Antenatal maternal hypoxic stress: adaptations of the placental renin-angiotensin system in the mouse

The stress of Antenatal Maternal Hypoxia (AMH) can lead to a number of physiological and pathological changes in both mother and fetus, changes which can be linked to alterations in placental morphology and gene regulation. Recently, in the Brown Norway rat "model" of placental insufficiency, we reported alterations in placental renin-angiotensin system (RAS) genes. Moreover, AMH can lead to reduced oxygen availability to the fetus, similar to a state of placental insufficiency. Thus, in pregnant mice dams we tested the hypothesis that antenatal maternal hypoxic stress leads to alterations in the placental RAS. These alterations may, in part, account for the phenotypic changes in both pregnant mice dams as well as fetus and adult offspring.

METHODS

Pregnant FVB/NJ mice dams were either maintained as controls, or exposed to 10.5% O(2) for 48 h from 15.5 to 17.5 day post coitum. We then measured placental mRNA and protein expression of several RAS genes (n = 4 to 5; P < 0.05 was considered significant).

RESULT

In murine placenta: (1) angiotensinogen (AGT) mRNA was undetectable; however, AGT protein was detectable and increased significantly with AMH. (2) In AMH, although renin mRNA was reduced protein expression increased, in association with decreased microRNA (miRNA) 199b, which can lead to increased renin translation. (3) Also in AMH placenta, angiotensin converting enzyme (ACE) -1 mRNA was unaltered; however, protein expression increased significantly, in association with decreased miRNA 27a, which can result in increased ACE-1 translation. (4) In AMH placenta, ACE-2 mRNA was reduced significantly, whereas protein expression was significantly greater, in association with reduced miRNA 429. (5) In AMH placenta, angiotensin II type (AT) -1a receptor mRNA expression was unaltered while AT-1b receptor mRNA was undetectable in both groups. Moreover, AT-1 receptor protein expression was unchanged in response to AMH. (6) AT-2 receptor mRNA and proteins were undetectable in both groups.

CONCLUSION

The normal murine placenta possesses several components of RAS, and in response to AMH several of these elements undergo important changes. In addition, differential expression of RAS mRNA, miRNA and protein, indicate post-transcriptional regulatory mechanisms involved with hypoxic stress, and necessitate further investigation.

Is hypoandrogenemia a component of metabolic syndrome in males?

OBJECTIVES

This study was done to assess testosterone deficiency in males with metabolic syndrome (MetS) and the effect of testosterone replacement on insulin resistance and biochemical parameters of this syndrome with hypogonadism. Sixty three males fulfilling the International Diabetes Federation 2005 MetS guidelines as cases and 32 healthy males as controls with the mean age of 35.29±8.16 and 34±6.76 years respectively were enrolled in the study. Fasting blood samples were collected for gonadal profile and insulin assay. Homeostasis model assessment for insulin resistance (HOMA-IR) and free testosterone index were calculated. Hypogonadism was defined when the calculated free testosterone value was <0.225 nmol/L.

FINDINGS

Total and calculated free testosterone, sex hormone binding globulin (SHBG) were lower in cases than controls (P<0.001). Hypogonadism was seen in 19 (30%) cases with MetS while 1 (3.1%) in controls. MetS cases with hypogonadism had significantly higher HOMA-IR than eugonadal cases. Hypogonadotropic hypogonadism was observed in 16 (84%) cases. Treatment with oral Testosterone 40 mg twice a day for 3 months led to significant improvement of HOMA-IR (P≤0.001) in the MetS males with hypogonadism.

CONCLUSIONS

This study revealed that males with MetS with or without diabetes had lower serum testosterone than their age matched healthy subjects. Hypogonadism was also common in subjects with MetS. Testosterone therapy to correct hypoandrogenimia improved insulin sensitivity and other biochemical parameters except High density lipoprotein cholesterol in MetS. This emphasizes that hypogonadism in all men with MetS or MetS in all men with hypogonadism needs clinical evaluation and subsequent management.

