Evaluation of incision healing status after transverse uterine fundal incision for cesarean delivery and postoperative pregnancy: a ten-year single-center retrospective study

BACKGROUND

Transverse uterine fundal incision (TUFI) is a beneficial procedure for mothers and babies at risk due to placenta previa-accreta, and has been implemented worldwide. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. We therefore evaluated the TUFI wound scar to determine the approval criteria for pregnancy after this surgery.

METHODS

Between April 2012 and August 2022, we performed TUFI on 150 women. Among 132 of the 150 women whose uteruses were preserved after TUFI, 84 women wished to conceive again. The wound healing status, scar thickness, and resumption of blood flow were evaluated in these women by magnetic resonance imaging (MRI) and sonohysterogram at 12 months postoperatively. Furthermore, TUFI scars were directly observed during the Cesarean sections in women who subsequently conceived.

RESULTS

Twelve women were lost to follow-up and one conceived before the evaluation, therefore 71 cases were analyzed. MRI scans revealed that the "scar thickness", the thinnest part of the scar compared with the normal surrounding area, was ≥ 50% in all cases. The TUFI scars were enhanced in dynamic contrast-enhanced MRI except for four women. However, the scar thickness in these four patients was greater than 80%. Twenty-three of the 71 women conceived after TUFI and delivered live babies without notable problems until August 2022. Their MRI scans before pregnancy revealed scar thicknesses of 50-69% in two cases and ≥ 70% in the remaining 21 cases. And resumption of blood flow was confirmed in all patients except two cases whose scar thickness ≥ 90%. No evidence of scar healing failure was detected at subsequent Cesarean sections, but partial thinning was found in two patients whose scar thicknesses were 50-69%. In one woman who conceived seven months after TUFI and before the evaluation, uterine rupture occurred at 26 weeks of gestation.

CONCLUSIONS

Certain criteria, including an appropriate suture method, delayed conception for at least 12 months, evaluation of the TUFI scar at 12 months postoperatively, and cautious postoperative management, must all be met in order to approve a post-TUFI pregnancy. Possible scar condition criteria for permitting a subsequent pregnancy could include the scar thickness being ≥ 70% of the surrounding area on MRI scans, at least partially resumed blood flow, and no abnormalities on the sonohysterogram.

TRIAL REGISTRATION

Retrospectively registered.

A novel extraperitoneal cesarean section of supravesical approach: Operative techniques

AIM

We have established a novel extraperitoneal cesarean section technique by supravesical approach. An advantage of this technique over the conventional paravesical approach is that the lower uterine segment is broadly exposed and that all operative procedures can be performed under direct vision. We present the details of this novel technique.

METHODS

The bladder and the peritoneum are exposed by removing the transversalis and extraperitoneal fasciae. Subsequently, a triangular area between the median umbilical ligament, the peritoneum, and the bladder is exposed. The median umbilical ligament is dissected at this site. Bladder dissection from the peritoneum is also initiated from this area and proceeds toward the lower uterine segment.

RESULTS

Operative times for pelvic fascia dissection and bladder removal from the peritoneal surface are currently around 15-25 min. During the process of development of this technique, there have been no bladder injuries in 501 patients that caused urine leakage.

DISCUSSION

The supravesical approach has been considered difficult due to the strong adhesion between the perivesical fascia and the peritoneum at the bladder fundus. In this paper, we show how to safely remove the bladder fundus from the peritoneum. The bladder can then be easily lowered down toward the lower uterine segment. Although this technique allows the lower uterine segment to be broadly exposed and all operative procedures can be performed under direct vision, a disadvantage is the comparatively long time currently required to perform it.

CONCLUSIONS

This technique could be a valuable option for extraperitoneal cesarean section, but disadvantages must also be considered.

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis

AIM

Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation).

METHODS

Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed.

RESULTS

25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes.

CONCLUSIONS

Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

Association of Pharmacist-led Deprescribing Intervention with the Functional Recovery in Convalescent Setting

So far, no studies investigated the association between pharmacist intervention and rehabilitation outcomes. The aim of study was to establish whether the pharmacist-led deprescribing intervention affects rehabilitation outcomes. This retrospective, observational, single-center, cohort study included consecutive geriatric patients (n = 448) with pharmacist-led intervention between 2017 and 2019. Participants were divided based on pharmacist-led deprescribing and non deprescribing interventions during hospitalization. Demographic data, laboratory data, the Functional Independence Measure were (FIM) analyzed between the groups. Multiple linear regression analysis was performed to analyze the relationship between pharmacist-led deprescribing and FIM total gain. The primary outcome was FIM total gain. The rate of pharmacist intervention during the study period was 92.4%. A multiple linear regression analysis of FMI-T gain, adjusting for confounding factors, revealed that the pharmacist-led deprescribing intervention was independently correlated with FMI-T gain. Particularly, the use of dyslipidemia drugs, antipsychotic drugs, hypnotics, and nonsteroidal anti-inflammatory drugs significantly decreased during hospitalization. The pharmacist-led deprescribing intervention was independently and significantly associated with FIM-T gain. The pharmacist-led deprescribing intervention improved functional recovery in a rehabilitation setting.

