A genome-wide association study of prostate cancer in Latinos

Latinos represent <1% of samples analyzed to date in genome‐wide association studies of cancer. The clinical value of genetic information in guiding personalized medicine in populations of non‐European ancestry will require additional discovery and risk locus characterization efforts across populations. In the present study, we performed a GWAS of prostate cancer (PrCa) in 2,820 Latino PrCa cases and 5,293 controls to search for novel PrCa risk loci and to examine the generalizability of known PrCa risk loci in Latino men. We also conducted a genetic admixture‐mapping scan to identify PrCa risk alleles associated with local ancestry. Genome‐wide significant associations were observed with 84 variants all located at the known PrCa risk regions at 8q24 (128.484–128.548) and 10q11.22 (MSMB gene). In admixture mapping, we observed genome‐wide significant associations with local African ancestry at 8q24. Of the 162 established PrCa risk variants that are common in Latino men, 135 (83.3%) had effects that were directionally consistent as previously reported, among which 55 (34.0%) were statistically significant with p < 0.05. A polygenic risk model of the known PrCa risk variants showed that, compared to men with average risk (25th–75th percentile of the polygenic risk score distribution), men in the top 10% had a 3.19‐fold (95% CI: 2.65, 3.84) increased PrCa risk. In conclusion, we found that the known PrCa risk variants can effectively stratify PrCa risk in Latino men. Larger studies in Latino populations will be required to discover and characterize genetic risk variants for PrCa and improve risk stratification for this population.

What's new?

There is strong evidence for a genetic predisposition to prostate cancer (PrCa). Most of this information has come from European ancestry populations, with Latinos representing less than 1% of samples in cancer genome‐wide association studies (GWAS). In this study, the majority of established PrCa risk variants (83.3%) were consistently associated with PrCa risk in Latinos. A polygenic risk score comprised of GWAS‐identified risk variants could identify 10% of Latino men with a ~three‐fold increase in PrCa risk. These findings suggest that common germline variants for PrCa can stratify risk in Latino men, which has implications for targeted screening and prevention.

Quantitative Methods to Investigate the 4D Dynamics of Heterochromatic Repair Sites in Drosophila Cells

Heterochromatin is mostly composed of long stretches of repeated DNA sequences prone to ectopic recombination during double-strand break (DSB) repair. In Drosophila, "safe" homologous recombination (HR) repair of heterochromatic DSBs relies on a striking relocalization of repair sites to the nuclear periphery. Central to understanding heterochromatin repair is the ability to investigate the 4D dynamics (movement in space and time) of repair sites. A specific challenge of these studies is preventing phototoxicity and photobleaching effects while imaging the sample over long periods of time, and with sufficient time points and Z-stacks to track repair foci over time. Here we describe an optimized approach for high-resolution live imaging of heterochromatic DSBs in Drosophila cells, with a specific emphasis on the fluorescent markers and imaging setup used to capture the motion of repair foci over long-time periods. We detail approaches that minimize photobleaching and phototoxicity with a DeltaVision widefield deconvolution microscope, and image processing techniques for signal recovery postimaging using SoftWorX and Imaris software. We present a method to derive mean square displacement curves revealing some of the biophysical properties of the motion. Finally, we describe a method in R to identify tracts of directed motions (DMs) in mixed trajectories. These approaches enable a deeper understanding of the mechanisms of heterochromatin dynamics and genome stability in the three-dimensional context of the nucleus and have broad applicability in the field of nuclear dynamics.

Abstract 1303: A genome-wide association study of prostate cancer in Latinos

Recent studies estimate that individuals of African or Latin American ancestry represent less than 4% of samples analyzed to date in genome-wide association studies. The clinical value of genetic information in guiding personalized medicine in populations of non-European ancestry will require additional discovery and risk locus characterization efforts in these populations. Here, we performed a genome-wide association study (GWAS) meta-analysis of prostate cancer in Latino men to search for risk loci that may be important in this population. We combined GWAS data for 1034 cases and 1046 controls genotyped with the Illumina 660 Beadarray with GWAS data for 1235 cases and 1053 controls genotyped with the Illumina Oncoarray as part of the ELLIPSE U19 GAME-ON Consortium. A total of ~11 million genotyped and imputed SNPs of ≥1% frequency were tested for association with prostate cancer risk in logistic regression models controlling for age, study and genetic ancestry. Genome-wide significant associations were observed with 24 variants all located at 8q24 (128.484-128.548), and which capture the first reported prostate cancer susceptibility locus in ‘region 1’ of 8q24. The most significant association genome-wide was with SNP rs7824776 (risk allele frequency, 0.35; OR=1.69, p=3.4x10-11). No novel genome-wide significant associations were noted outside of 8q24. We observed a high degree of generalizability of known prostate cancer risk loci, with 78 (76%) of the 103 known risk variants having effects that were directionally consistent in their association with prostate cancer risk as previously reported, of which 31 (30%) were statistically significant with p &lt; 0.05. In addition to these findings from the largest GWAS of prostate cancer in Latinos conducted to date, we will also present the results investigating effect heterogeneity by local ancestry (i.e. proportion Native American vs. European). In addition, we will present a comparison of polygenic risk models between Latinos, African Africans and men of European ancestry that incorporate the known risk loci to better understand how genetic risk tracks with population differences in prostate cancer incidence.

