Placental lakes vs lacunae: spot the differences

Sonographic sonolucencies are anechoic areas surrounded by tissue of normal echogenicity, commonly found in the placental parenchyma during the second and third trimesters of pregnancy. The ultrasound appearance of lakes and lacunae derives from the low echogenicity of villous-free areas within the placental parenchyma, filled with maternal blood of varying velocities. In normal placentation, lakes usually start appearing as soon as maternal blood begins to flow freely within the intervillous space at the end of the first trimester, whereas, in accreta placentation, lacunae develop progressively during the second trimester. Larger lakes are found mainly in areas of lower villous density under the fetal plate or in the marginal areas, but can also be found in the center of a lobule above the entry of a spiral artery. Lakes of variable size, position and shape are of no clinical significance, except if they transform into echogenic cystic lesions, which have been associated with poor fetal growth and placental malperfusion. Lacunae are formed by the distortion of one or more placental lobules developing inside a uterine scar, resulting from high-volume, high-velocity flows from the radial/arcuate arteries, and are associated with a high probability of placenta accreta spectrum at birth. They often present with ultrasound signs of uterine remodeling following scarring. Lakes and lacunae can coexist within the same placenta and both will change in size and shape as pregnancy advances. Better understanding of the etiopathology of placental sonolucent spaces and associated morphological changes is necessary to identify patients at risk of subsequent complications during pregnancy and/or at delivery. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Evaluation of preoperative ultrasound signs associated with bladder injury during complex Cesarean delivery: case-control study

OBJECTIVE

Intraoperative hemorrhage and peripartum hysterectomy are the main complications in patients presenting with a low-lying placenta or placenta previa undergoing repeat Cesarean delivery (CD). Patients with a high probability of placenta accreta spectrum (PAS) at birth also have a higher risk of intraoperative urologic injury. The aim of this study was to evaluate the ultrasound signs and intraoperative features associated with these injuries.

METHODS

This was a retrospective case-control study of consecutive singleton pregnancies included in a prospective cohort of patients with a history of at least one prior CD and diagnosed prenatally with an anterior low-lying placenta or placenta previa at 32-36 weeks' gestation. All patients underwent investigational preoperative transabdominal and transvaginal ultrasound examination within 48 h prior to delivery. Ultrasound anomalies of uterine contour and uteroplacental vascularity, and gross anomalies of the lower uterine segment (LUS) and surrounding pelvic tissue at delivery, were recorded using a standardized protocol, which included evaluation of the extent of uterine contour anomalies. The diagnosis of PAS was established when one or more placental lobules could not be separated digitally from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens, and was confirmed by histopathology. Data were compared between cases complicated by intraoperative bladder injury and controls from the same cohort matched at a 1:3 ratio by parity and the number of prior CDs using conditional logistic regression.

RESULTS

There were 16 (9.4%) patients with an intraoperative bladder injury in a cohort of 170 managed by the same multidisciplinary team during the study period. There were no patients diagnosed with ureteric or bladder trigone damage. There were 14 (87.5%) patients with a bladder injury that had histopathologic evidence of PAS at birth, including 11 (68.8%) cases described on microscopic examination as placenta increta and three (18.8%) as placenta creta. There was a significant (P = 0.03) difference between cases and controls in the distribution of the intraoperative LUS vascularity, whereby the higher the number of enlarged vessels, the higher the odds of bladder injury. Multivariable regression analysis revealed that both gestational age at delivery and LUS remodeling on transabdominal ultrasound were associated with bladder injury. A longer gestational age was associated with lower risk of injury. A higher LUS remodeling grade on transabdominal ultrasound was associated with an increased risk of bladder injury. Patients with Grade-3 remodeling (involving > 50% of the LUS) had 9-times higher odds of a bladder injury compared to patients with Grade-1 remodeling (involving < 30% of the LUS).

CONCLUSIONS

Preoperative ultrasound examination is useful in the evaluation of the risk of intraoperative bladder injury in patients with a history of prior CD presenting with a low-lying placenta or placenta previa. The larger the remodeling of the LUS on transabdominal ultrasound, the higher the risk of adverse urologic events. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis

OBJECTIVE

To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS).

METHODS

MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data.

RESULTS

There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis.

CONCLUSIONS

Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of ultrasound features of placenta accreta spectrum in women at high risk: association with outcome and interobserver concordance

OBJECTIVES

To evaluate the prenatal ultrasound features associated with operative complications and to assess the interobserver agreement of prenatal ultrasound assessment with histopathologic confirmation of placenta accreta spectrum (PAS) in a cohort of high-risk patients with detailed intraoperative and histopathologic data.

METHODS

This was a retrospective multicenter cohort study of patients at high risk of PAS referred for specialist perinatal care and management between January 2019 and May 2022. Deidentified ultrasound images were reviewed independently by two experienced operators blinded to clinical details, intraoperative features, outcome and histopathologic findings. The diagnosis of PAS was confirmed by failure of detachment of one or more placental cotyledons from the uterine wall at delivery, and the absence of decidua with distortion of the uteroplacental interface by fibrinoid deposition on histologic examination of the accretic areas obtained by guided sampling of partial myometrial resection or hysterectomy specimens. Patients were categorized as having a low or high likelihood of PAS at birth. Interobserver agreement of prenatal ultrasound assessment with histopathologic confirmation of PAS was assessed using the kappa statistic. Primary outcome was major operative morbidity (blood loss ≥ 2000 mL, unintentional injury to the viscera, admission to intensive care unit or death).

RESULTS

A total of 102 women at high risk of PAS were referred, of whom 66 had evidence of PAS at birth and 36 did not. When blinded to other clinical details, the examiners agreed on the low or high probability of PAS, according to ultrasound features, in 75/102 cases (73.5%). The kappa statistic was 0.47 (95% CI, 0.28-0.66), showing moderate agreement. Morbidity was twice as common with concordant prenatal diagnosis of PAS vs concordant diagnosis of not PAS. Concordant assessment of high probability of PAS was associated with the highest morbidity (66.6%) and a very high (97.6%) likelihood of histopathologic confirmation.

CONCLUSIONS

The probability of histopathologic confirmation is very high with concordant prenatal assessment suggestive of PAS. The interobserver agreement for preoperative assessment with histopathologic confirmation of PAS is only moderate. Morbidity is associated with both histopathologic diagnosis and concordant antenatal assessment of PAS. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Modified Delphi study of ultrasound signs associated with placenta accreta spectrum

OBJECTIVE

To determine, by expert consensus through a modified Delphi process, the role of standardized and new ultrasound signs in the prenatal evaluation of patients at high risk of placenta accreta spectrum (PAS).

