[A case and literature review of ovarian carcinosarcoma with long-term survival after repeated recurrences].

Ovarian carcinosarcoma is a rare and aggressive tumor with a poor prognosis. We report a case of ovarian carcinosarcoma and also review the literature. In 2000, a 63-year-old woman underwent optimal cytoreductive surgery for ovarian carcinosarcoma( International Federation of Gynaecology and Obstetrics[FIGO]stage III c[pT3cN0M0]). She received adjuvant chemotherapy with paclitaxel and carboplatin(TC). In 2005, a recurrent tumor was noted anterior to the sacrum. The patient had a complete response after 6 cycles of TC chemotherapy; however, a year later, the tumor recurred and was resected. In 2013, the tumor recurred adjacent to the right kidney and was surgically removed after a partial response to 3 cycles of TC chemotherapy. The pathologic findings included epithelial and non-epithelial components with histologic variation and differentiation; specifically, a leiomyosarcoma, cartilaginous tissues with cellular atypia, and a rhabdomyosarcoma were identified in specimens obtained during the first, second, and third surgical procedures, respectively. In keeping with the combination theory of histogenesis, the ovarian carcinosarcoma described herein may have originated from a monoclonal stem cell. The long survival of this patient is attributed to optimal cytoreduction during the primary operation, solitary recurrent tumors that were completely resected, and sensitivity to chemotherapy.

Spontaneous spinal epidural hematoma during pregnancy: three case reports.

We present three extremely rare cases of spontaneous spinal epidural hematoma occurring in pregnancy. The patients developed progressive paralysis of the upper and lower limbs and the diagnoses were confirmed by magnetic resonance imaging. Urgent decompression is required to prevent neurological sequelae. The pregnancy may either be continued or delivered depending on the gestational age and severity of the disorder. Pregnancy-induced structural changes of the vascular walls and hemodynamic changes may play a role in the pathogenesis of spontaneous spinal epidural hematoma.

2,4-Diamino-6-hydroxypyrimidine (DAHP) suppresses cytokine-induced VCAM-1 expression on the cell surface of human umbilical vein endothelial cells in a BH(4)-independent manner.

2,4-Diamino-6-hydroxypyrimidine (DAHP) is considered a specific inhibitor of BH(4) biosynthesis and is widely used in order to elucidate the possible biological function of BH(4) in various cells. In the present study, we found that both the synthesis of tetrahydrobiopterin (BH(4)) and expression of vascular cell adhesion molecule 1 (VCAM-1) were increased in human umbilical vein endothelial cells (HUVEC) treated with proinflammatory cytokines. Thus we examined the effects of DAHP to clarify whether BH(4) might be involved in the expression of VCAM-1 in HUVEC. DAHP reduced the levels of both BH(4) and VCAM-1 induced by TNF-alpha and IFN-gamma. However, the dose-response curves of DAHP for the suppression of the VCAM-1 level and that of BH(4) level were markedly different. Supplementation with sepiapterin failed to restore the depressed VCAM-1 level, although it completely restored the BH(4) level. Furthermore, DAHP significantly reduced the VCAM-1 level under the experimental conditions using TNF-alpha alone, which failed to induce BH(4) production. Taken together, these results indicate that DAHP inhibited the expression of VCAM-1 in a BH(4)-independent manner in HUVEC. In the present study, we also found that DAHP significantly suppressed the accumulation of cytokine-induced NF-kappaB (p65) in the nucleus as well as the mRNA levels of VCAM-1 and GTP cyclohydrolase I (GTPCH), the rate-limiting enzyme of BH(4) synthesis. The data obtained in this study suggest that DAHP reduced VCAM-1 and GTPCH protein synthesis at least partially via suppressing the NF-kappaB level in the nucleus of HUVEC.

Analysis of nitric oxide metabolism as a placental or maternal factor underlying the etiology of pre-eclampsia.

BACKGROUND: Defective nitric oxide (NO)-mediated vasodilation is widely regarded as an underlying cause of hypertension in pre-eclampsia, although there are also arguments against this hypothesis. METHODS: We examined both the mRNA levels and the presence of a Glu298Asp substitution in the NO synthase (NOS) gene, as well as the NO metabolite concentration, in placentas and maternal sera from women with pre-eclampsia and in normotensive pregnant controls (25-40 vs. 24-41 weeks of gestation). RESULTS: Pre-eclamptic and control placentas did not show any significant differences in their NO metabolite levels or their NOS expression levels as measured by quantitative RT-PCR. In addition, we did not find any association between pre-eclampsia and the occurrence of the Glu298Asp amino acid substitution in the NOS gene. In contrast, high maternal circulating NO metabolites were evident in severe pre-eclampsia (p < 0.0001). Although a positive correlation between circulating NO metabolites and blood pressure was not observed, uterine artery resistance measured by ultrasound was found to positively correlate with the maternal NO levels. CONCLUSIONS: Our current data suggest that an altered placental NOS pathway is unlikely to be the primary cause of pre-eclampsia and that the activation of this pathway is possibly in response to maternal symptoms.

