Immunosuppressives and biologics during pregnancy and lactation : A consensus report issued by the Austrian Societies of Gastroenterology and Hepatology and Rheumatology and Rehabilitation.

An increasing and early-onset use of immunosuppressives and biologics has become more frequently seen among patients with inflammatory bowel diseases (IBD) and rheumatic disorders. Many women in their childbearing years currently receive such medications, and some of them in an interdisciplinary setting. Many questions arise in women already pregnant or wishing to conceive with respect to continuing or discontinuing treatment, the risks borne by the newborns and their mothers and long-term safety. Together with the Austrian Society of Rheumatology and Rehabilitation, the IBD working group of the Austrian Society of Gastroenterology and Hepatology has elaborated consensus statements on the use of immunosuppressives and biologics in pregnancy and lactation. This is the first Austrian interdisciplinary consensus on this topic. It is intended to serve as a basis and support for providing advice to our patients and their treating physicians.

Management of uterine ectopic pregnancy - local vs. systemic methotrexate.

INTRODUCTION: The aim of this study was to compare ultrasound-guided local methotrexate (MTX) vs. systemic methotrexate in uterine ectopic pregnancy regarding the beta human chorionic gonadotropin (hCG) clearance duration. MATERIAL AND METHODS: Patients with interstitial pregnancy, cervical pregnancy or cesarean scar pregnancy were included. Methotrexate was administered locally ultrasound-guided (25 mg methotrexate fixed dose) or systemically (intramuscular; 50 mg/m2 body weight). Beta hCG clearance duration in days formed the main outcome measure. RESULTS: Forty-six patients with uterine ectopic pregnancy were included. The mean estimated beta hCG clearance duration was 29.2 days longer in patients with local methotrexate compared with systemic methotrexate (64.7 vs. 31.5 days, respectively; p = 0.026). There was no significant difference between local vs. systemic methotrexate regarding adverse events such as bleeding (p = 0.376), pain (p = 0.146) or secondary surgery (p = 0.631). There was no association of initial beta hCG levels (p = 0.746), initial progesterone levels (p = 0.870) or patients' age (p = 0.604) and the beta hCG clearance duration. No significant difference in beta hCG clearance duration comparing local methotrexate injection with aspiration vs. local methotrexate injection without aspiration could be found (mean 49.4 and 71.6 days, respectively, p = 0.225). CONCLUSIONS: In patients with uterine ectopic pregnancies, the mean estimated beta hCG clearance duration was 29.2 days longer when applying local methotrexate compared with systemic methotrexate.

Risk Factors for De Novo Malignancies in Women After Kidney Transplantation: A Multicenter Transversal Study.

OBJECTIVE: Transplantation results in a 5-time elevated risk for a variety of malignancies (Kaposi sarcoma, skin, liver, lung, gastrointestinal cancer). A patient's risk for malignancies could be of particular interest for the follow-up programs of patients and risk adaption after kidney transplantation. The aim of this study was to identify independent risk factors for de novo malignancies in women after renal transplantation. METHODS AND MATERIALS: This is a multicenter transversal study, conducted at the Medical University of Vienna and Hospital Rudolfstiftung, Vienna, Austria. We included female kidney graft recipients who were transplanted between 1980 and 2012 and followed-up at our institutions (N = 280). Clinical data of patients were extracted from hospital charts and electronic patient files. Patients were interviewed using a standardized questionnaire regarding their medical history, history of transplantation, and malignant diseases. Detailed information about present and past immunosuppressive regimens, rejection episodes and therapies, renal graft function, and information about primary disease was obtained. Diagnostic work-up and/or surgical exploration was performed if any presence of malignancy was suspected during routine follow-up. Histological specimens were obtained from all patients. MAIN OUTCOME MEASURES: the presence of de novo malignancy after kidney transplantation. RESULTS: Two hundred sixty-two women were included for statistical analysis. Median (interquartile range) follow-up period after transplantation was 101.1 (27.3-190.7) months. Thirty-two patients (12.2%) developed a malignancy: dermatologic malignancies (5.7%), breast cancer (3.4%), cervical cancer (0.8%), lung cancer (0.4%), gastrointestinal malignancies (1.5%), vulvar cancer (0.4%), and unclassified malignancies (1.9%). Median (interquartile range) time to malignancy after transplantation was 185.9 (92.0-257.6) months. Cumulative cancer rates were 4.9% (1 year), 14.4% (3 years), 16.4% (5 years), and 21.8% (10 years). Second transplantations were identified as independent risk factor for development of malignancy after transplantation. CONCLUSIONS: Long-term risk of developing a malignancy after kidney transplantation is high, which might justify a follow-up of more than 10 years.

