Usefulness of Practitioner-Led Pancreatic Cancer Screening.

The 5-year survival rate for pancreatic cancer has improved (10%) but remains worse than that for other cancers. Early pancreatic cancer diagnosis is challenging, and delayed diagnosis can delay treatment, which impairs survival. Practitioners do not promptly refer cases to a general hospital, causing delayed discovery. Herein, we aimed to examine the usefulness of the Pancreatic Cancer Project in Matsue, whose objective is to detect pancreatic cancer in patients presenting at any medical institution in Matsue City. Clinical data were extracted from medical records, and abdominal ultrasonography and tumor marker blood level assessments were performed (n = 234; median age, 71 [range, 41-94] years; 51% male). Cases with abnormal abdominal ultrasonography or blood test findings were referred for specialist imaging and followed up. The pancreatic cancer detection rate was 6.0% (n = 14); all cases were referred to a general hospital by practitioners within 1 month. Patients had stage IA (n = 1), IIA (n = 6), IIB (n = 2), III (n = 1), and IV (n = 4) disease. Overall, pancreatic cancer could be detected at an earlier stage (I-II), but referral to a general hospital by visiting practitioners should be prompt. The Pancreatic Cancer Project in Matsue may help improve the detection and prognosis of pancreatic cancer.

Real prevalence of neural tube defects in Japan: How many of such pregnancies have been terminated?

The vital role of folic acid is to reduce the risk of having a neonate afflicted with neural tube defects. The prevalence of neural tube defects (myelomeningocele and anencephaly) has been reported in an incomplete form over the last 40 years in Japan. We aimed to evaluate the total number of neural tube defects including those delivered or terminated, to clarify the proportion of those terminated, and to internationally compare their prevalence. Through information on >311 000 deliveries obtained from 262 hospitals/clinics for 2 years of 2014 and 2015, we identified that the rate of total neural tube defects (termination of pregnancy, live births and stillbirths) was 8.29 per 10 000 deliveries for the year 2014 and was 8.72 for 2015, which were 1.5 and 1.6 times higher than the respective values (live births and stillbirths) reported. It is also observed that the ratio of the total number of myelomeningocele (termination of pregnancy, live births, and stillbirths) to that of anencephaly was approximately 1:1.2, that a half of pregnancies afflicted with neural tube defects were terminated, and that the proportion of termination of pregnancy due to myelomeningocele and due to anencephaly was 20% and 80%, respectively. Internationally, the real prevalence of neural tube defects in Japan was comparatively high, ranking fifth among the seven developed countries. In conclusion, the real prevalence of total neural tube defects was approximately 1.5 times higher than that currently reported by the Japan Association of Obstetricians and Gynecologists.

Reliability of symptoms and endoscopic findings for diagnosis of esophageal eosinophilia in a Japanese population.

BACKGROUND/AIMS: The clinical characteristics of esophageal eosinophilia (EE), which is essential for diagnosis of eosinophilic esophagitis (EoE), have not been fully clarified in a Japanese population. The aim of this study was to analyze the reliability of symptoms and endoscopic findings for diagnosing EE in Japanese individuals. METHODS: We prospectively enrolled subjects who complained of esophageal symptoms suggesting EoE and/or those with endoscopic findings of suspected EoE at the outpatient clinics of 12 hospitals. Diagnostic utility was compared between the EE and non-EE groups using logistic regression analysis. RESULTS: A total of 349 patients, including 319 with symptoms and 30 with no symptoms but endoscopic findings suggesting EoE were enrolled. Of those with symptoms, 8 (2.5%) had EE, and 3 were finally diagnosed with EoE. Of those without symptoms but endoscopic findings, 4 had EE. Among 8 symptomatic patients, 7 had abnormal endoscopic findings suspicious of EoE. Although dysphagia was a major symptom in EE, none of the presenting symptoms was useful for diagnosis of EE. Among the endoscopic findings, linear furrow was the most reliable (OR = 41.583). CONCLUSION: EE is uncommon among patients with esophageal symptoms in Japanese individuals. The most useful endoscopic finding for diagnosis of EE was linear furrow, whereas subjective symptoms were not supportive.

Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta.