Bronchoscopic management of bronchopleural fistula

In recent years successful bronchoscopic management of bronchopleural fistulas (BPFs) by locating its site and then blocking the leaking segment with any of the several agents available has gained recognition. It is now considered as an alternate mode of management of BPF. Here we present a case of non-resolving pneumothorax that was managed successfully using bronchoscopic glue (cyanoacrylate glue) instillation.

High pharyngoesophageal strictures after laryngopharyngectomy can also be treated by self-expandable plastic stents

BACKGROUND

Permanent dysphagia occurring after laryngectomy or laryngopharyngectomy can usually be treated by periodic dilation. Occasionally, however, conservative treatment is insufficient, and patients require long-term tube feeding. We describe 4 cases with stricture after laryngopharyngectomy who underwent insertion of self-expandable plastic stents (SEPSs) across the stricture for treatment of dysphagia.

OBJECTIVE

The aim of this study was to evaluate the role of SEPSs in postlaryngopharyngectomy strictures.

DESIGN

An interventional study of management of 4 patients of dysphagia after laryngopharyngectomy with SEPSs.

SETTING

Medical gastroenterology unit in a tertiary care hospital.

PATIENTS

Four patients with dysphagia after laryngopharyngectomy.

INTERVENTIONS

SEPS placement and removal after 3 months.

MAIN OUTCOME MEASUREMENTS

Improvement in dysphagia.

METHODS

Four patients with dysphagia after laryngopharyngectomy underwent dilation of stricture followed by SEPS placement for 3 months.

RESULTS

Three patients had grade IV, and 1 grade III dysphagia. Endoscopy showed stricture at 10 to 14 cm from the incisors. Stricture was dilated up to 15 mm on 3 occasions, 2 weeks apart. A silicone Polyflex stent was placed across the stricture and removed after 3 months. No dysphagia recurred after 2 months. No significant complications were noted.

LIMITATIONS

Small sample size.

CONCLUSIONS

SEPSs dilate postlaryngopharyngectomy strictures and prevent restenosis even after removal.

Healing of solitary rectal ulcers with multiple sessions of argon plasma coagulation

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder of evacuation. Management of bleeding ulcers is usually unsatisfactory with conventional treatment. Argon plasma coagulation (APC) has been reported to control bleeding; however, it has not been shown to result in ulcer healing. The aim of the present study was to: (i) to investigate the efficacy and safety of APC in controlling bleeding from SRUS; and (ii) to study its efficacy in the healing of ulcer/s.

METHODS

Twenty-four patients with bleeding SRUS diagnosed on clinical, colonoscopic, and histological findings were randomized to receive either standard care alone (12 patients) or to undergo multiple sessions of APC in addition (12 patients). All patients were followed up to determine ulcer healing.

RESULTS

Twenty-four patients with a mean duration of symptoms of 12.6 +/- 4.8 months were included. Bleeding was controlled with one (n = 5) or two sessions (n = 7) of APC. Reduction in size and depth of ulcer was noted. Eight out of 12 patients who received APC had complete healing of ulcers after four to eight sessions, carried out 2-4 weeks apart. The remaining four patients had a reduction in size and depth of ulcers compared to their pretreatment appearance. All patients were advised to have a high intake of fluids, fiber and laxatives, and to undergo biofeedback and behavior modification therapy in addition to the treatment.

CONCLUSIONS

APC controls bleeding in patients with SRUS and it also improves the healing of these ulcers.

Healing of a bleeding solitary rectal ulcer with multiple sessions of argon plasma

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder of evacuation. Management of bleeding ulcers is usually unsatisfactory with conventional treatments. Argon plasma coagulation (APC) has been reported in case reports to control bleeding; however, it has not been shown to result in ulcer healing.

OBJECTIVE

To investigate the efficacy and safety of APC in controlling bleeding from SRUS and to study its efficacy in eventual healing of ulcers.

DESIGN

A randomized, controlled trial of the management of 24 consecutive patients with SRUS.

SETTING

The gastroenterology unit at 2 tertiary care hospitals.

PATIENTS

Twenty-four patients with bleeding SRUS.

MAIN OUTCOME MEASUREMENTS

Control of bleeding and endoscopic healing of SRUS.

