Isolation and Characterization of a Novel Alpha-Hemolytic Streptococcus spp. from the Oral Cavity and Blood of Septicemic Periparturient Immunodeficient Mice

MISTRG is an immunodeficient mouse strain that expresses multiple human cytokines that support hematopoietic stem cell maintenance and myelopoiesis. While establishing a breeding colony of MISTRG mice in a dedicated barrier room, 6 cases of death or disease occurred in pregnant or postpartum mice. Clinically, this manifested as hunched posture, dyspnea, and 1 case of emaciation with ataxia. Pathologic analysis of 7 mice revealed multisystemic necrosuppurative inflammation variably affecting the uterus and placenta, joints, meninges, inner and middle ears, kidneys, and small intestine. Bacteria cultured from the blood of septic mice were identified with 89% probability by the Vitek 2 identification system as Streptococcus sanguinus with atypical biochemical parameters; the API 20E/NE system fully differentiated the isolates as a novel Streptococcus species. MALDI Biotyper-based mass spectrometry also indicated that the phenotype represented a novel Streptococcus spp. Sequencing revealed that the full-length 16S rRNA gene identity was below 97% with known Streptococcus species, including the 2 closest species Streptococcus acidominimus and Streptococcus azizii. We propose the name Streptococcus murisepticum spp. nov to our novel isolates. All male mice in this colony remained healthy despite their association with diseased female mice. Overall, 19% of the colony carried the novel Streptococcus in their oral cavity, but it could not be detected in feces. The organism was sensitive to amoxicillin, which was administered via drinking water throughout pregnancy and weaning to establish a colony of pathogen-negative future breeders. The colony remained disease-free and culture-negative for Streptococcus murisepticum spp. nov after treatment with amoxicillin. We suspect that oral colonization of MISTRG mice with the novel Streptococcus species and its associated unique pathology in periparturient mice is potentially the principal cause of loss of this strain at several institutions. Therefore, screening the oral cavity for α-hemolytic streptococci followed by targeted antibiotic treatment may be necessary when establishing MISTRG and allied immunodeficient mouse strains.

Isolation and Characterization of a Novel Alpha-Hemolytic Streptococcus spp. from the Oral Cavity and Blood of Septicemic Periparturient Immunodeficient Mice

MISTRG is an immunodeficient mouse strain that expresses multiple human cytokines that support hematopoietic stem cell maintenance and myelopoiesis. While establishing a breeding colony of MISTRG mice in a dedicated barrier room, 6 cases of death or disease occurred in pregnant or postpartum mice. Clinically, this manifested as hunched posture, dyspnea, and 1 case of emaciation with ataxia. Pathologic analysis of 7 mice revealed multisystemic necrosuppurative inflammation variably affecting the uterus and placenta, joints, meninges, inner and middle ears, kidneys, and small intestine. Bacteria cultured from the blood of septic mice were identified with 89% probability by the Vitek 2 identification system as Streptococcus sanguinuswith atypical biochemical parameters; the API 20E/NE system fully differentiated the isolates as a novel Streptococcusspecies. MALDI Biotyper-based mass spectrometry also indicated that the phenotype represented a novel Streptococcusspp. Sequencing revealed that the full-length 16S rRNA gene identity was below 97% with known Streptococcus species, including the 2 closest species Streptococcus acidominimus and Streptococcus azizii. We propose the name Streptococcus murisepticum spp. nov to our novel isolates. All male mice in this colony remained healthy despite their association with diseased female mice. Overall, 19% of the colony carried the novel Streptococcus in their oral cavity, but it could not be detected in feces. The organism was sensitive to amoxicillin, which was administered via drinking water throughout pregnancy and weaning to establish a colony of pathogen-negative future breeders. The colony remained disease-free and culture-negative for Streptococcus murisepticum spp. nov after treatment with amoxicillin. We suspect that oral colonization of MISTRG mice with the novel Streptococcus species and its associated unique pathology in periparturient mice is potentially the principal cause of loss of this strain at several institutions. Therefore, screening the oral cavity for α-hemolytic streptococci followed by targeted antibiotic treatment may be necessary when establishing MISTRG and allied immunodeficient mouse strains.