METHODS

A systematic review of articles providing information on ultrasound imaging signs or markers associated with PAS was performed before the development of questionnaires for the first round of the Delphi process. Only peer-reviewed original research studies in the English language describing one or more new ultrasound sign(s) for the prenatal evaluation of PAS were included. A three-round consensus-building Delphi method was then conducted under the guidance of a steering group, which included nine experts who invited an international panel of experts in obstetric ultrasound imaging in the evaluation of patients at high risk for PAS. Consensus was defined as agreement of ≥ 70% between participants.

RESULTS

The systematic review identified 15 articles describing eight new ultrasound signs for the prenatal evaluation of PAS. A total of 35 external experts were approached, of whom 31 agreed and participated in the first round. Thirty external experts (97%) and seven experts from the steering group completed all three Delphi rounds. A consensus was reached that a prior history of at least one Cesarean delivery, myomectomy or PAS should be an indication for detailed PAS ultrasound assessment. The panelists also reached a consensus that seven of the 11 conventional signs of PAS should be included in the examination of high-risk patients and the routine mid-gestation scan report: (1) loss of the 'clear zone', (2) myometrial thinning, (3) bladder-wall interruption, (4) placental bulge, (5) uterovesical hypervascularity, (6) placental lacunae and (7) bridging vessels. A consensus was not reached for any of the eight new signs identified by the systematic review. With respect to other ultrasound features that are not specific to PAS but increase the probability of PAS at birth, the panelists reached a consensus for the finding of anterior placenta previa or placenta previa with cervical involvement. The experts were also asked to determine which PAS signs should be quantified and consensus was reached only for the quantification of placental lacunae using an existing score. For predicting surgical outcome in patients with a high probability of PAS at delivery, a consensus was obtained for loss of the clear zone, bladder-wall interruption, presence of placental lacunae and presence of placenta previa involving the cervix.

CONCLUSIONS

We have confirmed the continued importance of seven established standardized ultrasound signs of PAS, highlighted the role of transvaginal ultrasound in evaluating the placental position and anatomy of the cervix, and identified new ultrasound signs that may become useful in the future prenatal evaluation and management of patients at high risk for PAS at birth. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prospective evaluation of impact of post-Cesarean section uterine scarring in perinatal diagnosis of placenta accreta spectrum disorder

OBJECTIVE

Standardized ultrasound imaging and pathology protocols have recently been developed for the perinatal diagnosis of placenta accreta spectrum (PAS) disorders. The aim of this study was to evaluate prospectively the effectiveness of these standardized protocols in the prenatal diagnosis and postnatal examination of women presenting with a low-lying placenta or placenta previa and a history of multiple Cesarean deliveries (CDs).

METHODS

This was a prospective cohort study of 84 consecutive women with a history of two or more prior CDs presenting with a singleton pregnancy and low-lying placenta/placenta previa at 32-37 weeks' gestation, who were referred for perinatal care and management between 15 January 2019 and 15 December 2020. All women were investigated using the standardized description of ultrasound signs of PAS proposed by the European Working Group on abnormally invasive placenta. In all cases, the ultrasound features were compared with intraoperative and histopathological findings. Areas of abnormal placental attachment were identified during the immediate postoperative gross examination and sampled for histological examination. The data of a subgroup of 32 women diagnosed antenatally as non-PAS who had complete placental separation at birth were compared with those of 39 cases diagnosed antenatally as having PAS disorder that was confirmed by histopathology at delivery.

RESULTS

Of the 84 women included in the study, 42 (50.0%) were diagnosed prenatally as PAS and the remaining 42 (50.0%) as non-PAS on ultrasound examination. Intraoperatively, 66 (78.6%) women presented with a large or extended area of dehiscence and 52 (61.9%) with a dense tangled bed of vessels or multiple vessels running laterally and craniocaudally in the uterine serosa. A loss of clear zone was recorded on grayscale ultrasound imaging in all 84 cases, while there was no case with bladder-wall interruption or with a focal exophytic mass. Myometrial thinning (< 1 mm) in at least one area of the anterior uterine wall was found in 41 (97.6%) of the 42 cases diagnosed as non-PAS on ultrasound and 37 (88.1%) of the 42 diagnosed antenatally as PAS. Histological samples were available for all 48 hysterectomy specimens with abnormal placental attachment and for the three cases managed conservatively with focal myometrial resection and uterine reconstruction. Villous tissue was found directly attached to the superficial myometrium (placenta creta) in six of these cases and both creta villous tissue and deeply implanted villous tissue within the uterine wall (placenta increta) were found in the remaining 45 cases. There was no evidence of percreta placentation on histology in any of the PAS cases. Comparison of the main antenatal ultrasound signs and perioperative macroscopic findings between the two subgroups correctly diagnosed antenatally (32 non-PAS and 39 PAS) showed no significant difference with respect to the distribution of myometrial thinning and the presence of a placental bulge on ultrasound and of anterior uterine wall dehiscence intraoperatively. Compared with the non-PAS subgroup, the PAS subgroup showed significantly higher placental lacunae grade (P < 0.001) and more often hypervascularity of the uterovesical/subplacental area (P < 0.001), presence of bridging vessels (P = 0.027) and presence of lacunae feeder vessels (P < 0.001) on ultrasound examination, and increased vascularization of the anterior uterine wall intraoperatively (P < 0.001).

CONCLUSIONS

Remodeling of the lower uterine segment following CD scarring leads to structural abnormalities of the uterine contour on both ultrasound examination and intraoperatively, independently of the presence of accreta villous tissue on microscopic examination. These anatomical changes are often reported as diagnostic of placenta percreta, including cases with no histological evidence of PAS. Guided histological examination could improve the overall diagnosis of PAS and is essential to obtain evidence-based epidemiologic data. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Genetic evaluation of semen traits in Friesian bulls raised in Egypt

A total of 14696 semen records were collected from Friesian bulls, kept at International Livestock Management Training Center belonging to Animal Research Institute, Ministry of Agriculture, Dokki, Cairo. Traits studied were volume, motility, livability and sperm concentrates in other to construct selection indexes by using all combination between different traits of semen to improve semen traits in a herd of Friesian bull cattle. Data were analysed by using four traits repeatability model and includes effects of the following fixed factors: the age of animal at semen collection, the combined effect of the month and year of semen collection, and the number of times semen were collected per month. Semen motility, volume and livability were highly influenced (p < 0.001) by all the fixed factors. Heritability estimates for semen traits were moderate and ranged from 0.29 to 0.33. All phenotypic and genetic correlations between different traits are positive and ranged from 0.09 to 0.67 for phenotypic correlations and from 0.02 to 0.68 for genetic correlations, while permanent environmental correlations ranged from -0.69 to 0.12. Estimated Breeding Values ranged from -0.68 to 0.78 ml for semen volume, from -13.17 to 7.34% for motility, from -259.42 × 10^-6 to 239.64 × 10^-6 for concentrates and from -6.83 to 6.09% for livability. Eleven selection indexes were calculated, selection Indexes not including livability showed a reduced accuracy. This study demonstrated that selection index (I₃) which includes sperm volume, motility and livability or selection index (I₈) which includes sperm volume and livability are the best and both are recommended for Friesian bulls' selection.

