The Diagnostic Significance of Comorbidities of Congenital Heart Diseases, Low-Set Ears, and Intrauterine Growth Restriction in Neonates With Trisomies 13 and 18.

BACKGROUND: Trisomies 13 and 18 (T13/18) are autosomal trisomy syndromes with dismal prognoses. Deciding whether to perform a chromosomal analysis for the definitive diagnosis is often difficult (even for experienced pediatricians) because representative clinical signs may not be found in all T13/18 neonates. OBJECTIVES: This study aimed to investigate any clinical signs that could be useful for screening for T13/18 in participants without the representative clinical signs traditionally found in odd-looking neonates with malformation syndromes. PATIENTS AND METHODS: We retrospectively analyzed 15 T13/18 patients, 33 trisomy 21 patients, and 48 controls with other malformation syndromes, for apparent clinical signs during the neonatal period. All participants had been admitted to the neonatal intensive care unit of Kansai Medical University over a nine-year period. RESULTS: The three leading clinical signs in patients with T13/18 were congenital heart diseases (CHD; 100%), low-set ears (LSE; 80%), and intrauterine growth restriction (IUGR; 73.3%). A comorbidity of these two leading non-specific clinical signs was CHD with LSE, which showed the highest diagnostic accuracy between T13/18 and controls with a sensitivity of 80.0% and a negative predictive value of 92.5%. The chi-square test among these three groups (P < 0.01) and multiple comparison tests of proportional differences showed that the comorbidity of CHD with LSE was specific for autosomal trisomy syndromes. A comorbidity of CHD with IUGR also revealed a similar diagnostic accuracy with a sensitivity of 73.3% and a negative predictive value of 90.9% as well as a specificity for T13/18. CONCLUSIONS: The comorbidities of either CHD with LSE or CHD with IUGR should be suspected in neonates with autosomal trisomy syndromes, particularly T13/18 without the expected representative clinical signs.

Practicability of prenatal testing using lectin-based enrichment of fetal erythroblasts.

AIM: The aim of this study was to investigate the practicability and efficiency of lectin-based isolation of fetal erythroblasts for clinical use in non-invasive prenatal testing. METHODS: Peripheral blood samples were collected from 39 pregnant women. Leukocytes were removed with an anti-CD45 antibody after density gradient centrifugation. After blood cells were attached to slides by binding to a galactose-specific lectin and galactose-bound vinyl polymer, the slides were stained with May-Grünwald-Giemsa stain and cells were classified by automated image analysis based on their size and the nuclear area/cytoplasmic area ratio. In 14 samples from the women with male fetuses, fetal origin of the isolated erythroblasts was confirmed by detecting the Y chromosome using fluorescence in situ hybridization. In eight samples, single erythroblasts were collected by the laser capture microdissection technique for amplification of the sex-determining region Y gene to confirm fetal origin. RESULTS: Panning with an anti-CD45 antibody achieved stable removal of leukocytes without aggregation. In all samples, erythroblasts were successfully identified by automated image analysis (18-6000/10 mL of blood). The number of slides required to examine 10 mL of blood ranged from one to six, which was reasonable for clinical use. The Y chromosome was detected in 7.5-43.6% of erythroblasts by fluorescence in situ hybridization, and the sex-determining region Y gene was amplified in seven of eight samples. CONCLUSION: The combination of lectin-based erythroblast isolation and automated image analysis is a practical and efficient method for isolating fetal erythroblasts as a source of fetal genomes.

Fetal-maternal nitrite exchange in sheep: Experimental data, a computational model and an estimate of placental nitrite permeability.

