Intratumoral protein level of vascular endothelial growth factor in cervical cancer tissue correlates well with local tumor progression and tumor metastasis. Vascular endothelial growth factor might be a marker for evaluating disease severity.

Influence of histologic type and age on survival rates for invasive cervical carcinoma in Taiwan

OBJECTIVE

The aim of this study was to assess survival rates and to evaluate histologic type and age as prognostic factors for cervical carcinoma in an ethnically homogenous population in Taiwan.

METHODS

A retrospective analysis was conducted of 3678 cases of squamous cell carcinoma and adenocarcinoma that were diagnosed and treated for invasive cervical carcinoma between 1977 and 1994. Observed survival rates were estimated using the Kaplan-Meier method, and prognostic factors were assessed using Cox's proportional hazards regression analysis.

RESULTS

Correlating both FIGO stage and age with histologic type revealed a higher proportion of cases with adenocarcinoma in the lower FIGO stages (P = 0.0417). Further, we found that the younger the age group the higher the proportion of cases of cervical adenocarcinoma (P = 0.0006). The 5-year survival rate was lower for patients with adenocarcinoma than for patients with squamous cell carcinoma (66.5 vs 74.0%, P = 0.0009). The 5-year survival rates for FIGO stages I, II, III, and IV squamous cell carcinoma were 81.3, 75.2, 42.7, and 26.1%, respectively, while for adenocarcinoma they were 75.9, 62.9, 29.2, and 0%, respectively. The difference in survival rates between squamous cell carcinoma and adenocarcinoma was found mainly in stage I (P = 0.0039) and stage II (P = 0.0103), where radiotherapy was used as the primary treatment. Age also affected the overall Kaplan-Meier estimate of survival. The younger the age group, the better the survival rate (P < 0.0001). Multivariate analysis confirmed a highly significant association between survival rate and both histologic type (P < 0.0001) and age (P = 0.0037).

CONCLUSIONS

Early stage cervical cancer (stages I and II) with a glandular component had a lower 5-year survival rate than squamous cell carcinoma in cases where radiotherapy was the primary treatment. We speculate that this difference in survival rates between cervical adenocarcinoma and squamous cell carcinoma was due to the relative ineffectiveness of radiotherapy as a primary treatment in cases of adenocarcinoma.

Pregnancy with primary tubal placental site trophoblastic tumor--A case report and literature review

Placental site trophoblastic tumor (PSTT) is a rare trophoblastic neoplasm with malignant potential. The diagnosis and prognosis of this rare disease remain difficult. A case of tubal PSTT with the primary manifestation of internal bleeding at 30 weeks' gestation is presented. Emergency exploratory laparotomy and right partial salpingectomy were performed initially. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were done immediately after cesarean section at 34 weeks' gestation. No further adjuvant therapy was given after surgery. No evidence of tumor recurrence or signs of metastasis were noted during 12 months of follow-up. Heterotopic pregnancy, one with intrauterine normal pregnancy and the other with implanting in the right fallopian tube and placental site trophoblastic tumor transformation, was proposed. To our knowledge, this is the first such case in the English literature.

Fast tracking in cardiac surgery: implications for practice

Even though economic incentives might have been the impetus for its revival, fast tracking offers numerous other benefits, not the least of which is improved patient care. However, its benefits can be realized only through specific perioperative management, including preoperative assessment, identification and selection of appropriate candidates, optimal intra- and postoperative management and interdisciplinary discharge planning. Through interdisciplinary collaboration, the maximum benefits of fast tracking can be reaped by both the patient and the healthcare team.

Vascularity index as a novel parameter for the in vivo assessment of angiogenesis in patients with cervical carcinoma

BACKGROUND

The importance of angiogenesis now is well recognized. Conventionally, tumor angiogenesis is assessed by determination of microvessel density (MVD) in the surgical specimen. This study examines tumor angiogenesis using power Doppler ultrasound and a quantitative image processing system. The authors hope to develop an in vivo and noninvasive method for quantitating tumor angiogenesis.

