Novel Functional Peptide for Next-Generation Vital Pulp Therapy

Although vital pulp therapy should be performed by promoting the wound-healing capacity of dental pulp, existing pulp-capping materials were not developed with a focus on the pulpal repair process. In previous investigations of wound healing in dental pulp, we found that organic dentin matrix components (DMCs) were degraded by matrix metalloproteinase-20, and DMC degradation products containing protein S100A7 (S100A7) and protein S100A8 (S100A8) promoted the pulpal wound-healing process. However, the direct use of recombinant proteins as pulp-capping materials may cause clinical problems or lead to high medical costs. Thus, we hypothesized that functional peptides derived from recombinant proteins could solve the problems associated with direct use of such proteins. In this study, we identified functional peptides derived from the protein S100 family and investigated their effects on dental pulp tissue. We first performed amino acid sequence alignments of protein S100 family members from several mammalian sources, then identified candidate peptides. Next, we used a peptide array method that involved human dental pulp stem cells (hDPSCs) to evaluate the mineralization-inducing ability of each peptide. Our results supported the selection of 4 candidate functional peptides derived from proteins S100A8 and S100A9. Direct pulp-capping experiments in a rat model demonstrated that 1 S100A8-derived peptide induced greater tertiary dentin formation compared with the other peptides. To investigate the mechanism underlying this induction effect, we performed liquid chromatography-tandem mass spectrometry analysis using hDPSCs and the S100A8-derived peptide; the results suggested that this peptide promotes tertiary dentin formation by inhibiting inflammatory responses. In addition, this peptide was located in a hairpin region on the surface of S100A8 and could function by direct interaction with other molecules. In summary, this study demonstrated that a S100A8-derived functional peptide promoted wound healing in dental pulp; our findings provide insights for the development of next-generation biological vital pulp therapies.

Clinical feasibility of absorbable gelatin film adhesion barrier (GM142 "TENALEAF®") in gynecological laparoscopic surgery: Safety assessment for first-in-human use and surgical video

AIM

To evaluate the safety and operability of the GM142 (TENALEAF®, Medical Division, Gunze Limited, Tokyo, Japan) adhesion barrier applied in patients undergoing surgery for benign gynecologic disease.

METHODS

This multicenter open study enrolled 34 patients from November 2018 to October 2019.

RESULTS

The primary outcome was the incidence of adverse events (AE) within 12 weeks postoperatively. None of the 30 patients completing the study experienced a life-threatening AE. Thirteen patients (43.3%) suffered 30 mild or moderate AE in total. No intestinal obstruction (0/30) was observed, with the sample size justified by the AdSpray® trial (8/61 patients with AE). No gelatin-specific Immunoglobulin E (IgE) antibodies were induced in the patients. The adhesion barrier could be easily inserted (even via trocar) and positioned. After malfunctions were reported in six patients, the instructions for use were updated for trocar use.

CONCLUSION

This study showed the safety and clinical feasibility GM142 as an adhesion barrier.

IGF-2 mediated hypoglycemia and the paradox of an apparently benign lesion: a case report & review of the literature

BACKGROUND

Non-islet cell tumour hypoglycemia (NICTH) is rarely encountered in clinical practice. Insulin-like growth factor 2 (IGF2) is the most common cause of NICTH observed in the setting of mesenchymal and epithelial neoplasia. This is a paraneoplastic syndrome caused by IGF2 activation of the insulin receptor.

CASE PRESENTATION

An 80 year old female presented with a short history of recurrent episodes of confusion with laboratory confirmed hypoglycemia with a plasma glucose of 2.7 mmol/L on fasting which fulfilled Whipple's triad. Diagnostic clues to the aetiology at presentation include the fasting pattern of hypoglycemia, hypokalaemia and the absence of weight gain. A 72 hour fast with results showed early hypoglycemia and suppression of serum insulin, c-peptide, and proinsulin. Serum insulin antibody was not detected. Subsequent measurement of the serum IGF2:IGF1 ratio was elevated at 22.3 and consistent with IGF-2 mediated hypoglycemia and imaging studies demonstrated a pelvic mass. Dietary intervention and oral prednisolone abated hypoglycemia prior to surgery. Ultimately, hypoglycemia resolved following operative intervention and steroid therapy was successfully withdrawn. Histopathology was remarkable for dual neoplastic processes with uterine solitary fibrous tumour (SFT) confirmed as the source of IGF2 hypersecretion on IGF-2 immunohistochemistry and a coincidental invasive high grade serous carcinoma involving the fimbria of the right fallopian tube.

CONCLUSION

The paradox in this case is that the benign solitary fibrous tumour accounted for patient morbidity through secretion of IGF2 and without treatment, posed a mortality risk. This is despite the synchronous presence of a highly malignant fallopian tube neoplasm. This case reinforces the need for thorough clinical evaluation of hypoglycemia to allow prompt and definitive management.

Time trend analysis of perinatal mortality, stillbirth, and early neonatal mortality of multiple pregnancies for each gestational week from the year 2000 to 2019: A population-based study in Japan

Multiple pregnancies pose a high risk of morbidity and mortality in both mothers and infants; thus, obtaining reliable information based on a large population is essential to improve management. We used the maternal and child health statistics, which are published annually, from the database of the Ministry of Health, Labor, and Welfare. The data obtained were aggregated in 5-year intervals, and we used them to analyze the proportion of the number of births for each week of pregnancy to the total of each singleton and multiple pregnancy. For perinatal health indicators (perinatal mortality, stillbirth, and neonatal mortality), the obtained data were calculated and plotted on graphs for each week of pregnancy. Moreover, these indicators were calculated by dividing them into first twin and second twin fetuses. Stillbirth weights were aggregated in several groups, and a histogram was displayed. Between 2000 and 2019, there were 21,068,275 live births, 67,666 stillbirths, and 16,443 early neonatal deaths, excluding 7,148 (7,104 singletons, 44 multiple births) cases, in which the exact gestational weeks at birth were unknown. More than 95% of multiple pregnancies were twin births. Perinatal mortality, stillbirth, and early neonatal mortality rates in multiple pregnancies were the lowest at approximately 37 weeks of gestation and lower than those of single pregnancies at approximately 36 weeks of gestation. Perinatal mortality and stillbirth rates were higher during the delivery of the second twins than the first-born twins, but the early neonatal mortality rate remained approximately the same during the delivery of both twins. As the data in the government database are accumulated and published continuously, indicators can be calculated in the future using the method presented in this study. Further, our findings may be useful for policymaking related to managing multiple pregnancies.