For cesarean hysterectomy with placenta previa accreta, "universally achievable" measures are required. We propose eight measures: (i) placement of intra-iliac arterial occlusion balloon catheters; (ii) placement of ureter stents; (iii) "holding the cervix" to identify the site to be transected; (iv) uterine fundal incision; (v) avoidance of uterotonics; (vi) "M cross double ligation" for ligating the ovarian ligament; (vii) "filling the bladder" to identify the bladder separation site and "opening the bladder" for placenta previa accreta with bladder invasion; and (viii) to continue to clamp the medial side of the parametrium or the cervix or employment of the "double edge pick-up" to ligate it. These eight measures are simple, easy, effective, and thus "universally achievable".

Prevalence of organic colonic lesions in patients meeting Rome III criteria for diagnosis of IBS: a prospective multi-center study utilizing colonoscopy.

BACKGROUND: It remains unknown whether the Rome III criteria can exclude organic colonic lesions prior to the diagnosis of irritable bowel syndrome (IBS). We evaluated the colonoscopy results of patients meeting the Rome III criteria for the diagnosis of IBS to determine the presence of organic colonic lesions. METHODS: This study was prospectively conducted at 17 centers in Japan. We enrolled 4528 patients who underwent diagnostic colonoscopy examinations. The diagnosis of IBS was evaluated by questionnaire results according to the Rome III criteria. RESULTS: We evaluated 4178 patients (350 were excluded because of incomplete data or previous colonic surgery), of whom 203 met the Rome III criteria (mean age 57.9 years; range 14-87 years) prior to the diagnostic colonoscopy examination. We identified organic colonic diseases in 21 of these 203 patients (10.3 %) , and these disease were also identified in 338 (8.5 %) of 3975 patients who did not fulfill the Rome III criteria. There were no differences in regard to the prevalence of organic colonic diseases between patients who did and did not fulfill the Rome III criteria. CONCLUSIONS: The prevalence of organic colonic diseases in patients who met the Rome III criteria was at an acceptably low level, indicating that the Rome III criteria are adequately specific for the diagnosis of IBS without performing a colonoscopy examination.

Hydroxysteroid (17-ß) dehydrogenase 1 is dysregulated by miR-210 and miR-518c that are aberrantly expressed in preeclamptic placentas: a novel marker for predicting preeclampsia.

In this study, to search for novel preeclampsia (PE) biomarkers, we focused on microRNA expression and function in the human placenta complicated with PE. By comprehensive analyses of microRNA expression, we identified 22 microRNAs significantly upregulated in preeclamptic placentas, 5 of which were predicted in silico to commonly target the mRNA encoding hydroxysteroid (17-ß) dehydrogenase 1 (HSD17B1), a steroidogenetic enzyme expressed predominantly in the placenta. In vivo HSD17B1 expression, at both the mRNA and protein levels, was significantly decreased in preeclamptic placentas. Of these microRNAs, miR-210 and miR-518c were experimentally validated to target HSD17B1 by luciferase assay, real-time PCR, and ELISA. Furthermore, we found that plasma HSD17B1 protein levels in preeclamptic pregnant women reflected the decrease of its placental expression. Moreover, a prospective cohort study of plasma HSD17B1 revealed a significant reduction of plasma HSD17B1 levels in pregnant women at 20 to 23 and 27 to 30 weeks of gestation before PE onset compared with those with normal pregnancies. The sensitivities/specificities for predicting PE at 20 to 23 and 27 to 30 weeks of gestation were 0.75/0.67 (cutoff value=21.9 ng/mL) and 0.88/0.51 (cutoff value=30.5 ng/mL), and the odds ratios were 6.09 (95% CI: 2.35-15.77) and 7.83 (95% CI: 1.70-36.14), respectively. We conclude that HSD17B1 is dysregulated by miR-210 and miR-518c that are aberrantly expressed in preeclamptic placenta and that reducing plasma level of HSD17B1 precedes the onset of PE and is a potential prognostic factor for PE.

Non-surgical management of post-cesarean uterine infection with marked myometrial gas formation.

Gas in an infected organ generally indicates a severe infection, often requiring surgery; however, data are lacking as to post-cesarean gas-forming uterine infection. A 27-year-old Japanese primigravida underwent a difficult cesarean section, after which a high fever continued. Computed tomography (CT) revealed marked gas in the uterine anterior myometrium. Diagnosing this condition as post-cesarean uterine scar infection, we recommended surgical intervention, that is, hysterectomy or at least drainage; however, the patient refused it. Considering the patient's desire and lack of organ-failure signs, we employed intensive antibiotic treatment for 6 weeks. Serial CT indicated a gradual decrement in the gas amount and she recovered completely after 8 weeks. This case suggests that surgical procedure may not always be necessary for post-cesarean gas-forming uterine infection and CT may be useful to detect/follow this condition.

