Hypoxia ameliorates maternal diet-induced insulin resistance during pregnancy while having a detrimental effect on the placenta.

Maternal overweight/obesity contributes significantly to the development of gestational diabetes, which causes risks to both mother and fetus and is increasing sharply in prevalence worldwide. Since hypoxia reprograms energy metabolism and can alleviate weight gain, adiposity, insulin resistance (IR), and dyslipidemia, we set out to study the potential of sustained reduced ambient oxygen tension (15% O2 ) during pregnancy for alleviating the detrimental effects of diet-induced IR in C57Bl/6N mice, taking normal chow-fed and normoxia (21% O2 ) groups as controls. Our data show that hypoxic intervention reduced maternal weight gain, adiposity, and adipose tissue inflammation, and ameliorated maternal glucose metabolism and IR during gestation in diet-induced IR relative to normoxia. Where diet-induced IR reduced maternal hemoglobin and increased serum erythropoietin levels, hypoxic intervention compensated for these changes. Diet-induced IR reduced fetal growth in normoxia, and even more in hypoxia. Hypoxic intervention reduced liver weight gain during pregnancy in the dams with diet-induced IR, maternal liver weight being positively associated with embryo number. In case of diet-induced IR, the hypoxic intervention compromised placental energy metabolism and vascularization and increased end-pregnancy placental necrosis. Altogether, these data show that although hypoxic intervention mediates several beneficial effects on maternal metabolism, the combination of it with diet-induced IR is even more detrimental to the placental and fetal outcome than diet-induced IR alone.

The incidence of iatrogenic deaths in the Finnish cause-of-death statistics; a retrospective study.

PURPOSE: An adverse event in health care leading to death is a significant event when assessing patient safety. This study was designed in order to assess, how many iatrogenic deaths are registered in Finland annually, and what type of treatment they are mostly related to. METHODS: Material was collected using cause of death-statistics that includes "manner of death"-classification in Finland in 2014-2015. RESULTS: There were 350 cases that met the criteria of the study. In a majority of the cases (264, 75%), a medico-legal autopsy was performed. This represents only 1.4% of all medicolegal autopsies during the study period in Finland. The cases were most often related to medication (30%) or known high-risk procedures such as gastrointestinal surgery (23%) and cardiothoracic surgery (11%). Only 12% of the cases had no prior significant medical history. Patient characteristics were somewhat different among the surgical disciplines, probably reflecting treatment practices. CONCLUSION: Deaths that are classified as iatrogenic are mostly related to known high-risk surgery or medication. Further studies are needed to assess the true incidence of malpractice among this material.

Autopsy-Based Learning is Essential But Underutilized in Medical Education: A Questionnaire Study.

To this day, autopsies and dissections have been essential in medical education, but declining autopsy numbers have endangered this long-standing tradition. Students' perceptions of these teaching methods should be constantly updated to help educators understand how to achieve their teaching goals. The purpose of this study was to explore the state of autopsy- and dissection-based teaching in two Finnish universities based on the experiences of the students, survey their perceptions of such teaching, and to compare the Finnish situation with students' perceptions in other countries as it emerges from medical literature. A questionnaire went to 859 second-, fourth-, and sixth-year medical students. The questions concerned dissection and autopsy classes these students had attended, the views of the students in regard to the number of classes, and the benefits of and attitudes towards autopsy teaching. An open question of how to improve autopsy teaching was included. The response rate was 19.4%. Most respondents requested more autopsy and dissection classes, especially practical education. They found autopsies most beneficial in learning anatomy and dealing with one's own emotions related to death. Their experiences proved least beneficial for interaction with the relatives of a deceased patient and for people skills. Integrational methods and focusing on the main learning outcomes were suggested as improvements. Overall, students found dissection and autopsy teaching important, but felt concerned about the diminishing autopsy numbers. Focusing on main learning objectives and better integration of autopsies in the teaching of different specialties could help to utilize autopsies to a greater extent.

Systemic long-term inactivation of hypoxia-inducible factor prolyl 4-hydroxylase 2 ameliorates aging-induced changes in mice without affecting their life span.