Porous diaphragm syndrome presenting as hemothorax secondary to hemoperitoneum after laparoscopic myomectomy: A case report and literature review

Porous diaphragm syndrome includes all pleural cavity conditions, including pleural effusion, hemothorax, or pneumothorax, that occur secondary to peritoneal cavity disorders through defects in the diaphragm. In this report, we describe the first known case of porous diaphragm syndrome presenting as hemothorax after laparoscopic myomectomy. A 46-year-old nulliparous woman underwent laparoscopic myomectomy for multiple fibroids. Eight hours after surgery, the patient developed exertional dyspnea followed by hemoptysis. Radiological diagnosis revealed massive hemothorax in the right thoracic cavity. Thoracoscopic findings showed the presence of small fenestrae at the center of the right diaphragm, which were repaired thoracoscopically. Hence, quick postoperative diagnosis resulted in successful treatment. In this case, porous diaphragm syndrome is believed to be caused by retention of intraoperative bleed and saline from intra-abdominal lavage, in the abdominal cavity. Porous diaphragm syndrome is a potential life-threatening condition that gynecological surgeons should consider in this era of laparoscopic surgery.

Trocar-site hernia following laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: an initial case report after 40 years of experience at a single center and a brief literature review

Background

In gynecology, the number of laparoscopic surgeries performed has increased annually because laparoscopic surgery presents a greater number of advantages from a cosmetic perspective and allows for a less invasive approach than laparotomy. Trocar site hernia (TSH) is a unique complication that causes severe small bowel obstruction and requires emergency surgery. Its use has mainly been reported with respect to gastrointestinal laparoscopy, such as for cholecystectomy. Contrastingly, there have been few reports on gynecologic laparoscopy because common laparoscopic surgeries, such as laparoscopic salpingo-oophorectomy, are considered low risk due to shorter operative times. In this study, we report on a case of a woman who developed a TSH 5 days postoperatively following a minimally invasive laparoscopic surgery that was completed in 34 min.

Case presentation

A 41-year-old woman who had undergone laparoscopic salpingo-oophorectomy 5 days previously presented with the following features of intestinal obstruction: persistent abdominal pain, vomiting, and inability to pass stool or flatus. A computed tomography scan of her abdomen demonstrated a collapsed small bowel loop that was protruding through the lateral 12-mm port. Emergency surgery confirmed the diagnosis of TSH. The herniated bowel loop was gently replaced onto the pelvic floor and the patient did not require bowel resection. After the surgical procedure, the fascial defect at the lateral port site was closed using 2-0 Vicryl sutures. On the tenth postoperative day, the patient was discharged with no symptom recurrence.

Conclusions

The TSH initially presented following laparoscopic salpingo-oophorectomy; however, the patient did not have common risk factors such as obesity, older age, wound infection, diabetes, and prolonged operative time. There was a possibility that the TSH was caused by excessive manipulation during the tissue removal through the lateral 12-mm port. Thereafter, the peritoneum around the lateral 12-mm port was closed to prevent the hernia, although a consensus around the approach to closure of the port site fascia had not yet been reached. This case demonstrated that significant attention should be paid to the possibility of patients developing TSH. This will ensure the prevention of severe problems through early detection and treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01528-6.

Dynamic changes in serum steroid hormone during the first trimester of pregnancy between infertile women conceiving with and without hormone replacement therapy

Objective

Recent advances in cancer treatment and reproductive medicine have made the post-treatment quality of life an important concern for cancer survivors. We aimed to evaluate the safety of sex hormone (estradiol and progesterone) replacement therapy (HRT) in women who conceived by assisted reproductive technology (ART) with hormone receptor-positive breast cancer.

Methods

We measured serum E2 and P4 levels at 4–10 weeks of gestation in women who conceived naturally or after timed intercourse or intrauterine insemination for infertility without HRT for luteal support (non-HR group; n = 135). We conducted a retrospective comparison of the values from the non-HR group with those of women who conceived by ART with HRT for infertility (HR group; n = 75).

Results

Serum E2 levels were significantly higher in the non-HR group than in the HR group at 5, 6, and 8 weeks of gestation. Similarly, serum P4 levels were significantly higher in the non-HR group than in the HR group at 4, 5, and 6 weeks of gestation.

Conclusions

This study suggests that in cancer reproductive medicine for hormone-dependent breast cancer survivors, HRT administered during the first trimester of a pregnancy after primary disease treatment may not increase the sex hormone levels to levels above those seen in spontaneous pregnancy.

Risk factors for thrombocytopenia and analysis of time to platelet transfusion after azacitidine treatment

The use of azacitidine (AZA) has been known to lead to a high incidence of hematotoxic adverse events. The aims of this study were to identify the risk factors for thrombocytopenia after the administration of AZA and to analyze time to the initial platelet transfusion. Sixty-two patients with myelodysplastic syndrome (MDS), who were treated with AZA in Gifu Municipal Hospital between March 2012 and June 2020, were included in this study. The risk factors for thrombocytopenia were identified using univariate analysis of patient characteristics, disease type, and laboratory values immediately before the start of treatment. Variables with p<0.2 identified in the univariate analysis were used as independent variables in the multivariate analysis. This analysis identified "creatinine clearance (CCr) <60 mL/min" as a significant factor (odds ratio, 4.790; 95% confidence interval [CI], 1.380-16.70; p=0.014). Subsequently, time in days to the initial platelet transfusion after the initial administration of AZA was analyzed using the log-rank test. The overall median time in days to platelet transfusion was 370 days. The log-rank test was used to determine the influence of patient characteristics, disease type, and laboratory values immediately before the start of treatment. The subsequent Cox proportional hazard regression analysis using variables with p<0.2 as independent variables identified "hemoglobin (Hb) <8.0 g/dL" as a significant factor (hazard ratio, 2.143; 95% CI, 1.001-4.573; p=0.048). The results of this study led to the following clinical implications: first, patients with CCr of <60 mL/min at the start of treatment should be treated with caution due to the risk of thrombocytopenia. Second, patients with Hb of <8.0 g/dL at the start of treatment may require platelet transfusion in the early stage of treatment.

Prenatal evaluation of functional pulmonary hypoplasia via fetal magnetic resonance imaging

OBJECTIVE

The purpose of this study was to retrospectively examine the use of lung-to-liver signal intensity ratio (LLSIR) on T2-weighted images to predict functional pulmonary hypoplasia.

METHODS

The subjects of this study were pregnant women who underwent magnetic resonance imaging (MRI). Patients who required nitric oxide inhalation and those who died from respiratory disorders were classified as having functional pulmonary hypoplasia (FPH). All other cases were presented as the control group. We retrospectively analyzed MRI and perinatal data. LLSIR was defined as the ratio of lung signal intensity to liver signal intensity. We examined the relationship between LLSIR and gestational age, compared the LLSIRs in the two groups, and calculated the best cut-off value of the LLSIR to predict FPH.

