A cadaveric study of the testicular artery in the South Indian population

INTRODUCTION

The male gonadal arteries, namely the testicular arteries, may vary at their origin and arise from the renal artery, suprarenal artery or lumbar artery. They may also be doubled, tripled or even quadrupled and may arise as a common trunk. With the advent of new intra-abdominal operative and laparoscopic techniques, the anatomy of the gonadal vessels has assumed much more importance. Therefore, a study was designed to assess the percentage of normal and aberrant origin and course of the testicular artery in the Indian population.

METHODS

The posterior abdominal walls of 34 male cadavers (68 sides) were dissected and studied for the variations in the origin and course of the testicular arteries.

RESULTS

In 85.3 percent of the cases, the male gonadal artery was normal in origin, number and course. However, in the remaining 14.7 percent, various anomalies in the testicular artery were noted.

CONCLUSION

The variations in the testicular arteries are attributed to their embryological origin. A deep knowledge of these variations and their relations to the adjacent structures is very important in avoiding the complications in operative surgery.

Lithoclast(®) Master in Intracorporeal Lithotripsy during Percutaneous Nephrolithotomy : Our Experience

BACKGROUND

This study was carried out to compare the efficacy of Lithoclast(®) Master with pneumolithotriptor during percutaneous nephrolithotomy (PNL) in the treatment of renal staghorn calculi.

METHODS

In this prospective study, 60 patients suffering from partial or complete staghorn renal stones were included. Patients were divided randomly in two groups : Groups I and II and underwent PNL for removal of stones. In Group I patients, standard pneumolithotriptor and in Group II, Lithoclast(®) Master was used for stone fragmentation. The patients were evaluated for rate of fragmentation/clearance, presence of residual fragments by KUB radiograph/ultrasound. Result was analyzed by Chi-square test.

RESULT

The rate of fragmentation using Swiss Lithoclast(®) Master was more effective and quicker in comparison to standard pneumolithotriptor. The average time taken for fragmentation and clearance in Group I using pneumolithotriptor was 65 minutes, whereas it was 58 minutes using Lithoclast® Master, which was statistically significant (p< 0.01). Only 4% patients had significant residual fragments (> 4mm) in Group II and 16 (53%) patients in Group I, which was significant (p < 0.01). The complications in both the modalities were insignificant; one (1.33%) patient had bleeding and three (10%) patients had urine leak in Group I; whereas three(10%) patients had bleeding and five (16.7%) urine leak in Group II.

CONCLUSION

Lithoclast(®) Master is an effective intracorporeal lithotripter during percutaneous nephrolithotomy in the treatment of renal staghorn calculi for stone fragmentation/clearance with minimal residual fragments and complications.

Teratogenic effects of the anticonvulsant gabapentin in mice

INTRODUCTION

We aim to study and elucidate the safety profile of the antiepileptic doses of gabapentin during pregnancy, and to evaluate gabapentin-induced murine fetotoxicity at different dose levels.

METHODS

A total of 60 pregnant mice, divided into 12 groups of five mice each, were exposed to gabapentin in four different doses of 0 (control), 113, 226, or 452 mg/kg body weight per day, at three different gestational stages including early gestation (1-6 days), mid-gestation (7-12 days), and late gestation (13-17 days). The pregnant mice were euthanized on day 18 of gestation, and foetuses were examined for teratogenic manifestations. Their brains were dissected and examined for gross changes, malformations, histological changes, and quantitative protein estimation.

RESULTS

Foetal resorptions were observed in all treated groups with gabapentin administration at early gestation (1-6 days), and mid-gestation (7-12 days). On the other hand, growth retardation along with stunting in size of live foetuses were observed in all the mid-gestation (7-12 days), and late gestation (13-17 days) treated groups. Various gross malformations were observed with all the three doses (113, 226, and 452 mg/kg body weight per day) when gabapentin was administered at mid-gestation (7-12 days). The same trends were confirmed by gross and microscopic examination of brains along with quantitative protein estimation.

CONCLUSION

Gabapentin should not be prescribed during pregnancy, as no therapeutic dose of gabapentin is safe during this period as far as the foetal well-being is concerned.