Hypoxia inactivates hypoxia-inducible factor (HIF) prolyl 4-hydroxylases (HIF-P4Hs), which stabilize HIF and upregulate genes to restore tissue oxygenation. HIF-P4Hs can also be inhibited by small molecules studied in clinical trials for renal anemia. Knowledge of systemic long-term inactivation of HIF-P4Hs is limited but crucial, since HIF overexpression is associated with cancers. We aimed to determine the effects of systemic genetic inhibition of the most abundant isoenzyme HIF prolyl 4-hydroxylase-2 (HIF-P4H-2)/PHD2/EglN1 on life span and tissue homeostasis in aged mice. Our data showed no difference between wild-type and HIF-P4H-2-deficient mice in the average age reached. There were several differences, however, in the primary causes of death and comorbidities, the HIF-P4H-2-deficient mice having less inflammation, liver diseases, including cancer, and myocardial infarctions, and not developing anemia. No increased cancer incidence was observed due to HIF-P4H-2-deficiency. These data suggest that chronic inactivation of HIF-P4H-2 is not harmful but rather improves the quality of life in senescence.

Presumed adverse events in health care are a frequent indication for medico-legal autopsy in Finland.

The medico-legal autopsy is an essential tool in investigating deaths caused by an adverse event in health care, for both clinical risk management and for professional liability issues. However, there are no statistics available regarding the frequency of autopsies performed due to suspected adverse events. This study aimed to determine the number of medico-legal autopsies done because of presumed adverse events, whether these events were unintentional, medical errors or cases in which malpractice was suspected. Furthermore, differences in treatment types, causes and manner of death were analyzed. The data was obtained from all medico-legal autopsies performed in Northern Finland and Lapland during 2014-2015 (n = 2027). Adverse events were suspected in 181 (8.9%) cases. The suspicions of an adverse event occurring were most often related to medication, gastrointestinal surgery and orthopedic surgery. The manner of death was classified as medical (or surgical) treatment or investigative procedure in 22 (12.2%) cases. The causes of death were completely unrelated to the suspected adverse event in 41 (22.7%) cases. In conclusion, the frequency of presumed adverse events was quite high in this data set, but in the majority of the cases, the suspicion of an adverse event causing death was disproved by an autopsy. Nonetheless, proper investigation of these cases is essential to ensure legal protection of the deceased, next of kin and health care personnel, as well as to support clinical risk management.

Cyclins A, B, E and p27 in Endometrial Endometrioid Adenocarcinoma.

BACKGROUND/AIM: We have previously shown that cyclin A, B and E hold prognostic significance in endometrial endometrioid adenocarcinoma. The aim of this study was to investigate the impact of cyclin-dependent kinase inhibitor p27 on cancer-specific survival and other clinicopathological variables, as well as further analyze the relationship between p27 and cyclins A, B and E and their combined relation to prognosis in the disease. PATIENTS AND METHODS: The study comprised of 211 patients surgically treated for endometrial endometrioid adenocarcinoma at the Oulu University Hospital between 1992 and 2000. Tissue samples were immunohistochemically stained for cyclins A, B and E, as well as p27. Clinicopathological data were retrospectively retrieved from the patients' records. RESULTS: In this study, universally low cyclin expression was found to be an independent, favorable prognostic factor in endometrial endometrioid adenocarcinoma. A strong correlation was found between cyclin A and cyclin B expression and weaker correlations between other cyclin and p27 pairs. Nuclear p27 expression correlated with stage and produced near-significant results in univariate survival analysis. CONCLUSION: Combining the expression level of different cyclins may be useful in determining the prognosis in endometrial cancer. Unfortunately, it remains unclear whether high p27 expression is a poor or a favorable prognostic factor. Further large-scale studies are required to assess the effects of cyclins and p27 in endometrial cancer.

Claudin-5 is associated with elevated TATI and CA125 levels in mucinous ovarian borderline tumors.