Difficult maintenance of serum drug concentration in methicillin-resistant Staphylococcus aureus toxic shock syndrome during early puerperium

Toxic shock syndrome can be caused by methicillin-resistant Staphylococcus aureus (MRSA). During puerperium this condition is rare, and proper treatment during this period has not been clarified. Two patients developed toxic shock syndrome caused by MRSA soon after cesarean section. Despite the administration of antibiotics, both developed severe conditions and one of them required hysterectomy. The dosage was adjusted in the same way as nonpregnancy, but the actual drug concentration was significantly different from expectation. When there is severe infection during the early postpartum period, maintaining drug concentration at optimal levels may be difficult, and this could be life-threatening. Better understanding of the pharmacokinetics and establishment of a method to determine the optimal drug dose during puerperium is required.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

One-time umbilical cord milking after cord cutting has same effectiveness as multiple-time umbilical cord milking in infants born at <29 weeks of gestation: a retrospective study

OBJECTIVE

To compare two strategies to potentiate the effects of placental transfusion in infants born at <29 weeks of gestation.

STUDY DESIGN

Twenty infants who received one-time umbilical cord milking after umbilical cord cutting were compared with 20 infants from a previous study group who received multiple-time umbilical cord milking. The primary outcome measurements were the probability of not needing a red blood cell (RBC) transfusion during the hospital stay and the total number of RBC transfusions within 21 days after birth.

RESULT

There was no significant difference in the probability of not needing a transfusion during the hospital stay (P=0.75) and the mean number of RBC transfusions given within the first 21 days of life (1.1±1.8 for the one-time umbilical cord-milking group vs 0.7±1.2 for the multiple-time umbilical cord-milking group, P=0.48).

CONCLUSION

One-time umbilical cord milking after umbilical cord cutting had similar beneficial effects to multiple-time umbilical cord milking before umbilical cord cutting in very premature infants.

Obesity and survival among women with ovarian cancer: results from the Ovarian Cancer Association Consortium

Background:

Observational studies have reported a modest association between obesity and risk of ovarian cancer; however, whether it is also associated with survival and whether this association varies for the different histologic subtypes are not clear. We undertook an international collaborative analysis to assess the association between body mass index (BMI), assessed shortly before diagnosis, progression-free survival (PFS), ovarian cancer-specific survival and overall survival (OS) among women with invasive ovarian cancer.

Methods:

We used original data from 21 studies, which included 12 390 women with ovarian carcinoma. We combined study-specific adjusted hazard ratios (HRs) using random-effects models to estimate pooled HRs (pHR). We further explored associations by histologic subtype.

Results:

Overall, 6715 (54%) deaths occurred during follow-up. A significant OS disadvantage was observed for women who were obese (BMI: 30–34.9, pHR: 1.10 (95% confidence intervals (CIs): 0.99–1.23); BMI: ⩾35, pHR: 1.12 (95% CI: 1.01–1.25)). Results were similar for PFS and ovarian cancer-specific survival. In analyses stratified by histologic subtype, associations were strongest for women with low-grade serous (pHR: 1.12 per 5 kg m⁻²) and endometrioid subtypes (pHR: 1.08 per 5 kg m⁻²), and more modest for the high-grade serous (pHR: 1.04 per 5 kg m⁻²) subtype, but only the association with high-grade serous cancers was significant.

Conclusions:

Higher BMI is associated with adverse survival among the majority of women with ovarian cancer.

Time to first cigarette and lung cancer risk in Japan

BACKGROUND

Cigarette smoking is the major cause of lung cancer (LC). Although the time to first cigarette (TTFC) of the day is a distinct indicator of nicotine dependence, little information is available on its possible relation to LC.

PATIENTS AND METHODS

This case-control study includes a total of 1572 incident LC cases and 1572 non-cancer controls visiting for the first time the Aichi Cancer Center Hospital between 2001 and 2005. We estimated the odds ratio (OR) and 95% confidence interval (CI) for TTFC using a logistic regression model after adjustment for several potential confounders.

RESULTS

TTFC was inversely associated with the risk of LC. This association was consistent across histological subtypes of LC. For all LCs considered among ever smokers and after accurate allowance for smoking quantity and duration, besides other relevant covariates, compared with TTFC >60 min, the adjusted ORs were 1.08 (95% CI, 0.73-1.61) for TTFC of 31-60 min, 1.40 (0.98-2.01) for 6-30 min and 1.86 (1.28-2.71) for within 5 min (Ptrend, < 0.001). Statistically marginally significant heterogeneity by histological subtype was observed (Pheterogeneity, 0.002).

CONCLUSIONS

Nicotine dependence, as indicated by the TTFC, is associated with increased risk of LC and is therefore an independent marker of exposure to tobacco smoking.

Reproductive and hormonal risk factors for luminal, HER2-overexpressing, and triple-negative breast cancer in Japanese women

BACKGROUND

Although the clinical relevance of the molecular subtypes of breast cancer is evident, etiological differences among subtypes have not been well established, especially among Asian. Here, we evaluated the hypothesis that the etiologic impact of reproductive and hormonal features differs among molecular subtypes.

MATERIALS AND METHODS

We conducted a case-control study in pre- and postmenopausal Japanese. We examined 706 breast cancer patients and 1412 age- and menopausal status-matched noncancer controls. Immunohistochemical stains for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) were used to classify the cases into 554 luminal (hormone receptor positive), 84 HER2-overexpressing (hormone receptor negative, HER2 positive), and 68 triple-negative cases (hormone receptor negative, HER2 negative). Associations were evaluated using multivariate polytomous logistic regression models.

RESULTS

A significant association was observed between early age at menarche and risk of luminal disease (odds ratios = 1.67, 95% confidence interval: 1.22-2.29; P trend = 0.001). No significant differences in association with parity, age at first live birth, breastfeeding history, age at menopause, or synthetic hormonal use were seen across molecular subtypes of breast cancer.