Synchronous primary triple neoplasia (renal cell carcinoma and prostate cancer in combination with thyroid neoplasm). Report of an unusual case

We report a very rare case of triple primary neoplasia synchronously originating in the prostate, kidney and thyroid, in a 79-year-old male who presented with hematuria and continuous pain at the right hip. Examination revealed an enlarged nodular thyroid, while digital rectal examination showed prostatic enlargement with elevated PSA (16.7 ng/mL). Plain radiography showed an osteolytic lesion in the right ischium. Ultrasonography and CT scan of left kidney suggested renal cell carcinoma (RCC), which was subsequently confirmed on histopathology of the left radical nephrectomy specimen. Biopsies from prostate showed adenocarcinoma, along with deposits in ischial biopsy. Fine needle aspiration cytology (FNAC) of neck swellings suggested deposits from thyroid follicular carcinoma, which was subsequently confirmed by histopathology of the near-total thyroidectomy specimen. Currently, the patient is on regular follow-up since the past 24 months.

Arched left gonadal artery over the left renal vein associated with double left renal artery

Variations in the anatomical relationship of the gonadal arteries to the renal vessels are frequently reported. We present, on a male cadaver, an unusual origin and course of a left testicular artery arching over the left renal vein along with double renal arteries. The development of this anomaly is discussed in detail. Compression of the left renal vein between the abdominal aorta and the superior mesenteric artery usually induces left renal vein hypertension, resulting in varicocele. We propose that the arching of left testicular artery over the left renal vein could be an additional possible cause of the left renal vein compression. Therefore, knowledge of the possible existence of arching gonadal vessels in relation to the renal vein could be of paramount importance to vascular surgeons and urologists during surgery in the retroperitoneal region.

Lamotrigine in pregnancy: safety profile and the risk of malformations

The use of antiepileptic drugs in pregnancy always presents challenges to doctors and their patients as it may have deleterious effects on the developing embryo. Lamotrigine is most commonly-prescribed drug among the newer antiepileptic drugs; hence, it has been selected for the present review. A number of studies pertaining to the safety of lamotrigine use during pregnancy have been reported, with differing results. Contradictory results have been reported in animals regarding lamotrigine teratogenicity, and human studies have also proven inconclusive. In many countries, human pregnancy registries are maintained to establish the safety of antiepileptic drugs during pregnancy, as all the different suggestions favour some over others, with specific antiepileptic combinations still being questioned. It is our hope that the present work may integrate the available disparate relevant facts into a directed effort towards minimising the risk of foetal compromise.

Third head of biceps brachii in an Indian population

INTRODUCTION

The biceps brachii is one of the muscles of the anterior compartment of the upper arm. It is characteristically described as a two-headed muscle that originates proximally by a long head and a short head. The present study was carried out to find the occurrence of a third head of biceps brachii among a sample Indian population from the southern coastal part.

METHODS

The arms of 42 cadavers were dissected and observed for variations in the origin and insertion of biceps brachii muscle bilaterally. The cadavers were embalmed and preserved in ten percent formalin.

RESULTS

Among 42 arms studied, three had biceps brachii with three heads on the right side. The third head was of humeral origin, which inserted into the radial tuberosity by a common tendon with the long and short heads. The results of the present study compared with that of previous studies from medical literature shows that the occurrence of a third head of the biceps brachii muscle is relatively rare in Indians.

CONCLUSION

Knowledge of the existence of the third head of biceps brachii may become significant in preoperative diagnosis and during surgery of the upper limb.

Identification of Human Immunodeficiency Virus Type-1 Subtypes by Heteroduplex Mobility Assay

BACKGROUND

Human immunodeficiency virus type-1 (HIV-1) has developed marked genomic sequence differences over the course of an epidemic because of an error prone reverse transcriptase (RT), which rapidly incorporates mutations resulting in genomic diversity, altered cell tropism, immune escape and variable resistance to antiretroviral drugs. The best preventive strategy for HIV control is development of an efficacious prophylactic vaccine using the most appropriate (antigenically related) subtypes. On the basis of phylogenetic analysis, HIV strains can be separated into major group "M" consisting of genetic subtypes A-K, "N", the new group and "O", the outlier group.