METHODS

Thirty-five patients with FIGO Stage IB-IIA cervical carcinoma exhibiting visible cervical tumors by transvaginal ultrasound were included in this study. All patients underwent radical abdominal hysterectomy and pelvic lymph node dissection. Transvaginal power Doppler ultrasound was performed before surgery to search for blood flow signals from the tumor. The intratumoral vascularity index (VI) and resistance index (RI) were calculated. The VI was defined as the number of colored pixels divided by the number of total pixels in the defined tumor section. Maximal VI and minimal RI of a certain tumor were used for analysis. Clinical and pathologic data also were recorded. The MVD of the excised tumor was assessed immunohistochemically using a monoclonal antibody against CD34.

RESULTS

Significantly higher VI values were noted in Stage II tumors compared with Stage 1 tumors (19.01+/-10.90% vs. 9.09+/-6.59%; P = 0.008), tumors invad-ing+/-50% of the cervical stroma compared with tumors invading < 50% of the cervical stroma (13.20+/-8.20% vs. 5.72+/-5.00%; P = 0.003), tumors with lymphovascular emboli compared with tumors without lymphovascular emboli (17.28+/-8.26% vs. 6.98 +/- 5.09%; P = 0.001), and tumors with pelvic lymph node metastases compared with tumors without pelvic lymph node metastases (26.16+/-7.88% vs. 8.00+/-4.95%; P = 0.021). None of the variables mentioned earlier showed a significant difference in terms of the RI values. No correlation was noted between intratumoral RI and VI in respective tumors (P = 0.53). Analysis of VI revealed linear regression with regard to tumor size (P < 0.001, correlation coefficient [r] = 0.586) and depth of stromal invasion (P = 0.002, r = 0.497). In addition, the MVD exhibited a linear relation with VI (P = 0.006, r = 0.454), tumor size (P = 0.005, r = 0.465), and depth of stromal invasion (P = 0.009, r = 0.436) using simple regression analysis. No correlation could be found between MVD and RI.

CONCLUSIONS

In cervical carcinoma, intratumoral VI assessment by power Doppler ultrasound and quantitative image processing system showed better correlation with tumor stage, tumor size, and pathologic findings including depth of stromal invasion, lymphovascular emboli, and pelvic lymph node metastases than intratumoral RI. The in vivo indicator of angiogenic activity (VI) is well correlated with the conventional indicator of tumor angiogenic activity (MVD). Thus, VI could be a useful parameter for the in vivo assessment of global tumor angiogenesis.

Preoperative ultrasound study in predicting lymph node metastasis for endometrial cancer patients

OBJECTIVE

The objective of this study was to evaluate the efficacy of preoperative ultrasound (US) findings such as tumor size, status of myometrial invasion, and intratumoral "resistance index" (RI) in predicting lymph node metastasis in endometrial carcinoma patients.

METHODS

Forty-two patients with endometrial cancer were enrolled. All patients underwent total abdominal hysterectomy, pelvic lymph node dissection or sampling, and para-aortic lymph node sampling. Two-dimensional and color Doppler US were performed before surgery to measure tumor size, depth of myometrial invasion, and intratumoral arterial RI. Formalin-fixed, paraffin-embedded pathologic slides from surgical specimens were reviewed by a senior pathologist to evaluate histologic type and grade, depth of myometrial invasion, cervical involvement, lymph-vascular emboli, and status of lymph node metastasis.

RESULTS

There were 12 patients with pelvic and/or para-aortic lymph node metastases and 30 patients without nodal metastases. Patients with tumors larger than 2.5 cm by US (11/12 vs 14/30, P = 0.008), more than half myometrial invasion by US (9/12 vs 5/30, P < 0.001), and intratumoral RI values less than 0.4 by US (12/12 vs 4/30, P < 0.001) had a significantly higher incidence of nodal metastases as compared with patients with tumors smaller than 2.5 cm, no or superficial myometrial invasion, and RI values higher than 0.4, respectively. Multiple regression analysis showed that only intratumoral RI values less than 0.4 were significantly correlated with nodal metastasis (P < 0.001, r2 = 0. 650). We used the intratumoral RI value as the parameter to evaluate nodal metastasis in endometrial cancer patients. Twelve of sixteen patients with intratumoral RI values <0.4 had a high incidence of nodal metastases. None of the 26 patients with intratumoral RI values >0.4 had nodal metastases.