Citation Format: Hannah Hopp, Sue Ingles, Chad Huff, Xin Sheng, Brandi Weaver, Mariana Stern, Sara Strom, Ian Thompson, David Conti, Christopher A. Haiman. A genome-wide association study of prostate cancer in Latinos [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1303. doi:10.1158/1538-7445.AM2017-1303

Temporal expression of CD184(CXCR4) and CD171(L1CAM) identifies distinct early developmental stages of human retinal ganglion cells in embryonic stem cell derived retina

Human retinal ganglion cells (RGCs) derived from pluripotent stem cells (PSCs) have anticipated value for human disease study, drug screening, and therapeutic applications; however, their full potential remains underdeveloped. To characterize RGCs in human embryonic stem cell (hESC) derived retinal organoids we examined RGC markers and surface antigen expression and made comparisons to human fetal retina. RGCs in both tissues exhibited CD184 and CD171 expression and distinct expression patterns of the RGC markers BRN3 and RBPMS. The retinal progenitor cells (RPCs) of retinal organoids expressed CD184, consistent with its expression in the neuroblastic layer in fetal retina. In retinal organoids CD184 expression was enhanced in RGC competent RPCs and high CD184 expression was retained on post-mitotic RGC precursors; CD171 was detected on maturing RGCs. The differential expression timing of CD184 and CD171 permits identification and enrichment of RGCs from retinal organoids at differing maturation states from committed progenitors to differentiating neurons. These observations will facilitate molecular characterization of PSC-derived RGCs during differentiation, critical knowledge for establishing the veracity of these in vitro produced cells. Furthermore, observations made in the retinal organoid model closely parallel those in human fetal retina further validating use of retinal organoid to model early retinal development.

[Intrauterine treatment of incomplete fetal heart block in a mother with Sjögren syndrome]

BACKGROUND

Isolated fetal heart block is considered as an immunological disorder in the majority of cases. Mothers of affected fetuses often suffer from connective tissue disease (Sjögren syndrome or Lupus erythematodes). All of them test positive for anti-SS-A (anti Ro) and/or anti-SS-B (anti La) antibodies. Once established, third-degree congenital heart block is permanent and often requires a pacemaker.

CASE

We report on a pregnancy in a mother with Sjögren syndrome which was complicated by the development of incomplete fetal heart block, diagnosed by pulsed wave Doppler echocardiography. We started oral dexamethasone treatment to reduce immune-mediated fetal cardiac damage and to prevent complications like hydrops fetalis.

CONCLUSION

Detection of isolated fetal heart block is possible with pulsed Doppler sonography, but there are no clear recommendations for treatment.

Early diagnosis of conjoined twins by real-time three-dimensional ultrasound--case report and review of the literature

In 1:50 000 to 1:100 000 births, conjoined twins occur, caused by incomplete division of the embryonic disc more than 13 days after fertilisation. We present a case of cephalothoracopagus janiceps, a very rare form of conjoined twins, which was diagnosed at 13 weeks of gestation. Three-dimensional and colour Doppler ultrasound enabled precise prenatal visualisation of the fusion of the foetal head and chest up to the umbilicus. We could demonstrate the presence of two foetal hearts connected by an arterio-arterial shunt as well as two pairs of upper and lower extremities. After the clear 3-D presentation of the anomaly, making the poor prognosis visible, the mother decided to have the pregnancy terminated. Autopsy confirmed the prenatal diagnosis.

Possibilities to control the horse chestnut leaf miner (Cameraria ohridella) in urban environments

The continuous epidemic infestation of horse chestnuts by C. ohridella is a serious aesthetic and economic problem in urban environments. The aim of the presented studies was therefore to develop control measures which meet the special needs of urban plant protection. Removal of infested leaves in autumn and appropriate disposal of the leaflitter is the only practicable measure to reduce infestation levels so far. Another two methods, which are currently in an experimental stage, had an impact on the leafminer populations. A gelformulated combination of the C. ohridella-pheromone with a contact insecticide as attract-and-kill-system proved to be efficient at low population levels. Easily applicable and safe banks of systemic insecticides turned out to be effective in killing preimaginal stages of the leafminer on young trees. The complex of parasitoids attacking C. ohridella is comparable to that of other leafminers. Nevertheless, parasitism rates are very low at present and far away from having any controlling effect on the pest insect.