515 How Has ‘Montgomery’ Changed the Way We Document Risks on Consent Forms for Deceased Donor Kidney Transplantation? A Single-Centre Audit and Re-Audit

Introduction

The 2015 Montgomery case changed the remit of risk discussions required during the consent process. This audit reviewed single kidney transplant (SKT) consent forms to establish which risks are documented, and whether this legal case affected discussions. Following the audit, we introduced a pre-printed consent form and closed the audit loop by assessing its uptake.

Method

Trust paper consent forms for all patients aged 50+ who received a deceased donor SKT in our centre in 2014 (n = 58; pre-Montgomery) and 2017 (n = 70; post-Montgomery) were reviewed to see if 20 perceived ‘gold standard’ risks were documented. A pre-printed procedure-specific consent form including all gold standard risks was then introduced in July 2019. A re-audit reviewed the case-notes of every alternate recipient aged 50+ of a deceased donor SKT from 01/08/19 to 29/02/20 to check if the pre-printed form was used.

Results

Overall, 53% of the 20 ‘gold standard’ risks were documented in 2014 versus 59% in 2017 (p = 0.55). There was a 91% uptake of the pre-printed consent form.

Discussion

This audit established the importance of using a pre-printed consent form to standardise risk discussions We propose that pre-printed procedure-specific forms should be encouraged throughout the NHS to support ‘Montgomery-appropriate’ consent discussions.

Combinatorial metabolism drives the naive to primed pluripotent chromatin landscape

Since epigenetic modifications are a key driver for cellular differentiation, the regulation of these modifications is tightly controlled. Interestingly, recent studies have revealed metabolic regulation for epigenetic modifications in pluripotent cells. As metabolic differences are prominent between naive (pre-implantation) and primed (post-implantation) pluripotent cells, the epigenetic changes regulated by metabolites has become an interesting topic of analysis. In this review we discuss how combinatorial metabolic activities drive the developmental progression through early pluripotent stages.

Effects of low dose of aliskiren on isoproterenol-induced acute myocardial infarction in rats

This study examined the effects of aliskiren (Ali) (direct renin inhibitor) on serum cardiac enzymes (LDH and CK-MB), electrocardiography (ECG) changes, myocardial oxidative stress markers (MDA, CAT, and GSH) and the expression of Bcl2, HO-1, and Nrf2 genes in isoproterenol (ISO)-induced myocardial infarction (MI). A total of 40 male albino rats were allocated into four groups, (1) normal control (NC) group, (2) Ali group (rats received Ali at 10 mg/kg/day p.o. for 5 days), (3) ISO group (rats received ISO 150 mg/kg i.p. for two consecutive days at 24 h intervals), and (4) Ali + ISO group (rats received ISO + Ali at 10 mg/kg/day p.o. for 5 days from the 2^nd dose of ISO). ISO group showed significant rise in serum cardiac enzymes (CK-MB and LDH), myocardial damage scores, myocardial MDA, HO-1, myocardial Nrf2 expression with significant reduction in myocardial antioxidants (CAT and GSH), and Bcl2 expression compared to the normal group (p < 0.05). ECG showed ST segment elevation, prolonged QT interval and QRS complex, and increased heart rate in ISO group. Co-administration of Ali and ISO caused significant increase in cardiac enzymes and morphology with increase in MDA, serum K, and creatinine with significant decrease in Bcl2, HO-1, and Nrf2 without significant changes in ECG parameters compared to ISO group. We concluded that low dose of Ali seems to exacerbate the myocardial injury in ISO-MI, which might be due to the enhanced oxidative stress and apoptosis.

Morphometric parameters and histological study of the filum terminale of adult human cadavers and magnetic resonance images

BACKGROUND

Morphology and histology of filum terminale (FT) has a role in the pathophysiology of tethered cord syndrome (TCS). This research was implemented to investigate the morphometric parameters and histological structure of normal FT in adult human cadavers and magnetic resonance imaging (MRI) scans to correlate them with the pathophysiology of TCS.

MATERIALS AND METHODS

Twenty five adult human cadavers (15 males, 10 females) and 100 MRI echo scans of lumbosacral region (50 males and 50 females), were used in this study. MRI patients were divided into 21-40 and 41-60 age groups. The cadavers were dissected at the prone position to explore their fila. The length of FT, filum terminale internum (FTI), filum terminale externum (FTE), vertebral level of beginning, dural piercing and termination of FT, and the initial, midpoint, and mid-FTE diameters were determined. Four segments were excised from lower conus, upper, middle, and lower thirds of FT. The specimens were processed for light microscopic examination. Statistical analysis was done for these parameters.

RESULTS

MRI morphometrical parameters of FT, except FTI length, revealed no age effect or sex differences, where length of FTI, FTE, initial diameter, level of conus medullaris termination (CMT) and dural sac termination (DST) were 174.1 ± 16.8, 75.8 ± 9.5, 1.6 ± 0.21, L1-2 and S2U in males and 166.9 ± 18.9, 74.1 ± 9.3, 1.53 ± 0.25, L1-2 and S2M vertebrae in females, respectively. However, non-significant sex difference was observed in morphometric parameters of cadaveric FT, where length of FTI and FTE, initial diameter, CMT and DST levels were 164.2 ± 11.6, 76.7 ± 8.1, 1.7 ± 0.14, L1L and S2U vertebrae in males and 159.2 ± 10.1, 71.02 ± 7.3, 1.6 ± 0.29, L1L and S2U in females, respectively. Moreover, CMT below L2 vertebra was seen in 5% of MRI scans and 8% of cadavers. Also, the initial diameter of FT > 2 mm was recorded in 7% of MRI and 8% of cadaveric cases. Histologically, the structure of FT showed gradual reduction in nervous, glial, and vascular tissues with converse increase in collagen content in FTE compared with those of FTI.

CONCLUSIONS

Knowledge of the morphometric parameters and the histological structure of FT are necessary for clinicians who dealing with diagnosis or treatment of tethered cord syndrome.

Does allicin combined with vitamin B-complex have superior potentials than alpha-tocopherol alone in ameliorating lead acetate-induced Purkinje cell alterations in rats? An immunohistochemical and ultrastructural study

BACKGROUND

The current article aims to explore the protective potentials of α-tocopherol alone and the combination of allicin and vitamin B-complex against lead-acetate neurotoxicity on the cerebellar cortex.