A Novel Orthotopic Implantation Technique for Osteosarcoma Produces Spontaneous Metastases and Illustrates Dose-Dependent Efficacy of B7-H3-CAR T Cells

The outcome for metastatic pediatric osteosarcoma (OS) remains poor. Thus, there is an urgent need to develop novel therapies, and immunotherapy with CAR T cells has the potential to meet this challenge. However, there is a lack of preclinical models that mimic salient features of human disease including reliable development of metastatic disease post orthotopic OS cell injection. To overcome this roadblock, and also enable real-time imaging of metastatic disease, we took advantage of LM7 OS cells expressing firefly luciferase (LM7.ffLuc). LM7.ffLuc were implanted in a collagen mesh into the tibia of mice, and mice reliably developed orthotopic tumors and lung metastases as judged by bioluminescence imaging and histopathological analysis. Intratibial implantation also enabled surgical removal by lower leg amputation and monitoring for metastases development post-surgery. We then used this model to evaluate the antitumor activity of CAR T cells targeting B7-H3, an antigen that is expressed in a broad range of solid tumors including OS. B7-H3-CAR T cells had potent antitumor activity in a dose-dependent manner and inhibited the development of pulmonary metastases resulting in a significant survival advantage. In contrast T cells expressing an inactive B7-H3-CAR had no antitumor activity. Using unmodified LM7 cells also enabled us to demonstrate that B7-H3-CAR T cells traffic to orthotopic tumor sites. Hence, we have developed an orthotopic, spontaneously metastasizing OS model. This model may improve our ability not only to predict the safety and efficacy of current and next generation CAR T cell therapies but also other treatment modalities for metastatic OS.

Morphologic and Immunohistochemical Characterization of Spontaneous Lymphoma/Leukemia in NSG Mice

The NOD.Cg-Prkdc^scid Il2rg^tm1Wjl/SzJ strain (NOD scid gamma, NSG) is a severely immunodeficient inbred laboratory mouse used for preclinical studies because it is amenable to engraftment with human cells. Combining scid and Il2rg^null mutations results in severe immunodeficiency by impairing the maturation, survival, and functionality of interleukin 2-dependent immune cells, including T, B, and natural killer lymphocytes. While NSG mice are reportedly resistant to developing spontaneous lymphomas/leukemias, there are reports of hematopoietic cancers developing. In this study, we characterized the immunophenotype of spontaneous lymphoma/leukemia in 12 NSG mice (20 to 38 weeks old). The mice had a combination of grossly enlarged thymus, spleen, or lymph nodes and variable histologic involvement of the bone marrow and other tissues. All 12 lymphomas were diffusely CD3, TDT, and CD4 positive, and 11 of 12 were also positive for CD8, which together was consistent with precursor T-cell lymphoblastic lymphoma/leukemia (pre-T-LBL). A subset of NSG tissues from all mice and neoplastic lymphocytes from 8 of 12 cases had strong immunoreactivity for retroviral p30 core protein, suggesting an association with a viral infection. These data highlight that NSG mice may develop T-cell lymphoma at low frequency, necessitating the recognition of this spontaneously arising disease when interpreting studies.

Combinatorial screening using orthotopic patient derived xenograft-expanded early phase cultures of osteosarcoma identify novel therapeutic drug combinations

Lead discovery in osteosarcoma has been hampered by the lack of new agents, limited representative clinical samples and paucity of accurate preclinical models. We developed orthotopic patient-derived xenografts (PDXs) that recapitulated the molecular, cellular and histologic features of primary tumors, and screened PDX-expanded short-term cultures and commercial cell lines of osteosarcoma against focused drug libraries. Osteosarcoma cells were most sensitive to HDAC, proteasome, and combination PI3K/MEK and PI3K/mTOR inhibitors, and least sensitive to PARP, RAF, ERK and MEK inhibitors. Correspondingly, PI3K signaling pathway genes were up-regulated in metastatic tumors compared to primary tumors. In combinatorial screens, as a class, HDAC inhibitors showed additive effects when combined with standard-of-care agents gemcitabine and doxorubicin. This lead discovery strategy afforded a means to perform high-throughput drug screens of tumor cells that accurately recapitulated those from original human tumors, and identified classes of novel and repurposed drugs with activity against osteosarcoma.

Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs

BACKGROUND

Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options.

OBJECTIVE

To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care.

DESIGN

This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs.

SETTING/SUBJECTS

Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases.

MEASUREMENTS

The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare.

RESULTS

We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793).

CONCLUSIONS

ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.

Ultrasonic Instrumentation Instruction in Dental Hygiene Programs in the United States

PURPOSE

The purpose of this study was to determine the extent of ultrasonic scaling instrumentation instruction in dental hygiene programs in the U.S. Currently, there is no publication available defining a consensus of instruction for ultrasonic instrumentation.

METHODS

Exempt status was received from the West Virginia University Institutional Review Board. A survey was developed with dental hygiene administrators and faculty, based on assumptions and a list of questions to be answered. The survey was tested for validity and revised after feedback from additional faculty. The instrument was 64 questions divided into demographics, curriculum and equipment. Most questions included a text box for additional comments. An email survey was sent to all directors of accredited dental hygiene programs in the U.S. (n=323). The final possible number of respondents was n=301. Results were collected in aggregate through the Secure Online Environment (SOLE). Results were transferred to an Excel spreadsheet for statistical analysis.

RESULTS

After 3 emails, the response rate was 45% (n=136). No significant differences in methods of instruction were found between associate and baccalaureate degree granting programs. Eighty-nine percent of programs introduce hand scaling prior to ultrasonic scaling instruction. Students in 96% of the programs were required to administer pre-procedural mouth rinse intended to reduce the amount of bacteria. The magnetostrictive ultrasonic scaler is widely used in dental hygiene instruction. A variety of inserts/ tips were available although a universal or straight insert/tip was most common. Calculus, not inflammation, was the primary criterion for ultrasonic scaler use.

CONCLUSION

The results of this study demonstrate that ultrasonic instrumentation is an integral component of the clinical curriculum and the majority of the dental hygiene programs prescribe to similar teaching methods. Programs could benefit from incorporating current scientific research findings of using site specific inserts to perform periodontal debridement based on thorough biofilm removal measured by resolution of inflammation.

Langerhans-Zellhistiozytose des Magens mit BRAF-V600E-Mutation: Fallbericht und Literaturübersicht

Langerhans-Zellhistiozytose ist eine Erkrankung mit sehr unterschiedlichen klinischen Präsentationen. Extrem selten kann die Langerhans-Zellhistiozytose den Gastrointestinaltrakt erwachsener Patienten betreffen. Ein Fall mit Magenschleimhautinfiltration durch eine Langerhans-Zellhistiozytose bei endoskopischem Normalbefund wird vorgestellt. Der neoplastische Charakter dieses Infiltrats wird durch den Nachweis einer BRAF-V600E-Mutation unterstrichen. Darüber hinaus wird eine Übersicht zu den 5 bislang in englischsprachiger Literatur publizierten Fällen mit isolierter Magenschleimhautinfiltration durch Langerhans-Zellhistiozytose gegeben.

Disease Management Project Breast Cancer in Hesse - 5-Year Survival Data: Successful Model of Intersectoral Communication for Quality Assurance

Introduction: The Disease Management Project Breast Cancer (DMP Breast Cancer) was first launched in Hesse in 2004. The project is supported by the health insurance companies in Hesse and the Professional Association of Gynaecologists in Hesse. The aim is to offer structured treatment programmes to all women diagnosed with breast cancer in Hesse by creating intersectoral cooperations between coordinating clinics, associated hospitals and gynaecologists in private practice who registered in the DMP programme. Method: Between 1 January 2005 and 30 June 2011, 13 973 women were enrolled in the DMP programme. Results: After data cleansing, survival rates were calculated for a total of 11 214 women. The 5-year overall survival (OS) rate was 86.3 %; survival rates according to tumour stage on presentation were 92.2 % (pT1) and 82.3 % (pT2), respectively. The impact of steroid hormone receptor status on survival (87.8 % for receptor-positive cancers vs. 78.9 % for receptor-negative cancers) and of age at first diagnosis on survival (≤ 35 years = 91 %) were calculated. Conclusion: The project showed that intersectoral cooperation led to significant improvements in the quality of treatment over time, as measured by quality indicators and outcomes after treatment.