RESULTS

One hundred and ninety-one patients were eligible for this study, and 12 cases were classified as having FPH. In the control group, LLSIR increased with age (r = 0.383, p < 0.001). We used the observed/expected LLSIR (o/e LLSIR), which was the ratio of obtained LLSIR to expected LLSIR calculated by the regression line to correct the effect of gestational age. In the FHP group, o/e LLSIR was significantly lower than in the control group (p < 0.001). A receiver operating characteristic curve analysis showed that cases with o/e LLSIR above 0.85 were less likely to cause FPH.

CONCLUSIONS

Low o/e LLSIR might reflect the histological characteristics of hypoplastic lung structures. O/e LLSIR seems to be a useful MRI parameter for screening FPH.

POS0975 CLINICAL CHARACTERISTICS OF NONRADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN ASIAN COUNTRIES COMPARED TO OTHER REGIONS: RESULTS OF THE INTERNATIONAL CROSS-SECTIONAL ASAS-COMOSPA STUDY

Background:

Clinical characteristics of nonradiographic axial spondyloarthritis (nr-ax-SpA) are highly variable across patients, and may potentially vary across patient populations, particularly due to differing distributions of human leukocyte antigens (HLA) and other genetic factors. The majority of nr-ax-SpA studies have been conducted in Europe, the United States, and small studies are reported from Asia [1].

Objectives:

To delineate clinical characteristics of patients with nr-ax-SpA in Asian countries in comparison to other areas of the world.

Methods:

Utilizing the ASAS-COMOSPA data, an international cross-sectional observational study of SpA patients, we analyzed information on demographics, disease characteristics, comorbidities, and risk factors. Patients were classified by region: Asia (China, Japan, Singapore, South Korea, and Taiwan), and non-Asian countries (Europe, Americas, and Africa); patient characteristics, including diagnosis and treatment, were compared.

Results:

Among 3984 SpA patients included in the study, 1094 were from centers in Asian countries, and 2890 from other regions. 112/780 (14.4%) of axial SpA patients in Asian countries were nr-ax-SpA, substantially less than in other countries (486/1997, 24.3%). Nr-ax-SpA patients in Asian countries compared to nr-ax-SpA in other countries were more likely male (75.9 vs 47.1%), have onset (22.8 vs 27.8 years) and diagnosis (27.2 vs 34.5 years) at younger age, and experience less diagnostic delay (1.88 vs 2.92 years) (Table 1). Nr-ax-SpA patients in Asian countries have higher prevalence of positive HLA-B27 (90.6% vs 61.9%) and fewer peripheral signs such as arthritis, enthesitis, or dactylitis (53.6% vs 66.3%) but have similar rate of extra-articular manifestations (psoriasis, IBD, or uveitis) and co-morbidities. Disease activity, functional impairment, and inflammation on MRI were less in nr-ax-SpA patients in Asian countries. NSAIDs response was higher and use of methotrexate and b-DMARDs were lower among nr-ax-SpA in Asian countries.

Conclusion:

Among axial SpA patients, substantially lower frequency of nr-ax-SpA was observed in Asian countries compared to other regions of the world. Nr-ax-SpA patients in Asian countries were predominantly male, and had younger disease onset with higher HLA-B27 positivity rate and less peripheral signs, and better response to NSAIDs. These results offer an opportunity to improve both early diagnosis and treatment of nr-ax-SpA patients in Asian countries.

Table 1.

Characteristics of nonradiographic axial SpA in Asia versus non-Asian regions

VariablesAsianon-Asian regionsp valueN112486Age at disease diagnosis, yrs27.2 [21.1, 39.6]34.5 [27.7, 41.7]<0.001Diagnostic delay, yrs1.88 [0.27, 5.56]2.92 [0.59, 9.58]0.011Male (%)85 (75.9)229 (47.1)<0.001Sacroiliitis on MRI among tested (%)49 (67.1)341 (82.2)0.005HLA B27 positivity among measured (%)96 (90.6)273 (61.9)<0.001Inflammatory Back Pain (%)107 (95.5)478 (98.4)0.076Arthritis, enthesitis, or dactylitis (%)60 (53.6)322 (66.3)0.016Psoriasis (%)12 (10.7)82 (16.9)0.142Uveitis (%)20 (17.9)81 (16.7)0.870Inflammatory bowel disease (%)5 (4.5)27 (5.6)0.817Elevated CRP (%)37 (33.0)213 (43.8)0.048Physician global assessment (0-10)2.0 [1.0, 5.0]2.0 [1.0, 4.0]0.741Patient global assessment (0-10)3.0 [1.0, 6.0]4.0 [2.0, 6.0]0.012ASDAS-CRP1.40 [0.95, 2.08]1.97 [1.21, 2.78]<0.001BASFI0.8 [0.05, 2.65]2.9 [0.8, 5.6]<0.001Good response to NSAIDs (%)80 (71.4)272 (56.0)0.004Methotrexate use (%)18 (16.1)134 (27.6)0.016Biological DMARDs use (%)27 (24.1)191 (39.3)0.004

References:

[1]López-Medina C, Ramiro S, van der Heijde D, et al. Characteristics and burden of disease in patients with radiographic and non-radiographic axial Spondyloarthritis: a comparison by systematic literature review and meta-analysis. RMD Open. 2019 Nov 21;5(2): e001108.

Acknowledgements:

This study was conducted under the umbrella of the International Society for Spondyloarthritis Assessment (ASAS) and COMOSPA study was supported by unrestricted grants from Pfizer, AbbVie and UCB.

Disclosure of Interests:

Keisuke Ono: None declared, Mitsumasa Kishimoto Speakers bureau: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma, Consultant of: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma, Sho Fukui: None declared, Satoshi Kawaai: None declared, Gautam A. Deshpande: None declared, Kazuki Yoshida Consultant of: OM1, Inc., Grant/research support from: Corrona, LLC, Naomi Ichikawa: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB, Taku Kawasaki: None declared, Kazuo Matsui: None declared, Mitsuhiro Morita: None declared, Kurisu Tada: None declared, Naoho Takizawa: None declared, Naoto Tamura: None declared, Atsuo Taniguchi: None declared, Yoshinori Taniguchi: None declared, Shigeyoshi Tsuji: None declared, Shigeto Kobayashi: None declared, Masato Okada: None declared, Clementina López-Medina: None declared, Anna Moltó Consultant of: AbbVie, Pfizer, MSD, Novartis, Gilead, Lilly and UCB, Grant/research support from: AbbVie, Pfizer, MSD, Novartis, Gilead, Lilly and UCB, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma, Employee of: Imaging Rheumatology bv. (Director), Maxime Dougados: None declared, Yoshinori Komagata: None declared, Tetsuya Tomita: None declared, Shinya Kaname: None declared.