MATERIALS AND METHODS

Forty rats were divided into four groups (n = 10). Group 1 was the control group; Group 2 received 10 mg/kg body weight (BW) of lead acetate; Group 3 was exposed to 10 mg/kg BW of lead acetate plus a combination of allicin (100 mg/kg BW) and vitamin B-complex (40 mg/kg BW); Group 4 was administered lead acetate (10 mg/kg BW) and α-tocopherol (100 mg/kg BW). The animals received the treatment for 60 days by oral gavage. All the groups were studied ultrastructurally and immunohistochemically with glial fibrillary acidic protein (GFAP).

RESULTS

The affected groups revealed shrunken and degenerated Purkinje cells with irregular nuclei. The cytoplasm comprised several lysosomes, unhealthy mitochondria, and dilated Golgi saccules. The myelinated nerve fibres demonstrated breaking of the myelin sheaths, apparent vacuoles, and broad axonal spaces. Immunohistochemically, there was a tremendous surge in GFAP-positive astrocytes in the lead acetate-treated group. These histological and ultrastructural variations were ameliorated by the administration of a-tocopherol and the combination of allicin and vitamin B complex. Moreover, an apparent decrease in the number of GFAP-positive astrocytes was obvious in the protected groups.

CONCLUSIONS

Although both a-tocopherol and the combination of allicin and vitamin B-complex can be used as possible adjuvant therapies to ameliorate nervous system ailments attributable to lead acetate, α-tocopherol showed more protective potential.

Ameliorative potentials of a combination of fenugreek and alpha-tocopherol on cadmium induced testicular toxicity: an ultrastructural study

BACKGROUND

The current study aimed to elucidate the protective role of combined fenugreek and a-tocopherol against cadmium induced histopathological changes in the testes.

MATERIALS AND METHODS

Thirty adult male albino rats divided into three equal groups 10 rats each. Group I is the control group. Group II received 5 mg/kg/ day cadmium chloride. Group III received 5 mg/kg/day cadmium chloride and 150 mg/kg/day fenugreek and 100 mg/kg/day of a-tocopherol. The treatment of all groups was done by oral gavage for 60 consecutive days. The testes were removed and subjected to histopathological and ultrastructure study.

RESULTS

Rats exposed to cadmium showed severe histopathological changes in the testicular spermatogenic series, many vacuoles and multinucleated giant cells. Treatment with fenugreek and a-tocopherol partially improved the morphological changes, reduced tissue damage and rebuilt of the spermatogonia layer.

CONCLUSIONS

Fenugreek and a-tocopherol might represent a promising medicinal combination to ameliorate the toxic effects of cadmium exposure.

Activation of Nrf2 by ischemic preconditioning and sulforaphane in renal ischemia/reperfusion injury: a comparative experimental study

Objectives of the study were to investigate impact of ischemic preconditioning (Ipre) and sulforaphane (SFN) and combination of them on nuclear factor 2 erythroid related factor 2 (Nrf2) gene and its dependent genes, heme oxygenase-1 (HO1) and NADPH-quinone oxidoreductase1 (NQO-1) and inflammatory cytokines TNF-alpha, IL1beta, and intercellular adhesion molecule-1 (ICAM1) and caspase-3 in renal ischemia/reperfusion (I/R) injury. Ninety male Sprague Dawely rats were classified into 5 groups (each consists of 18 rats): sham, control, Ipre, sulforaphane and Sulfo+Ipre. Each group was subdivided into 3 subgroups each containing 6 rats according to time of harvesting kidney and taking blood samples; 24 h, 48 h, and 7 days subgroups. Renal functions including serum creatinine, BUN were measured at basal conditions and by the end of experiment. Expression of Nrf2, HO-1, NQO-1, TNF-alpha, IL-1beta, and ICAM-1 was measured by real time PCR in kidney tissues by the end of experiment. Also, immunohistochemical localization of caspase-3 and chemical assay of malondialdehyde (MDA), GSH and SOD activity were measured in kidney tissues. Both Ipre and SFN improved kidney functions, enhanced the expression of Nrf2, HO-1, and NQO-1, attenuated the expression of inflammatory (TNF-alpha, IL-1, and ICAM-1) and apoptotic (caspase-3) markers. However, the effect of sulforaphane was more powerful than Ipre. Also, a combination of them caused more improvement in antioxidant genes expression and more attenuation in inflammatory genes but not caspase-3 than each one did separately. Sulforaphane showed more powerful effect in renoprotection against I/R injury than Ipre as well as there might be a synergism between them at the molecular but not at the function level.

Alkyl Heteroaromatics as Building Blocks in Organic Synthesis: The Reactivity of Alkyl Azoles toward Electrophilic Reagents

Oxazolone (1) couples with aromatic diazonium salts to yield the arylhydrazones (3a-c). Compound 3 reacts with aniline to give aryl hydrazone (5). Compound 5 was also obtained via converting 1 into the imidazolone (4) and subsequent treatment of 4 with aromatic diazonium salts. Compounds 1 and 12 reacted with arylidenemalononitrile (6) to yield compounds 8 and 14 respectively. Also compounds 1, 12 condensed with an aromatic aldehydes to yield 11 and 17. Compounds 11, 17 reacted further with one molecule of malononitrile to give compounds 8 and 14, respectively. Compound 20 which was generated in situ by heating phenacylthiocyanate (19) in acetic anhydride on treatment with hydrazine hydrate or phenyl hydrazine gives 21 and 22 respectively. A lso 20 reacted with malononitrile or with ethyl cyanoacetate to give 23 and 24, respectively.

Nitriles in Heterocyclic Organic Synthesis: Synthesis of Pyrano[2,3-h]coumarines, Pyrano[3,2-c]coumarines, and their Derivatives

Several new 4H-pyrano[2,3-h]coumarines 5a-e were prepared by the reaction of 7-hydroxycoumarine with cinnamonitriles 1. Also, the reaction of 7-hydroxycoumarine with a mixture of aliphatic aldehydes and malononitrile afforded compounds 5f,g. Similarly, 4-hydroxycoumarine was reacted with the same reagents to give compounds 9a-g. The reaction of 9 g with different nucleophilic reagents afforded the pyrimido[4′,5′:6,5]pyrano[3,2-c]coumarin-4-one derivatives 10-12, 4-methyl-2-(ethoxymethylenamino)4H-pyrano[3,2-c]coumarine-3-carbonitrile (13) and pyrazolo[3′,4′;6,5]pyrano[3,2-c]coumarine (14) respectively.