Clinical features and characteristics of blood flow of uterine vascular abnormalities.

PURPOSE: The purpose of this study was to assess the clinical features and characteristics of the blood flow in uterine vascular abnormalities using ultrasound and magnetic resonance imaging (MRI). METHODS: A total of 17 women were diagnosed with uterine vascular abnormalities by ultrasound. The clinical characteristics of the patients and the distribution and waveform of the intrauterine vessels were examined using transvaginal gray-scale and Doppler ultrasonography, spin-echo MRI, and MR angiography. RESULTS: The average age of the 17 subjects was 44.3 years, and 5 were postmenopausal women. The number of pregnancies and deliveries was 2.0 and 1.7, respectively. Of the 17 subjects, 7 had a moderate or severe grade of dysmenorrhea and 7 had a history of vascular disease. In all subjects, vaginal ultrasound demonstrated tubular or numerous tortuous anechoic areas in the uterine wall, and Doppler ultrasound showed that the tubular or numerous dilated tortuous vessels had an atypical wave flow, unlike that of an artery or a vein. The distribution of displayed flow varied, and the waveforms of the Doppler ultrasound displayed three patterns. The averages of the pulse Doppler flow indices showed low impedance in the abnormal uterine vessel and the uterine artery, especially in cases of true arteriovenous malformations. MR angiography demonstrated distinct, tortuous, and coiled vascular channels in the pelvis during and just after the arterial phase. CONCLUSION: Characterization of the clinical features of uterine vascular abnormalities is considered to be valuable for obstetricians and gynecologists.

A highly sensitive assay for ritodrine in human serum by hydrophilic interaction chromatography-tandem mass spectrometry.

We developed a sensitive assay for ritodrine (RTD), a beta2-adrenergic agonist, in human serum. This method was based upon the selective and sensitive technique by a tandem mass spectrometry (MS/MS) using a hydrophilic interaction chromatography (HILIC) technique. This method involved a mixed-mode cation-exchange solid-phase extraction of RTD and isoxsuprine, the internal standard (IS), from serum with Waters Oasis MCX cartridges. The detection was made using a Micromass Quattromicro API LC-MS/MS system with electrospray ionization source in positive ion mode. The separation of the analytes was achieved within 4 min on a silica column with a mobile phase of ammonium acetate (10 mM, pH 4.5) and acetonitrile (10:90, v/v). Multiple reaction monitoring was utilized by monitoring 288.2-->121.1 for RTD, 302.2-->107.0 for IS. The calibration curve for RTD was linear over a range of 0.5-1000 ng/mL. When 50 microL serum was used for extraction, the lower limit of quantification was 0.39 ng/mL (97.5 fg on-column). The percent coefficient of validation for accuracy and precision (inter- and intra-day) was less than 9.8% and the recovery was ranged from 83.5 to 94.7% for RTD. This method enabled us to successfully determine RTD in maternal and fetal sera.

Postoperative adhesion formation after laparoscopic uterine horn resection in a porcine model: comparison of five instruments.

PURPOSE: To evaluate the postoperative adhesion formation caused by instruments used in gynecologic laparoscopic surgery and to determine the optimal instruments to use to reduce adhesions. MATERIALS AND METHODS: Seventeen juvenile pigs underwent laparoscopic bilateral resection of the uterine horns under general anesthesia and pneumoperitoneum. The laparoscopic procedures were carried out using monopolar electrocautery (ME) (n = 8), an electrothermal bipolar vessel sealer (EBVS) (n = 6), an ultrasonically activated scalpel (UAS) (n = 6), a loop-type ligature (LTL) with a steel scalpel for severing the tissues (n = 6), and an automatic stapling device (ASD) (n = 8). Second- look laparotomy was performed 14 days postoperatively, and the degree of postoperative adhesions was scored from 0 to 6. RESULTS: The mean and range of adhesion scores were 0.00 with EBVS, 0.13 (range, 0-1) with ASD, 0.33 (range, 0-2) with LTL, 1.17 (range, 0-3) with UAS, and 3.13 (range, 2-6) with ME. We found a statistically significant difference in the extent of postoperative adhesion formation associated with these 5 instruments (P < 0.001, Kruskal-Wallis test). CONCLUSION: Adhesion formation increased in the order EBVS < ASD < LTL < UAS < ME. Our study strongly suggests that surgical instruments can be selected to reduce postoperative adhesion formation, a particular concern in women of reproductive age.

cAMP inhibits cytokine-induced biosynthesis of tetrahydrobiopterin in human umbilical vein endothelial cells.