CONCLUSIONS

Preoperative ultrasound features can offer important information for predicting lymph node metastasis in endometrial cancer patients. Patients with tumors with intratumoral RI values less than 0.4 should be highly suspected of having lymph node metastases and further management such as pelvic lymph node dissection or postoperative pelvic radiotherapy would be needed for these patients.

Iron and the restless legs syndrome

STUDY OBJECTIVES

Using blinded procedures, determine the relation between serum ferritin levels and severity of subjective and objective symptoms of the restless legs syndrome (RLS) for a representative patient sample covering the entire adult age range.

DESIGN

All patient records from the past 4 years were retrospectively reviewed to obtain data from all cases with RLS. All patients were included who had ferritin levels obtained at about the same time as a polysomnogram (PSG), met diagnostic criteria for RLS, and were not on iron or medications that would reduce the RLS symptoms at the time of the PSG.

SETTING

Sleep Disorders Center.

PATIENTS

27 (18 females, 9 males), aged 29-81 years.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Measurements included clinical ratings of RLS severity and PSG measures of sleep efficiency and periodic limb movements (PLMS) in sleep with and without arousal. Lower ferritin correlated significantly to greater RLS severity and decreased sleep efficiency. All but one patient with severe RLS had ferritin levels < or = 50 mcg/l. Patients with lower ferritin (< or = 50 mcg/l) also showed significantly more PLMS with arousal than did those with higher ferritin, but the PLMS/hour was not significantly related to ferritin. This last finding may be due to inclusion of two 'outliers' or because of severely disturbed sleep of the more severe RLS patients.

CONCLUSIONS

These data are consistent with those from a prior unblinded study and suggest that RLS patients will have fewer symptoms if they have ferritin levels greater than 50 mcg/l.

Clinical application of intratumoral blood flow study in patients with endometrial carcinoma

BACKGROUND

The objective of this study was to evaluate the correlation between intratumoral blood flow as assessed by color Doppler ultrasound with stage, tumor grade, depth of invasion, and lymph node metastasis in endometrial carcinoma and determine its clinical usefulness.

METHODS

Sixty-six patients with endometrial carcinoma were enrolled. All patients received surgical treatment. Transvaginal color Doppler ultrasound was performed before surgery to detect the arterial blood flow signals within the tumors and the lowest resistance index (RI) was recorded. Formalin fixed, paraffin embedded pathology slides were reviewed by a senior pathologist to evaluate the histologic grading, tumor size, depth of myometrial invasion, and presence of lymph node metastasis.

RESULTS

Intratumoral RI correlated well with surgical staging, histologic grading, the depth of myometrial invasion, and the presence of lymph node metastasis. Significantly lower RI was noted in tumors of advanced stage (> than International Federation of Obstetrics and Gynecology [FIGO] Stage I) (0.38 +/- 0.09 vs. 0.54 +/- 0.11; P < 0.001), tumors with higher histologic grade (Grade 3) (0.36 +/- 0.08 vs. 0.53 +/- 0.11; P < 0.001), tumors with deep myometrial invasion (> 50% myometrial thickness) (0.38 +/- 0.07 vs. 0.54 +/- 0.11; P < 0.001), and tumors with lymph node metastasis (0.34 +/- 0.07 vs. 0.52 +/- 0.11; P < 0.001) compared with tumors with Stage I, Grade 1/2 histology, no or superficial myometrial invasion, and absence of lymph node metastasis, respectively.

CONCLUSIONS

Intratumoral blood flow analysis assessed by color Doppler ultrasound correlates well with surgical stage, tumor grade, myometrial invasion, and lymph node metastasis in patients with endometrial carcinoma. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, histologic grade, depth of myometrial invasion, and presence of lymph node metastasis in patients with endometrial carcinoma. The authors believe routine pelvic lymph node dissection should be performed for those patients whose lowest RI values of intratumoral blood flow are < or = 0.4 because those patients are at very high risk for pelvic lymph node involvement.