Rapid recovery achieved by intensive therapy after preterm cesarean section for worsening COVID-19-induced acute respiratory failure: A case report and literature review

A 31-year-old woman (gravida 3, para 2) presented at hospital in the 33rd week of gestation with concerns of general malaise, a productive cough, and impaired taste. She was diagnosed with coronavirus disease 2019 (COVID-19) after a nasal antigen test; a computed tomography (CT) scan of the chest showed pneumonia. The patient developed dyspnea on the third day of hospitalization, and it worsened the following day. Oxygen inhalation and steroid administration were started. Since the dyspnea was worsening, an emergency cesarean delivery was performed to allow intensification of maternal treatment. A postoperative CT scan showed that the pneumonia was getting worse, and the administration of remdesivir was started immediately. The dyspnea improved rapidly, and medication was discontinued on postoperative day 4. The patient was discharged on postoperative day 6. Thus, a patient in the third trimester of pregnancy with COVID-19 whose respiratory condition worsened was successfully treated by early delivery and subsequent intensive treatment.

•

The risk of developing severe COVID-19 may be higher in the third trimester of pregnancy.

•

Expediting delivery should be considered for women with worsening COVID-19.

•

Starting medication at an early stage, before COVID-19 becomes severe, may prevent maternal complications.

Biochemical effects of intraoperative cell salvage and autotransfusion during cesarean section: A prospective pilot study

AIM

Intraoperative cell salvage and autotransfusion (ICSA) is a useful technique for women undergoing cesarean sections who are predicted to experience significant bleeding. This method can reduce allogeneic transfusions as well as its associated risks and costs. Amniotic fluid embolism (AFE) is an abnormal maternal response to ICSA similar to the classic systemic inflammatory response syndrome, but its mechanism is not well understood. This study was conducted to investigate the biochemical aspects of AFE.

METHODS

A prospective case-controlled pilot study was conducted in a general perinatal hospital in Japan. ICSA was performed using a two-step retransfusion process. Blood samples were collected presurgery, immediately postsurgery, and 24 h after surgery. Changes in sialyl Tn antigen (STN), complement C3 and C4, fibrinogen, and fibrin degradation product and D-dimer, C1 esterase inhibitor, and interleukin-8 (all considered AFE-related markers) activities were compared between patients who underwent cesarean sections with ICSA (ICSA group) versus without ICSA (control group).

RESULTS

Fibrinogen levels were significantly lower in the ICSA group than in the control group before surgery but not immediately after or 24 h after surgery. D-dimer was significantly higher immediately after surgery but not 24 h later. STN was significantly lower only before surgery. None of the AFE-related markers showed significant differences between the groups after 24 h. No adverse events were observed in the ICSA group.

CONCLUSIONS

There is no clinical evidence that ICSA alters the biochemical statuses of AFE-related markers in a manner that could lead to adverse maternal responses.

iPREFACE score: Integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring

AIM

Cardiotocography is used worldwide to evaluate fetal well-being during pregnancy and labor. In past guidelines, the management plan was determined based on the assessment of the most severe waveform. There are no guidelines for evaluating the integrated recurrent decelerations; however, we believe their assessment to be essential for predicting the status of the fetus. The objective of this study was to propose an indicator for performing medical interventions during labor by creating a scoring system that reflects integrated recurrent decelerations.

METHODS

In this retrospective cohort study, we included data for only full-term single fetus births from vaginal deliveries. The score named the iPREFACE score (integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring) was calculated using cardiotocography findings from continuing 30 min before delivery. We examined the iPREFACE score and fetal acidemia association and calculated the cut-off iPREFACE scores for acidemia using receiver operating characteristic curves.

RESULTS

The study included 469 delivery cases. Their iPREFACE scores exhibited a significant negative correlation with the umbilical artery blood pH (correlation coefficient; -0.43). The cut-off iPREFACE scores for the umbilical artery blood with pH <7.20, <7.10 and <7.0 were 44, 46 and 67, respectively (the areas under the curve were 0.776, 0.962 and 0.996, respectively).

CONCLUSION

The iPREFACE score may predict fetal acidemia and could be used as an indicator for timely medical interventions during labor. Because assessments using a cardiotocography are quick and easy to perform, the iPREFACE score could be a valuable tool in clinical practice.

Measurement of fetal automated fractional shortening using two-dimensional tracking in multiple centers

PURPOSE

To establish a normal reference range for automated fractional shortening (Auto FS) in normal singleton fetuses measured at multiple centers.

METHODS

This study was conducted from May 2017 to March 2019. It was undertaken on normal singleton fetuses. First, a four-chamber view of the fetal heart was recorded in the B-mode. Then, the region of interest was set on the edge of the ventricular septum and on the edge of the ventricular muscle at a point one-third away from the atrioventricular valve and toward the cardiac apex. Tracking was automatically performed. Values measured in the right ventricle were defined as R-Auto FS, and in the left ventricle as L-Auto FS. Furthermore, combined-Auto FS was defined as the measurement across both ventricles.

RESULTS

A total of 442 normal fetuses were assessed. R-Auto FS decreased significantly with gestational age, and L-Auto FS showed a similar tendency (Spearman's correlation analysis: r_s =  - 0.415 and r_s =  - 0.252, respectively). Combined-Auto FS showed a similar decline as the gestational age increased (r_s =  - 0.451).

CONCLUSION

In this study, we succeeded in defining a reference Auto FS value not only at one institution but also multiple centers. This study suggests that Auto FS can be used clinically and effectively.

DuoStim: a new option for fertility preservation for a woman with Turner syndrome

INTRODUCTION

Turner syndrome (TS) is associated with hypergonadotropic hypogonadism due to gonadal dysgenesis, which results in premature ovarian failure and subsequent infertility. Therefore, counseling and evaluation for fertility preservation are required as early as possible for women with TS.

CASE PRESENTATION

A 23-year-old unmarried woman with mosaic TS (45, X [4/30] 46, XX [26/30]) presented to the pediatric department of our hospital for fertility counseling; she was accompanied by her mother. She was referred to the reproduction center of our hospital for ovarian reserve assessment and counseling regarding fertility preservation. We decided to retrieve oocytes using DuoStim as the controlled ovarian stimulation protocol. During the first and second oocyte retrievals, a total of 17 (9 and 8, respectively) mature metaphase II oocytes were cryopreserved.

CONCLUSION

DuoStim may be a useful option for fertility preservation for women with TS and reduced ovarian reserve. This new strategy may obtain the required number of oocytes in the shortest time and preserve the future fertility of women with TS.

Conservative management of uterine artery pseudoaneurysm occurring during treatment of gestational trophoblastic disease: A case report

Uterine artery pseudoaneurysm (UAP) is a rare disease that causes genital bleeding during the postpartum period after cesarean section. Uterine artery embolization (UAE) is an effective procedure for UAP. UAP was unexpectedly encountered in a patient with gestational trophoblastic disease; however, this patient was conservatively managed without UAE. UAP can occur during treatment for gestational trophoblastic disease. Since asymptomatic UAP may spontaneously disappear, in the selection of conservative treatment, it is important to carefully monitor patients using transvaginal ultrasonography focusing on the size of the UAP and the speed of internal blood flow.