Prenatal Diagnosis of Isolated Foramen ovale Obstruction

Premature obstruction of the foramen ovale is a rare but serious clinical entity. Obstruction can be associated with right ventricular failure, fetal hydrops, tricuspid regurgitation, left heart obstructive defects and supraventricular tachycardia. In most cases, the diagnosis is made at the postmortem examination. The etiology is unknown. We discuss 2 prenatal cases with the sole diagnosis of ventricular asymmetry. The right ventricle was dilated and hypertrophic, and the foramen ovale ballooned into the left atrium without color Doppler detection of right-to-left flow. After delivery, the infants had no hydrops or symptoms of cardiac or respiratory distress. Echocardiography demonstrated a structurally normal heart with increased right ventricle dimensions until the 7th day of life. Delivery should be induced if possible in cases of foramen ovale obstruction with signs of cardiac decompensation.

Preeclampsia is associated with loss of neuronal nitric oxide synthase expression in vascular smooth muscle cells of the human umbilical cord

AIMS

Umbilical blood vessels are not innervated and regulation of blood flow to the placenta must depend on structural changes and the effect of vasoactive factors. Failure to achieve these adaptations may result in reduced fetoplacental perfusion. The purpose of this study was to determine whether neuronal nitric oxide synthase (nNOS) is expressed in human vascular smooth muscle cells (VSMCs) of the fetoplacental circulation. nNOS has been described as a non-endothelial NOS counterregulating vasoconstriction only in the VSMCs of animal models. Therefore, we investigated nNOS expression in the fetoplacental unit from preeclamptic and healthy pregnancies.

METHODS AND RESULTS

We investigated nNOS regulation by immunohistochemistry, Western blotting and reverse transcriptase-polymerase chain reaction analysis. nNOS activity was determined by measuring the conversion of L-3H-arginine to L-3H-citrulline. nNOS expression was revealed only in VSMCs of the human umbilical veins, but not in umbilical arteries. A more direct assessment of nNOS activity showed that a small, but consistent amount of nNOS is present in the denuded media of the umbilical vein. In VSMCs of the umbilical veins during preeclampsia a total loss of nNOS protein expression and a significant decrease in mRNA expression were seen.

CONCLUSIONS

Loss of nNOS expression is associated with preeclampsia. It may alter the regulation of blood flow in the fetal and maternal placental vasculature in preeclampsia. However, the impact of NO produced by nNOS on the vascular tone of umbilical veins remains to be elucidated.

[The impact of pregnancy-prolonging management on maternal and neonatal morbidity in HELLP syndrome]

OBJECTIVE

Until recently, delivery immediately after diagnosing HELLP syndrome was recommended due to the life-threatening risk to mother and child. Prolongation at least until lung maturation is being increasingly considered because of the high rate of premature births characterized by extreme immaturity. We investigated the influence of the time of delivery on maternal and neonatal morbidity at a gestational age of less than 34 + 0 weeks of pregnancy. -

MATERIAL AND METHODS

The disease course was reevaluated in 37 patients who developed HELLP syndrome (thrombocytes < 100 000/microl, transaminase > 70 U/l, haptoglobin < 0.5 g/l) between 1994 and 1999. An attempt was made to stabilize the mother's condition under therapeutic volume expansion. Pregnancy was terminated with the onset of a renewed HELLP episode. -

RESULTS

HELLP syndrome occurred with an incidence of 1 : 310 births. There were no maternal or neonatal deaths or any severe complications. Prolonging pregnancy until completing drug-induced lung maturity was successful in 16 of 25 patients before the 34(th) week of pregnancy. In the case of immediate delivery with inadequate stabilization, 5 of 9 patients had postpartum complications. A severe RDS occurred in 3 premature babies without drug-induced maturity. -

CONCLUSION

If there is no life-threatening risk to the fetus or mother in patients with HELLP syndrome, the objective is the prolongation of pregnancy in a perinatal center until lung maturation. Stabilization is successful in a high percentage of patients under therapeutic volume expansion with optimal monitoring of mother and child.

Culturing human umbilical cord blood: a comparison of mononuclear vs CD34+ selected cells

We compared UCB mononuclear cells (MNC) with CD34+ selected cells in a serum-free static culture system. Cell number proliferation of MNCs was inferior to CD34+ selected cells. MNCs, however, showed a substantial increase from 0.94% CD34+ cells on day 0 to 5.8% on day 7, whereas in the CD34+ selected samples the CD34+ cell content declined continously from 62.2% on day 0 to 27.7% on day 7. The number of CFU-GM increased during culture of both cell fractions. Here, only the MNCs showed a substantial increase in clonogenicity on day 7 and day 14 to 11.1- and 4.1-fold input, respectively. This expansion of the CD34+ progenitor cell pool in the MNCs fraction was at least in part attributable to T cells, since the physical abrogation of T cells blocked this effect. Refeeding and reseeding of cells on day 7 had stimulating effects especially on the CD34+ cells, where cell number proliferation increased from 16.3-fold without to 58.1-fold on day 14. Also, we could find sporadic chromosomal aberrations in four of 100 metaphases examined after 7-20 days of ex vivo expansion. The significance of this observation needs to be clarified in a larger series.