An adaptive and robust online method to predict gait events.

Accurate timing of interventions during the gait cycle are critical for optimal efficacy of assistive devices, e.g., to reduce the metabolic cost of walking. However, timing control generally relies on methods that can neither account for changes in the stride duration over time due to different walking speeds, nor reject isolated abnormal strides, which could be caused by stumbling or obstacle avoidance for example. In order to address these issues, a method, named the Gait Phase Estimator (GPE), is proposed to predict temporal gait events and stride duration. Predictions are based on the weighted forward moving-average of stride duration. Prediction performance in steady-state walking, robustness to stride disturbances, and adaptation to speed changes were evaluated in an experiment with three subjects walking on a treadmill at three different speeds. Results suggest that, on average, the GPE produces better predictions than a predefined estimate. On top, it automatically adapts to changes in speed, while offering the benefit of robustness to irregular strides unlike a conventional moving-average. Thus, the proposed GPE has the potential to improve and greatly simplify the process of obtaining stride duration estimates, which could benefit gait-assistive devices and experimental protocols.

Measurement of Thermal Effects of Doppler Ultrasound: An In Vitro Study.

OBJECTIVE: Ultrasound is considered a safe imaging modality and is routinely applied during early pregnancy. However, reservations are expressed concerning the application of Doppler ultrasound in early pregnancy due to energy emission of the ultrasound probe and its conversion to heat. The objective of this study was to evaluate the thermal effects of emitted Doppler ultrasound of different ultrasound machines and probes by means of temperature increase of in-vitro test-media. METHODS: We investigated the energy-output of 5 vaginal and abdominal probes of 3 ultrasound machines (GE Healthcare, Siemens, Aloka). Two in-vitro test objects were developed at the Center for Medical Physics and Biomedical Engineering, Medical University Vienna (water bath and hydrogel bath). Temperature increase during Doppler ultrasound emission was measured via thermal sensors, which were placed inside the test objects or on the probes' surface. Each probe was emitting for 5 minutes into the absorbing test object with 3 different TI/MI settings in Spectral Doppler mode. RESULTS: During water bath test, temperature increase varied between 0.1 and 1.0°C, depending on probe, setting and focus, and was found highest for spectral Doppler mode alone. Maximum temperature increase was found during the surface heating test, where values up to 2.4°C could be measured within 5 minutes of emission. CONCLUSIONS: Activation of Doppler ultrasound in the waterbath model causes a significant increase of temperature within one minute. Thermally induced effects on the embryo cannot be excluded when using Doppler ultrasound in early pregnancy.

Ultra-high-risk pregnancies in women after renal transplantation.