BACKGROUND/AIM: Claudin proteins represent a large family of integral membrane proteins crucial for tight junction (TJ) formation and function and are abnormally regulated in several human cancers. The aim of the present study was to study the expression levels of claudin-5 in pre-malignant disease as borderline mucinous ovarian tumors. Previous reports have suggested that claudin-5 over-expression correlates with aggressive behaviour in serous ovarian adenocarcinoma, breast cancer and in pancreatic andenocarcinoma. PATIENTS AND METHODS: We investigated the expression of claudin-5 in mucinous ovarian borderline tumors and its correlation with clinico-pathological parameters and the expression of serum markers cancer antigen (CA) 125 and tumor-associated trypsin inhibitor (TATI). RESULTS: A total of 29 mucinous borderline tumor tissue samples were analyzed using immunohistochemical staining for claudin-5. An association between strong claudin-5 expression and higher serum levels of TATI (p=0.04) and CA125 (p=0.008) were found. There was also an association between claudin-5 expression and the presence of ascites (p=0.02). CONCLUSION: Changes in claudin-5 expression may play a role in malignant transformation.

Mesenchymal stromal cells from female donors enhance breast cancer cell proliferation in vitro.

The interplay between tumor stroma and breast cancer cells (BCCs) is thought to play a significant role in breast cancer. The current knowledge of human mesenchymal stromal cell (MSC) and BCC interaction is contradictory, and the donor sex issue is not addressed at all. We hypothesized that donor sex could have an effect on proliferation of MSCs or BCCs in co-culture in vitro. Three estrogen receptor-negative BCC lines, 19 primary human MSCs and breast tissue-derived fibroblasts from 4 donors were used. MSCs from female donors enhanced BCC proliferation (p = 0.005). The change in BCC proliferation was only partly due to soluble factors excreted by MSCs. The highly aggressive BCC line MDA-MB- 231 induced the proliferation of MSCs (p < 0.001) and fibroblasts (p = 0.037) in co-culture experiments. The magnitude in proliferation change was cell line dependent and partly sex dependent.

Mortalin antibody-conjugated quantum dot transfer from human mesenchymal stromal cells to breast cancer cells requires cell-cell interaction.

The role of tumor stroma in regulation of breast cancer growth has been widely studied. However, the details on the type of heterocellular cross-talk between stromal and breast cancer cells (BCCs) are still poorly known. In the present study, in order to investigate the intercellular communication between human mesenchymal stromal cells (hMSCs) and breast cancer cells (BCCs, MDA-MB-231), we recruited cell-internalizing quantum dots (i-QD) generated by conjugation of cell-internalizing anti-mortalin antibody and quantum dots (QD). Co-culture of illuminated and color-coded hMSCs (QD655) and BCCs (QD585) revealed the intercellular transfer of QD655 signal from hMSCs to BCCs. The amount of QD double positive BCCs increased gradually within 48h of co-culture. We found prominent intercellular transfer of QD655 in hanging drop co-culture system and it was non-existent when hMSCs and BBCs cells were co-cultured in trans-well system lacking imminent cell-cell contact. Fluorescent and electron microscope analyses also supported that the direct cell-to-cell interactions may be required for the intercellular transfer of QD655 from hMSCs to BCCs. To the best of our knowledge, the study provides a first demonstration of transcellular crosstalk between stromal cells and BCCs that involve direct contact and may also include a transfer of mortalin, an anti-apoptotic and growth-promoting factor enriched in cancer cells.

A prognostic index in skin melanoma through the combination of matrix metalloproteinase-2, Ki67, and p53.

The objective of this immunohistochemical study was to explore the roles of Ki67 and p53 in conjunction with matrix metalloproteinase-2 and matrix metalloproteinase-9, tissue inhibitors of metalloproteinase-1 and tissue inhibitors of metalloproteinase-2 in a series of 157 cases of skin melanomas. Elevated Ki67 expression and positive staining for p53 correlated to the propensity to metastasize (P = .016) and to declined disease-specific survival, as well as to shortened recurrence-free survival. In patients with a high immunoreaction for Ki67, the 10-year disease-specific survival was 39% compared with 73% in patients with a low Ki67 expression (P = .03). In cases with a positive p53 expression in melanoma cells, the 10-year disease-specific survival was 59% compared with 76% in patients with a negative immunoreaction for p53 (P = .005). Overexpression of the matrix metalloproteinase 2 protein in conjunction with overexpression of Ki67 characterized melanomas with high metastatic potential and was associated with declined survival with a 10-year disease-specific survival of 33% compared with 85% in the cases with low matrix metalloproteinase-2 and low Ki-67 levels (P = .002). Similarly, in cases with overexpression of matrix metalloproteinase-2 and a positive immunoreaction for p53, the 10-year disease-specific survival was only 42% compared with 80% in patients with matrix metalloproteinase-2 less than 20% and a negative immunostaining for p53 (P < .001). The presence of all 3 adverse prognostic factors was prognostically more significant than any marker alone with a 10-year survival of only 28%. This combination of determining matrix metalloproteinase 2, Ki67, and p53 immunoreactive proteins could be beneficial in the selection of high-risk melanoma patients for future adjuvant trials.