Prolonged activated partial thromboplastin time in thromboprophylaxis with unfractionated heparin in patients undergoing cesarean section.

AIM: Hemorrhage is an important complication of heparin-thromboprophylaxis after surgery. We attempted to clarify the incidence rate of prolonged activated partial thromboplastin time (APTT), representative of hemorrhagic tendency, in Japanese women who received thromboprophylaxis with unfractionated subcutaneous heparin administration after cesarean section (CS). We also determined factors which affected postoperative APTT. METHODS: We studied 280 women who were administered thromboprophylaxis with unfractionated subcutaneous heparin 5000 IU two times per day after CS. Postoperative APTT under heparin was measured and the incidence of its prolongation was determined. Preoperative APTT, blood loss during surgery, postoperative hematocrit, postoperative serum total protein level, and postpartum body weight were measured, and their correlation with postoperative APTT was determined. RESULTS: Preoperative and postoperative APTT values were 28.3 (26.7-30.3) and 33.8 (31.0-37.5) seconds for median (interquartile range), respectively. Overall, 7.1% of patients showed >or=45 s postoperative APTT. Two patients (0.7%) showed >or=60 s APTT, one of whom suffered subcutaneous hemorrhage around the abdominal incision with complete healing. There were no other hemorrhagic complications. Preoperative APTT positively, and postpartum body weight inversely, correlated with postoperative APTT. The amount of blood loss, postoperative hematocrit, and postoperative serum total protein level did not correlate with postoperative APTT. No discernible deep vein thrombosis or pulmonary embolism occurred. CONCLUSION: Although 7.1% of women under heparin-thromboprophylaxis showed a prolonged APTT that was 150% of the preoperative APTT, serious side effects were not observed. Subcutaneous administration of unfractionated heparin, if checking APTT prolongation 1 day after surgery, may be safe method of thromboprophylaxis after CS.

Human villous trophoblasts express and secrete placenta-specific microRNAs into maternal circulation via exosomes.

In this study, we performed small RNA library sequencing using human placental tissues to identify placenta-specific miRNAs. We also tested the hypothesis that human chorionic villi could secrete miRNAs extracellularly via exosomes, which in turn enter into maternal circulation. By small RNA library sequencing, most placenta-specific miRNAs (e.g., MIR517A) were linked to a miRNA cluster on chromosome 19. The miRNA cluster genes were differentially expressed in placental development. Subsequent validation by real-time PCR and in situ hybridization revealed that villous trophoblasts express placenta-specific miRNAs. The analysis of small RNA libraries from the blood plasma showed that the placenta-specific miRNAs are abundant in the plasma of pregnant women. By real-time PCR, we confirmed the rapid clearance of the placenta-specific miRNAs from the plasma after delivery, indicating that such miRNAs enter into maternal circulation. By using the trophoblast cell line BeWo in culture, we demonstrated that miRNAs are indeed extracellularly released via exosomes. Taken together, our findings suggest that miRNAs are exported from the human placental syncytiotrophoblast into maternal circulation, where they could target maternal tissues. Finally, to address the biological functions of placenta-specific miRNAs, we performed a proteome analysis of BeWo cells transfected with MIR517A. Bioinformatic analysis suggests that this miRNA is possibly involved in tumor necrosis factor-mediated signaling. Our data provide important insights into miRNA biology of the human placenta.

Opening the bladder for cesarean hysterectomy for placenta previa percreta with bladder invasion.

Cesarean hysterectomy for placenta previa percreta with bladder invasion often induces not only massive hemorrhage but also severe bladder/ureter injuries. A 37-year-old woman with previous cesarean delivery suffered placenta previa percreta with bladder invasion. At the 34th week, we performed cesarean hysterectomy. Without separating the bladder from the uterus/cervix, we incised the bladder lateral wall using an automatic stapling/cutting device, leaving the bladder posterior wall adhering to the uterus and resecting it with the uterus. The bladder was easily repaired without urological sequelae. We suggest a new, simple and safe technique for cesarean hysterectomy for this disease.