METHODS

Heteroduplex mobility assay (HMA) is a rapid, economical and reliable technique of subtyping HIV-1. It is based on the principle of determining the genomic relatedness and divergence of the unknown sample with the known reference plasmid HIV-1 subtypes by studying the mobility patterns of the resulting heteroduplexes formed on the polyacrylamide gel.

RESULT

A total of 70 HIV-1 seropositive samples obtained from service personnel, their families and civilians from service hospitals were analyzed and their subtype distribution studied. 66 (94.28%) were HIV-1 subtype C and two (2.85%) subtype B. In two (2.85%) samples, the subtype distribution was homotypic recombinant, one each of subtype C1 & C2 and C2 & C4 respectively.

CONCLUSION

Service personnel and their families represent a divergent population from different regions of India. An analysis of subtypes in these HIV-1 seropositive individuals will help in understanding the geographical distribution and evolution of the virus. Determination of HIV-1 subtypes has significant implications for development of candidate vaccine for India.

A meta-analysis on the influence of inflammatory bowel disease on pregnancy

BACKGROUND

Inflammatory bowel disease (IBD) has a typical onset during the peak reproductive years. Evidence of the risk of adverse pregnancy outcomes in IBD is important for the management of pregnancy to assist in its management.

AIM

To provide a clear assessment of risk of adverse outcomes during pregnancy in women with IBD.

DESIGN

The Medline literature was searched to identify studies reporting outcomes of pregnancy in patients with IBD. Random-effect meta-analysis was used to compare outcomes between women with IBD and normal controls.

PATIENTS AND SETTING

A total of 3907 patients with IBD (Crohn's disease 1952 (63%), ulcerative colitis 1113 (36%)) and 320 531 controls were reported in 12 studies that satisfied the inclusion criteria.

RESULTS

For women with IBD, there was a 1.87-fold increase in incidence of prematurity (<37 weeks gestation; 95% CI 1.52 to 2.31; p<0.001) compared with controls. The incidence of low birth weight (<2500 g) was over twice that of normal controls (95% CI 1.38 to 3.19; p<0.001). Women with IBD were 1.5 times more likely to undergo caesarean section (95% CI 1.26 to 1.79; p<0.001), and the risk of congenital abnormalities was found to be 2.37-fold increased (95% CI 1.47 to 3.82; p<0.001).

CONCLUSION

The study has shown a higher incidence of adverse pregnancy outcomes in patients with IBD. Further studies are required to clarify which women are at higher risk, as this was not determined in the present study. This has an effect on the management of patients with IBD during pregnancy, who should be treated as a potentially high-risk group.

Cadavers as teachers in medical education: knowledge is the ultimate gift of body donors

In most of the medical colleges in India, unclaimed bodies from various mortuaries reach the dissection hall; and here, the body donors club has yet to gain the desired dimensions. In spite of all the adverse circumstances, the cadaver and the dissection both have survived the most rigorous test of pedagological fitness--the test of time. Today, many of the Western countries have long donor waiting lists where cadavers are acquired as anatomical gifts or through body donor programmes. Thailand's approach to body donors offers a role model for resolving the present situation. The spirit of volunteerism reflects the drastic shift in public perception and a global change in approach is needed in the present time.

Placental pathology of recurrent spontaneous abortion: the role of histopathological examination of products of conception in routine clinical practice: a mini review

BACKGROUND

Histopathological examination of products of conception from miscarriages is part of routine clinical practice. The extent of additional clinically relevant information provided by this investigation in the setting of recurrent spontaneous abortion remains uncertain.

METHODS

Review of the literature was performed to identify studies reporting on findings of histological examination of routinely obtained products of conception in the setting of recurrent spontaneous abortion. The initial search identified 312 potential references, but 300 were excluded on further examination due to lack of data on specific histopathological findings in routine products of conception specimens from patients with recurrent spontaneous abortion. The 12 included studies indicated that such examination may identify hydatidiform moles, villous dysmorphic features suggesting fetal aneuploidy, chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition and impaired trophoblast invasion. However, in most cases, morphological assessment cannot reliably determine the cause of the miscarriage or distinguish recurrent from sporadic miscarriage. Studies reporting on the use of additional immunohistochemical methods do not currently provide additional clinically useful diagnostic or prognostic information.