OBJECTIVES: This study evaluates pregnancy outcomes in renal transplant recipients who have additional obstetrical, surgical, or urological risk factors. STUDY DESIGN: Data from our transplantation and obstetrical databases were retrospectively analyzed to identify all women of reproductive age who had undergone renal transplantation between 1999 and 2013 at our tertiary referral center and had subsequently become pregnant. Characteristics of pregnancy and perinatal outcome parameters; obstetrical, urological, and surgical risk factors; and graft function were assessed. Descriptive data analysis, Fisher's exact test, unpaired Student's t-test and one-way analysis of the variance were performed. RESULTS: The overall pregnancy rate after renal transplantation was 5% (n=13). 77% of the patients (n=10) had ultra-high-risk pregnancies due to additional risk factors. These included twin pregnancy, placenta previa/percreta, hypertension; previous heart transplantation, previous myocardial infarction; postoperative lymphocele, urinary leakage, hydronephrosis, or vesico-ureteral reflux. Two patients had two consecutive pregnancies. A total of 12 deliveries with 13 newborns were achieved. Cesarean section and preterm delivery rates were 67% and 50%, respectively. Mean gestational week at delivery was 36 ± 3. Mean creatinine levels were higher in women with preterm deliveries and in those of advanced age. Mean time between transplantation and delivery was 79 ± 36 months. All patients had adequate graft function after a mean follow-up of 128 ± 50 months after renal transplantation. CONCLUSIONS: Pregnant women after renal transplantation commonly present with additional risk factors. In these ultra-high-risk pregnancies successful outcomes can be achieved in a multidisciplinary setting. Adequate graft function and urinary tract evaluation is necessary.

Live birth after in vitro fertilization and single embryo transfer in a kidney transplant patient: a case report and review of the literature.

BACKGROUND: To present a successful case of in vitro fertilization (IVF) and single embryo transfer (SET) in a kidney transplant (NTX) patient and review of the literature. METHODS: Case report and review of the literature. SETTING: IVF-Unit in a university medical center. PATIENT(S): A 31 year-old nulliparous woman with primary infertility and a history of two kidney transplants. INTERVENTION(S): IVF-SET MAIN OUTCOME MEASURE(S): Live birth, renal transplant function. RESULTS(S): IVF-SET resulted in a pregnancy with labor induction and cesarean delivery in the 37th week of gestation due to rising serum creatinine. There was no significant maternal or fetal morbidity. CONCLUSION(S): Successful IVF-SET is possible in NTX patients. To date, including this case, five cases of IVF in NTX patients have been reported in the literature without an apparently increased renal morbidity.

Stilbene analogues affect cell cycle progression and apoptosis independently of each other in an MCF-7 array of clones with distinct genetic and chemoresistant backgrounds.

The development of chemoresistant breast cancer is poorly understood and second treatment options are barely investigated. The term 'chemoresistance' is ill-defined and thus, our experimental analyses aimed to disentangle the resistance to cell cycle arrest from the resistance to trigger apoptosis, both of which are important mechanisms to be targeted by anticancer therapy. Therefore, an MCF-7 array, which encompassed clones harboring distinct genetically- and pharmacologically-induced stages of resistance, was established. For this, MCF-7 cells were stably transfected with erbB2 cDNA and a dominant negative p53 mutation and the two clones were subjected to long-term treatment with the clinical agents 2'-deoxy-5-fluorouridine (5-FdUrd) or arabinosylcytosine (AraC) to develop specific chemoresistance. This array was tested with 3,4',5-trihydroxy-trans-stilbene (resveratrol) and the methoxylated paired stilbene analogue 3,4',5-trimethoxy-trans-stilbene (M5) to investigate whether these agents can overcome genetically- and pharmacologically-induced chemoresistance and to correlate the structure-activity relationship of resveratrol and M5. In all conditions tested, M5 exhibited stronger anticancer activity than resveratrol, but the cell cycle inhibitory properties of the tested drugs were dependent on the genetic background and the chemoresistant phenotype. In contrast, the proapoptotic properties were rather similar in the distinct genetic backgrounds of the clone array and therefore, apoptotic triggers and cell cycle checkpoints were distinctly affected and are thus independent of each other. The study demonstrates the merits or virtues of the genotypically- and phenotypically-defined clones of the MCF-7 array as a testing tool for novel drugs, which discriminates the two types of chemoresistance mechanisms.

Synergistic effects of deuterium oxide and gemcitabine in human pancreatic cancer cell lines.