Noninvasive prenatal testing aids identification of tetrasomy 18p: A case report

Tetrasomy 18p syndrome (Online Mendelian Inheritance in Man 614290) is a rare chromosomal disorder that is seen in approximately 1 in every 180,000 live births. It is caused by the presence of isochromosome 18p, which is a supernumerary marker composed of two copies of the short arms of chromosome 18. Isochromosome 18p is one of the most commonly observed isochromosomes. We report tetrasomy 18p syndrome diagnosed prenatally after noninvasive prenatal testing (NIPT) was positive for trisomy 18. Tetrasomy 18p was finally diagnosed by G-banding and fluorescence in situ hybridization of chromosome 18p, before invasive confirmatory testing the karyotype findings by NIPT showed an increase in the DNA fragments from chromosome 18p, indicating duplication of chromosome 18p. NIPT can detect not only trisomy 13, 18, and 21, but also structural chromosomal anomalies, such as deletions and duplications. An NIPT report "positive for trisomy 18" indicates the possibility of tetrasomy 18p, and detailed analysis of NIPT data can reveal subchromosomal copy number variations, to a certain extent, before definitive diagnostic testing.

THU0236 EFFICACY AND SAFETY OF NON-MITOGENIC ANTICD3 ANTIBODY ADMINISTRATION IN THE TREATMENT OF LUPUS-PRONE MICE

Background:

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease characterized by the production of autoantibody and systemic tissue damages including glomerulonephritis. Immune responses mediated by autoreactive T-cells, as well as by autoantibody, is involved in the development and progression of end-organ damages1. Biologic agents which manipulate T-cell function such as CTLA4-Ig and anti-CD40L have been revisited and tried to treat human SLE, however, both of them failed to demonstrate efficacy.

A mouse specific anti-CD3ε mAb, clone 145-2C11 (2C11) is known to be immunosuppressive by down-modulation of TCR and depletion of T-cells2. Administration of Fc-deleted 145-2C11 F(ab’)2to lupus-prone mice was reported to reduce lymphadenopathy and prolong survival, but had no significant effect on anti-DNA antibody titer3. The mechanisms by which 2C11 ameliorates lupus are still unclear.

In this study, we used non-mitogenic Fc-modified silent 145-2c11 (2C11S), which disables interaction between target cells and Fc receptor-bearing cells, abolishes antibody directed cytotoxicity, and has longer half-life than F(ab’)2. 2C11S is expected to exert its effect in safe and stable as compared with functional parent-2C11 (2C11P) antibody.

Objectives:

The purpose of our study is to clarify the difference between 2C11S and 2C11P and to examine their therapeutic effects against murine lupus-prone (NZB/W F1) mice.

Methods:

20 μg of 2C11P (absolute antibody), 2C11S (absolute antibody), or isotype control immunoglobulin G1 κ (IC)(BioLegend) were administered intraperitoneally to C57BL6 mice. The difference of their action on T-cells were evaluated in a time series from peripheral blood. Plasma cytokine levels were measured within 24 hours after antibody administration.

In NZB/W F1 mice from weeks 10 or 20, 2C11P, 2C11S, and IC were administered (100 μg / week, 4 times, intraperitoneally). Plasma anti-dsDNA antibody titer, spleen and kidney blood cell subpopulation, and histology of renal tissue were evaluated before and/or after treatment.

Results:

Duration of reduced TCR expression in 2C11S group was approximately twice as long as that in 2C11P group, and the levels of plasma TNF-α was not increased in 2C11S group while significant increase was observed in 2C11P group (IC; mean 48.3 ± SD 16.7 pg/ml, 2C11S; 57.9 ± 6.12, 2C11P; 168 ± 50.6, IC VS 2C11S; p>0.99, IC VS 2C11P; p=0.03, ANOVA).

In NZB/W F1 mice, the number of follicular helper T (Tfh) cells in spleen significantly decreased in 2C11S group (IC; median 9.0*104[interquartile range 8.5*104], 2C11S; 1.8*104[1.0*104], 2C11P; 1.0*105[9.4*104], IC VS 2C11S; p=0.03, IC VS 2C11P; p>0.99, Kruskal-Wallis). The number of germinal center B (GCB) cells in spleen also decreased in 2C11S group (IC; 1.2*105[1.7*105], 2C11S; 9.0*103[2.3*104], 2C11P; 8.0*104[2.3*105], IC VS 2C11S; p=0.03, IC VS 2C11P; p>0.99). The number of infiltrating CD4+T-cells in kidney significantly reduced in 2C11S group (IC; 3.4*103[1.0*104], 2C11S; 6.4*102[8.8*102], 2C11P; 1.2*103[4.4*103], IC VS 2C11S; p=0.048, IC VS 2C11P; p=0.23). In addition, the rate of increase in anti-dsDNA IgG titers significantly decreased in 2C11S group (IC; 2.3 [1.3], 2C11S; 0.9 [1.0], 2C11P; 1.3 [1.4], IC VS 2C11S; p=0.03, IC VS 2C11P; p=0.24). Finally, glomerular hypercellularity was markedly alleviated only in 2C11S group (IC; 4.4*10 [8.4], 2C11S; 3.8*10 [1.1], 2C11P; 3.9*10 [8.2], IC VS 2C11S; p=0.02, IC VS 2C11P; p=0.57).

Conclusion:

2C11S did not induce cytokine release with maintaining longer effect on TCR down-modulation. 2C11S reduced autoantibody production by suppressing GCB differentiation, possibly through down-regulation of Tfh cell number. Consequently, 2C11S ameliorated lupus nephritis. On the other hand, 2C11P did not show therapeutic effect.

References:

[1]George C Tsokos. et al. Nat. Rev. Rheum (2016) 12: 716-730.

[2]Kuhn C. et al. Immunotherapy (2016) 8: 889-906.

[3]Henrickson M. et al. Arthritis Rheum (1994) 37: 587-589.

Disclosure of Interests: :

None declared

0590 Reliability of Simple Sleep Evaluation Device at Split-Night Polysomnography

Introduction

Watch-PAT is a sleep evaluation device that measures the peripheral blood volume continuously with a probe attached to a fingertip and does not use an electroencephalogram or a nasal cannula. There has been no report on the usefulness of watch-PAT to determine the apnea diagnosis and continuous positive airway pressure (CPAP) use effects in split-night sleep study.

Methods

The consent of the study was obtained. Watch-PAT was simultaneously worn on a patient admitted for split-night polysomnography. The apnea-hypopnea index (AHI) obtained from PSG and the pAHI gained from the watch-PAT were measured when not using CPAP and when using CPAP respectively. And also we examined whether the reduction rates of AHI and pAHI could be correlated.