Stretch-activated cation channel in human umbilical vein endothelium in normal pregnancy and in preeclampsia

OBJECTIVE

To determine whether stretch-activated cation channels (SAC) are present in intact human umbilical vein endothelium (HUVE) and in an endothelial cell line (EA.hy) and whether they act as endothelial mechanosensors, and to determine whether endothelial SAC in HUVE from women with pregnancies complicated by preeclampsia undergo functional changes compared with those in HUVE from women with normotensive pregnancies.

METHODS AND RESULTS

By use of the patch-clamp technique we identified a SAC in intact HUVE and in an endothelial cell line. The SAC had mean conductances of 29+/-5 pS (n = 38) for K+ and 12+/-2 pS (n = 4) for Ca2+. Administration of 50 micromol/I gadolinium, a blocker of mechanosensitive ion channels, completely blocked activity of this channel. We found from single-channel recordings that influx of Ca2+ through SAC directly activated high-conductance Ca2+-dependent potassium channels, proving that a significant influx of Ca2+ through SAC occurs at physiologic concentrations of Ca2+. In a comparative study, apparent channel density of SAC (percentage of patches with SAC activity) in HUVE from women with pregnancies complicated by preeclampsia (36.2 +/- 4.3%) was twofold higher than that in HUVE from women with normal pregnancies (17.9+/-2.9%, P< 0.01). Channel conductance and sensitivity to stretching of SAC were not altered by preeclampsia.

CONCLUSIONS

Since SAC are capable of acting as endothelial mechanosensors, the greater than normal density of SAC associated with preeclampsia might reflect an alteration of mechanotransduction.

[Notch in the umbilical artery Doppler profile in umbilical cord compression in a twin]

Monoamniotic twins have a mortality rate of up to 50%, mainly due to umbilical cord accidents, e.g. true knots. Because of the rarity of monoamniotic twin gestation, few data are presently available on the optimal management of these gestations. Some authors recommend delivery at 32 weeks of gestation, while others state that the risk of cord accidents declines with advancing gestational age, thus questioning the usefulness of routine delivery at 32 weeks. It is possible nowadays to obtain an impression of the fetal blood supply by Doppler sonography. In our case, Doppler sonographic evaluation showed a notch in the umbilical artery in the twin, who later developed a pathological CTG requiring delivery at 28 weeks of gestation. Both fetuses are liveborn and developed normally. Our case shows that a notch in the umbilical artery could be an indication of umbilical cord compression and that attention should be paid to it in monoamniotic twin gestation.

Ex vivo expansion of human umbilical cord blood does not lead to co-expansion of contaminating maternal mononuclear cells

One of the main limiting factors for increased use of human umbilical cord blood (UCB) in adult allogeneic transplantation is the small number of progenitor cells that can be collected and infused. Ex vivo expansion of UCB might help to overcome this limitation. Whether an expansion of UCB cells will also lead to co-expansion of contaminating maternal cells, and thus may alter graft characteristics and lead to an increased incidence of GVHD, has not been looked at so far. We initiated cultures with UCB mononuclear cells (MNC) in a standard medium containing stem cell factor (SCF), flt-3L, II-3, IL-6, EPO and G-CSF. To address the question of contaminating maternal cells we performed interphase FISH analysis of the X and Y chromosome simultaneously. Male (XY) cord blood samples were investigated for maternal (XX) cells at day 0 and at several time points during culture. We could not detect maternal cells in any of the nine samples studied when cultures were started at day 0. Culturing did not expand previously undetected maternal cells into a range that could be seen with FISH technology, as all samples remained negative for maternal cells throughout culture periods of 14 days. We then artificially contaminated male UCB with maternal mononuclear cells at concentrations of 5 and 15% at day 0. After 14 days, maternal MNC were still detectable, but the percentage was reduced to 1.7% and 6%, respectively. During culturing of CD34+-selected UCB the content of maternal cells also declined from a mean of 1.6% after contamination to 0.4% on day 7. Taken together we could show that maternal cells co-cultured with UCB do not co-expand and thus do not interfere with ex vivo expansion of UCB for adult allogeneic transplantation.

Histochemical evaluation of placental dipeptidyl peptidase IV (CD26) in pre-eclampsia: enzyme activity in villous trophoblast indicates an enhanced likelihood of gestational hypertensive disorders

PROBLEM

To determine whether differences in placental dipeptidyl peptidase IV (DPP IV, CD26) activities occurred in hypertensive complicated pregnancies as compared with uncomplicated pregnancies.

METHOD

DPP IV activity was detected with H-Gly-Pro-4M2NA as the substrate in placental cryostat sections from 65 patients with gestational hypertension and 67 patients with uncomplicated pregnancies. The graduated intensities of the reaction product in the villous trophoblast were scored semiquantitatively by light microscopy and were related to the relative frequencies of hypertensive disorders (proportional odds model). After detection of enzyme activity, the same tissue samples were homogenized and used for kinetic fluorometric measurements.