CONCLUSION

Routine histological examination of products of conception in the setting of recurrent spontaneous abortion can provide important clinical information in a minority of cases.

Genetic thrombophilic mutations among couples with recurrent miscarriage

BACKGROUND

Some cases of recurrent first trimester miscarriage (RM)-the loss of three or more consecutive pregnancies at <12 weeks' gestation-have a thrombotic aetiology.

METHODS

We determined (i) the prevalence of three thrombophilic mutations [factor V Leiden (FVL), prothrombin G20210A (PTG) and methylenetetrahydrofolate reductase (MTHFR) C677T] amongst 357 Caucasian couples with RM and 68 parous Caucasian couples with no history of miscarriage and (ii) the prospective outcome of untreated pregnancies amongst couples with RM in which either partner carried a thrombophilic mutation.

RESULTS

The allele frequencies of FVL (2%), PTG (2%) and MTHFR C677T (31%) were similar between cases and controls. The prevalence of multiple thrombophilic mutations (greater than one mutation) was also similar between cases and controls. Amongst couples in whom either partner carried greater than one thrombophilic allele, the relative risk of miscarriage in a future untreated pregnancy was 1.9 (95% confidence interval, 1.3-2.8) compared with those couples who carried no thrombophilic mutation.

CONCLUSION

The prevalence of thrombophilic mutations is similar in couples with RM and parous controls. In couples with RM, multiple genetic thrombophilic mutations in either partner significantly increases the risk of miscarriage in a subsequent pregnancy.

Study of apoptosis and heat shock protein (HSP) expression in hepatocytes following radiofrequency ablation (RFA)

BACKGROUND

Radiofrequency ablation (RFA) of the liver produces necrosis of the hepatocytes. Histological examination shows a sharp demarcation between ablated and normal liver tissue. This experiment was carried out to study the cellular injury produced by RFA in area surrounding the ablated tissue and effect of reperfusion on this zone.

MATERIAL AND METHODS

Five pigs underwent RFA of liver parenchyma. Four pigs were sacrificed 30 min after RFA and one pig was sacrificed 5 days later. Ablated lesions including surrounding liver parenchyma was examined for apoptosis and HSP 70 expression.

RESULTS

There was a zone of transition surrounding the necrotic ablated area that showed apoptosis as well as increased HSP 70 expression. This was more prevalent in the pig that was sacrificed 5 days later.

CONCLUSION

RFA produces sub lethal injury in the zone of transition causing apoptosis and increase in HSP 70 expression. Increased HSP expression enhances immunogenicity of these cells that can have therapeutic implications for the treatment of liver.

Creation of porcine liver tumor using human hepatoma cell lines: experimental study

BACKGROUND

Pig is an ideal animal to study the efficacy of surgical and ablative treatment options available for the treatment of liver tumors. But there is no liver tumor model available in pig. This experiment was carried out to create liver tumors in the pig using immunosuppression and portal tolerance.

MATERIAL AND METHODS

Two mini pigs (specific pathogen free) were immunosupressed using cyclosporine, azathioprine and prednisolone immunotherapy. Human hepatoma cell line (HepG2) was delivered into the liver through portal vein injection. Engraftment of the tumor cell was monitored using regular measurement of serum alfa- fetoprotein level (AFP). Pigs were sacrificed at the end of six weeks to confirm any evidence of tumor in the liver.

RESULT

Although there was rise in serum AFP level in the first week, tumor cells did not engraft in the liver and there was no evidence of liver tumor at the end of experiment.

CONCLUSION

Effect of immunosuppression and portal tolerance does not prevent rejection of human hepatoma cells by porcine immune system.

Assessment of adrenocortical function in the critically ill

OBJECTIVE

To review current concepts in the diagnosis of adrenocortical disease in the critically ill patient.