CONCLUSIONS

These findings indicate that reproductive events in adolescence have differential impact on the risk of breast cancer molecular subtypes in Japanese.

Genetic polymorphism of IGF-I predicts recurrence in patients with gastric cancer who have undergone curative gastrectomy

BACKGROUND

To our knowledge, no reports have evaluated the effects of genetic polymorphisms of insulin-like growth factor-I (IGF-I) on clinical outcomes of gastric cancer patients.

METHODS

We retrospectively analyzed the impact of IGF-I polymorphisms on recurrence-free survival (RFS) in 430 patients with gastric cancer who underwent curative gastrectomy between 2001 and 2005 in our institution.

RESULTS

Among the 430 gastric cancer patients, 345 were pathological stage I or II, while 85 were stage III or IV. The median 5-year RFS rate was 85.3% (95% confidence interval [CI] 81.4-88.5). In a multivariate Cox model (adjusted for age, gender, histology, pathological stage, adjuvant chemotherapy, and history of diabetes), two IGF-I polymorphisms, rs1520220 and rs2195239, were significantly associated with RFS (hazard ratio [HR] 0.60, 95% CI 0.40-0.91; and HR 0.60, 95% CI 0.41-0.89, respectively, in a per-allele model). When stratified by stage (I-II versus III-IV), rs1520220 in particular was associated with RFS in patients with stage III-IV disease, with a P-value for interaction of 0.01.

CONCLUSIONS

Our findings indicate that genetic polymorphisms of IGF-I may have a substantial effect on recurrence for gastric cancer patients who have undergone curative gastrectomy. This information may help identify population subgroups that could benefit from IGF-I-targeting agents.

Association between dietary folate intake and clinical outcome in head and neck squamous cell carcinoma

BACKGROUND

The association between dietary folate intake, two polymorphisms in methylenetetrahydrofolate reductase (MTHFR) and thymidylate synthase (TYMS), and survival in head and neck squamous cell carcinoma (HNSCC) patients is not clarified.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 437 HNSCC patients treated at Aichi Cancer Center. We evaluated the survival impact of pretreatment dietary folate intake, which was estimated using a food-frequency questionnaire, and two polymorphisms, MTHFR C677T and a 6-bp insertion/deletion in the 3'-untranslated region of TYMS, using multivariate proportional hazard models.

RESULTS

Patients with high folate intake (≥320 μg/day; n=144) had significantly higher survival than patients with low or medium folate intake (<320 μg/day; n=278; 79.1% versus 68.2%, respectively, P=0.020). This association was consistent with multivariate analyses adjusted for established prognostic factors (hazard ratio 0.56; 95% confidence interval 0.37-0.84). MTHFR and TYMS polymorphisms did not show significant association with survival, although the TYMS 6-bp insertion allele showed potential association with a reduced risk of death. Notably, no significant interaction was observed between folate intake and the two examined polymorphisms.

CONCLUSIONS

High pretreatment dietary folate intake was identified as an independent prognostic factor associated with improved clinical outcomes in HNSCC patients. Further study is warranted.

P1-09-04: A Genetic Predictor for Breast Cancer Risk in a Japanese Population

Objective Genome-wide association studies (GWASs) have identified genetic variants associated with breast cancer. Most GWASs to data were conducted in women with European background and the extent to which these variants contribute as predictors of breast cancer among Japanese population is unknown.

Methods We analyzed 24 genetic variants that have been identified in previous GWASs and conducted a case-control study with 697 cases and age- and menopausal status- matched 1394 controls in the framework of the Hospital-based Epidemiologic Study at Aichi Cancer Center (HERPACC). All subjects were asked to provide information on lifestyle factors and blood samples for genetic studies. We fit conditional regression models with genetic variants and conventional risk factors including age, age at menarche, menopausal status, current body-mass-index, age at first live birth, regular exercise, family history of breast cancer, and referral pattern to our hospital. In addition, we created a polygenetic risk score, using the single nucleotide polymorphisms (SNPs) with statistically significant association with the breast cancer risk to measure the cumulative effect of multiple genetic risk variants. Furthermore, we evaluated the prediction model that included conventional risk factors by comparing with and without the genetic risk score, using c statistic.

Results Eleven SNPs (FGFR2-rs2981579, rs2981578, rs1219648, rs2420946, rs2981582, TOX3/TNRC9-rs8051542, rs3803662, LOC643714-rs4784227, C6orf97-rs2046210, 8q24-rs13281615, SLC4A7-rs4973768) revealed significant associations with breast cancer risk (each P &lt; 0.05 in either per allele, dominant, or recessive model). A dose-dependent association was observed between the risk of breast cancer and the genetic risk score, which is an aggregate measure of the alleles in 7 selected variants; rs2981579, rs3803662, rs2046210, rs13281615, rs4973768, rs3817198 and rs10931936. Compared to women with scores of 3 or less, odds ratios (ORs) for women with scores of 4–5, 6–7, 8–9 and 10 or more were 1.33 (95% confidence interval, 1.00 - 1.80), 1.71 (1.26 - 2.30), 3.01 (1.97 - 4.58) and 8.69 (2.74 - 27.5), respectively (Ptrend &lt; 0.001). The ORs for premenopausal women with the corresponding risk scores were 1.71 (1.12 - 2.63), 1.79 (1.15 - 2.78), 3.70 (1.98 - 6.93), and 14.0 (3.30–59.5), respectively, and those for postmenopausal women with the corresponding risk scores were 1.09 (0.72 - 1.66), 1.71 (1.12 - 2.61), 2.60 (1.44 - 4.71), 3.75 (0.57 - 24.4), respectively, compared to those with scores of 3 or less (each Ptrend &lt; 0.001). The c statistic for a model including the genetic risk score in addition to the conventional risk factors was 0.633, whereas 0.602 without it (P &lt; 0.001). Population-attributable fraction of the risk score was 33.8%.