We studied the effects of cAMP on cytokine (interferon-gamma plus tumor necrosis factor-alpha)-induced stimulation of tetrahydrobiopterin (BH4) synthesis in human umbilical vein endothelial cells (HUVEC). The cytokine mixture caused a marked increase in the biosynthesis and release of BH4 by HUVEC. Dibutyryl-cAMP produced a dose-dependent inhibition of this cytokine-induced stimulation of synthesis and release of BH4 by these cells. 8-Bromo-cAMP also caused a significant inhibition, although the effects were less marked than those of dibutyryl-cAMP. Both forskolin and the stable analog of prostacyclin, iloprost, caused cAMP accumulation and a concomitant diminution of the cytokine-induced BH4 synthesis in HUVEC. Dibutyryl-cAMP and iloprost also significantly inhibited the cytokine-induced stimulation of GTP cyclohydrolase I (GCHI) activity and mRNA production. We concluded that the suppression by the cAMP messenger system of cytokine-induced stimulation of synthesis and release of BH4 by HUVEC can be attributed to the inhibition of the activity of GCHI, the rate-limiting enzyme in BH4 biosynthetic pathway, in HUVEC. The data also suggest that the cAMP-mediated reduction in the GCHI mRNA level may at least partially explain the decline in GCHI activity. It is reasoned that under inflammatory conditions, cAMP-elevating agents such as prostacyclin exert regulatory effects on circulation by inhibiting cytokine-induced synthesis and release of BH4 by HUVEC.

Novel scoring system as a useful model to predict the outcome of patients with acute liver failure: Application to indication criteria for liver transplantation.

AIM: In Japan, the indication for liver transplantation in patients with acute liver failure (ALF) is currently determined according to the guideline published in 1996. However, its predictive accuracy has fallen in recent patients. Thus, we attempted to establish a new guideline. METHODS: The subjects were 1096 ALF patients enrolled in a nationwide survey. All patients showed a prothrombin time <40% of the standardized value and grade II or more severe hepatic encephalopathy. A multiple logistic regression analysis and receiver operating characteristic analysis were performed in 698 patients seen between 1998 and 2003 to identify significant parameters determining the outcome of patients. The extracted parameters were graded as numerical scores. An established scoring system was validated in patients seen between 2004 and 2008. RESULTS: Six parameters were identified and graded as 0, 1 and/or 2; the interval between disease onset and development of hepatic encephalopathy, prothrombin time, serum total bilirubin concentration, the ratio of direct to total bilirubin concentration, peripheral platelet count and the presence of liver atrophy. When the prognosis of the patients with total score of 5 or more was judged as "death", the predictive accuracy was 0.80 with sensitivity, specificity, positive predictive value and negative predictive value greater than 0.70. The values were similarly high in patients for validation. CONCLUSION: Novel scoring system for predicting the outcome of ALF patients may be useful to determine the indication of liver transplantation, since the system showed high predictive accuracy even after validation.

Impact of indoleamine 2,3-dioxygenase on the antioxidant system in the placentas of severely pre-eclamptic patients.

Indoleamine 2,3-dioxygenase (IDO) is the rate limiting enzyme of the kynurenine pathway that degrades L-tryptophan, but a wider range of functions have now been proposed for this enzyme, including antioxidant activity. Our previous study revealed that reduced IDO expression in the placenta induces defective feto-maternal immuno-tolerance leading to the onset of pre-eclampsia. In our present study, we assessed the effects of low placental IDO activity as an antioxidant. The placental levels of 8-hydroxy-2'-deoxy-guanosine (8-OHdG), a maker for oxidative damage to DNA, were significantly higher in pre-eclamptic than normotensive pregnancies (P<0.05). Immunohistochemical signals of 8-OHdG were detected mainly in syncytiotrophoblasts and vascular endothelial cells, and co-localized with those for IDO. Furthermore, a significant inverse correlation was found between the IDO activity and 8-OhdG levels. These results show that oxidative stress is associated with decreased IDO activity in the pre-eclamptic placenta and suggest an impact of low IDO activity other than immune modulation in promoting the onset of this disorder.

Cilostazol inhibits cytokine-induced tetrahydrobiopterin biosynthesis in human umbilical vein endothelial cells.