Activation of nuclear factor erythroid 2-related factor 2 (Nrf2) and Nrf-2-dependent genes by ischaemic pre-conditioning and post-conditioning: new adaptive endogenous protective responses against renal ischaemia/reperfusion injury

AIM

To investigate the impact of ischaemic pre-conditioning (Ipre) and post-conditioning (Ipost) on expression of nuclear factor erythroid 2-related factor 2 (Nrf2) gene and its dependent genes, haem oxygenase-1 (HO-1) and NADPH-quinone oxidoreductase-1 (NQO-1); inflammatory cytokines TNF-α, IL1β and ICAM-1; and apoptotic markers such as caspase-3 in renal ischaemia/reperfusion (I/R) injury.

METHODS

One hundred and fifty male Sprague Dawley rats were classified into five groups (each consisted of 30 rats): sham, control (I/R), Ipre + I/R, Ipre without I/R and Ipost + I/R. Serum creatinine and blood urea nitrogen (BUN) were measured at 2, 24 and 48 h after ischaemia. In kidney tissues, mRNA of Nrf2, HO-1, NQO-1, TNF-α, IL-1β and ICAM-1 and immunohistochemical expression of Nrf2 and caspase-3 were assessed.

RESULTS

Serum creatinine and BUN improved significantly in Pre + I/R group; however, they did not show any significant improvement in Post + I/R group. Also, Ipre-I/R group showed non-significant change in serum creatinine and BUN. The expression of Nrf2, HO-1 and NQO-1 is increased significantly in Pre + I/R and Pre - I/R groups, while the enhancement in Post + I/R group was non-significant. Moreover, the expression of proinflammatory cytokines (TNF-α, IL-1 and ICAM-1) and apoptotic (caspase-3) markers showed high significant attenuation in Pre + I/R group, but slight significant attenuation in Pre + I/R group.

CONCLUSION

The renoprotective action of Ipre might include early activation and enhanced expression of Nrf2 gene and its dependent antioxidant genes, HO-1 and NOQ1, as endogenous adaptive renoprotective genes, as well as reduction in TNF-α, IL-1β, ICAM-1 and caspase-3.

Effect of dehydroepiandrosterone (DHEA) on memory and brain derived neurotrophic factor (BDNF) in a rat model of vascular dementia

The effect of dehydroepiandrosterone (DHEA) on memory and cognition in experimental animals is well known, but its efficacy in clinical dementia is unproven. So, the aim of the present study was to investigate the effect of DHEA on learning and memory activities in a rat model of vascular dementia (VD). Forty-eight male rats that positively passed the holeboard memory test were chosen for the study before bilateral permanent occlusion of the common carotid artery. They were divided into four groups (n=12, each) as follows (i) untreated control, (ii) rats exposed to surgical permanent bilateral occlusion of the common carotid arteries (BCCAO) leading to chronic cerebral hypoperfusion, (iii) rats exposed to BCCAO then received DHEA (BCCAO + DHEA) and (i.v.) rats exposed to BCCAO then received donepezil (BCCAO + DON). Holeboard memory test was used to assess the time, latency, working memory and reference memory. Central level of acetylcholine, norepinephrine and dopamine in the hippocampus were measured. Furthermore, the expression of brain derived neurotrophic factor (BDNF) in the hippocampus was determined. Histopathological studies of the cerebral cortex and transmission electron microscope of the hippocampus were performed. BCCAO decreased the learning and memory activities in the holeboard memory. Also, it decreased the expression of BDNF as well as the central level of acetylcholine, noradrenaline and dopamine as compared to control rats. Treatment with DHEA and donepezil increased the working and reference memories, BDNF expression as well as the central acetylcholine in the hippocampus as compared to BCCAO rats. DHEA produced neuroprotective effects through increasing the expression of BDNF as well as increasing the central level of acetylcholine and catecholamines which are non-comparable to donepezil effects.

Effect of testosterone replacement therapy on cardiac performance and oxidative stress in orchidectomized rats

AIM

To investigate the effects of testosterone on myocardial contractility, oxidative stress status and expression of sodium channel protein (Nav1.5) and inward rectifying K channels (Kir 2.x) in normal and orchidectomized (ORX) rats.

METHODS

One hundred four rats were randomly assigned into four groups (n = 26, each) as follows: (i) untreated controls, (ii) testosterone treated, (iii) orchidectomized rats and (iv) orchidectomized, testosterone-treated rats. Treatments with the vehicle or testosterone were carried out for 12 weeks, three times per week. At the end of treatment, surface ECG, isolated heart, tissue oxidative stress and lipid peroxidation experiments were carried out on the cardiac tissues. Also, immunohistochemical examination for Nav1.5 and PCR detection of mRNA of Kir2.1, Kir2.2 and Kir2.4 subunits of K channels were carried out.

RESULTS

Orchidectomy impaired cardiac contractile function parameters left ventricular developed pressure (LVDP) and the peaks of the positive and negative pressure derivatives (dP/dtmax and -dP/dtmax respectively), increased heart rate and prolonged QT and QTc intervals, elevated pro-oxidant state in rat's hearts and decreased the expression of Kir 2.1 but not Kir2.2, Kir 2.4 and Nav1.5 channels. Exogenous testosterone administration to orchidectomized rats restored heart contractility and shortened QT and QTc intervals to their normal values, ameliorated the generated pro-oxidant state and improved the expression of Nav1.5 and Kir2.1, but not Kir2.2 or Kir2.4 channels.

CONCLUSION

Testosterone improved cardiac contractility and shortened QT and QTc intervals in ORX rats. An effect that might be dependent of reduction in oxidative stress and enhancement of Kir2.1 channels but independent of Nav1.5 channel protein.

Haematogenous dissemination of tuberculous lymphadentitis

OBJECTIVE

To determine whether Mycobacterium tuberculosis infection spreads through the blood to different lymph-node groups in patients with tuberculous lymphadenitis.

DESIGN

Prospective analytical study.

SETTING

The patients were recruited, managed and followed at the lymphodenopathy clinic, Central Police Hospital, Burr, Khartoum, Sudan.

SUBJECTS

Fifty two sequential patients were enrolled. Thirty patients with FNAC diagnosis of tuberculous lymphadenitis and positive PCR for M. tuberculosis complex had a mean age of 26.9 +/- 11.2 years and similar male, female affection. Nine patients with FNAC tuberculous lymphadenitis, but negative PCR had a slightly higher mean age (32.6 +/- 18.2 years) with similar male: female proportions. Patients with reactive lymphadenopathy (9/52) were older than patients with tuberculous lymphadenitis with a mean age of 45 +/- 24.6 years.

RESULTS

None of the patients were positive for HIV or had clinical or radiological evidence of pulmonary tuberculosis. M. tuberculosis DNA was detected in the blood samples of 30/39 (77%) patients with tuberculous lymphadenitis, but in none of the cases with reactive or malignant lymphadenopathy. The presence of M. tuberculosis DNA correlated strongly to multiple lymph-node involvement [OR (odds ratio) = 96.7, 95% confidence interval (CI) 9.0 - 1,039] and to caseating-granulomatous and predominantly necrotic cytomorphological categories [OR = 70, 95% confidence interval (CI) 7.0 - 703].