METHODS

Twenty-four patients with bleeding SRUS, whose diagnoses were based on clinical, colonoscopic, and histologic findings, were randomized to receive either standard care only (12 patients, biofeedback therapy [BT] group) or multiple sessions of APC in addition to BT (12 patients, APC group). All patients were advised to intake a high level of fluids and fibers, laxatives, biofeedback, and behavior modification therapy in addition to the treatment. Patients were followed to determine whether ulcers healed.

RESULTS

Twenty-four patients with symptoms that lasted 12.6 +/- 4.8 months were included. Bleeding was controlled in all 12 patients in the APC group, but only in 5 of 12 patients in BT group. We also made the following observations about healing of the ulcers: 8 of 12 patients in the APC group had complete healing of their ulcers after 4 to 8 sessions, whereas in the BT group, ulcers healed in only 2 of 12 patients.

CONCLUSIONS

APC controls the bleeding in patients with SRUS and also improves the healing of these ulcers.

Rhodotorula mucilaginosa as a cause of persistent femoral nonunion

We present a case of postoperative infection which presented as nonunion fracture femur in a 30-year-old man due to Rhodotorula mucilaginosa. This is the first report of Rhodotorula infection in a patient with fracture nonunion. The patient underwent repeated surgical debridement and received intensive antibiotic therapy before the diagnosis was made. The diagnosis could have been made earlier if the fungal etiology had been suspected earlier. Early suspicion and diagnosis of infection with atypical yeasts could be under-reported because of difficulties in accurate diagnosis and a tendency of attributing isolates to specimen contamination.

Placental gene expression responses to maternal protein restriction in the mouse

OBJECTIVE

Maternal protein restriction has been shown to have deleterious effects on placental development, and has long-term consequences for the progeny. We tested the hypothesis that, by the use of microarray technology, we could identify specific genes and cellular pathways in the developing placenta that are responsive to maternal protein deprivation, and propose a potential mechanism for observed gene expression changes.

METHODS

We fed pregnant FVB/NJ mice from day post-coitum 10.5 (DPC10.5) to DPC17.5, an isocaloric diet containing 50% less protein than normal chow. We used the Affymetrix Mouse 430A_2.0 array to measure gene expression changes in the placenta. We functionally annotated the regulated genes, and examined over-represented functional categories and performed pathway analysis. For selected genes, we confirmed the microarray results by use of qPCR.

RESULTS

We observed 244 probe sets, corresponding to 235 genes, regulated by protein restriction (p<0.001), with ninety-one genes being up-regulated, and 153 down-regulated. Up-regulated genes included those involved in the p53 pathway, apoptosis, negative regulators of cell growth, negative regulators of cell metabolism and genes related to epigenetic control. Down-regulated genes included those involved in nucleotide metabolism.

CONCLUSIONS

Microarray analysis has allowed us to describe the genetic response to maternal protein deprivation in the mouse placenta. We observed that negative regulators of cell growth and metabolism in conjunction with genes involved in epigenesis were up-regulated, suggesting that protein deprivation may contribute to growth restriction and long-term epigenetic changes in stressed tissues and organs. The challenge will be to understand the cellular and molecular mechanisms of these gene expression responses.

Duodenal mucosal nodularity in Strongyloides stercoralis infection

A 22-year-old man presented with a two-year history of colicky upper abdominal and dyspnoea. His absolute eosinophil count (AEC) was 980/mm3. Chest x-ray revealed hilar prominence. An upper gastrointestinal endoscopy showed marked oedema and nodularity of duodenal mucosal folds. Duodenal biopsy disclosed heavy lymphoplasmacytic infiltrates in the lamina propria and sheets of eosinophils and rhabdtiform larvae of Strongyloides stercoralis in the crypts. The patient was not on steroids and his HIV ELISA was nonreactive. His IgG ELISA for Strongyloides stercoralis was positive. Nodular duodenal mucosa may thus be seen with Strongyloides stercoralis infection.