Conclusion we identified a genetic predictor of breast cancer in a Japanese population. A risk model including genetic risk score may be useful to distinguish women at high-risk of breast cancer from those at low-risk, particularly in the context of targeted prevention.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-09-04.

Inverse association between soy intake and non-Hodgkin lymphoma risk among women: a case-control study in Japan

BACKGROUND

Non-Hodgkin lymphoma (NHL) is one of the common malignant tumors worldwide. Environmental factors, such as diet have an important association with the risk of cancer. Although soy intake has been associated with a reduced risk of several cancers, its association with NHL is not known.

PATIENTS AND METHODS

We evaluated the association between soy consumption and risk of NHL by conducting a hospital-based case-control study in 302 patients with NHL and 1510 age- and sex-matched control subjects. Odds ratio (OR) and 95% confidence intervals (CIs) for groups with moderate (27-51 g/day) to high (>51 g/day) relative to low (<27 g/day) intake were calculated using multivariate conditional logistic regression model.

RESULTS

Soy intake was significantly associated with a reduced risk of NHL in women but not in men (OR [95% CI] for moderate and high intake: women, 0.64 [0.42-1.00] and 0.66 [0.42-1.02], respectively; men, 1.40 [0.87-2.24] and 1.33 [0.82-2.15], respectively; P-interaction = 0.02). This finding appeared consistent across NHL subtypes.

CONCLUSION

These results indicate the potential importance of certain ingredients in soy for lymphomagenesis. Further studies to evaluate the mechanism behind the association between soy intake and lymphomagenesis are warranted.

Blood pressure and urine output during the first 120 h of life in infants born at less than 29 weeks' gestation related to umbilical cord milking

OBJECTIVE

To investigate the effects of umbilical cord milking on cardiopulmonary adaptation in very low birth weight infants.

PATIENTS AND METHODS

This study was the secondary analysis of a randomised control study of the effect of umbilical cord milking in premature infants. Forty singleton infants born between 24 and 28 weeks' gestation were randomly assigned to groups in which the umbilical cord was clamped either immediately after birth (control group, n = 20) or after umbilical cord milking (milked group, n = 20). Blood pressure, heart rate, urine output, fluid intake, and ventilatory index values in both groups were measured during the first 120 h after birth.

RESULTS

There were no significant differences in gestational age or birth weight between the two groups. The initial haemoglobin value was higher in the milked group (mean (SD) 16.5 (1.4) g/dl in the milked vs 14.1 (1.6) g/dl in the control; p<0.01). During the first 12 h, blood pressure was significantly higher in the milked group. Urine output in the milked group was higher than that in the control group during the first 72 h. There were no significant differences in heart rate, water intake, or ventilatory index values between the groups.

CONCLUSION

Umbilical cord milking may facilitate early stabilisation of both blood pressure and urine output in very low birth weight infants.

Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks' gestation: a randomised controlled trial

OBJECTIVE

To investigate the effects of umbilical cord milking on the need for red blood cell (RBC) transfusion and morbidity in very preterm infants.

PATIENTS AND METHODS

40 singleton infants born between 24 and 28 weeks' gestation were randomly assigned to receive umbilical cord clamped either immediately (control group, n = 20) or after umbilical cord milking (milked group, n = 20). Primary outcome measures were the probability of not needing transfusion, determined by Kaplan-Meier analysis, and the total number of RBC transfusions. Secondary outcome variables were haemoglobin value and blood pressure at admission.

RESULTS

There were no significant differences in gestational age and birth weight between the two groups. The milked group was more likely not to have needed red cell transfusion (p = 0.02) and had a decreased number (mean (SD)) of RBC transfusions (milked group 1.7 (3.0) vs controls 4.0 (4.2); p = 0.02). The initial mean (SD) haemoglobin value was higher in the milked group (165 (14) g/l) than in the controls (141 (16) g/l); p<0.01). Mean (SD) blood pressure at admission was significantly higher in the milked group (34 (9) mm Hg) than in the controls 28 (8) mm Hg; p = 0.03). There was no significant difference in mortality between the groups. The milked group had a shorter duration of ventilation or supplemental oxygen than the control group.

CONCLUSION

Milking the umbilical cord is a safe procedure, reducing the need for RBC transfusions, and the need for circulatory and respiratory support in very preterm infants.

Expression of Twist increases the risk for recurrence and for poor survival in epithelial ovarian carcinoma patients

Twist is a transcription factor that regulates the expression of tumour suppressors such as E-cadherin. We examined the distribution and expression of Twist in human epithelial ovarian carcinoma (EOC) to examine its clinical significance. Paraffin sections from EOC tissues (n=82) were immunostained with Twist antibody, and the staining intensity was evaluated. The clinicopathological factors examined were age, International Federation of Gynecology and Obstetrics staging, histological type, tumour grade, preoperative value of CA125, peritoneal cytology, volume of ascites and residual tumour after cytoreductive surgery. Overall survival (OS) and progression-free survival (PFS) were evaluated using the Kaplan-Meier method, and multivariate analysis was performed using the Cox proportional hazard analysis. Of the 82 carcinomas, 49 (59.8%) cases were negative for Twist immunoexpression, and 33 (40.2%) were positive immunoexpression. When categorized into negative vs positive expression, Twist was not associated with any of the clinicopathological parameters examined. However, positive Twist expression significantly predicted poorer OS and PFS when compared with negative expression (P<0.0001). In the multivariate analyses, positive Twist expression was the only independent prognostic factor for survival in this study (P<0.0001). Positive Twist expression seems to be a useful marker in patients with EOC likely to have an unfavourable clinical outcome.