Clinical efficacy of mifepristone and misoprostol in second trimester pregnancy termination.

OBJECTIVE: the aim of this study was to evaluate factors affecting clinical effectiveness of 2nd trimester medical terminations using mifepristone and misoprostol combination. DESIGN: a retrospective observational study. POPULATION: ninety consecutive women who had undergone medical termination of pregnancy after 12-24 weeks of gestation. METHODS: clinical data were collected from Oulu University Hospital patient records for the period between February 2003 and August 2005. The associations between patient characteristics and different outcomes were evaluated using standard statistical tests for correlation. MAIN OUTCOME MEASURES: the time elapsed from induction to successful abortion. RESULTS: the majority (94%) of women aborted successfully within 24 hours. Those who were considered day cases (no overnight hospitalization) were more likely to have a successful termination (p = 0.004), while those who were hospitalized for three or more days were more likely to have a complication (p = 0.046). Women with no previous live births or women with gestation ≥ 17 weeks required opiate analgesia more often (p = 0.019, p = 0.02, respectively). Induction to abortion time was shorter (p < 0.001) when pregnancy had lasted <17 weeks. Nulliparous women were more likely to have a longer induction-to-abortion interval (p < 0.001) than uni- and multiparous women. Women with previous live births aborted more often within 8 hours than women with no previous births (p = 0.032). CONCLUSIONS: multiparous women and women with early gestation complete medical termination faster. Multiparity and shorter gestation time are also associated with lesser need for opiate analgesia, compared to nulliparous women or longer gestation time (≥ 17 weeks).

Low circulating levels of ProMMP-2 are associated with adverse prognosis in bladder cancer.

OBJECTIVES: In this study the serum levels of proMMP-2, active MMP-2, TIMP-2 and MMP-2:TIMP2 complex were evaluated. We also studied the correlation of these parameters with clinicopathological parameters in patients suffering from bladder carcinoma and outcome in this patient group. METHODS: The levels of circulating proMMP-2, active MMP-2, proMMP-9, TIMP-1, TIMP-2 and MMP-2:TIMP-2 complex of 84 patients with bladder cancer were measured by ELISA. The proMMP-2 and TIMP-2 immunoreactive proteins were studied. These results were compared to clinicopathological parameters and patient outcome. RESULTS: Low circulating proMMP-2 levels significantly correlated with poor prognosis. The 5-year disease-specific survival rate was 46% in patients with high levels of proMMP-2 versus 23% in patients with low proMMP-2 levels (p = 0.011). Low TIMP-2 levels could also present as a marker of poor prognosis. In this study, the 5-year disease-specific survival in patients with low circulating TIMP-2 levels was 19% compared to 66% in patients with high TIMP-2 levels (p = 0.004). CONCLUSION: These results indicate that high levels of circulating proMMP-2 and TIMP-2 levels are both associated with a better clinical course; moreover, total proMMP-2 is an independent prognostic marker of bladder cancer progression.

High preoperative plasma TIMP-1 is prognostic for early relapse in primary breast carcinoma.