IR spectroscopy on isolated Co(n)(alcohol)m cluster anions (n=1-4, m=1-3): structures and spin states

Isolated cobalt-alcohol cluster anions containing n=1-4 cobalt and m=1-3 alcohol molecules (alcohol=methanol, ethanol, propanol) are produced in a supersonic beam by using a laser ablation source. By applying IR photodissociation spectroscopy vibrational spectra in the OH stretching region are obtained. Several structures in different spin states are discussed for the (n,m) clusters. In comparison with density functional theory calculations applied to both the Co/alcohol clusters and the naked Co cluster anions, an unambiguous structural assignment is achieved. It turns out that structures are preferred with a maximum number of hydrogen bonds between the OH groups and the Co···Co units. These hydrogen bonds are typical for anionic species leading to an activation of the OH groups which is indicated by large red-shifts of the OH stretching frequencies compared to the naked alcohols. For each (n,m) cluster, the frequency shifts systematically with respect to the different alcohols, but the type of structure is identical for all alcohol ligands. The application of IR spectroscopy turns out to be an ideal tool not only as a probe for structures but also for spin states which significantly influence the predicted OH stretching frequencies.

IR/UV spectroscopy on jet cooled 3-hydroxyflavone (H2O)n (n = 1,2) clusters along proton transfer coordinates in the electronic ground and excited states

The structure and reactivity of isolated 3-hydroxyflavone (3-HF) aggregates with one and two water molecules has been investigated by applying combined infrared/ultraviolet (IR/UV) spectroscopy in a supersonic jet both for the electronic ground and excited states. In combination with density functional theory (DFT) calculations, the IR spectra of the S(0) states recorded from the upper fingerprint region to the OH stretching vibrations are assigned to the most stable isomers of the clusters. For the first electronically excited (pi pi(*)) state of the 3-HF(H(2)O)(2) cluster structural information are obtained from the IR spectra in combination with time-dependent-DFT (TD-DFT) calculations. No proton transfer structure is observed in the case of a low excess energy within the electronically excited state. By raising the excitation energy, additional bands appear that can be assigned to a tautomeric form indicating the induction of a proton transfer reaction.

Strong and selective inhibitors of hepatitis B virus replication among novel N4-hydroxy- and 5-methyl-beta-L-deoxycytidine analogues

Novel N(4)-hydroxy- and 5-methyl-modified beta-L-deoxycytidine analogues were synthesized and evaluated as anti-hepatitis B virus (HBV) agents. Their in vitro efficiencies were investigated in HepG2.2.15 cells stably transfected with HBV. beta-L-2',3'-Didehydro-2',3'-dideoxy-N(4)-hydroxycytidine (beta-L-Hyd4C) was most effective in reducing secreted HBV DNA (50% effective concentration [EC(50)], 0.03 microM), followed by beta-L-2',3'-dideoxy-3'-thia-N(4)-hydroxycytidine (EC(50), 0.51 microM), beta-L-2',3'-dideoxy-N(4)-hydroxycytidine (EC(50), 0.55 microM), and beta-L-5-methyl-2'-deoxycytidine (EC(50), 0.9 microM). The inhibition of the presumed target, the HBV DNA polymerase, by the triphosphates of some of the beta-L-cytidine derivatives was also assessed. In accordance with the cell culture data, beta-L-Hyd4C triphosphate was the most active inhibitor, with a 50% inhibitory concentration of 0.21 microM. The cytotoxicities of some of the 4-NHOH-modified beta-L-nucleosides were dramatically lower than those of the corresponding cytidine analogues with the unmodified 4-NH(2) group. The 50% cytotoxic concentrations for beta-L-Hyd4C in HepG2 and HL-60 cells were 2,500 microM and 3,500 microM, respectively. In summary, our results demonstrate that at least beta-L-Hyd4C can be recommended as a highly efficient and extremely selective inhibitor of HBV replication for further investigations.