Preventive management of hypoglycemia in very low-birthweight infants following indomethacin therapy for patent ductus arteriosus

BACKGROUND

To evaluate the effects of an increase in glucose infusion rate of 2 mg/kg per min from the basal infusion rate on the prevention of hypoglycemia in very low-birthweight (VLBW) infants, following indomethacin therapy for patent ductus arteriosus (PDA).

METHODS

Forty VLBW infants with PDA were given indomethacin 0.2 mg/kg intravenously up to three doses. In 15 of the 40 infants (supplemented group: between April 1995 and March 1996) the glucose infusion rate was increased in 2 mg/kg per min increments from the basal rate just before the initial indomethacin administration, compared with 25 historical control infants who received a fixed glucose infusion rate during the first 12 h after the initial dose. We evaluated the changes in blood glucose levels and glucose infusion rates in both groups.

RESULTS

In the control group 11 of 25 (44%) infants had a blood glucose value below 40 mg/dL between 12 and 60 h (mean 32.7 h). In contrast only two out of 15 infants in the supplemented group reached the glucose level below 40 mg/dL between 72 and 96 h but both two were light-for-dates infants (defined as birthweight below the 10th percentile for gestational age on the standard intrauterine growth curve). Blood glucose values in the supplemented group were significantly higher than those in the control group between 12 and 96 h. However, glucose infusion rates were similar before and between 72 and 96 h.

CONCLUSIONS

This retrospective study shows that an increase in glucose infusion rate of 2 mg/kg per min, in addition to the pre-existing stable maintenance glucose intake, might prevent against the occurrence of unexpected hypoglycemia in VLBW infants following indomethacin therapy.

Effect of vibration on auditory organ systems in low-birth weight infants treated with high-frequency oscillatory ventilation: 5 year outcome

BACKGROUND

To determine the effects of vibration exposure caused by high-frequency oscillatory ventilation (HFOV) on the auditory organ systems in low-birth weight (LBW) infants.

METHODS

Between 1989 and 1990, 30 LBW infants who received assisted ventilation with HFOV (n = 14) or conventional mechanical ventilation (CMV; n = 16) in the level III neonatal intensive care unit at Tokyo Metropolitan Ohtsuka Hospital were enrolled in this study. The effects of vibration exposure on the auditory system structures were investigated with auditory brainstem responses (ABR) at 37-41 weeks of postconceptional age and at 6, 12, 18 and 24 months of age until they passed and follow-up studies were performed at least until 5 years of age.

RESULTS

All infants enrolled in the study survived at discharge and one (7.1%) infant in the HFOV group and two (12.5%) in the CMV group failed the initial ABR test, but there were no significant differences between the two groups. Auditory brainstem response abnormalities were still observed in one infant in the HFOV group at 6 months of age, but this child died at 9 months of age because of meningitis. In contrast, in the CMV group, one patient passed the ABR test at 6 months of age, but another remained abnormal at 5 years of age. One of three infants with ABR abnormalities at 6 months of age had neurologic sequelae at 5 years of age and one of 28 infants who passed the initial ABR test was detected with cerebral palsy. No patients with hearing loss were clinically detected at 5 years of age.

CONCLUSIONS

The results of the serial ABR examinations and the 5 year follow-up studies suggest that vibration exposure caused by HFOV may not increase the adverse effects on the auditory system in LBW infants.

Effects of albumin infusion therapy on total and unbound bilirubin values in term infants with intensive phototherapy

BACKGROUND

The purpose of the present study was to evaluate the effect of intravenous albumin administration on the serum total and unbound bilirubin values in term non-hemolytic hyperbilirubinemic neonates during intensive phototherapy.

METHODS

Fifty-eight infants (gestational age 39.4 +/- 1.4 weeks; birth weight 3,245 +/- 435 g) were given phototherapy with similar light energy. Twenty infants (control group) received only phototherapy, while 38 others (albumin-treated group) were also given human albumin at 1 g/kg bodyweight, i.v., during the first 2 h of phototherapy.

RESULTS

When comparing changes in total and unbound bilirubin values 0, 2, 6 and 24 h after entering the study between the albumin-treated group and the control group, there was a significant reduction in the serum unbound bilirubin values at the end of albumin treatment and at 6 and 24 h. However, there was no significant reduction in total serum bilirubin values during the study period. In the albumin-treated group, the mean serum unbound bilirubin reduction from the baseline level at the end of albumin treatment and at 6 and 24 h was 0.40 +/- 0.19, 0.41 +/- 0.20 and 0.43 +/- 0.20 microg/dL, respectively.

CONCLUSIONS

The results suggest that albumin priming may be effective for an immediate reduction in serum unbound bilirubin values, the fraction that is potentially neurotoxic.