DATA SOURCES

A review of articles reported on adrenocortical insufficiency in the acutely ill patient.

SUMMARY OF REVIEW

The contribution of adrenal insufficiency to the morbidity of critically ill patients is currently under renewed scrutiny. The debate continues about the role of steroids in sepsis and essentially the question remains unanswered. Central to this debate is the issue of whether adrenal insufficiency is common in the critically ill patient. What is incontrovertible is that adrenocortical function is essential for host survival during critical illness, but what constitutes adrenocortical insufficiency in critically ill patients is not clear. Absolute adrenocortical insufficiency (diagnosed by very low plasma cortisol concentrations) is uncommon in the intensive care population. The diagnosis of relative adrenocortical insufficiency (elevated basal plasma cortisol with a subnormal increase in plasma concentrations following an ACTH stimulus) continues to generate debate. The controversy surrounding the role of steroids in sepsis and the confusion over the criteria for diagnosing adrenal insufficiency in the critically ill are reviewed.

CONCLUSIONS

We suggest that the following caveats be borne in mind when diagnosing adrenal insufficiency in the critically ill patient. Firstly, the gold standard for the diagnosis has not been established. Secondly, caution must be exercised when interpreting a single plasma cortisol value. In the event of a single result indicating adrenal hypofunction, we suggest repeating the measurements after a 6 to 12 hour interval. The clinician must also be aware of variations in cortisol concentrations induced by the assay. Thirdly, the clinician must be aware of the potential limitations of the conventional high dose corticotrophin test. We also suggest that plasma free cortisol is more relevant than total plasma cortisol in the assessment of adrenal function in critical illness and that the low dose corticotrophin test is more sensitive than the conventional high dose test. These areas should be the subject of further investigations.

Medical arthroscopy--emerging era of rheumatological intervention

OBJECTIVE

To evaluate the safety and diagnostic value of arthroscopy performed by a rheumatologist.

METHODS

Decisions for performing arthroscopy were taken when detailed clinical history-and relevant rheumatological investigations failed to arrive at a definite diagnosis. Arthroscopies were performed under local anesthesia as a daycare procedure. Synovial biopsies taken during procedures were subjected to histopathological examination (HPE).

RESULTS

Of the 50 patients enrolled, 39 were males while 11 were females with mean age of 35.5 years. In lower limb oligoarthritis group of patients, three had macroscopic picture of crystal arthropathy, rest of the 29 patients revealed gross picture indicative of non-specific synovitis. While in polyarticular group of eight patients, three had macroscopic picture suggestive of crystal arthropathy (probably polyarticlar gout) while five were indicative of rheumatoid arthritis. In monoarticular disease pattern (n= 10) macroscopic picture findings were as follows- crystal arthropathy-two, tubercular-three, synovial chondromatosis-one and non-specific synovitis-two. HPE of synovium did not correlate in many cases.

CONCLUSION

Arthroscopy using a 4 mm scope under local anesthesia in the hands of rheumatologists is a safe daycare procedure. In few cases arthroscopy helped in arriving at a final diagnosis but many patients remained undiagnosed. Both the rheumatologists and the pathologists require further experience in this field.

Preoperative treatment of hepatocellular carcinoma with intra-arterial injection of 131I-labelled lipiodol (Br J Surg 2003; 90: 1379-1383)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.

Thromboelastography, whole-blood haemostasis and recurrent miscarriage

BACKGROUND

Some cases of recurrent miscarriage have a thrombotic basis. Thromboelastography is a rapid, reproducible test of whole-blood haemostasis.

METHODS

Thromboelastography was performed in 494 consecutive, non-pregnant women (median age 35 years; range 21-48) with a history of miscarriages at <12 weeks gestation (median 4; range 3-12) and 55 parous women (median age 33 years; range 20-41) with no history of pregnancy loss. The prospective outcome of untreated pregnancies amongst 108 women with recurrent miscarriage was studied.