TIMP-1 is a natural inhibitor of extracellular matrix degrading enzymes called matrix metalloproteinases. In addition to its capacity to inhibit matrix degradation, TIMP-1 has been shown to promote cell growth and inhibit apoptosis. The expression of TIMP-1 in tumor tissue, as well as in circulating blood, has therefore been shown to associate with worsened survival in several malignancies. In our study, a prospective series of 213 patients with primary breast carcinoma was assessed. Circulating pre- and postoperative TIMP-1 levels were assayed using enzyme-linked immunosorbent assay analysis. It was shown that high preoperative plasma TIMP-1 was a powerful predictor of systemic early relapse in breast carcinoma, with HR 8.1 (95% CI 1.8-37.6) (p = 0.007) as a log-transformed continuous variable in Cox regression univariate analysis. It was shown to be independent of, and superior to, nodal status as a prognostic variable in multivariate analysis, and not associated with any known prognostic clinicopathological parameters. Kaplan-Meier analysis showed that the patients belonging to the highest quartile of circulating TIMP-1 levels had a worsened recurrence-free survival of 79% compared to 94% RFS among patients in the lower quartiles (p = 0.016). The postoperative levels of circulating plasma TIMP-1 were not found to be prognostic for relapse. In conclusion, preoperative plasma TIMP-1 was found to be a powerful prognostic factor for early systemic relapse in primary breast carcinoma.

Low serum level of pro-matrix metalloproteinase 2 correlates with aggressive behavior in breast carcinoma.

Malignant tumors that are capable of invading surrounding structures and metastasizing possess certain capacities to cross tissue barriers. Matrix metalloproteinases (MMPs), especially gelatinases and their inhibitor molecules, are known to affect the extracellular matrix turnover, and the proteolytic imbalance due to the abnormal expression of these enzymes eventually leads to cancer progression. This has been well documented at the tissue level. In this study, the different forms of the circulating MMP-2 have been studied in the preoperative sera of 71 patients with breast carcinoma. A quantitative enzyme-linked immunosorbent assay was performed for total proMMP-2, proMMP-2-tissue inhibitor of metalloproteinase 2 (TIMP-2) complex, and free active MMP-2. It is shown here, for the first time, that the total proMMP-2 levels in the serum correlate inversely with node positivity, high stage of the disease, and high nuclear grade of the breast tumor. An association with the levels of lower free active MMP-2 and tumor recurrence is also demonstrated. Interestingly, the tumor tissue expression of MMP-2 had an inverse correlation with proMMP-2-TIMP-2 complex levels in the serum. In conclusion, the levels of the total proMMP-2 correlate inversely with tumor burden, whereas free active MMP-2 might be associated with survival. This could indicate that the prognostic value of the circulating forms of MMP-2 is not congruent with the prognostic information obtained from tissue expression. This is further supported by the inverse correlation of the proMMP-2-TIMP-2 complex and MMP-2 tissue expression in the tumor. Therefore, the different forms of circulating metalloproteinases need to be evaluated further to explore their full potential for clinical use.

The absence of immunoreactivity for tissue inhibitor of metalloproteinase-1 (TIMP-1), but not for TIMP-2, protein is associated with a favorable prognosis in aggressive breast carcinoma.

OBJECTIVES: High tumor grade and lymph node positivity are associated with poor prognosis in breast carcinoma. Prognostic markers are used to define which patient groups benefit from different treatment modalities, some of which are potentially very toxic. Matrix metalloproteinases (MMPs) degrade the extracellular matrix, and type IV collagenases MMP-2 and -9 have been linked to invasive behavior of several malignancies. Tissue inhibitors of metalloproteinases (TIMPs) -1 and -2 inhibit their activity and are therefore considered to have an inhibitory effect on tumor progression. The role of TIMPs in progression of breast carcinoma is, however, still poorly known. Here the effect of TIMP-1 and -2 on survival was examined in lymph node-positive breast carcinoma patients. METHODS: TIMP-1 or -2 was evaluated with avidin-biotin immunohistochemical staining from paraffin-embedded sections of primary breast carcinoma of 132 cases. RESULTS: Positive staining for TIMP-1 and -2 was observed in 81 and 84% of the tumors respectively. TIMP-1 correlated to the grade of the tumor (p = 0.047). Absence of TIMP-1 protein correlated with favorable disease-specific survival of the patients with high-grade tumors. After 10 years of follow-up as high as 88% of patients with a grade 2-3, but TIMP-1-negative tumor were alive, when only 61% of the TIMP-1-positive cases in this group survived by that time (p = 0.03). CONCLUSION: Our results suggest that lack of TIMP-1 protein expression is associated with a favorable prognosis in patients with node-positive high-grade breast carcinoma.