RESULTS

Enhanced villous trophoblastic DPP IV activity was significantly associated with an increased frequency of proteinuric hypertension in pregnant women (cumulative odds ratio theta1 = 1.6; P < 0.01).

CONCLUSION

This study demonstrates for the first time that increased villous trophoblastic DPP IV activity indicates an increased likelihood of the presence and of the severity of hypertensive disorders in pregnancy.

Binding of antibodies against high and low molecular weight cytokeratin proteins in the human placenta with special reference to infarcts, proliferation and differentiation processes

Recent immunocytochemical studies have shown that placental villous trophoblasts contain the high molecular weight cytokeratin (CK) proteins 5/6 and 17. In the case of CK 17, trophoblastic immunostaining was positive in villi covered by fibrinoid. CKs 5/6 and 17 are expressed by hyperproliferative cells. The aim of this investigation was to examine the location of these CKs in placental infarcts, known to be demarcated by fibrinoid and hyperproliferative trophoblasts. The results were compared with those obtained by immunostaining against Ki-67, tenascin and alpha 1-, alpha 6- and beta 1-integrins, which are involved in cell proliferation, differentiation and regenerative processes. Furthermore, the expression of the single CKs 7, 8, 10, 13, 14, 18 and 19 was investigated by immunocytochemistry and immunoblotting. While low and high molecular weight CKs were present in villous and extravillous trophoblasts, only low molecular weight CKs were detected in vascular and extravascular placental smooth muscle cells. Placental infarcts revealed different immunoreactivities in the infarct margin and centre: high molecular CKs, tenascin, Ki-67 and oncofoetal fibronectin predominated in the infarct margin, low molecular CKs, fibrin and integrins in the centre. The expression of tenascin and a defined change in the expression of CK 17 indicates villous repair and hyperproliferative mechanisms in placental infarcts.

Interleukin-8 in urine: a new diagnostic parameter for intra-amniotic infection after premature rupture of the membranes

Interleukin-8 (IL-8), a 72 amino acid peptide secreted by cells of the immune system and of the amnion, chorion and decidua, was measured in women in late pregnancy. IL-8 was detected in the urine of 91 of 104 women with premature rupture of the fetal membranes, with values exceeding 1000 ng/L in cases of severe intra-amniotic infection. Women with urinary tract infections were excluded. The routine measurement of IL-8 in urine, together with C-reactive protein in serum, thus provides a low risk and technically simple approach to the assessment of intra-amniotic infection.

[Coincidence of pulmonary cryptococcoma in an immunocompetent patients with a chondrohamartoma and chronic tuberculoma--differential diagnostic considerations concerining pulmonary coin lesions]

Of primary importance in the differential diagnosis of multiple circular foci in the lungs are the lung metastases. This study involves a patient with three circular foci, each of which could have been metastases. They proved, however, to be a rare coincidence of three benign lung affections, namely, an old tuberculoma, a chondrohamartoma, and a seldom encountered pulmonary cryptococcoma. Computerized tomography utilizing the spiral technique was valuable diagnostically, as it led to the discovery of the smallest of the three circular foci in the basodorsal left lower lobe. The form of the cryptococcosis among immunocompetent patients--only rarely localized in our experience--must be included in the differential diagnostical considerations of a circular focus in the lungs. In the event there are multiple circular foci with an unknown primary tumor, surgical intervention with a pathohistological clarification regarding a possible malignancy is absolutely necessary.

[Insulin-like-growth-factor-binding-protein 1 (IGFBP-1) and fetal fibronectin in diagnosis of premature rupture of fetal membranes]

The diagnosis of a premature rupture of membranes presents no problem in the vast majority of cases. However, a reliable diagnosis is clinically not possible in about 10%. Most methods available lack the necessary sensitivity and specificity. Since the clinical consequences of a false diagnosis are considerable (overtreatment for false-positive and risk of infection for false-negative results), it is essential to clinically establish new, minimally invasive methods with higher predictive powers. In the present study we compared: the AMNI Check for detection of insulin-like growth-factor binding protein 1 (IGFBP-1); a membrane immunoassay for detection of fetal fibronectin (fFn); pH indicator paper; and, to verify a rupture of membranes in unclear cases, amniocentesis with installation of indigo carmine. The examination was performed in a group of 75 patients, 35 with and 40 without rupture of the membranes. The best results were obtained for the AMNI Check (sensitivity and negative correctness 100%, specificity and positive correctness 83%). With the same sensitivity and negative correctness, the membrane immunoassay for fFn achieved a specificity of 70% and a positive correctness of 74%. The pH indicator paper had the lowest predictive value (sensitivity 94%, negative correctness 93%, specificity 63%, positive correctness 69%). Both the AMNI Check and the test for detection of fetal fibronectin can be recommended for reliable exclusion of premature rupture of membranes. Amniocentesis should however be performed in uncertain cases with a positive test result. Nevertheless, considerable reduction of this invasive method is possible.