Results

38 subjects (32 men, age 55 ± 13 years old). BMI 28.3 ± 5.7 kg / m2. When CPAP was not used, AHI was 57.2 ± 23.3 / h and pAHI was 50.8 ± 20.3 / h (r = 0.93, p &lt; 0.0001), when CPAP was used, AHI was 5.2 ± 4.5 /h and pAHI was 6.2 ± 4.5 h (r = 0.82, p &lt; 0.0001), AHI reduction rate was 90.4 ± 8.0% and pAHI reduction rate was 85.4 ± 14.6% (r = 0.76, p &lt; 0.0001).

Conclusion

It was suggested that Watch-PAT had a good correlation with AHI at split night-sleep study.

Support

None

New physician specialty training system impact on distribution of trainees in Japan

OBJECTIVES

The problem of uneven distribution of medical services and inequitable distribution of physicians is drawing much attention worldwide. Revealing how changes in the specialty training system in Japan have affected the distribution of doctors could help us understand this problem. In 2018, a new and standardized specialty training system was implemented by the Japanese Medical Specialty Board, which is recognized by the Ministry of Health, Labor and Welfare. The purpose of this study was to investigate how this new system has affected the geographical distribution of doctors commencing specialty training (trainees) and choice of specialty in Japan.

STUDY DESIGN

Retrospective observational study.

METHODS

The change in the number of trainees between the control period (2012-2014) and 2018 was investigated, taking into account the prefecture and specialty selected. Population, the proportion of residents aged 65 years or older (aging rate), and the total number of overall doctors in each prefecture were considered as the background characteristics of each prefecture. We created a Lorenz curve and calculated the Gini coefficient for the distribution of trainees.

RESULTS

In 2018, the number of trainees per 100,000 population increased to 6.6 nationwide compared with 5.5 during the control period. The number of trainees per 100,000 population in 2018 increased in prefectures with a large population of ≧ 2,000,000, a low aging rate (<27%), and a high doctor density (≧ 250 doctors per 100,000 population). The Gini coefficient showed an increase to 0.226 in 2018 compared with only 0.160 during the control period.

CONCLUSIONS

After the implementation of the new training system, there was an increase in the number of doctors enrolling in specialty programs, and the specialties other than internal medicine and surgery have attracted more trainees. Inequality in the distribution of doctors between urban and rural prefectures worsened. This indicates the need to explore new ways of balancing distribution while maintaining optimal opportunities for specialist training.

Apixaban therapy in a pregnant woman with heparin-induced thrombocytopenia and venous thromboembolic events caused by congenital antithrombin deficiency: A case report

We report the case of a 35-year-old pregnant woman (gravida 3, para 1) with antithrombin deficiency who was successfully treated with apixaban. She had a history of heparin-induced thrombocytopenia and venous thromboembolic events. Pregnancy was confirmed while the patient was having anticoagulant therapy for a persistent thrombus. Choice of anticoagulation during her pregnancy was limited because of her antithrombin deficiency: heparin was not an option because of her history of heparin-induced thrombocytopenia; antithrombin-dependent anticoagulant drugs were not an option because of her antithrombin deficiency, and she preferred outpatient management. Despite the fact that there are no reports of its use in pregnant women, we selected apixaban (10 mg/day), a direct Xa inhibitor, as the best solution. No progression of thrombus was noted during the pregnancy. The newborn baby had no external congenital anomalies, intracranial hemorrhage, or bleeding tendency. Thus, apixaban may be a candidate for anticoagulant therapy in pregnant women with a history of venous thromboembolic events and heparin-induced thrombocytopenia.

•

Pregnant women are at higher risk for venous thromboembolism than women who are not pregnant.

•

Anticoagulant therapy is limited for a pregnant woman with heparin-induced thrombocytopenia caused by congenital antithrombin deficiency.

•

Apixaban may be an alternative option of anticoagulant therapy during pregnancy.

Metastasis to para-aortic lymph nodes cephalad to the renal veins in patients with ovarian cancer

Background

In patients with epithelial ovarian cancer, whether metastasis to para-aortic lymph nodes located cephalad to the renal veins (supra-renal PAN) should be classified as regional lymph node metastasis or distant metastasis remains controversial. This study was a preliminary retrospective evaluation of the pattern of supra-renal PAN metastasis in patients with epithelial ovarian cancer.

Methods

The subjects were 25 patients with epithelial ovarian cancer, primary peritoneal cancer, or fallopian tube cancer who underwent systematic dissection of the para-aortic nodes, including the supra-renal PAN, and pelvic lymph nodes (PLN). Patient factors, perioperative factors, the number of dissected lymph nodes, and pathological lymph node metastasis were investigated.

Results

Supra-renal PAN metastasis was found in 4/25 patients (16.0%). None of the 14 patients with pT1 or pT2 disease had supra-renal PAN metastasis, while 4/11 patients (36.4%) with pT3 or ypT3 disease had such metastases. None of the patients had isolated supra-renal PAN metastasis, while patients with supra-renal PAN metastasis also had multiple metastases to the infra-renal PAN and PLN.

Conclusions

In patients with epithelial ovarian cancer, supra-renal PAN metastases might be considered to be distant rather than regional metastases. Further studies are needed to better define the clinical significance of supra-renal PAN metastasis.

Safety of uterine fundal pressure maneuver during second stage of labor in a tertiary perinatal medical center: A retrospective observational study

OBJECTIVE

This study aimed to evaluate the conformity of the indications and implementation status of uterine fundal pressure maneuver (UPFM) and to examine its safety according to the Japan Society of Obstetrics and Gynecology (JSOG) guidelines.

MATERIALS AND METHODS

We selected all the patients (n = 265) who were treated with UFPM between January 2015 and March 2017. We first evaluated the conformity of the indications and implementation status of UFPM concerning the guidelines for obstetrical practice in Japan, 2017. Second, we retrospectively examined maternal and fetal adverse events (AEs) to determine the safety of UFPM.

RESULTS

In total, 265 patients underwent UFPM; of all the UFPM-assisted deliveries, 189 patients (72%) were evaluated for conformity. Of these 189 patients, 181 (95.7%) were confirmed to be compliant. Laceration of the birth canal was the most frequently occurring maternal AE, followed by cervical laceration. No cases of uterine rupture, severe AEs leading to an extended hospital stay, and maternal deaths were observed. Although fetal AEs requiring admission to neonatal intensive care unit (NICU) were recorded for 33 patients (12.5%), all newborns developed normally without sequela.

CONCLUSION

The findings of this study may support the validity of the 2017 guidelines. Because it is difficult to find evidence of the safety of use of UFPM, it is essential to accumulate experiences and results learned in clinical practice to build a consensus in the future using the current 2017 guidelines as a standard as done in the current study.