E-cadherin is a WT1 target gene

The WT1 tumor suppressor gene encodes a transcription factor that can activate and repress gene expression. Transcriptional targets relevant for the growth suppression functions of WT1 are poorly understood. We found that mesenchymal NIH 3T3 fibroblasts stably expressing WT1 exhibit growth suppression and features of epithelial differentiation including up-regulation of E-cadherin mRNA. Acute expression of WT1 in NIH 3T3 fibroblasts after retroviral infection induced murine E-cadherin expression. In transient transfection experiments, the human and murine E-cadherin promoters were activated by co-expression of WT1. E-cadherin promoter activity was increased in cells overexpressing WT1 and was blocked by a dominant negative form of WT1. WT1 activated the murine E-cadherin promoter through a conserved GC-rich sequence similar to an EGR-1 binding site as well as through a CAAT box sequence. WT1 produced in vitro or derived from nuclear extracts bound to the WT1-response element within the murine E-cadherin promoter, but not the CAAT box. E-cadherin, a gene important in epithelial differentiation and neoplastic transformation, represents a downstream target gene that links the roles of the WT1 in differentiation and growth control.

Successful transcutaneous arterial embolization of a giant hemangioma associated with high-output cardiac failure and Kasabach-Merritt syndrome in a neonate: a case report

We describe the case of a patient with a neonatal giant cutaneous hemangioma with high-output cardiac failure and Kasabach-Merritt syndrome and successfully treated with transcutaneous arterial embolization aimed at controlling severe congestive heart failure and consumption coagulopathy. A patient was admitted to the neonatal care unit on the first day of age because of a large hemangioma on his right lateral chest wall and respiratory distress, associated with cardiac failure resulting from arteriovenous shunting. On the second day of age the platelet count decreased to 5.7 x 10(4)/microliter and fibrinogen level was 85 mg/dl. The values of prothrombin time and activated partial thromboplastin time were prolonged. Intravenous predonisone therapy was started immediately, but bleeding tendency was getting worse and the evidence of congestive heart failure persisted. On the third day the patient then underwent embolization of feeding arteries with microcoils. The cardiac failure and thrombocytopenic coagulopathy had improved significantly without complications. We conclude that transcutaneous arterial embolization is an effective and safe treatment in this neonate and should be considered for the treatment of control high-output cardiac failure and coagulopathy in infants with hemangioma and Kasabach-Merritt syndrome.

Reduction in blood glucose values following indomethacin therapy for patent ductus arteriosus

PURPOSE

To evaluate the effects of indomethacin on blood glucose values in premature infants with patent ductus arteriosus (PDA).

METHODS

Twenty-five very low birthweight infants with PDA were given 0.2 mg/kg, i.v., indomethacin for up to three doses. We examined the relationship between blood glucose values and glucose infusion rate before and after indomethacin therapy.

RESULTS

There was a significant reduction in blood glucose values between 12 and 96 h following i.v. indomethacin therapy. Eleven of 25 infants (44%) had blood glucose values below 40 mg/dL between 12 and 60 h (mean 32.7 h) after the initial dose. Although the glucose infusion rate during the first 12 h was constant (3.56 +/- 0.98 mg/kg per min), the blood glucose values decreased from 96 +/- 32 mg/dL at the starting point to 75 +/- 29 mg/dL at 12 h (P < 0.05). The maximum blood glucose reduction was 51.6 +/- 34.7 mg/dL and the maximum blood glucose reduction rate was 50.4 +/- 20.2%.

CONCLUSIONS

The results suggest that blood glucose values should be measured at least every 6 h for 72 h until they stabilize in order to prevent unexpected hypoglycemia.

WT1 expression induces features of renal epithelial differentiation in mesenchymal fibroblasts

The WT1 tumor suppressor gene, implicated in hereditofamilial and sporadic Wilms' tumor, is required for normal renal development and is up-regulated during the mesenchymal-epithelial transition. NIH3T3 fibroblasts overexpressing WT1 were less proliferative, larger in size and more firmly attached to tissue culture plastic, suggesting an alteration of their state of differentiation. These cells were studied in vivo by subcutaneous injection into nude mice. The resulting tumors exhibited epithelioid histopathology and formed desmosome-like structures. Molecular analyses of these WT1 expressing fibroblasts grown in culture and in nude mice revealed significant alterations in the expression of many kidney epithelial markers. These studies indicate that WT1 expression can initiate features of a program of epithelial differentiation consistent with a prominent role for WT1 in the mesenchymal epithelial transition that occurs during renal development. Through this work we identified a number of novel target genes for the WT1 transcription factor, including uvomorulin, integrin alpha8 and perlecan, and suggest that WTI may activate the IGF-II gene, also implicated in the development of Wilms' tumor.

An evaluation of infants' growth in the Kingdom of Nepal

BACKGROUND

The His Majesty's Government/Japan International Cooperation Agency Primary Health Care Project began in April 1993 in collaboration with the Saitama Prefectural Government, for the purpose of improving the health status of the people in model districts of the Kingdom of Nepal. Growth monitoring is one of the basic methods that defines the health and nutritional status of children.

METHODS

Anthropometric indices were measured in 759 children in the Bhaktapur district. We used the World Health Organization prototype growth chart and national growth standard for Japanese children (1990) to analyze the growth data.

RESULTS

We found that the average bodyweight growth curve of children up to 4 months of age followed the 50th percentile reference curve. For children of 5-12 months of age, there was a delay in bodyweight gain and the growth curve reached the 3rd percentile curve. For children more than 1 year old, the growth curve moved below the third percentile curve. Catch-up growth did not occur before the children reached 5 years of age. The main causes of catch-up growth being hampered were chronic undernutrition and inadequate nutritional balance.