INTRODUCTION: Nitrite conveys NO-bioactivity that may contribute to the high-flow, low-resistance character of the fetal circulation. Fetal blood nitrite concentrations depend partly on placental permeability which has not been determined experimentally. We aimed to extract the placental permeability-surface (PS) product for nitrite in sheep from a computational model. METHODS: An eight-compartment computational model of the fetal-maternal unit was constructed (Matlab(®) (R2013b (8.2.0.701), MathWorks Inc., Natick, MA). Taking into account fetal and maternal body weights, four variables (PS, the rate of nitrite metabolism within red cells, and two nitrite distribution volumes, one with and one without nitrite metabolism), were varied to obtain optimal fits to the experimental plasma nitrite profiles observed following the infusion of nitrite into either the fetus (n = 7) or the ewe (n = 8). RESULTS: The model was able to replicate the average and individual nitrite-time profiles (r(2) > 0.93) following both fetal and maternal nitrite infusions with reasonable variation of the four fitting parameters. Simulated transplacental nitrite fluxes were able to predict umbilical arterial-venous nitrite concentration differences that agreed with experimental values. The predicted PS values for a 3 kg sheep fetus were 0.024 ± 0.005 l∙min(-1) in the fetal-maternal direction and 0.025 ± 0.003 l∙min(-1) in the maternal-fetal direction (mean ± SEM). These values are many-fold higher than the reported PS product for chloride anions across the sheep placenta. CONCLUSION: The result suggests a transfer of nitrite across the sheep placenta that is not exclusively by simple diffusion through water-filled channels.

Role of nitrite in regulation of fetal cephalic circulation in sheep.

Nitrite has been postulated to provide a reservoir for conversion to nitric oxide (NO), especially in tissues with reduced oxygen levels as in the fetus. Nitrite would thus provide local vasodilatation and restore a balance between oxygen supply and need, a putative mechanism of importance especially in the brain. The current experiments test the hypothesis that exogenous nitrite acts as a vasodilator in the cephalic vasculature of the intact, near term fetal sheep. Fetuses were first instrumented to measure arterial blood pressure and carotid artery blood flow and then studied 4-5 days later while in utero without anaesthesia. Initially l-nitro-arginine (LNNA) was given to block endogenous NO production. Carotid resistance to flow increased 2-fold from 0.54 ± 0.01 (SEM) to 1.20 ± 0.08 mmHg min ml(-1) (in 13 fetuses, P < 0.001), indicating NO tonically reduces cerebral vascular tone. Sodium nitrite (or saline as control) was then infused in increasing step-doses from 0.01 to 33 µm in half-log increments over a period of 2 h. Carotid artery pressure, blood flow and vascular resistance did not change compared to fetuses receiving saline, even at plasma nitrite concentrations two orders of magnitude above the physiological range. The results indicate that while cephalic vascular tone is controlled by endogenous nitric oxide synthase activity, exogenously administered nitrite is not a vasodilator at physiological concentrations in the vasculature served by the carotid artery of fetal sheep.

Survival rate of extremely low birth weight infants and its risk factors: case-control study in Japan.

Aim. To clarify the effect of perinatal events on the survival of ELBW infants in Japan. Methods. 1,713 ELBW infants, from 92,630 live births in 2001 and 2002, born at 22-36 weeks of gestation were registered. Case was defined as death at discharge. The relevant variables were compared between the cases (n = 366) and the controls (n = 1,347). Results. The total survival rate was 78.6%. There was a significant difference between the survival rate in cesarean and vaginal delivery at 24-31 weeks of gestation. Cesarean delivery in infants with a birth weight >400 g was significantly advantageous to the survival rate of ELBW infants than vaginal delivery. The significant contributing factors were gestational age at delivery (OR: 0.97), Apgar score at 5 min (0.56), antenatal steroid (0.41), and birth weight (0.996). Nonvertex presentation (1.81), vaginal delivery (1.56), and placental abruption (2.50) were found to be significantly associated with neonatal death. Conclusions. Cesarean section might be advantageous for survival in ELBW infants over 24 gestational weeks or 400 grams of birth weight. Nonvertex presentation, vaginal delivery, and placental abruption could be significant risk factors for survival of ELBW infants.

Changes in the prevalence of the measles, rubella, varicella-zoster, and mumps virus antibody titers in Japanese pregnant women.