CONCLUSION

M. tuberculosis most probably disseminates through the blood from one node group to the other in patients with tuberculous lymphadenitis.

Diagnosis of tuberculous lymphadenitis by FNAC, microbiological methods and PCR: a comparative study

Despite its usefulness in the diagnosis of tuberculous lymphadenitis, fine needle aspiration cytology (FNAC) faces several limitations, and its sensitivity and specificity are not well established. The diagnostic accuracy and limitations of FNAC were studied in comparison with conventional microbiological methods and polymerase chain reaction (PCR). Sixty patients with lymphadenopathy and a clinical diagnosis of tuberculous lymphadenitis were subjected to FNA. The aspirate was used for cytological examination, Ziehl-Neelsen staining, mycobacterial culture and PCR. PCR was performed using two sets of oligonucleotide primers for Mycobacterium tuberculosis and a single primer for M. bovis species. The results of FNAC, microbiological methods and PCR correlated with the clinical outcome after follow-up for an average period of 24 months. Twenty-five cases (41.6%) were treated and responded well to anti-tuberculosis therapy, among them 17 were correctly diagnosed by FNAC (68%), eight by microbiological methods (32%) and 24 by PCR (96%). When PCR is considered the gold standard, FNAC predicted the correct diagnosis in 62% of cases with a high false negative rate (38%) due to the absence of granuloma/necrosis in smears from cases of early tuberculosis. In the latter group PCR proved to be the most valuable and a diagnostic success of 100% was achieved when FNAC and PCR were combined. In addition, PCR allowed immediate characterization of M. tuberculosis in the vast majority (96.2%) of cases in the study population.

Granulomatous mammary disease: ten years' experience with fine needle aspiration cytology

OBJECTIVE

To determine the aetiological types of granulomatous disease of the breast in women presenting with mammary complaints in the Sudan.

METHODS

Clinical history and physical examination, complete blood counts, Mantoux test, histopathology and fine needle aspiration cytology (FNAC).

RESULTS

Granulomatous mastitis was seen in 11/2500 (0.44%) patients with mammary disease over a 10-year period. All were of childbearing age (mean 26.0 +/- 5.9 years). Common presentations were diffuse swelling, well-circumscribed masses, nipple retraction, multiple sinuses and superficial skin ulcers. Lymphadenopathy was seen in more than 60% of the patients. Diagnosis was based on cytomorphological features in 10/11 cases and histopathology in one. Nine were diagnosed with tuberculous mastitis and two with idiopathic granulomatous mastitis. Acid-fast bacilli (AFB) could not be demonstrated in any of the cytology smears. Tuberculous mastitis responded to empirical anti-tuberculosis treatment, with a minimum follow-up of 2 years in seven women.

CONCLUSION

Tuberculous mastitis is a rare entity in women with mammary disease in the Sudan. Alternative diagnoses such as idiopathic granulomatous mastitis should be made only after failure of an adequate trial of anti-tuberculosis treatment. FNAC is a useful diagnostic tool even if AFB cannot be demonstrated.

Ligation-anopexy for treatment of advanced hemorrhoidal disease

PURPOSE

Destruction of the anchoring tissue system is considered to be the essential prerequisite to the pathogenesis of advanced hemorrhoidal disease. Ligation-anopexy was designed to 1) restore fixation of the hemorrhoidal cushions to the underlying internal sphincter, 2) reduce hemorrhoidal prolapse, and 3) minimize the hemorrhoidal blood flow. The purpose of this study was to evaluate the ligation-anopexy as a new technique for the treatment of advanced stages of hemorrhoidal disease.

METHODS

This study included 40 patients with hemorrhoidal disease (mean age 29.63 +/- 9.79 years, male/female ratio 34:6). Twenty-two patients had third-degree and 18 patients had fourth-degree hemorrhoids; of those with fourth-degree hemorrhoids, two patients had associated anal fissure and three patients had partial mucosal prolapse. Informed consent was obtained from all patients. After reduction of hemorrhoidal prolapse and under general or spinal anesthesia, a needle with 2-0 polyglactin (Vicryl) was inserted 1.5 cm above the dentate line using a Sims' speculum. The needle was inserted deep enough to fix the mucosa and the submucosa to the underlying internal sphincter. After the suture was tied, the redundant mucosa was pulled distally to be incorporated in the ligature, and the thread was relegated around it to form a mucosal tag.

RESULTS

Inclusion of a part of the internal sphincter with ligation of the redundant mucosa ensures adequate retraction of prolapsed hemorrhoids (hemorrhoid lift). Postoperative pain was accepted by 90 percent of the patients and disappeared after treatment with oral diclofenac. The immediate complications included anal spasm in 10 percent, postoperative bleeding in 2.5 percent, and thrombosis of the external hemorrhoids in 2.5 percent of patients. Neither recurrence nor anal stenosis was observed after 12 months of follow-up.

CONCLUSION

Despite the limited number of patients and the short follow-up, the preliminary results of ligation-anopexy in the treatment of advanced hemorrhoidal disease are encouraging.

Schistosomal pelvic floor myopathy contributes to the pathogenesis of rectal prolapse in young males

PURPOSE

Rectal prolapse is common in young males in Egypt. The role of schistosomiasis in the pathogenesis of rectal prolapse is not clearly defined. The purpose of this work is to study changes in the pelvic floor muscles in patients of rectal prolapse associated with schistosomiasis.

METHODS

This study included 33 male patients with rectal prolapse of whom 27 patients with schistosomiasis and 6 patients free from schistosomiasis. Biopsies were taken from the pelvic floor muscle during surgery. The prepared sections were examined for histopathologic structural changes, for ultrastructural changes (by using electron microscopy) and after immunohistochemical staining by using anti-IgG and anti-IgM antibodies.

RESULTS

The muscles from the patients without schistosomiasis had no histologic or EM changes and showed negative staining for IgG and IgM. Myopathic changes were found in the group of patients with schistosomiasis, including increased variation in the fiber diameter in 66.6 percent of patients, degenerative changes in 59.26 percent of patients, fiber splitting and fragmentation in 44.4 percent of patients, and endomysial fatty changes in 55.5 percent of patients. Ultrastructural study revealed starting loss of striation and margination of the nucleus in 70.37 percent of patients, distorted myofibrillar pattern in 51.85 percent of patients, disturbed endoplasmic reticulum and increased glycogen granules in all patients, the mitochondria are irregularly arranged with electron dense matrix in 40.74 percent of patients, and prominent nuclear sap in 13.72 percent of patients. The muscles of all the schistosomal patients showed a positive cytoplasmic staining for immunoglobulin G, of them only 12 patients showed positive staining for IgM.