CONCLUSIONS

As this was the first opportunity to evaluate infant growth in this district, the first important consequence of the results was to analyze the causes of growth faltering and failure-to-thrive in Nepalese children. Even more important, was the need to give appropriate counseling on improving feeding and other health-related practices, and the most important consequence of all was to instruct Nepalese health workers that utilizing the growth charts is an integral part of health care.

The complete genome sequence of the gram-positive bacterium Bacillus subtilis

Bacillus subtilis is the best-characterized member of the Gram-positive bacteria. Its genome of 4,214,810 base pairs comprises 4,100 protein-coding genes. Of these protein-coding genes, 53% are represented once, while a quarter of the genome corresponds to several gene families that have been greatly expanded by gene duplication, the largest family containing 77 putative ATP-binding transport proteins. In addition, a large proportion of the genetic capacity is devoted to the utilization of a variety of carbon sources, including many plant-derived molecules. The identification of five signal peptidase genes, as well as several genes for components of the secretion apparatus, is important given the capacity of Bacillus strains to secrete large amounts of industrially important enzymes. Many of the genes are involved in the synthesis of secondary metabolites, including antibiotics, that are more typically associated with Streptomyces species. The genome contains at least ten prophages or remnants of prophages, indicating that bacteriophage infection has played an important evolutionary role in horizontal gene transfer, in particular in the propagation of bacterial pathogenesis.

Myeloperoxidase-specific anti-neutrophil cytoplasmic autoantibodies -- related scleroderma renal crisis treated with double-filtration plasmapheresis

A 46-year-old female patient who was diagnosed with systemic sclerosis (SSc) developed rapidly progressive renal failure without elevation of blood pressure or plasma renin concentration. Renal biopsy revealed necrotizing crescentic glomerulonephritis (pauci-immune type) and the myeloperoxidase-specific anti-neutrophil cytoplasmic autoantibodies (MPO-ANCA) titer was found to be elevated to 669 EU/ml. Methylprednisolone (MP) pulse therapy followed by prednisolone (PSL) and mizoribine (MZR) did not suppress the progression of renal failure. Therefore, we started double-filtration plasmapheresis (DFPP) which effectively removed MPO-ANCA and prevented renal failure despite the relatively low dose of immunosuppressive agents.

Systematic sequencing of the 283 kb 210 degrees-232 degrees region of the Bacillus subtilis genome containing the skin element and many sporulation genes

As part of the Bacillus subtilis genome sequencing project, we have determined a 283 kb contiguous sequence from 210 degrees to 232 degrees of the B. subtilis genome. This region contains the 48 kb skin element which is excised during sporulation by a site-specific recombinase. In this region, 310 complete ORFs and one tRNA gene were identified: 66 ORFs have been sequenced and characterized previously by other workers, e.g. acc, ans, bfm, blt, bmr, comE, comG, dnaK, rpoD and sin operons; cwiA, gpr and lysA genes; many sporulation genes and operons, spo0A, spoIIA, spoIIM, spoiiP, spoIIIA, spoIIIC, spoIVB, spoIVCA, spoIVCB and spoVA, etc. The products of 84 ORFs were found to display significant similarity to proteins with known function in data banks, e.g., proteins involved in nucleotide metabolism, lipid biosynthesis, amino acid transport (ABC transporter), phosphate-specific transport, the glycine cleavage system, the two-component regulatory system, cell wall autolysis, ferric uptake and sporulation. However, the functions of more than half of the ORFs (52%, 160 ORFs) are still unknown. In the skin element containing 60 ORFs, 32 ORFs (53%) encode proteins which have significant homology to gene products of the B. subtilis temperate phage phi 105 and/or the defective phage PBSX.

The transcriptional effect of WT1 is modulated by choice of expression vector

The WT1 Wilms' tumor suppressor gene encodes a zinc finger transcription factor which plays a critical role in renal and genitourinary development. The WT1 protein was reported to both activate and repress transcription. We found that the transcriptional effect of WT1 on the Egr1 promoter could be modulated by the use of expression vectors containing different promoters. WT1 activated the Egr1 promoter when expression of WT1 was driven by the Rous sarcoma virus promoter. In contrast, a cytomegalovirus (CMV) promoter-containing WT1 expression vector repressed the Egr1 promoter. However, WT1 activated transcription of a simple test promoter, EGR3tkCAT, regardless of the expression vector used. Co-transfection of the parental CMV-based vector strongly depressed the basal activity of the Egr1-CAT reporter, suggesting that the CMV promoter competes with the Egr1 promoter for transcription factors or co-factors which may be required for activation by WT1. In support of this hypothesis, WT1 was converted from an activator to a repressor by co-transfection of an excess of the parental CMV-based vector. These results provide an important caveat to the interpretation of co-transfection studies and confirm the bi-functional nature of the WT1 transcription factor.