Expression of inducible nitric oxide synthase in placenta of women with gestational diabetes

Gestational diabetes is one of the most prevalent medical complications of pregnancy and causes increased fetal wastage. Investigation of placentas from diabetic mothers indicate chronic disturbances in intervillous, circulation, dilatation of capillaries, and a relatively immature villous structure. Abnormal levels of nitric oxide (NO) may contribute to maternal disorders such as the pathogenesis of diabetic vascular complications. In the normal placenta NO is generated only by endothelial NOS, which apparently serves to regulate vascular tone in the fetoplacental circulation. In contrast, studies have reported the absence of inducible nitric oxide synthase (iNOS) in human placentas under normal conditions. The aim of our study was to investigate whether iNOS is expressed in placentas from patients with gestational diabetes. Reverse transcription-polymerase chain reaction and Western blot analysis demonstrated iNOS mRNA and protein expression in placental tissue only from patients with gestational diabetes. Immunohistochemistry localized iNOS staining to endothelial cells and trophoblasts. We conclude that iNOS can be expressed in human placenta. Its expression might play an important role in placental pathophysiology.

Histochemical evaluation of placental angiotensinase A in pre-eclampsia: enzyme activity in villous trophoblast indicates an enhanced likelihood of gestational proteinuric hypertension

The aim of this study was to examine whether differences in placental angiotensinase A (glutamyl aminopeptidase, EC 3.4.11.7) activities occurred in hypertensive complications of pregnancy compared with uncomplicated pregnancies. Biochemical and semiquantitative histochemical methods were used and compared for their applicability. Angiotensinase A activity was detected using L-alpha glutamyl-4-methoxy-2-naphthylamide (alpha-Glu-MNA) as substrate and Fast Blue B salt for simultaneous azo-coupling in cryostat sections of placental tissue samples from 32 patients with pre-eclampsia, 11 patients with pregnancy-induced hypertension and 44 participants with uncomplicated pregnancies. The graduated intensity of reaction product in the villous trophoblast and in fetal blood vessels was evaluated semiquantitatively in a double-blind study by light microscopy (semiquantitative score method). Score levels were related to relative frequencies of hypertensive disorders (proportional odds model) and correlated to the severity of gestational hypertension (Spearman's rank correlation). After detection of enzyme activity, the same tissue samples were homogenized and used for kinetic fluorometric measurements under the same substrate and buffer conditions as in enzyme histochemistry. Enhanced villous trophoblastic angiotensinase A activity was significantly associated with an increased frequency of pre-eclampsia in pregnant women (cumulative odds ratio x 0(1) 6.37; P < 0.001) and showed significant correlations with the severity of gestational hypertensive disorders, represented by systolic (r = 0.31; P < 0.05) and diastolic (r = 0.34; P < 0.05 blood pressure and by concomitant proteinuria (r = 044; P < 0.01). Histochemical evaluation of fetal blood vessels and biochemical measurements revealed no statistically significant results. In conclusion this study demonstrates for the first time that increased villous trophoblastic angiotensinase A activity indicates an increased likelihood of the presence of pre-eclampsia and the severity of hypertensive disorders in pregnancy.

Indication and results of insulin therapy for gestational diabetes mellitus

The aim of this study was to determine whether amniotic fluid insulin concentration (AFI) is a better parameter than mean maternal blood glucose values (MBG) for deciding about insulin therapy in patients with gestational diabetes. MBG's were calculated on the base of 9 blood glucose levels during a 24 hour period after one week of diet therapy. In a prospective trial between 1987 and 1989 in Karlsburg, 123 gestational diabetic patients were randomized into two groups. Treatment was either based on the concentration of AFI or MBG levels. In a second series in Berlin, 103 patients were offered amniocentesis. 81 patients agreed and 22 refused. Treatment was then analogous to that in Karlsburg. In both groups of the randomized population, strict metabolic control was achieved. There was no difference regarding pregnancy complications. Earlier labor induction and higher cesarean section rates were seen in the non-invasive group (p < 0.05). The incidence of diabetic fetopathy and neonatal hypoglycemia was significantly lower in the invasive group (p < 0.01), even though the metabolic control parameters did not differ between the two groups. The results in Berlin correspond to these findings. In conclusion, AFI enables the recognition of any hyperinsulinism reaction to the maternal metabolic situation. We recommend the additional measurement of the AFI concentration between 28 and 36 weeks as the direct fetal parameter for deciding about insulin treatment.