Asymmetrical Hemodynamic Influence of Twin-Twin Transfusion Syndrome on Fetal E/e' by the Dual Gate Doppler Method in Recipient Twins

OBJECTIVES

To assess the hemodynamic influence of twin-twin transfusion syndrome (TTTS) on diastolic function, using left ventricle (LV) and right ventricle (RV) E/e' measured in the same cardiac cycle using the dual-gate Doppler (DD) method.

METHODS

This study included 56 monochorionic twin pregnancies that underwent fetoscopic laser surgery (FLS) for TTTS in 2015-2018. E/e' by the DD method was measured 24 h before and 4-7 days after FLS.

RESULTS

Recipients showed higher LV-E/e' Z score in stage I-, II-, and III-recipients (IIIr) and higher RV-E/e' Z score in stage III-donors and IIIr than donors (p < 0.05). After FLS, LV-E/e' Z score of recipients significantly decreased due to LV-E velocity Z score decrease (p < 0.05). RV-E/e' Z score after FLS significantly decreased due to RV-e' velocity Z score increase in recipients (p < 0.05).

CONCLUSIONS

E/e' by the DD method helped assess cardiac changes of recipients. LV-E/e' could assess early hemodynamic changes by TTTS, and RV-E/e' can assess later influence on cardiac diastolic function. Furthermore, in recipient twins, the decrease in LV-E/e' after FLS might reflect the improvement of volume overload and the decrease in RV-E/e' might reflect the improvement of diastolic relaxation function in the RV.

Correction to: Feasibility of automated fetal fractional shortening measurement with two-dimensional tracking and construction of a reference range for normal fetuses

In the original publication of the article, the Conflict of interest statement.

Successful use of fetoscopic laser surgery as treatment for a monochorionic-triamniotic triplet pregnancy complicated by twin-reversed arterial perfusion sequence and severe selective fetal growth restriction: A case report

Monochorionic triplet pregnancy is a rare condition, and twin-reversed arterial perfusion (TRAP) sequence and severe selective fetal growth restriction (FGR) are associated with high perinatal morbidity and mortality rates. We report a case of TRAP sequence and selective FGR typeIIconcurrently complicating a monochorionic triplet pregnancy. Fetoscopic laser surgery (FLS) was performed at 16 + 1 weeks of gestation and was technically successful. Inter-fetus placental anastomoses were coagulated. The pregnancy continued until 28 + 4 weeks of gestation, when the patient presented with preterm rupture of membranes and preterm labor. Two live female newborns were delivered by a cesarean section, and their postnatal course of the neonates was uneventful and in accordance with their gestational age at birth. To our knowledge, this is the first case report of FLS resulting in favorable outcomes for a monochorionic triplet pregnancy concurrently complicated with TRAP sequence and selective FGR type II.

Feasibility of automated fetal fractional shortening measurement with two-dimensional tracking and construction of a reference range for normal fetuses

PURPOSE

To assess the feasibility of an automated fractional shortening (Auto FS) measurement method using two-dimensional tracking and to construct a reference range for normal fetuses.

METHODS

This study was conducted from May 2017 to March 2018. First, cardiac motion in the four-chamber view was recorded in the B-mode. Subsequently, the region of interest was set on the edge of the ventricular septum or ventricular muscle at a point one-third away from the atrioventricular valve toward the cardiac apex. Tracking was automatically performed. Values measured between the ventricular septum and right ventricle were defined as R-Auto FS, whereas those measured between the ventricular septum and left ventricle were defined as L-Auto FS. Those on each ventricular muscle were defined as Combined-Auto FS.

RESULTS

Data were obtained from 131 singleton fetuses. R-Auto FS significantly decreased with an increase in the number of gestational weeks, and L-Auto FS and Combined-Auto FS showed the same tendency (Spearman's correlation analysis: p = - .528, p = - .351, and p = - .636, respectively).

CONCLUSION

We succeeded in defining a reference Auto FS value for normal singleton pregnancies. Auto FS was negatively correlated with gestational age. This novel technique can assess fetal heart contractility.

Early first trimester uteroplacental flow and the progressive disintegration of spiral artery plugs: new insights from contrast-enhanced ultrasound and tissue histopathology

STUDY QUESTION

Does the use of a vascular contrast agent facilitate earlier detection of maternal flow to the placental intervillous space (IVS) in the first trimester of pregnancy?

SUMMARY ANSWER

Microvascular filling of the IVS was demonstrated by contrast-enhanced ultrasound from 6 weeks of gestation onwards, earlier than previously believed.

WHAT IS KNOWN ALREADY

During placental establishment and remodeling of maternal spiral arteries, endovascular trophoblast cells invade and accumulate in the lumen of these vessels to form 'trophoblast plugs'. Prior evidence from morphological and Doppler ultrasound studies has been conflicting as to whether the spiral arteries are completely plugged, preventing maternal blood flow to the IVS until late in the first trimester.

STUDY DESIGN, SIZE, DURATION

Uteroplacental flow was examined across the first trimester in human subjects given an intravenous infusion of lipid-shelled octofluoropropane microbubbles with ultrasound measurement of destruction and replenishment kinetics. We also performed a comprehensive histopathological correlation using two separately archived uteroplacental tissue collections to evaluate the degree of spiral artery plugging and evaluate remodeling of the upstream myometrial radial and arcurate arteries.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pregnant women (n = 34) were recruited in the first trimester (range: 6+3 to 13+6 weeks gestation) for contrast-enhanced ultrasound studies with destruction-replenishment analysis of signal intensity for assessment of microvascular flux rate. Histological samples from archived in situ (Boyd Collection, n = 11) and fresh first, second, and third trimester decidual and post-hysterectomy uterine specimens (n = 16) were evaluated by immunohistochemistry (using markers of epithelial, endothelial and T-cells, as well as cell adhesion and proliferation) and ultrastructural analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Contrast agent entry into the IVS was visualized as early as 6+3 weeks of gestation with some variability in microvascular flux rate noted in the 6-7+6 week samples. Spiral artery plug canalization was observed from 7 weeks with progressive disintegration thereafter. Of note, microvascular flux rate did not progressively increase until 13 weeks, which suggests that resistance to maternal flow in the early placenta may be mediated more proximally by myometrial radial arteries that begin remodeling at the end of the first trimester.

LIMITATIONS REASONS FOR CAUTION

Gestational age was determined by crown-rump length measurements obtained by transvaginal ultrasound on the day of contrast-enhanced imaging studies, which may explain the variability in the earliest gestational age samples due to the margin of error in this type of measurement.