Core antigen mutations of human hepatitis B virus in hepatomas accumulate in MHC class II-restricted T cell epitopes

Despite the extensive molecular information on serum-derived human hepatitis B viruses (HBV), liver-derived replicative HBV genomes have remained largely uninvestigated. We have examined the sequences of the entire core antigen (nucleocapsid) of liver-derived HBVs in 15 different hepatoma patients. Bona fide mutations, rather than subtype polymorphism, have been identified based on the high-frequency occurrence of structural differences from wild type at the highly evolutionarily conserved positions, instead of at the positions known to contain genetic heterogeneity among different isolates from different geographic locations. The distribution of these naturally occurring mutations of HBV core gene appears to be nonrandom and is found predominantly within three major (I, IV, and V) and four minor domains (II, III, VI, and VII). In general, domain IV mutations correlate with domain V mutations. The replicative HBV DNAs tend to accumulate a higher number of mutated core domains than the integrated HBV DNAs. At the domain level, there is no significant difference in HBV core mutation frequencies between the liver tumors and the adjacent nontumorous livers. Strikingly, domains I, III, and V coincide with three major known T cell epitopes within the core protein in acute and chronic hepatitis B patients. Furthermore, these domains coincide with HLA class II-restricted T cell epitopes, rather than with the conventional HLA class I-restricted epitopes of cytotoxic T lymphocytes. Our results support the hypothesis that HBV core antigen variants can accomplish immunoevasion via accumulated escape mutations. In addition, they also provide a potential molecular explanation for the maintenance of persistent infection of human hepatitis B virus in chronic carriers.

The tumor suppressor gene WT1 inhibits ras-mediated transformation

Wilms' tumor belongs to a small group of pediatric neoplasms that have served as paradigms of human cancers in which recessive mutations play a primary role in tumorigenesis. WT1 is a candidate tumor suppressor gene that is mutationally inactivated in a proportion of both familial and sporadic Wilms' tumors. Recent studies demonstrated that WT1 can partially suppress growth of a Wilms' tumor cell line in vitro and in vivo. We investigated the ability of WT1 to inhibit the expression of the transformed phenotype in non-Wilms' tumor cells. The expression of WT1 cDNA in ras-transformed NIH3T3 cells yielded large, flat cells that exhibited complete contact-inhibition. These morphologic changes were associated with decreased proliferation, suppression of clonogenicity in soft agar and inhibition of tumor growth in nude mice. Moreover, expression of WT1 in non-transformed NIH3T3 cells resulted in similar morphologic changes and profound resistance to transformation by an activated ras oncogene. These studies suggest that tumor inhibition by WT1 in these cells may be achieved by interference with the ras-mediated signalling pathway.

Infrequent mutation of p53 gene in hepatitis B virus positive primary hepatocellular carcinomas

Somatic mutation of the p53 oncogene/anti-oncogene allele has been shown to be involved in many different human solid tumors. Recently, there have been reports that p53 mutations are found to occur at high frequency (50%) in aflatoxin-related human primary hepatocellular carcinomas (HCC) (Hsu et al., 1991 Nature, vol 350, p. 427; Bressac et al., 1991 Nature, vol 350, p. 429). Most strikingly, a hotspot G to T mutation at amino acid position 249 was identified. These reports appear to contradict our earlier publications that although p53 mutation is found frequently in human HCC cell lines, it is rarely found in primary tumors. In this paper, we have further examined 20 different primary HCC samples (17 were hepatitis B surface antigen positive) and their adjacent nontumourous tissues, using restriction fragment length polymorphism (RFLP) analyses. Clear loss of heterozygosity (LOH) was found in only 3 out of 20 samples. All three samples were also found to carry a point mutation within the remaining p53 allele. None of these mutations was found to be at the proposed aflatoxin hotspot of amino acid 249. All three point mutations are of somatic origin. Ten samples, randomly chosen from the remaining 17 LOH negative HCC tumors, were analyzed further by DNA sequencing and Western blot analyses. No point mutations of p53 were found. Taken together with our previous report (Hosono et al., 1991, Oncogene vol 6, p. 237-243), we conclude that p53 mutation occurs infrequently, only approximately 18%, in HBV-positive primary hepatomas from Taiwan. Furthermore, p53 mutation appears to be acquired later in tumor development at least in some HCC samples.

Trace elements and mineral requirements for very low birth weight infants in rickets of prematurity

To establish mineral and trace element requirements for very low birth it is important to prevent bone mineral disorder. Those infants fed mother's milk only are thought to be at higher risk of this disorder. Both calcium and phosphorus supplementation were thought to be needed to prevent it. Copper and zinc are important as cofactors of major enzymes involved in the synthesis of collagen. These trace elements especially zinc may not be enough for very low birth weight infants fed mother's milk. At present however the relationship between these trace elements and minerals, and bone metabolic disease in preterm infants is not completely clear.

Molecular analysis of the p53 alleles in primary hepatocellular carcinomas and cell lines

We have examined p53 oncogene/anti-oncogene alleles in 10 different human hepatoma cell lines and 18 primary hepatocellular carcinomas. The p53 allele in these hepatoma cell lines appears to be a frequent target of mutation as demonstrated by Southern and Northern blotting, immunoprecipitation and Western blot analysis. In general, the steady state level of p53 specific RNA or protein in these hepatoma cell lines is higher than in normal liver. However, in three out of ten cell lines, normal-sized p53 mRNA cannot be detected. In contrast, the involvement of the p53 allele in primary hepatocellular carcinoma appears to be an exceedingly rare event. Steady state levels of p53 specific RNA in primary hepatomas are practically indistinguishable from those in normal adult liver. Using the polymerase chain reaction technique, we have amplified and subcloned exons 5, 6, 7 and 8 of p53 from 10 different hepatoma samples. DNA sequence analysis of these exon subclones reveals no apparent structural alterations. Finally, synthesis of p53 specific mRNA or protein in a HepG2 human hepatoblastoma cell line does not appear to be affected by gene expression and replication of human hepatitus B virus. Surprisingly, unlike many other kinds of human solid tumors, point mutations in p53 do not appear to be important in primary tumors of hepatocellular carcinomas.