Successful emergency splenectomy during pregnancy in a patient with life-threatening idiopathic thrombocytopenia. Case report

Thrombocytopenia can be a pathophysiological feature of pregnancy. In the case reported, the thrombocyte count was reduced to 1% of normal (1 x 10(9) thrombocytes/l) at 28 weeks of gestation. In chronological order, the patient showed epistaxis, macrohematuria and gingival, conjunctival, intracerebral and pulmonary bleeding. The latter was life-threatening. An emergency splenectomy was undertaken, without complications. The operation was followed by a massive increase in the thrombocyte count, reaching 200 x 10(9)/l four days later. Unfortunately, a premature rupture of the membranes, with signs of amnion infection, occurred on the seventh day. A Cesarean section was undertaken (30 weeks of gestation), without complications. Both mother and baby are in good health 10 months later. The newborn had a normal thrombocyte count at delivery and thereafter. The life-threatening hemorrhage of the mother, the delivery of an unaffected baby and the relatively quick remission after splenectomy suggest an upregulated destruction of thrombocytes by the maternal spleen. The increased level of Macrophage-Colony Stimulating Factor (M-CSF), a normal feature of pregnancy, has the potential to augment thrombocyte destruction by activating macrophages. The production of anti-thrombocyte antibodies, especially if localized in the spleen, could result in increased thrombocyte sequestration by macrophages with severe effects focused on the mother.

[Cystosarcoma phylloides of the breast. A retrospective analysis of 12 cases]

INTRODUCTION

Phyllodes tumours, also known as cystosarcoma phyllodes (CSP), are rare fibroepithelial tumours with an incidence of 0.3-1.0% of all breast neoplasms. CSP tends to recur locally and metastasizes haematogenously. The treatment of CSP remains controversial. The present study demonstrates the recent experiences in diagnosis, therapeutical management and clinical follow-up of this disease.

MATERIALS AND METHODS

Twelve female patients who developed CSP from 1982 to 1994 were recalled for clinical assessment and examined for local recurrence or metastatic disease. All histological samples from cases of CSP were evaluated by a single pathologist who was blinded to the patients' histories. The tumours were classified according to international criteria of three types of tumour status: benign CSP, borderline type tumours and malignant tumours.

RESULTS

The average age of disease was 46 years. Three patients had benign tumours. There was one borderline type of tumour and eight malignancies. Six patients with malignant CSP underwent mastectomy and axillary dissection. In two cases of malignant CSP simple mastectomy was performed. In two cases of malignancy the operation was followed by radiation therapy. The borderline type of tumour and the benign CSP were treated by tumour removal, segmental resection or subcutaneous mastectomy. In one case of benign CSP two more benign recurrencies ocurred 18 months after the initial operation. Preoperative determination of the tumour marker CEA was normal. The tumour marker CA 15-3 was only elevated in one case. The growth fraction varied from 5-40%. In 8/8 patients the oestrogen and progesterone receptors were negative. We could not find any correlation between the development of cystosarcoma phyllodes and oral contraceptives, nicotine use, diabetes mellitus, age of menarche, allergies, or family history of cancer.

CONCLUSION

The clinical finding of a large, firm, non-tender, well-defined, mobile tumour with gradual growth should lead to a suspicion of a phyllodes tumour. Our results and the review of the current literature lead to the following therapeutic recommendations: 1. Benign phyllodes tumour warrants wide local excision with a 2 cm tumour-free zone. 2. Borderline malignant phyllodes tumours should be treated via simple mastectomy. 3. Axillary dissection is recommended only if nodes are palpable. 4. Adjuvant radiation is necessary, if wide local spread of the tumour is present and a resection of the lesion with a 2 cm tumour-free zone is not possible. Close follow-up is mandatory.

[Diagnostic reliability of vaginal ultrasound in ectopic pregnancy]

The therapeutic approach to ectopic pregnancy (EP) has changed over the last decade. A prerequisite for a differentiated management is an early diagnosis of EP. This can be achieved by transvaginal sonography (TVS). The purpose of this study was to evaluate the accuracy of TVS in the diagnosis of EP. 184 patients with clinically suspected ectopic pregnancy were examined by TVS. In 103 cases suspicion of EP was confirmed, in 81 cases it was ruled out. All cases were evaluated by laparoscopy, D&C, serial HCG determinations or sonographic follow-up in case of an intrauterine pregnancy. Sensitivity of TVS in the diagnosis of EP was 96%, specificity 88%, the positive predictive value was 89%, the negative predictive value was 95%. Four cases with a false negative result at TVS were very early in pregnancy and were subjected to laparoscopy because of persistent high HCG values without demonstration of an intrauterine pregnancy. Five cases of sonographically confirmed ectopic pregnancies were missed by the first laparoscopy. These cases required intervention because of clinical symptoms and had low levels of HCG. TVS has a high diagnostic accuracy in the diagnosis of ectopic pregnancy.