Decidualization of ovarian endometriosis during pregnancy mimicking malignancy: report of three cases with a literature review.

BACKGROUND: Intracystic papillary excrescence is a characteristic morphological feature of ovarian malignancy. A few recent reports have demonstrated that ovarian endometriotic cysts, undergoing decidualization during pregnancy, occasionally show excrescence, necessitating surgery during pregnancy; however, this phenomenon is not well recognized among clinicians. CASES: Three pregnant women with decidualized ovarian endometriosis showed excrescence. Both ultrasound and magnetic resonance imaging (MRI) preoperatively suggested the presence of underlying ovarian endometriotic cysts in 2 women, but not in the other. Intracystic papillary excrescence prompted us to perform laparotomy at 14, 14, and 19 weeks of pregnancy, respectively, with 1 woman aborting in the 21st week, and with 2 delivering healthy term infants. Histological examination confirmed the diagnosis of decidualized ovarian endometriotic cysts in all 3 patients. CONCLUSIONS: We provide the first report of pregnant women in whom excrescence occurred from ovarian endometriotic cysts without preoperative evidence. Decidualized ovarian endometriosis, even without preoperative morphological features of endometriosis, should be added to the differential diagnosis of ovarian malignancy during pregnancy.

Acute promyelocytic leukemia: an unusual cause showing prolonged disseminated intravascular coagulation after placental abruption.

BACKGROUND: Disseminated intravascular coagulation (DIC) caused by placental abruption usually improves rapidly after prompt delivery and adequate anti-DIC treatment. CASE: A 30-year-old nulliparous woman suffered from placental abruption at the 25th week of pregnancy, and emergent cesarean section was done immediately. She exhibited DIC, which continued even after termination of the pregnancy and anti-DIC treatment. She also showed neutropenia. We closely observed her, and at the 58th day postpartum, blast cells appeared in the peripheral blood and she was diagnosed with acute promyelocytic leukemia (APL). Induction chemotherapy was done successfully. The close observation after delivery enabled us to make the prompt diagnosis/treatment, leading to the complete remission. CONCLUSION: APL should be added to the list of differential diagnosis when DIC persists even after prompt delivery and appropriate anti-DIC treatment after placental abruption.

Uterine rupture during pregnancy soon after a laparoscopic adenomyomectomy.

Although laparoscopic adenomyomectomy may be a possible risk factor for uterine rupture in subsequent pregnancy, few reports have described it. A 35-year-old woman became pregnant 1 month after laparoscopic adenomyomectomy. At the 28th week, uterine contraction occurred, leading to intravenous ritodrine infusion. Severe abdominal pain and a non-reassuring fetal heart rate occurred abruptly and an emergency cesarean section was carried out. The uterus ruptured at the site of previous surgery of the uterine body, which was reconstructed. The mother and the infant did well postoperatively. We report the second case of uterine rupture during pregnancy subsequent to laparoscopic adenomyomectomy. A history of adenomyomectomy and a short interval to subsequent pregnancy may be risk factors for uterine rupture. (Reprod Med Biol 2007; 6: 175-177).

Effect of maternal age on blood loss during parturition: a retrospective multivariate analysis of 10,053 cases.

OBJECTIVE: An extensive study as to whether maternal age itself is a risk factor for blood loss during parturition. METHOD: A total of 10,053 consecutive women who delivered a singleton infant were studied. The excess blood loss was defined separately for women with vaginal and cesarean deliveries as > or = 90th centile value for each delivery mode. The effects of 13 potential risk factors on blood loss were analyzed using multivariate analysis. RESULTS: The 90th centile value of blood loss was 615 ml and 1,531 ml for women with vaginal and cesarean deliveries, respectively. A low lying placenta (odds ratio [OR], 4.4), previous cesarean (3.1), operative delivery (2.6), leiomyoma (1.9), primiparity (1.6), and maternal age > or = 35 years (1.5) were significant independent risk factors for excess blood loss in women with vaginal delivery. Placenta previa (6.3), leiomyoma (3.6), low lying placenta (3.3), and maternal age > or = 35 years (1.8) were significant independent risk factors for excess blood loss in women with cesarean sections. CONCLUSION: A maternal age of > or = 35 years was an independent risk factor for excess blood loss irrespective of the mode of delivery, even after adjusting for age-related complications such as leiomyoma, placenta previa, and low lying placenta.