Thyroid hormone resistance

Thyroid hormone resistance (THR) is a rare syndrome of reduced end organ sensitivity. Patients with THR have elevated serum free thyroxine (FT4), free triiodothyronine (FT3), but normal or slightly elevated serum thyrotropin values. The characteristic clinical feature is goitre without symptoms and metabolic consequences of thyroid hormone excess. THR can be classified on the basis of tissue resistance into pituitary, peripheral or generalised (both pituitary and peripheral) types. Mutations in the TRbeta gene, cell membrane transporter and genes controlling intracellular metabolism of thyroid hormone have been implicated. THR is differentiated from thyroid stimulating hormone (TSH) secreting pituitary adenoma by history of THR in the family. No specific treatment is often required for THR; patients with features of hypo- or hyperthyroidism are appropriately treated with levo-triiodothyronine (L-T3), levo-thyroxine (L-T4), dextro-thyroxine(D-T4) or 3,3,5 triiodo-thyroacetic acid (TRIAC). The diagnosis helps in appropriate genetic counselling of the family.

Serum transferrin receptor-ferritin index shows concomitant iron deficiency anemia and anemia of chronic disease is common in patients with rheumatoid arthritis in north India

Anemia is a frequent cause of morbidity in patients with rheumatoid arthritis (RA). We studied the prevalence of anemia of chronic disorders (ACD) and ACD with coexistent iron deficiency anemia (IDA) in patients with RA using sTfR/log ferritin ratio (sTfR - F index). Complete blood counts, percent transferrin saturation, serum ferritin, sTfR, sTfR-F index measurements were carried out in 100 anemic RA patients. Twenty-five IDA subjects without any other illness and 25 age- and sex-matched normal controls were studied. Prevalence of anemia in RA patients was 50.5%. Patients with sTfR-F index value < 1.5 were classified as pure ACD and patients with sTfR-F index value> 1.5 were classified as ACD with coexistent IDA. Using these criteria, 20% patients were found to have pure ACD and 80% patients had coexistent ACD and IDA. In the normal control group, sTfR-F index was found to be 0.16-1.8. We found that sTfR-F index can clearly distinguish IDA control cases and normal subjects with no overlap in the range of sTfR-F index.

Gabapentin attenuates acute hypoxic stress-induced behavioral alterations and oxidative damage in mice: possible involvement of GABAergic mechanism

The effect of gabapentin has been investigated on acute hypoxic stress-induced behavioral alterations and oxidative damage in mice. Mice were subjected to hypoxia for 2 hr. Treatment with gabapentin (50 and 100 mg/kg) significantly increased ambulatory movements, exerted anti-anxiety like effect and reduced oxidative damage in mice subjected to acute hypoxic stress. Treatment with picrotoxin (1.0 mg/kg) per se had no significant effect on behavioral and biochemical parameters of stressed mice. Treatment with muscimol (0.05 mg/kg) per se significantly increased the locomotor activity of stressed mice, exerted significant anti anxiety effect and significantly reduced the oxidative damage. Further, pretreatment with picrotoxin (1.0 mg/kg) significantly blocked whereas pretreatment with muscimol (0.05 mg/kg) significantly potentiated the neuroprotective effect of gabapentin. These results suggest that gabapentin produces its neuroprotective effect in mice subjected to acute hypoxic stress through GABA(A) receptor mechanism.

Intraosseous schwannoma of the frontal bone

Schwannomas or neurilemomas are relatively frequent benign tumors; however, intraosseous schwannomas are rare. The most common site for intraosseous schwannoma is the mandible. Other sites include the vertebra, ulna, humerus, femur, tibia, patella, scapula, rib, and small bones of the hands. The skull vault is a rare site for intraosseous schwannoma, and only 4 cases have been reported previously in the literature. This article presents a case of intraosseous schwannoma in the frontal bone in an 11-year-old boy. Radiologically, intraosseous schwannomas are lytic, sharply demarcated defects that often expand the involved bone. Perilesional sclerosis may surround the area of central lucency. Histologic features of intraosseous schwannomas are similar to that observed for soft-tissue schwannomas including Antoni type A areas (compactly arranged spindle-shaped cells with palisading or Verocay bodies) and Antoni type B areas (widely separated cells with loose intervening collagenous matrix). In our patient, typical radiologic and histologic findings including immunohistochemistry and electron microscopy results led to a diagnosis of intraosseous schwannoma.