[Management of premature rupture of fetal membranes in obstetrical departments in Germany]

Since the treatment of premature ruptures of membranes is not only controversial in the German but also in the international literature, we performed a survey of all obstetrics departments in Germany. From a total of 843 hospitals, 444 questionnaires were returned for evaluation (52.7%). The purpose was to determine which diagnostic and therapeutic regimes are used and how these agree with the literature. In addition to questions on the type of hospital, birth rates with a percentage of premature births and applied diagnostic parameters, our special interest focused on therapy, particularly with regard to prophylactic antibiotic application, tocolytic treatment and lung maturity induction. Prophylactic antibiotics are used in 36.7% and prophylactic tocolytic therapy in 41.7% of the departments. Interestingly, lung maturity induction was performed in 93.5%, in part even before the 28th week of pregnancy, although the effect of this therapy has not yet been proven at a very early stage of gestation. Due to the different views in the literature and, in part, a lack of basic scientific data, it seems there is a preference for the procedure, in which the best personal experience has been made. Because premature ruptures of the membranes is responsible for 30-40% of premature births, it is urgently necessary to clarify this controversial problem by large multicenter studies so that the treatment of early premature ruptures of the amnion can be founded on a rational basis.

Antibodies to cytokeratins bind to epitopes in human uterine smooth muscle cells in normal and pathological pregnancies

Cytokeratin antibodies have been widely used for the identification of trophoblast cells in the placental bed, following their invasion from the developing conceptus. Their identification centres upon the expression of cytokeratin in epithelial cells, from which trophoblast cells are derived. Our recent observations indicate that this strict relationship may be more complex than was thought. Cryostat and paraffin sections of human decidua and myometrium, taken from the placental bed and the uterotomy cut, were examined immunocytochemically for cytokeratins using ten antibody clones selected to identify different cytokeratin proteins and antigenic epitopes. Biopsy specimens were obtained from normal and pathological pregnancies (pre-eclampsia, fetal retardation, amnioninfection, hysterorrhexis, placenta praevia) at the time of caesarean section (26-41 weeks of pregnancy). Antibodies against nine clones, CAM 5.2, MNF 116, AE1/AE3, CK5, KS-B17.2, CY-90, M20, E3, and 34 beta E12 identified, as expected, syncytial giant cells and mononuclear trophoblasts within the placental bed and glandular epithelial cells throughout the uterus. In addition, they stained numerous fusiform cells that were classified by established criteria to represent smooth muscle cells, both within blood vessels and myometrium. No staining differences were observed between normal and pathological disorders. These results indicate that cytokeratin antibodies CAM 5.2, MNF 116 and AE1/AE3, and other antibodies targeting proteins 8 and 18, cross-react with epitopes expressed in cells other than giant trophoblastic cells and mononuclear trophoblasts in the uterus and, thus, caution has to be used when such antibodies are used for the diagnostic characterization of tissues related to the placental bed.

[Diabetic retinopathy and nephropathy--complications in pregnancy and labor]

The purpose of this retrospective study was to determine the risk factors for the morbidity of the mothers and their fetus in patients with diabetic retinopathy and/or nephropathy with an open family planning. We compared the course of pregnancies, complications as well as the maternal and neonatal morbidity in 76 patients with diabetic retinopathy or nephropathy (White R F) with 85 patients without severe microangiopathy (White C D). We found a correlation between retinopathy progression and hyperglycaemia during the first trimester (p < 0.05). There was an increase in the deterioration of visual acuity up to blindness due to the progression of this microangiopathy in cases of proliferative retinopathy. There was a significant increase of the mean diastolic blood pressure (mdp) and preeclamptic symptoms occurred in 71% of the cases with severe microangiopathy (p < 0.05). Deterioration of the diabetic nephropathy with excessive proteinuria (> 10 g/d) and unmanageable hypertension or a progression of the retinopathy led to an earlier delivery in 80% of the patients (p < 0.05). A high rate of preterm deliveries (39%) and a frequent occurrence of intrauterine growth retardation's (9%) characterised the fetal outcome. The following examinations for a patient with an open family planning, if diabetes is diagnosed during childhood or the course of the disease is between 10 and 15 years, should be done: Ophthalmological evaluation, control of the renal function, contraceptive advice and an improvement of the metabolic situation. In case of a diabetic nephropathy in combination with hypertonus the patients shoud be warned against pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

[An unusual series of complications in therapy with implantable cardioverter-defibrillator]

A 48-year-old man with dilative cardiomyopathy and a history of resuscitation due to ventricular fibrillation received an implantable cardioverter-defibrillator (ICD) with epicardial sensing and defibrillation electrodes in March 1990. An early battery depletion due to increased electrical leakage of a filter capacitor necessitated a generator exchange in July 1990. Subsequent inappropriate discharges occurred, but no underlying cause could be documented by history, clinical examination, Holter monitoring, and beepograms. Only 3 months later was it possible to demonstrate oversensing by repeated beepograms, and a new generator and transvenous sensing electrode were implanted in October 1991. Four months later, inappropriate shocks were suspected again. Once more, history, clinical examination, Holter monitoring, and beepograms were without pathological result. At follow-up, repeated beepograms during exercise demonstrated an oversensing, and an insulation defect of the newly implanted sensing electrode close to the edge of the generator could be documented on x-ray. Since replacement of generator and sensing electrode in July 1992 the patient is doing well. He received two appropriate shocks which were associated with presyncope. ICD therapy is very complex and therefore should only be performed in centers providing the necessary personal, apparative and logistic conditions.