CONCLUSION

Patients with schistosomiasis suffer from pelvic floor myopathic changes that may contribute to the pathogenesis of rectal prolapse in young males. The immunohistochemical findings suggest immunologic mechanism for this myopathy.

New polycyclic azines derived from pyrazolo[3,4-b]pyridine

The aminoimidazolinyl derivative 3 was synthesized using the pyrazole amino aldehyde 1 as a starting material. Compound 3 has been used as a key intermediate in the synthesis of the title compounds.

Supra-sternal notch tuberculous abscess: a report of three cases

Extra-pulmonary tuberculosis remains a diagnostic and therapeutic challenge; its clinical presentation can mimic a wide range of pathological conditions. Here we report on 3 female patients who presented with supra-sternal masses that were suspected clinically to be of thyroid origin. By use of fine-needle aspiration cytology (FNAC), they were proved to be tuberculous lesions involving the pre-tracheal lymph nodes. Serological examination for HIV-I/II was not reactive in the 3 patients. The patients responded well to a regimen of multi-drug therapy. It is concluded that extra-pulmonary tuberculosis should be considered in the differential diagnosis of thyroid or para-thyroid swellings and that FNAC is a simple, quick and reliable procedure in the diagnosis of extra-pulmonary tuberculous lesions involving the neck.

A phase I/II study of high-dose cyclophosphamide, cisplatin, and thioTEPA followed by autologous bone marrow and granulocyte colony-stimulating factor-primed peripheral-blood progenitor cells in patients with advanced malignancies

The purpose of the present study was to determine the maximally tolerated dose of thioTEPA given with fixed high-dose cyclophosphamide (CPA) and cisplatin (cDDP) followed by autologous bone marrow (ABM) with or without granulocyte colony-stimulating factor (G-CSF)-primed peripheral-blood progenitor cells (PBPCs) in patients with advanced malignancies. Patients were required to have histologically documented malignancies and adequate renal, hepatic, pulmonary, and cardiac function. CPA was given at 1,875 mg/m2 per day as a 1-h i.v. infusion for 3 consecutive days, and cDDP was given at 55 mg/m2 per day as a 24-h continuous i.v infusion over 3 days concurrently with CPA. ThioTEPA was given once as a 1-h i.v. infusion (300-900 mg/m2) either following (the first 13 patients) or prior to CPA and cDDP. In all, 31 patients received PBPCs. A total of 46 patients were treated. There were 6 deaths among the 15 patients who did not receive PBPCs (13 received thioTEPA following CPA and cDDP). Among the other 31 patients who received PBPCs (all of whom also received thioTEPA prior to CPA and cDDP), there were 4 deaths, all involving patients with refractory ovarian carcinoma. The main toxicities were mucositis, esophagitis, hepatotoxicity, and nephrotoxicity. The median time required to achieve an absolute neutrophil count of 500 microliter was 10 days (range, 9-12 days) for those who received PBPCs and 15 days (range, 15-34 days) for those who did not receive PBPCs. Altogether, 47% of the major organ toxicities (grades 3 and 4 renal, hepatic, and cardiac toxicities) occurred among the 15 patients who did not receive PBPCs, although these patients received thioTEPA at the lowest 2 dose levels. There were 3 complete responses and 22 partial responses among 35 evaluable patients (overall response rate, 71%), with the median duration of response being 3.5 months (range, 2-17 months). The maximally tolerated dose of thioTEPA was 600 mg/m2 given as a 1-h i.v. infusion on the day prior to CPA and cDDP administration, The combination of high-dose CPA, cDDP, and thioTEPA is a well-tolerated regimen when thioTEPA is given prior to CPA and cDDP and when the combination also includes PBPCs in addition to ABM. This regimen is active in a variety of malignancies.

Effects of granulocyte-macrophage colony stimulating factor produced in Chinese hamster ovary cells (regramostim), Escherichia coli (molgramostim) and yeast (sargramostim) on priming peripheral blood progenitor cells for use with autologous bone marrow after high-dose chemotherapy

Peripheral blood progenitor cells (PBPCs) were collected without prior association with chemotherapy but after the administration of granulocyte-macrophage colony-stimulating factor (GM-CSF) produced in Chinese hamster ovary cells (CHO-GM, regramostim), Escherichia coli (E. coli-GM, molgramostim), or yeast (Yeast-GM, sargramostim) and used in conjunction with autologous bone marrow after high-dose chemotherapy in 69 patients with breast cancer or melanoma. The mean peripheral white blood cell (WBC) counts increased by 2.2 to 2.7-fold after regramostim, 4.5 to 7.3-fold after molgramostim and 4.3-fold after sargramostim. All patients underwent three leukaphereses. The mean (+/- standard error) total nucleated pheresed cells per kg x 10(8) were 4.15 +/- 0.56, 15.10 +/- 1.77 and 7.24 +/- 1.00 for patients receiving regramostim, molgramostim or sargramostim respectively. The mean (+/- standard error) granulocyte-macrophage colony-forming units per kg x 10(4) mobilized into the PB were 8.75 +/- 3.63, 71.03 +/- 17.85, and 65.11 +/- 18.74 for patients receiving regramostim, molgramostim, or sargramostim respectively. The total mean (+/- standard error) CD34+ cells per kg x 10(7) collected by three leukaphereses were 3.28 +/- 1.62, 1.34 +/- 0.51 and 2.57 +/- 1.93, for patients receiving regramostim, molgramostim or sargramostim respectively. The use of either molgramostim- or sargramostim-primed PBPCs led to complete elimination of absolute leukopenia with a WBC count under 100/mm3 in 64% and 77% of patients treated, respectively. Patients receiving molgramostim-primed PBPCs required fewer red blood cells transfusions than patients receiving regramostim-primed PBPCs (p = 0.0062). Our data indicate that PBPCs collected without prior association with chemotherapy but after either molgramostim or sargramostim with autologous bone marrow support and GM-CSF shorten the hematopoietic recovery after myeloablative chemotherapy in patients with breast cancer or melanoma.