In the present study, immunity against infectious diseases, which are capable of influencing both the mother and fetus during pregnancy and the infant in the postnatal period, were assessed in pregnant women to elucidate the necessity of vaccination during the childbearing age. It was determined that there was a trend of increases in the proportion of patients that had low antibody titers observed at a young age. Overall, after adjusting for age, low antibody titers of measles (≤ 4 via the neutralization test [NT]), rubella (≤ 16 via the hemagglutination inhibition [HI]), and varicella and mumps (plus minus or negative on the enzyme-linked immunosorbent assay [EIA]) indicated that the rates of necessity for vaccination against measles, rubella, varicella, and mumps were 27.6%, 16.1%, 3.9%, and 23.8%, respectively. In Japan, acquired immunity for measles, rubella, and mumps was dependent on vaccination, whereas acquired immunity for varicella was dependent on natural infection. We recommend that women be vaccinated after delivery, as these vaccines are live, and thereby, are contraindicated during pregnancy.

Low titers of measles antibodies in Japanese pregnant women: a single-center study.

AIM: Measles during pregnancy has deleterious effects on both perinatal and maternal outcomes. In Japan, local epidemics of measles and cases of measles during pregnancy are still being reported; therefore, the seroprevalence of antibodies to measles is suspected to be still not sufficient. The aim of this study was to analyze the seroprevalence of antibodies to measles in Japanese pregnant women and estimate the percentage of these women who require vaccination or revaccination against measles. MATERIAL AND METHODS: We analyzed the seroprevalence of immunity to measles by the neutralization test in 10 349 pregnant women in the first trimester managed at the National Center for Child Health and Development between February 2004 and December 2010. The neutralization test titers were interpreted as follows: ≧1:8, seropositive; =4, low-positive; ≦4, seronegative. RESULTS: Of the total number of pregnant women tested, 7408 (71.6%) were seropositive, 1864 (18.0%) were low-positive, and 1079 (10.4%) were seronegative for measles antibodies, respectively. CONCLUSION: Our results revealed that 28% of our pregnant population was seronegative or low-positive for measles antibodies, and thought to require revaccination or vaccination. Screening for measles immunity might be advisable for women of childbearing age.

Risk factors associated with altered fetal growth in patients with pregestational diabetes mellitus.

OBJECTIVE: To assess the risk factors for abnormal fetal growth in patients with pregestational diabetic mellitus (DM). METHODS: A retrospective study was performed in 336 patients with pregestational DM. Small-for-gestational-age (SGA) and large-for-gestational-age (LGA) infants were defined as newborns with birth weights < 10th percentile and > 90th percentile, respectively. Logistic regression analysis was performed to identify risk factors for SGA and LGA. RESULTS: Multivariate analysis of the patients with pregestational DM revealed a significant difference between patients who delivered SGA and appropriate-for-gestational-age (AGA) infants in terms of retinopathy (OR = 5.73, 95%CI = 1.39-23.59) and hemoglobin A1C (HbA1C) before delivery (OR = 0.80, 95%CI = 0.68 - 0.94, with a 0.1% increase in DCCT unit). Multivariate analysis revealed a significant difference between patients who delivered LGA and AGA infants in terms of primipara (OR = 3.40, 95%CI = 1.47-7.87) and HbA1C before delivery (OR = 1.14, 95%CI = 1.07-1.21, with a 0.1% increase in DCCT unit). CONCLUSIONS: HbA1C before delivery influenced both SGA and LGA infants in patients with pregestational DM. Tight glycemic control might be harmful to fetal growth in pregestational diabetic patients, especially when complicated with retinopathy.

[A case of intravascular malignant lymphoma with initial progressive non-specific neurological symptoms].