Spread of hepatitis B viruses in vitro requires extracellular progeny and may be codetermined by polarized egress

Viruses can spread by different mechanisms: via intracellular particles through cell junctions to neighboring cells or via secreted virions to adjacent or remote cells. The observation of clusters of hepadnavirus-infected cells both in vivo and in primary hepatocytes neither proves the first mechanism nor excludes the second. In order to test which mechanism, if not both, is used by hepatitis B viruses in order to spread, we used primary duck hepatocytes and duck hepatitis B virus (DHBV) as an infection model. If extracellular progeny virus alone determines spreading, neutralizing antisera or drugs blocking virus binding to hepatocytes should abolish secondary infection. In order to test this, we used DHBV envelope-specific neutralizing antisera, as well as suramin, a known inhibitor of infection. Both reagents strongly reduced hepatocellular attachment of viral particles and almost completely abolished primary infection, whereas an ongoing intracellular infection was not affected as long as no progeny virus was released. In contrast, incubation of infected primary hepatocytes with these reagents during release of progeny virus completely prevented secondary infection. Moreover, the combination of electron and immunofluorescence microscopy analyses revealed the residence of viral particles in cytoplasmic vesicles preferentially located near the basolateral membrane of infected hepatocytes. Taken together, these data strongly suggest that hepatitis B viruses mainly spread by secreted, extracellular progeny and point to polarized egress of viral particles into intercellular compartments, which restricts their diffusion and favors transmission of virus to adjacent cells.

[Prostate carcinoma (PC)--an organ-related specific pathological neoplasm]

The organ- and tumour-related specific characteristics of prostate carcinoma (PC) are presented in an overview under various aspects. It is the key for understanding pathological changes, including PC, to consider the subdivision of the prostate into anatomically and functionally distinguishable zones, especially the transitional zone (TZ) and the peripheral zone (PZ). The pseudoneoplastic hyperplasia of the TZ, combined with inflammatory consequences and age-related changes, forms a differential diagnostic challenge to both clinico-radiological diagnosis and macroscopic and microscopic examination. High-degree prostatic intra-epithelial neoplasia (PIN III) and atypical adenomatous hyperplasia (AAH) are presented as precursor lesions of PC with varying significance and assessment. Moreover, there are discussed the following characteristic features of PC: localisation types, focality, volume, progression, double-graduation according to Gleason, tumour stage, and prognosis. The most important prognosis factors of PC (category I) include the categories of the TNM system, such as stage, surgical marginal situation, degree and also the preoperative PSA level as a (poor) substitute for the tumour volume. Potential prognosis parameters (category II) show the tumour volume and the DNS ploidy, while there continues to exist a large number of non-established parameters (category III). The prognostic validity of the pathological examinations depends, on the one hand, on the tissue extent (needle biopsy, transurethral resection (TURP), so-called simple prostatectomy, radical prostatectomy (RPE)) and the prostate zones covered. On the other hand, the prognostic certainty also depends on the tumour-adequate macroscopic and microscopic assessment of an RPE that can only be a partial or complete handling in transversal large-area sections.

[Criteria of dignity in ultrasound mammography using a 10-MHz-transducer, also with regard to tumor size]

AIM

Ongoing technical progress has increased the accuracy of imaging in ultrasound mammography. Using a 10-MHz-transducer, eight different criteria of dignity were evaluated for validity, also with regard to the size of a tumor.

MATERIALS AND METHODS

Over a period of three years, 446 breast tumors were ultrasonographically examined by two experienced medical doctors. The study comprised only suspicious lesions detected by mammography and/or manual palpation. Diagnostic validity was quantified by means of sensitivity, specificity, positive and negative predictive value, as well as the ODDS-ratio.

RESULTS

Ultrasound mammography demonstrated a sensitivity of 94.0 %, specificity of 91.4 %, positive predictive value of 95.9 %, and a negative predictive value of 99.1 %. Eight different sonographic criteria were validated separately. The most important signs of malignancy were (in descending order): a highly echogenic halo, spikes, jagged contour, posterior acoustic shadowing, and discontinuity of tissue structure. Features of benign disease were: smooth edge, posterior acoustic enhancement, displacement margin, bilateral acoustic shadowing and continuity of tissue structure. Furthermore, it appeared that the size of a tumor only had consequences on posterior shadowing (p = 0.017). All other features did not show significant variation in relation to tumor size.

CONCLUSION

We were able to prove that ultrasound mammography is an excellent medium for the differentiation of benign and malignant breast lesions, when precise indication criteria were adhered to, even in cases of small tumor size.