RESULTS

The maximum clot amplitude (MA) (median 66.0 mm; range 48.0-76.0) was significantly higher and the rate of clot lysis (LY30) (median 2.5%; range 0.5-7.8) significantly lower amongst women with recurrent miscarriage compared with controls (MA 61.5 mm; range 50.0-67.0; P = 0.01; LY30 4.9%; range 2.9-9.7; P = 0.01). The pre-pregnancy MA was significantly higher amongst women who subsequently miscarried (median 66.0 mm; range 54.0-73.0) compared with those whose had a live birth (median 61.7 mm; 48.0-71.5; P < 0.01). A pre-pregnancy MA >or=64 mm has a sensitivity of 68% and specificity of 82% to predict miscarriage.

CONCLUSIONS

Thromboelastography identifies a subgroup of women with recurrent miscarriage to be in a prothrombotic state outside of pregnancy. Women in such a state are at increased risk of miscarriage in future untreated pregnancies.

Circadian periodicity of plasma lipid peroxides and other anti-oxidants as putative markers in gynecological malignancies

BACKGROUND

The chronome (from chronos, time, and nomos, rule), or time structure, of lipid peroxidation and anti-oxidant defense mechanisms may relate to prevention and curative chronochemotherapeutic efficacy and management.

PATIENTS AND METHODS

Newly diagnosed women with gynecological malignancies (N = 30), 30-60 years of age, and age-matched clinically healthy women (N = 35) provided blood samples every 6 hours for 24 hours under standardized conditions. Plasma malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and glutathione reductase (GR) activities, and serum ascorbate, urate and high-density lipoprotein cholesterol (HDL-C) concentrations were determined.

RESULTS

Each variable underwent circadian variation (p < or = 0.002). Patients differed from controls by their overall chronome-adjusted mean value (MESOR) and by the circadian dynamics in the spectral element of their chronome.

CONCLUSION

Chronomes of putative anti- and pro-oxidants should be mapped to explore their putative chemotherapeutic role as markers in cancer chronoprevention and management of established disease.

Biology and pathology of the placenta in relation to antiphospholipid antibody-associated pregnancy failure

The placenta is a complex organ composed of maternal and foetal components whose anatomy and function is often greatly simplified in order to explain a range of presumed placenta-related pregnancy complications. Since one of the major roles of the placenta is its materno-foetal transfer function, abnormalities at the materno-foetal interface may be responsible for a range of pregnancy complications manifesting from the first through third trimesters according to the severity of the pathological process in each case. This article reviews some aspects of abnormal early placental development and its consequences, with particular regard to recurrent pregnancy failure and obstetric complications in association with primary antiphospholipid antibody syndrome.

Installation of solarium--2000 for phototherapy

Sunlight is the cheapest and most easily available source of ultraviolet light for phototherapy. The disadvantage of using sunlight as the source of ultraviolet light includes its variation with time , place and season, lack of privacy, and atmospheric conditions. To ensure correct dose of UV light in spite of variation in irradiation from the sunlight,we used a PMA2100 meter [Figure:2] and 2110 UVA detector ( Solar light Co, Philadelphia). Privacy for the patients was achieved by erecting a solarium and incidental UVB radiation was cut off by using window glass as the roof of the solarium. We recommend the solarium as a less expensive alternative to artificial phototherapy units, especially in places where there is plenty of sunlight.

Defective endovascular trophoblast invasion in primary antiphospholipid antibody syndrome-associated early pregnancy failure

BACKGROUND

Primary antiphospholipid antibody syndrome (PAPS) is an established cause of recurrent pregnancy loss, traditionally presumed to be due to 'intraplacental thromboses'. This study examines products of conception (POC) from early pregnancy failures to investigate the mechanism of pregnancy loss.

METHODS

POC from patients attending a recurrent miscarriage clinic and from terminations of pregnancy for non-medical reasons were examined histologically with particular regard to the presence or absence of vascular or intervillous thromboses and decidual endovascular trophoblast invasion.

RESULTS

There were 31 PAPS-positive, 50 PAPS-negative, 34 aneuploid and 20 control cases at 6-14 weeks gestation. Villous morphology and frequency of intervillous thrombosis were not different among groups. Normal intradecidual endovascular trophoblast invasion was identified significantly less frequently in PAPS+ cases (24%), compared with controls (75%), aneuploid (53%), or PAPS- cases (61%; Z = -3.0, P < 0.01). In all cases there was apparently normal interstitial extravillous trophoblast invasion.