AIMS: Cilostazol, a type III phosphodiesterase inhibitor, is utilized for the treatment of intermittent claudication and is considered to have the beneficial effects against the atherogenic process. In the present study, we examined the effects of cilostazol on BH(4) biosynthesis in HUVEC treated with a mixture of the pro-inflammatory cytokines IFN-γ and TNF-α. METHODS: Isolated HUVECs were grown to confluence and treated with IFN-γ (300 units/mL) and TNF-α (300 units/mL) for 16 h in order to stimulate BH(4) biosynthesis. The BH(4) levels were measured by HPLC. The mRNA expression of GTP cyclohydrolase I (GTPCH), the rate-limiting enzyme of BH(4) biosynthesis, and GTPCH feedback regulatory protein (GFRP) were quantified by real-time PCR. The GTPCH protein expression was assessed by western blot analysis. RESULTS: Cilostazol significantly reduced the BH(4) levels in cytokine-stimulated HUVEC. Cilostazol produced a concomitant increase in the cAMP levels in HUVEC. Cilostazol decreased the GTPCH activity as well as the expression of GTPCH mRNA and protein. 8-bromo-cAMP (8Br-cAMP), a cell-permeable cAMP analogue, did not reproduce the effects of cilostazol. Cilostazol did not affect the cytokine-induced inhibition of GFRP mRNA expression. CONCLUSIONS: We conclude that cilostazol inhibited cytokine-stimulated BH(4) biosynthesis via a cAMP-independent mechanism in HUVEC. Our data indicate that cilostazol reduced GTPCH activity and did so by suppressing the GTPCH protein levels.

Bilateral interruption of mid-fallopian tubes and ovarian anomalies including ectopic ovary and cystic teratoma, a previously unreported combination.

A 25-year-old infertile woman underwent laparoscopy because of a dermoid cyst of the left ovary and was found to have an ectopic ovary, to which an abnormal right fimbria was connected, with an isolated right ovary in the normal position and the bilateral segmental absence of the middle portion of the fallopian tubes. The complex of these anomalies is rare. A fundamental error might have existed in the mesenchyme of the gonadal ridges of the early embryo, rather than the epithelial origin of the müllerian and wolffian ducts.

Reactivation of human herpesvirus 6 and 7 in pregnant women.

To elucidate the roles of human herpesvirus (HHV)-6 and -7 in pregnant women, peripheral blood samples and genital tract secretions were collected serially from pregnant women, and both serological testing and polymerase chain reaction (PCR) were carried out to detect viral DNA in the secretions. HHV-6 or HHV-7 Immunoglobulin(Ig)M antibodies were not detected in 432 plasma samples collected from pregnant women and cord blood, but IgG antibodies against both viruses were detected in all plasma samples. Significant increases in HHV-6 and HHV-7 IgG antibodies were observed in two (1.6%) and three (2.4%) pregnant women respectively of a total of 123 cases. HHV-6 DNA was detected in the genital tract in three (3.7%) of 82 pregnant women at the first trimester, and in 10 (12.2%) of the same women in the third trimester. The detection rate in the third trimester was significantly higher than that in the first trimester (P = 0.043). Although HHV-7 DNA was detected in the genital tract of two (2.7%) and seven (9.6%) pregnant women of a total of 73 during the first and third trimesters respectively, there was no statistical difference in the detection rate of the viral DNA between the trimesters. Because a significant increase in HHV-6 IgG antibodies was detected in only two pregnant women, it was not possible to carry out statistical analysis to determine the relationship between HHV-6 infection and associated clinical features. Although there was a significant increase in HHV-7 antibody titers in three pregnant women, a positive correlation between the virus infection and the clinical features was not demonstrated. There was no statistical association between virus shedding in the genital tract and the clinical features examined in this study.

cGMP inhibits GTP cyclohydrolase I activity and biosynthesis of tetrahydrobiopterin in human umbilical vein endothelial cells.

Tetrahydrobiopterin (BH4) acts as an essential cofactor for the enzymatic activity of nitric oxide (NO) synthases. Biosynthesis of the cofactor BH4 starts from GTP and requires 3 enzymatic steps, which include GTP cyclohydrolase I (GCH I) catalysis of the first and rate-limiting step. In this study we examined the effects of cGMP on GCH I activity in human umbilical vein endothelial cells under inflammatory conditions. Exogenous application of the cGMP analogue 8-bromo-cGMP markedly inhibited GCH I activity in the short term, whereas an cAMP analogue had no effect on GCH I activity under the same condition. NO donors, NOR3 and sodium nitroprusside, elevated the intracellular cGMP level and reduced GCH I activity in the short term. This inhibition of GCH I activity was obliterated in the presence of an NO trapper carboxy-PTIO. NO donors had no effect on GCH I mRNA expression in the short term. Moreover, cycloheximide did not alter the inhibition by NO donors of GCH I activity. These findings suggest that stimulation of the cGMP signaling cascade down-regulates GCH I activity through post translational modification of the GCH I enzyme.