Prune-belly syndrome: therapeutic options including in utero placement of a vesicoamniotic shunt

The prune-belly syndrome (PBS) consists of abdominal wall distention with deficiency of the abdominal wall musculature, urinary tract abnormalities, and cryptorchidism. The impaired drainage of the bladder leads to oligohydramnios and pulmonary hypoplasia. We present 4 cases of PBS diagnosed by prenatal sonography. In 2 cases, vesicoamniotic shunt therapy was not indicated because of a poor prognosis based on sonographic and laboratory findings; the pregnancies were terminated. In another case, treatment was not performed because of a twin pregnancy, and the neonate with PBS died the day of delivery by cesarean section at 31 weeks' menstrual age. In the other case, vesicoamniotic shunt therapy was successfully performed, and a healthy child was delivered. Several conditions must be met for vesicoamniotic shunt therapy to have a good chance of success: the karyotype must be normal, other malformations must be excluded by careful sonographic examination, and renal function must be normal, as determined by serial analyses of fetal urine. Generally, the shunt should be inserted as early as possible.

[Significance of detecting impaired uteroplacental perfusion for diagnosis of antiphospholipid antibody syndrome--a case report]

INTRODUCTION

The antiphospholipid antibody syndrome (APA) is a potentially life-threatening disease in pregnancy, associated with spontaneous abortion, intrauterine growth retardation (IUGR), preeclampsia and foetal death in utero. One of the sequelae of the antiphospholipid-antibodies is an impaired uteroplacental circulation. We present a case where we diagnosed an antiphospholipid antibody syndrome (APA) on the basis of a highly pathological Doppler flow in both uterine arteries.

CASE REPORT

A 35-year-old G2P0 with a history of intrauterine foetal death in the 24th week was seen at 15 weeks in her second pregnancy for an ultrasound scan. The Doppler study of both uterine arteries showed highly pathological resistance indices and bilateral notching. Laboratory studies revealed elevated levels of antibodies against Cardiolipin and phospholipids. Therapy trials with low-dose aspirin, heparin, corticosteroids, hemodilution therapy and immunoglobulin remained unsuccessful. The foetus developed severe IUGR, anhydramnios and foetal distress. In the 26th week the parents insisted on a caesarean section because of a pathological heart rate pattern. The birth weight was 365 grams and the infant died immediately.

DISCUSSION

There are several mechanisms which impair the uteroplacental circulation in an APA syndrome. Therefore it is essential to perform laboratory tests when detecting a pathological blood flow in both uterine arteries. In this case all therapies failed, and the preterm infant died due to severe IUGR and distress. The diagnosis, however, facilitated the introduction of early anticoagulation therapy for the mother, the exclusion of systemic lupus erythematodes and the counselling of the parents with regard to further pregnancies.

[Effect of menstrual cycle on Doppler measurements of adnexa tumors]

In a collective of 80 premenopausal women presenting with a total of 83 adnexal masses we tried to find out whether there is any influence on Doppler results by the phase of menstrual cycle. All measurements were performed with a 5.0 MHz transvaginal probe of an Acuson 125 Xp10 between April 1993 and September 1998. In 39 tumours measurements were performed during the follicular phase, in 44 tumours during the luteal phase. Histopathological evaluation showed 72 benign and 11 malignant adnexal masses. A cut-off of 0.69 for PI and 0.45 for RI was used to differentiate preoperatively between benign and malignant masses. In the follicular phase was a sensitivity of 40% and a specificity of 76.5% for RI. Referring values for PI were 60% and 70.6%. In the luteal phase RI led to a sensitivity of 83.3% and a specificity of 71.1%. Regarding PI a sensitivity of 100% and a specificity of 68.4% was achieved. There was no statistically significant difference when sensitivity and specificity for both parameters were compared in the two phases of menstrual cycle. These results are in contrast to the hypothesis that Corpora lutea are responsible for a higher degree of false positive results during the luteal phase. We therefore think that there is no advantage in performing Doppler measurements strictly during the follicular phase.