CONCLUSIONS

Defective decidual endovascular trophoblast invasion, rather than excessive intervillous thrombosis, is the most frequent histological abnormality in PAPS+ associated early pregnancy loss. Furthermore, endovascular trophoblast invasion is not significantly reduced in the majority of fetal aneuploidy-associated pregnancy failures.

Pinopode expression during human implantation

Implantation failure is considered the major impediment to successful in vitro fertilization pregnancy rate. Despite recent advances in reproductive medicine, the role played by uterine receptivity in contributing to human infertility remains unclear. Several clinical studies suggest the importance of blastocyst implantation in a narrow window of uterine receptivity, between 6 and 8 days after ovulation. This brief and precise period, called "implantation or nidation window", lasts less than 48 h and coincides with the formation of large and smooth projections, called "pinopodes", on the apical membranes of the endometrial epithelial cells. Pinopode expression appears to advance or retard depending on the hormonal treatments and an individual's particular response. This displacement can be followed through endometrial biopsy and scanning electron microscopy (SEM). Therefore, pinopode expression could be considered a useful biological marker to assess endometrial receptivity and to locate the implantation window.

Factor V Leiden and recurrent miscarriage-prospective outcome of untreated pregnancies

BACKGROUND

Some cases of recurrent miscarriage and later pregnancy complications have a thrombotic basis. Factor V Leiden is a common thrombophilic mutation.

METHODS

The prospective outcome of untreated pregnancies amongst 25 women heterozygous for the Factor V Leiden allele who had a history of either recurrent early miscarriages only (three or more miscarriages at <12 weeks gestation; n = 19) or of late miscarriage (>12 weeks gestation; n = 9) was studied. Control groups of women with a similar pregnancy history but who had a normal Factor V genotype were also studied.

RESULTS

The live birth rate was significantly lower amongst women with a history of recurrent early miscarriage who carried the Factor V Leiden allele (6/16; 37.5%) compared with that amongst those with a normal Factor V genotype (106/153; 69.3%; odds ratio 3.75, 95% confidence intervals 1.3-10.9). The live birth rate was 11.1% (1/9) amongst those with a history of late miscarriage carrying the Factor V Leiden allele and 48.9% (22/45) amongst those with a normal Factor V genotype.

CONCLUSIONS

Attention should be directed at screening women with recurrent miscarriage associated with placental thrombosis for Factor V Leiden and a policy of targeted thromboprophylaxis during future pregnancies should be assessed in the form of a randomized controlled trial.

In vitro intestinal permeability of factor Xa inhibitors: influence of chemical structure on passive transport and susceptibility to efflux

PURPOSE

To study the in vitro intestinal permeability of a number of newly synthesised factor Xa inhibitors to better understand the poor oral absorption of these compounds.

METHODS

The bidirectional transport of the fXa inhibitors was studied in the Caco-2 cell model and isolated rat ileal tissue. An attempt was made to characterize efflux mechanisms with the help of commonly used substrates and inhibitors of various transport proteins. In addition, the transport of the fXa inhibitors was studied in MDCK cells transfected with the human MDR1 gene and expressing large amounts of P-glycoprotein (Pgp).

RESULTS

The in vitro absorptive permeability was low for all but one of the fXa inhibitors. For compounds with non-substituted amidine, a charge (due to ionisation at neutral pH) may have resulted in poor membrane partitioning. Neutral compounds with substituted amidines were effluxed from the epithelial cells. The significance of the secretion process was illustrated by the results obtained for a neutral analogue showing high absorptive Caco-2 cell permeability that was not obviated by efflux. Transport inhibition studies in Caco-2 and permeability studies in the MDR1-transfected MDCK cells consistently showed that Pgp is not involved in the secretion of fXa inhibitors. Besides efflux, metabolic liability limited the permeation of the neutral lipophilic analogues with a carbamate ester.