PURPOSE: Pancreatic cancer still remains a treatment-refractory cancer. Standard therapy for metastatic cancer is gemcitabine (dFdC) chemotherapy. Since heavy water (deuterium oxide, D2O) was shown to be active in pancreatic cancer in vitro, we examined the simultaneous or sequential cytotoxic effects of D2O and dFdC in pancreatic cancer cell lines (AsPC-1, BxPC-3, and PANC-1). Moreover, we investigated the effect of D2O treatment on the colony formation of peripheral blood mononuclear cells (PBMNC) as well as the apoptosis inducing activity of D2O and dFdC and the regulation of tumor suppressor gene p21. RESULTS: Simultaneous incubation of human pancreatic carcinoma cells with D2O and dFdC led to a decrease of IC50 values of dFdC alone in all cell lines examined. Sequential application of D2O and dFdC caused synergistic effects. Treatment with 10-30% D2O did not show any significant inhibition effects on the colony formation of peripheral blood mononuclear cells (PBMNC), indicating limited adverse effects of D2O on bone marrow cells. Treatment with D2O in combination with dFdC significantly (p<0.05) increased the induction of apoptosis in PANC-1 and AsPC-1 cells and led to an overexpression of p21 tumor suppressor gene compared to incubation with dFdC alone. As the combination of D2O and dFdC might offer an additional option for the control of pancreatic cancer, this treatment should be investigated in a pancreas carcinoma animal model in order to scrutinize the in vitro data.

5-FdUrd-araC heterodinucleoside re-establishes sensitivity in 5-FdUrd- and AraC-resistant MCF-7 breast cancer cells overexpressing ErbB2.

ErbB2 overexpressing breast tumors have a poor prognosis and a high risk to develop chemoresistance to therapeutic treatment. "Chemoresistance" is a response of cells to toxic stress, and, although it is a common phenomenon, it is still poorly defined. However, a detailed understanding is required to target desensitized pathways and mechanisms for successful reactivation as part of a tailored therapy. To gain insight, which malfunctions contribute to chemoresistance, two mechanisms relevant for tissue homeostasis, the regulation of the cell cycle and of apoptosis, were investigated. Maternal MCF-7- and ErbB2-overexpressing MCF-7(erbB2) breast cancer cells were long term pretreated with 2'-deoxy-5-fluorodeoxyuridine (5-FdUrd) or 1-beta-d-arabinofuranosylcytosine (AraC) and the acquisition of drug-insensitivity was analyzed. A phosphate-conjugated heterodinucleoside consisting of one 5-FdUrd- and one AraC-moiety (5-fluoro-2'-desoxyuridylyl-(3'-->5')-Arabinocytidine) was utilized as a tool to assess the type of acquired resistances. ErbB2-overexpression disrupted proper cell cycle regulation and furthermore facilitated the development of an apoptosis-refractory phenotype upon exposure to 5-FdUrd. Experiments with dimer 5-FdUrd-araC in ErbB2-overexpressing MCF-7(erbB2) cells, and also with nucleoside 5-FdUrd in maternal MCF-7 cells, evidenced that the phenotypes of resistance to cell cycle inhibition and to apoptosis induction were differently affected. The expression profile of cyclin D1 (but not that of p53, p21, or p27) correlated with the proliferative phenotypes and nuclear accumulation of apoptosis inducing factor (but not activation of caspase 7) with apoptotic phenotypes. Dimer 5-FdUrd-araC overrode acquired chemoresistances, whereas combined application of 5-FdUrd and AraC exhibited significantly less activity. Dimer 5-FdUrd-araC remained active in MCF-7 clones most likely by circumventing the prerequisite of first-step phosphorylation. The acquisition of chemoresistance encompassed the affection of apoptosis- and cell-cycle regulation to, respectively, different extents. Thus, drug-induced cell cycle arrest and apoptosis induction are independent of each other.