[Lethal osteochondrodysplasias: prenatal and postnatal differential diagnosis]

PURPOSE

Lethal osteochondrodysplasias show an abnormal maturation and a disturbed growth of cartilage and bones. They represent a heterogeneous group of rare genetic diseases. Their incidence is 1 to 3 in 10,000 births.

MATERIAL AND METHODS

We report altogether 5 cases: two of thanatophoric dysplasia, one of achondrogenesis type II and two cases of the rare fibrochondrogenesis. The differential diagnosis in respect to ultrasonographic, morphologic, radiographic and histopathologic criteria of the most common of these diseases are discussed together with a review of the literature.

RESULTS

On the basis of the ultrasound finding of the short-rib-syndrome, it is possible to differentiate between viable and lethal osteochondrodysplasias at 19 to 22 weeks of gestation. The short-rin-syndrome leads to pulmonary hypoplasia.

CONCLUSIONS

It is essential to obtain an exact diagnosis postnatally by radiographic and histopathological examinations to counsel the parents concerning the risk of recurrency. The risk in this heterogeneous group of genetic diseases ranges between less than 1% up to 50% depending on the final diagnosis. Our two cases of fibrochondrogenesis in a consanguineous couple strongly suggest an autosomal recessive inheritance in this disease.

Doppler sonographic findings for hypertension in pregnancy and HELLP syndrome

Doppler examinations of the umbilical artery, both uterine arteries, and the fetal middle cerebral artery were performed in the third trimester in 18 patients with pregnancy induced hypertension, 52 patients with preeclampsia, and 32 patients with HELLP syndrome and the results were correlated with the parameters fetal outcome. For 74% of the patients this was the first pregnancy, in 93% of the cases a cesarean section was necessary; 66% of the newborn babies were dystrophic and 90% of them were born prematurely. The blood flow in one uterine artery was restricted in 95% of all 102 pregnant women, only 5% did not show any pathological findings. A pathological blood flow was observed on Doppler sonography in the umbilical artery in 70% of the group and 39% showed a pathologically increased perfusion of the fetal middle cerebral artery. The average birth weights and gestational ages in the study group were markedly reduced in comparison with healthy pregnant women (pregnancy induced hypertension: 1620 g/35 weeks; preeclampsia: 1660 g/34 weeks; HELLP syndrome: 1160 g/31 weeks, respectively). The lowest values for average birth weight and gestational age occurred when all four investigated blood vessels showed pathological Doppler findings: 1180 g/31 weeks (0 to 1 pathological vascular findings: 2780 g/38 weeks; 2 pathological vascular findings: 1845 g/34.5 weeks; 3 pathological vascular findings: 1330 g/31 weeks). This Doppler study underlines the importance of examining four blood vessels: the uterine, the umbilical, and the fetal middle cerebral arteries for a complete analysis of the fetoplacental hemodynamics. On account of the severely impaired hemodynamics observed in the placentas of our patients with hypertensive diseases in pregnancy or HELLP syndrome, we believe the early diagnosis of these disorders by Doppler sonography and an early start of therapy to be essential.

Blockade of central angiotensin AT(1) receptors improves neurological outcome and reduces expression of AP-1 transcription factors after focal brain ischemia in rats

BACKGROUND AND PURPOSE

Angiotensin-converting enzyme inhibitors have been shown to protect against stroke in hypertensive rats and to improve neurological outcome after cerebral ischemia in normotensive rats. The present study was designated to test the hypothesis that blockade of brain AT(1) receptors improves the recovery from focal cerebral ischemia and reduces expression of AP-1 transcription factors c-Fos and c-Jun, which have been associated with programmed cell death and neurodegeneration.

METHODS

Experiments were carried out in normotensive male Wistar rats. Focal cerebral ischemia was induced by middle cerebral artery occlusion lasting for 90 minutes and followed by reperfusion. The selective AT(1) receptor antagonist irbesartan was infused intracerebroventricularly over a 5-day period before the induction of ischemia at a dose that inhibited brain but not vascular AT(1) receptors. Twenty-four hours after ischemia, neurological outcome was evaluated and expression of c-Fos and c-Jun proteins in the brain was studied immunocytochemically.