CONCLUSIONS

Poor intestinal permeability may be an important factor in the incomplete oral absorption of the bisbenzimidazole-type fXa inhibitors. Poor permeability may be related to poor membrane partitioning for hydrophilic analogues, whereas susceptibility to efflux transports and gastro-intestinal enzymatic degradation may limit the permeability of some of the neutral less hydrophilic derivatives.

Metformin therapy in the management of polycystic ovary syndrome: endocrine, metabolic and reproductive effects

Polycystic ovary syndrome (PCOS) is a convergence of multisystem endocrine derangements. Impairment in insulin metabolism is a prominent feature of the syndrome and appears to play a key pathogenetic role precipitating the cascade of other disorders associated with PCOS. Recent studies report that insulin-sensitizing agents, such as metformin, reduce hyperinsulinemia, reverse the endocrinopathy of PCOS and normalize endocrine, metabolic and reproductive functions, leading to the resumption of menstrual cyclicity and ovulation. In this review, we report the most recent evidence regarding metformin usage in women with PCOS.

Optimization of a screening lead for factor VIIa/TF

The structure-based design and progression of a screening lead to a 3nM factor VIIa/TF inhibitor with improved selectivity versus related enzymes is described.

Development of serine protease inhibitors displaying a multicentered short (<2.3 A) hydrogen bond binding mode: inhibitors of urokinase-type plasminogen activator and factor Xa

Novel scaffolds that bind to serine proteases through a unique network of short hydrogen bonds to the catalytic Ser195 have been developed. The resulting potent serine protease inhibitors were designed from lead molecule 2-(2-hydroxyphenyl)1H-benzoimidazole-5-carboxamidine, 6b, which is known to display several modes of binding. For instance, 6b can recruit zinc and bind in a manner similar to that reported by bis(5-amidino-2-benzimidazolyl)methane (BABIM) (Nature 1998, 391, 608-612).(1) Alternatively, 6b can bind in the absence of zinc through a multicentered network of short (<2.3 A) hydrogen bonds. The lead structure was optimized in the zinc-independent binding mode toward a panel of six human serine proteases to yield optimized inhibitors such as 2-(3-bromo-2-hydroxy-5-methylphenyl)-1H-indole-5-carboxamidine, 22a, and 2-(2-hydroxybiphenyl-3-yl)-1H-indole-5-carboxamidine, 22f. Structure-activity relationships determined that, apart from the amidine function, an indole or benzimidazole and an ortho substituted phenol group were also essential components for optimal potency. The affinities (K(i)) of 22a and 22f, for example, bearing these groups ranged from 8 to 600 nM toward a panel of six human serine proteases. High-resolution crystal structures revealed that the binding mode of these molecules in several of the enzymes was identical to that of 6b and involved short (<2.3 A) hydrogen bonds among the inhibitor hydroxyl oxygen, Ser195, and a water molecule trapped in the oxyanion hole. In summation, novel and potent trypsin-like serine protease inhibitors possessing a unique mode of binding have been discovered.

Green fluorescent protein-Dal80p illuminates up to 16 distinct foci that colocalize with and exhibit the same behavior as chromosomal DNA proceeding through the cell cycle of Saccharomyces cerevisiae

Four GATA family DNA binding proteins mediate nitrogen catabolite repression-sensitive transcription in Saccharomyces cerevisiae. Gln3p and Gat1p are transcriptional activators, while Dal80p and Deh1p repress Gln3p- and Gat1p-mediated transcription by competing with these activators for binding to DNA. Strong Dal80p binding to DNA is thought to result from C-terminal leucine zipper-mediated dimerization. Many Dal80p binding site-homologous sequences are relatively evenly distributed across the S. cerevisiae genome, raising the possibility that Dal80p might be able to "stain" DNA. We demonstrate that cells containing enhanced green fluorescent protein-Dal80p (EGFP-Dal80p) exhibit up to 16 fluorescent foci that colocalize with DAPI (4',6'-diamidino-2-phenylindole)-positive material and follow DNA movement through the cell cycle, suggesting that EGFP-Dal80p may indeed be useful for monitoring yeast chromosomes in live cells and in real time.