A 79-year-old woman was admitted to a nearby hospital for seven days due to low-grade fever, loss of appetite and general fatigue. She was diagnosed with normal condition and discharged. She was admitted to our hospital one week later with disturbed consciousness. Laboratory findings upon admission revealed anemia, elevated alanine amino transferase, elevated total birirubin and thrombocytopenia. Abdominal CT demonstrated multiple low intensity lesions in the liver. Enhanced brain CT revealed multiple lesions with increased signal intensity lesions in the white matter and cortex. The value of soluble IL-2 receptor antibody was 16,000U/ml. Intravascular lymphoma was suspected because of brain CT finding and IL-2 receptor antibody titer. Methylprednisolone pulse therapy was started considering her age and general condition, but she was died thirteen days after admission. Postmorten examination revealed widespread intravascular aggregation of malignant lymphoma cells in the liver, spleen, bone marrow, bladder, ovary and stomach indicating a diagnosis of an Asian variant of intravascular large B cell lymphoma (AIVL). Neurological abnormalities are not usually associated with AIVL, but this patient had rare AIVL presenting with initial progressive nonspecific neurological symptoms.

Prenatal diagnosis and management of vasa previa: a 6-year review.

AIM: To evaluate the methods of screening and prenatal diagnosis of vasa previa. MATERIAL AND METHODS: We reviewed cases of vasa previa in our hospital between January 2002 and December 2007. During this period, we visualized the site of cord insertion using transabdominal ultrasonography and observed the internal os using gray-scale transvaginal ultrasonography. A diagnosis of vasa previa was confirmed by transvaginal color Doppler imaging. RESULTS: We encountered 10 cases of vasa previa among 5131 deliveries. All cases had one or more known risk factors. In all of the four cases that underwent screening in the second trimester (i.e. between 20 and 25 weeks of gestation), the diagnosis was correct. Routine ultrasonography detected in only three of the other six cases of vasa previa that were referred to our hospital after 26 weeks of gestation. Of the other three cases referred after 26 weeks of gestation, in two cases vasa previa was detected by detailed examination using color Doppler transvaginal ultrasonography after fetal heart rate monitoring detected the presence of non-reassuring fetal status; in the remaining case, we were unable to make an antenatal diagnosis. Non-reassuring fetal status was seen on fetal heart rate monitoring in four of the five detected cases complicated by preterm labor. CONCLUSION: We consider that the best timing of antenatal screening for vasa previa is the second trimester. Non-reassuring fetal heart rate pattern without other possible causes warrants detailed examination of vasa previa.

Cows milk-dependent exercise-induced anaphylaxis under the condition of a premenstrual or ovulatory phase following skin sensitization.

BACKGROUND: A 24 year-old woman with atopic dermatitis occasionally developed symptoms, including dyspnea and generalized urticaria, following ingestion of food containing cows milk. Similar episodes had continued, and had been treated empirically since the age of 16 years. CASE SUMMARY: Although a skin test and IgE RAST showed positive reactions to cows milk, a provocation test with cows milk alone did not induce any symptoms. Therefore, food-dependent exercise-induced anaphylaxis (FDEIA) was suspected, but examination using various combinations of cows milk, aspirin and exercise failed to elicit any symptoms. Finally, a provocation test during the ovulatory phase with cows milk followed by aspirin and exercise evoked systemic urticaria, dyspnea and hypotension. DISCUSSION: The symptoms against cows milk began when she took baths with bath salts containing cows milk as its main ingredient for one year at the age 15 years. Sensitization to cows milk through eczematous skin is indicated from this history. Hormonal change during a premenstrual or ovulatory phase is also an important factor for the development of FDEIA in this case.

[Chemotherapy for cervical carcinoma].

Although cisplatin-based chemotherapy is standard regime for cervical cancer, the major question remains as to what kind of drug is the best candidate for combination with cisplatin. According to recent reports, platinum+taxane is supposed to be a promising combination for not only squamous cell carcinoma but also adenocarcinoma of cervix. Studies of neoadjuvant chemotherapy followed by radiotherapy demonstrate no advantage for overall survival of locally advanced cervical carcinoma. Otherwise, neoadjuvant chemotherapy followed by radical surgery was confirmed to offer a survival advantage in a few prospective randomized trials but its statistical power was low due to small number of patient cases. The platinum+taxane combination is good and its effects should be evaluated on overall survival in the same modality. Concurrent radiotherapy with weekly cisplatin is standard therapy for primary and adjuvant setting for squamous cell carcinoma and adenocarcinoma of cervix.