Antioxidant activity of resveratrol, piceatannol and 3,3',4,4',5,5'-hexahydroxy-trans-stilbene in three leukemia cell lines.

trans-Resveratrol (t-RES) is one of the most relevant and extensively investigated stilbenes with a broad spectrum of biological activities. In contrast to the detailed knowledge of t-RES activities in biological systems, much less is known about the effects of higher hydroxylated stilbenes. Therefore, the aim of this study was to evaluate the protective effects (antioxidant activities) of t-RES and two analogues: the natural metabolite piceatannol (PCA) and the synthesized 3,3',4,4',5,5'-hexahydroxy-trans-stilbene (HHS) against H2O2-induced DNA damage in leukemic L1210, K562 and HL-60 cells using single-cell gel electrophoresis (SCGE). After 24 h pre-treatment of cells all compounds investigated significantly inhibited the incidence of DNA single strand breaks induced by H2O2. The protective effects of PCA and HHS in L1210 cells and of HHS in HL-60 cells were significantly higher compared to the activity of t-RES (+P < 0.05). In K562 cells the differences of the antioxidant activities of PCA and HHS, and of PCA in HL-60 cells were of much higher significance when compared to t-RES (++P < 0.01). In conclusion, we can prove that all stilbenes investigated, t-RES, PCA, and HHS, manifested potent antioxidant effects on three leukemic cell lines and the presence of ortho-dihydroxy structures enhanced the protective effect against DNA damage caused by .OH radicals.

Effect of resveratrol and mixtures of resveratrol and mitomycin C on cancer cells under irradiation.

The radiation-biological effects of resveratrol (Res) alone or with mitomycin C (MMC) were investigated under various conditions in human breast cancer cells (MCF-7). The data of the survival curves obtained in aerated media (acting species: 42% OH, 54% 02*-) showed that Res possesses antitumor activity and also acts as an efficient radical scavenger. This property was extremely enhanced in the presence of MMC. In media saturated with N2O (90% OH, 10% H) Res at low concentrations acted as a radiation-protecting agent, but at higher concentrations its cytostatic effect predominated. At the same time, the MMC-activity was reduced. In anaerobic media, Res demonstrated its radiation-protecting ability, but in mixtures the MMC-ability was reduced in comparison to that of pure MMC due to competition reactions between Res and MMC for the available free radicals. Finally, in a cell suspension containing formate as a specific scavenger for OH and H radicals (pH = 7.4), Res successfully competed for these species and showed antitumor activity. Considering the reaction rate constants of the involved substrates and the implemented concentrations in each medium, the kinetic probability of each survival curve was calculated. Based on these data it was evident that the bifunctional property of Res (acting as radiation protector and also having antitumor activity) was based on an electron ejection process from its excited single state and on its reactivity with the primary radicals (OH, H, e(aq)-).

Effects of heavy water (D2O) on human pancreatic tumor cells.

BACKGROUND: Pancreatic cancer constitutes an entity which is difficult to treat and, therefore, mostly fatal. Since heavy water (deuterium oxide, D2O) was shown to be active in various cancer cell lines in vitro and in vivo, we now investigated its effects in human pancreatic tumor cells. MATERIALS AND METHODS: The cytotoxic effects of D2O were examined in three pancreatic cancer cell lines (AsPC-1, BxPC-3 and PANC-1). Induction of apoptosis was determined by Hoechst/propidium iodide double staining and cell cycle distribution was investigated by FACS analysis. RESULTS: Employing a clonogenic assay, D2O yielded IC50 values of 15%, 18% and 27% in AsPC-1, PANC-1 and BxPC-3 cells, respectively, and led to the induction of apoptosis when compared to untreated controls. Moreover, D2O caused a cell cycle arrest in the G2-M-phase (BxPC-3, PANC-1) or in the S-phase (AsPC-1). CONCLUSION: It is hoped that D2O might offer an additional option for the treatment of pancreatic carcinomas.