RESULTS

Focal brain ischemia resulted in a strong induction of c-Fos and c-Jun proteins in the cortex, which positively correlated with the degree of neurological deficits. Treatment of rats with irbesartan significantly improved neurological outcome of focal cerebral ischemia when compared with the vehicle-treated group and markedly reduced the expression of c-Fos and c-Jun proteins in the cortex on the ligated side of the brain. Irbesartan pretreatment completely abolished the ischemia-induced c-Fos expression in the hippocampus.

CONCLUSIONS

The present study shows a relationship between c-Fos and c-Jun expression and neurological outcome after focal brain ischemia. Our data indicate that long-term blockade of central AT(1) receptors improves the recovery from brain ischemia and reduces the expression of c-Fos and c-Jun proteins in the brain. Pretreatment with an AT(1) receptor antagonist has beneficial effects after cerebral ischemia.

Different placentation patterns in viable compared with nonviable tubal pregnancy suggest a divergent clinical management

OBJECTIVE

In contrast to tubal abortions, viable ectopic pregnancies in color Doppler ultrasonography exhibit a signal-intensive ring around the gestational sac. We investigated the underlying differences in implantation and placentation.

STUDY DESIGN

Histologic sections of fallopian tubes carrying viable tubal pregnancies (13 patients) and tubal pregnancies that aborted (8 patients) were immunostained for cytokeratin, MIB-1, CD-34, and CD-68. The data were studied by computer-aided image analysis followed by statistical evaluation (Student t test, P <.05).

RESULTS

In contrast to tubal abortions, viable tubal pregnancies are characterized by implantation at the mesosalpingial rather than at the antimesosalpingial side of the organ. They exhibit deeper trophoblast invasion into the thickened tubal wall, more intense trophoblast proliferation (P <.001), and increased villous vascularization (P <.001).

CONCLUSION

The morphologic findings correlate with preoperative Doppler ultrasonography. They suggest that trophoblast invasion, placental growth, and the fate of tubal pregnancies depend on the implantation site. They encourage a conservative management of anti-mesosalpingially implanted, nonviable ectopic pregnancies in clinically stable patients.

[Prune belly syndrome--diagnosis and therapeutic possibilities]

The Prune Belly Syndrome combines dilation of the bladder and a laxity of the abdominal wall, and is of unknown etiology. The sequelae are a pulmonary hypoplasia and a deterioration of the kidney function, which determine prognosis. Via early ultrasound diagnosis, intrauterine application of a vesico-amniotic shunt can be performed and can improve survival rates. Inclusion criteria for a vesicoamniotic shunt are a lack of further sonomorphological abnormalities, a lack of an indication for an alteration of the kidney function by ultrasound or laboratory tests, and a normal karyotype.

Pulsation of blood flow in the umbilical vein during the second trimester of pregnancy correlated to fetal malformation and chromosomal abberation

In the present study the flow profile of the umbilical vein between the 14th and 24th weeks of pregnancy was examined for the first time in connection with pathological pregnancies and chromosomal/fetal anomalies, and compared with the flow pattern of normal pregnancies. The aim of our study was to clarify whether at this early stage in gestation the diagnosis of the fetal condition should be extended to include the monitoring of the umbilical vein and to assess the possibility of making predictions about the further course of pregnancy. 50 pregnant patients without complications, 21 patients later developing pregnancy-induced hypertension/intrauterine growth retardation, 16 pregnancies with fetal anomalies, and 4 pregnancies with chromosomal aberrations were scanned with color Doppler sonography to determine the flow spectra of the umbilical vein in a free loop. Admission criteria were single-child pregnancies and precise knowledge of the duration of gestation. Pulsations of the venous blood flow, which are physiological during the first three months of pregnancy, cease in normal pregnancies from the beginning of the second trimester. In cases where pregnancy-induced hypertension/intrauterine growth retardation developed, 2 out of 21 patients showed pulsations. In the pregnancies in which fetal and/or chromosomal anomalies occurred, pulsations in the flow pattern of the umbilical vein were detected in 14 out of 20 cases. The pulsations of the venous blood flow, which are attributable to a late diastolic reflux component in the venous circulation, are common finding in fetal/chromosomal anomalies. In our opinion, the flow spectrum of the umbilical vein should therefore be incorporated in sonographic screenings, and if pulsations are detected, we advise careful sonographic abnormality diagnostics and an investigation of the karyotype.