WIDER IMPLICATIONS OF THE FINDINGS

Our comprehensive in situ histological analysis, in combination with the use of an in vivo imaging modality that has the sensitivity to permit visualization of microvascular filling, has allowed us to reveal new evidence in support of increasing blood flow to the IVS from 6 weeks of gestation. Histologic review suggested the mechanism may be blood flow through capillary-sized channels that form through the loosely cohesive 'plugs' by 7 weeks gestation. However, spiral artery remodeling on its own did not appear to explain why there is significantly more blood flow at 13 weeks gestation. Histologic studies suggest it may be related to radial artery remodeling, which begins at the end of the first trimester.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by the Oregon Health and Science University Knight Cardiovascular Institute, Center for Developmental Health and the Struble Foundation. There are no competing interests.

Elastic modulus estimation based on local displacement observation of elastic body

A method is proposed that provides estimates of the spatial variation of elastic moduli using local displacements of the elastic body. A central issue of elastography imaging has been the limited area of measurement. With the proposed method, stiffness parameter estimations are considered as minimization problems using finite-element models. The sparseness of the gradient of tissue elasticity is also exploited to improve estimation accuracy. Simulation experiments show that based on a 5% area of observation of a simple plate model with non-uniform elasticity the spatial variation of Young's modulus is reconstructed to within 5% accuracy. This result suggests that the proposed framework significantly extends the area of estimation overcoming the limitations of conventional elastography techniques.

Assessment of diastolic function of normal fetal heart using dual-gate Doppler

OBJECTIVES

The ratio of mitral peak early diastolic filling to early diastolic mitral annular velocity (E/e') reflects diastolic cardiac function in adults. Dual-gate Doppler (DD) enables measurements of E/e' in the same heart beat. This study was designed to assess the utility of the DD method for measurement of fetal E/e' and determine reference ranges for normal fetuses.

METHODS

This prospective study comprised normal singleton pregnancies undergoing fetal echocardiography between 16 and 36 weeks of gestation. According to the DD method, E-wave velocity on pulsed-wave Doppler and e'-wave on tissue Doppler imaging were measured simultaneously on an apical or basal four-chamber view, and fetal E/e' was calculated. Spearman's correlation coefficient was used to assess the relationship between gestational age (GA) and E-wave and e'-wave velocities and E/e'.

RESULTS

A total of 133 pregnancies were included in this study and all E/e' measurements were successful. Significant correlation was observed between GA and both left ventricular (LV) E/e' (r _s  = -0.666, P < 0.001) and right ventricular (RV) E/e' (r _s  = -0.607, P < 0.001). The regression equations for bilateral E/e' were: LV-E/e' = 17.341 - 0.631GA + 0.008 × GA² (mean ± SD, R ²  = 0.440 ± 1.333); and RV-E/e' = 19.156 - 0.794GA + 0.012GA² (R ²  = 0.419 ± 1.329).

CONCLUSIONS

Bilateral E/e' of normal fetuses, measured using the DD method, decreased with GA, which is considered to be related to myocardial maturity. DD is a useful and convenient method for evaluating fetal E/e' in order to assess diastolic function in the prenatal period. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Trend in unequal geographical distribution of doctors by age and sex in Japan from 2004 to 2014

OBJECTIVES

In Japan, the proportion of female doctors and elderly doctors is increasing as in other countries. We investigated the relationship between doctors' demographic changes and their geographical distribution.

STUDY DESIGN

A national database study.

METHODS

We assessed trends in unequal geographical distribution of the number of doctors by sex and age from 2004 to 2014 in Japan.

RESULTS

The Gini coefficient values for the number of female doctors (0.18) were larger than those for male doctors across all generations (0.13-0.14). The Gini coefficient values for the number of elderly doctors aged 60 years and older (male: 0.12, female: 0.18-0.23) were larger than those for majority age groups aged 40-59 years (male: 0.10, female: 0.16-0.17).

CONCLUSION

The persisting geographical maldistribution of doctors may be associated with demographic changes, such as increase in the number of female doctors.

Utility of fetal anteroposterior to transverse cerebellar diameter ratio to exclude cerebellar hypoplasia in trisomy 18

AIM

This study was aimed to determine reference ranges for fetal cerebellar hemisphere biometry, including the transverse cerebellar diameter (TCD), anteroposterior cerebellar diameter (APCD) and APCD/TCD ratio in normal fetuses. In addition, we investigated which parameter would be useful for cerebellar hypoplasia in trisomy 18.

METHODS

This retrospective study included 340 normal singleton pregnancies and 15 cases of trisomy 18, in all of which fetal cerebellar biometry was performed between 14 and 40 weeks of gestational age (GA). The TCD, APCD and APCD/TCD ratio were assessed ultrasonographically.

RESULTS

In normal fetuses, the TCD (r_s = 0.876, P < 0.001) and APCD (r_s = 0.791, P < 0.001) were strongly correlated with GA. However, the APCD/TCD ratio was not correlated with GA (r_s = 0.058, P = 0.289), with median values of 0.52. Low TCD, APCD and APCD/TCD ratio values were detected in 53%, 100% and 100% of trisomy 18 cases, respectively. The median APCD/TCD ratio for trisomy 18 was 0.39 (range, 0.30-0.43), which was significantly lower than that of normal fetuses (P < 0.001). A cut-off APCD/TCD ratio of 0.44 served as a good predictor for trisomy 18 (sensitivity 100%, specificity 95.3% and negative predictive value 100%).

CONCLUSION

This study shows that TCD and APCD are correlated with GA, while the APCD/TCD ratio is a fixed value throughout gestation. Using the APCD/TCD ratio to assess cerebellar hypoplasia in trisomy 18 is useful because it does not require the individual evaluation of the TCD and APCD.

Ultrasound-guided laparotomic oocyte retrieval during surgery for fertility preservation in a case of tumor recurrence after a unilateral salpingo-oophorectomy

Case

A 28 year old unmarried woman underwent a unilateral salpingo‐oophorectomy and was suspected of having a malignant tumor in the remaining ovary. After consultation with the patient and her family, it was decided to cryopreserve the unfertilized oocytes. In order to reduce the risk of puncturing or rupturing the tumor when performing the oocyte retrieval from the ovary that was affected by the malignant tumor, it was chosen to use direct laparotomic oocyte retrieval during surgery, instead of conventional transvaginal retrieval. In order to further reduce the risk of tumor rupture, an ultrasound was used in the laparotomy field to precisely puncture only the follicle and thus avoid the tumor. A total of 11 oocytes was retrieved and 10 of them were cryopreserved in the MII phase.

Outcome

By using an ultrasound at the same time as the oocyte retrieval, it was possible to avoid the ovarian tumor site. Furthermore, by checking and puncturing the follicles, it became possible to retrieve oocytes from the healthy parts of the ovary with greater precision. The combined use of an ultrasound with oocyte retrieval can be considered to be an effective method because it can be performed relatively easily.

Conclusion

The authors believe that not only macroscopic, but also ultrasonic, methods are useful to reduce the risk of tumor rupture.