Evaluation of GM-CSF mouthwash for prevention of chemotherapy-induced mucositis: a randomized, double-blind, dose-ranging study

Uncontrolled clinical trials have shown that parenteral administration of GM-CSF reduces the frequency of chemotherapy-induced mucositis. The mechanism of this effect could be related to acceleration of haematopoiesis and/or increase in functional activation of WBC. We conducted a double-blind, placebo-controlled, dose ranging study of GM-CSF (mol-gramostim) mouthwash in patients with breast cancer during the first treatment cycle of a combination chemotherapy regimen which has historically produced dose-limiting (grade > or = 3) mucositis in approximately 39% of patients. Subjects were randomized to receive either placebo mouthwash (0.1 percent albumin) or one of four concentrations of GM-CSF mouthwash (0.01, 0.1, 1.0 or 10 mcg/ml). The primary endpoint was to evaluate the relationship between dose of GM-CSF mouthwash received and probability of grade > or = 3 mucositis using a logistic model. Solutions were administered four times daily starting within 24 hours of chemotherapy initiation and continuing until the end of the cycle (day 21). Mucositis was assessed on days 1-6, 10, 15 and 21. Day 6 plasma samples were assayed for GM-CSF. Forty-five patients were evaluable for response (nine per dosing group). A 42% risk (15/36) of mucositis grade > or = 3 was evident on day 15 in patients receiving GM-CSF compared to 2 of 9 patients on the placebo arm. No evidence of dose response was found by logistic regression. Five patients had a detectable plasma concentration of GM-CSF (56-209 pg/ml). A positive correlation between GM-CSF dose and leukocyte recovery was noted (P = 0.04).

Protection against cytosine arabinoside-induced alopecia by minoxidil in a rat animal model

BACKGROUND

Alopecia is one of the most physically and psychologically distressing side effect of cancer chemotherapeutic agents. In the past 2 years, we reported that: (a) treatment of 8-day-old rats with 1-B-D-arabinofuranosylcytosine (Ara-C), doxorubicin, and cyclophosphamide (CYC) consistently produced alopecia; (b) Imuvert, a biological response modifier, produced complete protection against alopecia induced by Ara-C and doxorubicin, but not that produced by CYC, most probably through the release of interleukin-1; and (c) n-acetylcysteine protected against CYC-induced alopecia in the newborn rat.

METHODS

As an extension to these observations, we chose to test the efficacy of minoxidil, a drug known to be a hypertrichotic agent, in preventing chemotherapy-induced alopecia in the newborn rat animal model.

RESULTS

Minoxidil, when injected locally, offered good local prevention against Ara-C but not CYC-induced alopecia. Minoxidil 2% dissolved in a vehicle of ethanol, propylene glycol, and water was not effective when applied topically.

CONCLUSIONS

The mechanism of action of minoxidil in its prevention against Ara-C-induced alopecia is currently unknown. This observation may shed some light on the in vivo mechanism of action of minoxidil and may prove to be important in our efforts to search for agents to prevent alopecia among patients receiving chemotherapy.

Effects of granulocyte-macrophage colony stimulating factor produced in Chinese hamster ovary cells (regramostim), Escherichia coli (molgramostim) and yeast (sargramostim) on priming peripheral blood progenitor cells for use with autologous bone marrow after high-dose chemotherapy

Peripheral blood progenitor cells (PBPCs) were collected without prior association with chemotherapy but after the administration of granulocyte-macrophage colony-stimulating factor (GM-CSF) produced in Chinese hamster ovary cells (CHO-GM, regramostim), Escherichia coli (E. coli-GM, molgramostim), or yeast (Yeast-GM, sargramostim) and used in conjunction with autologous bone marrow after high-dose chemotherapy in 69 patients with breast cancer or melanoma. The mean peripheral white blood cell (WBC) counts increased by 2.2 to 2.7-fold after regramostim, 4.5 to 7.3-fold after molgramostim and 4.3-fold after sargramostim. All patients underwent three leukaphereses. The mean (+/- standard error) total nucleated pheresed cells per kg x 10(8) were 4.15 +/- 0.56, 15.10 +/- 1.77 and 7.24 +/- 1.00 for patients receiving regramostim, molgramostim or sargramostim respectively. The mean (+/- standard error) granulocyte-macrophage colony-forming units per kg x 10(4) mobilized into the PB were 8.75 +/- 3.63, 71.03 +/- 17.85, and 65.11 +/- 18.74 for patients receiving regramostim, molgramostim, or sargramostim respectively. The total mean (+/- standard error) CD34+ cells per kg x 10(7) collected by three leukaphereses were 3.28 +/- 1.62, 1.34 +/- 0.51 and 2.57 +/- 1.93, for patients receiving regramostim, molgramostim or sargramostim respectively. The use of either molgramostim- or sargramostim-primed PBPCs led to complete elimination of absolute leukopenia with a WBC count under 100/mm3 in 64% and 77% of patients treated, respectively. Patients receiving molgramostim-primed PBPCs required fewer red blood cells transfusions than patients receiving regramostim-primed PBPCs (p = 0.0062). Our data indicate that PBPCs collected without prior association with chemotherapy but after either molgramostim or sargramostim with autologous bone marrow support and GM-CSF shorten the hematopoietic recovery after myeloablative chemotherapy in patients with breast cancer or melanoma.

Protection against chemotherapy-induced alopecia by cyclosporin A in the newborn rat animal model

BACKGROUND

We have previously shown that several agents will protect against chemotherapy-induced alopecia in the newborn rat animal model. Such protective agents render the hair follicle keratinocytes resistant to chemotherapy possibly by the expression of P-glycoprotein (Pgp). Cyclosporin A (CSA) is a potent inhibitor of Pgp.

METHODS AND RESULTS

Efficacy of CSA was tested in its effects on chemotherapy-induced alopecia in the newborn rat animal model. CSA, when applied topically, protected rats from local alopecia induced by various agents.

CONCLUSION

The mechanism of protection by CSA and its relationship to Pgp remain uncertain. The potential clinical applicability of this observation remains to be determined.

Chemotherapy-induced alopecia: new developments

Alopecia (hair loss) is one of the most physically and psychologically distressing side effects of cancer chemotherapeutic drugs. Since its first recognition as a common outcome to most chemotherapeutic agents, only a few trials have been reported, using either a method to temporarily reduce the scalp blood flow (scalp tourniquet or hypothermia) or vitamin E, with undocumented and variable efficacy. The lack of progress in the treatment and prevention of chemotherapy-induced alopecia is in part due to the lack of a reproducible animal model. In the past 2 years, we reported on the following observations: (1) treatment of 8-day-old rats with vidarabine (ara-C), doxorubicin, and cyclophosphamide consistently produced either total body alopecia (ara-C and cyclophosphamide) or alopecia confined to the head and proximal part of the back (doxorubicin); (2) Imuvert, a biologic response modifier derived from the bacterium Serratia marcescens, uniformly produced complete protection against alopecia induced by ara-C and doxorubicin but not that produced by cyclophosphamide; (3) the protective effect of Imuvert against chemotherapy-induced alopecia is mediated by a monocyte-mediated cytokine; and (4) this monocyte-derived cytokine is, possibly, interleukin-1. These observations constitute important progress in the understanding and prevention of chemotherapy-induced alopecia.

Phase II trial of 4'-0-tetrahydropyranyladriamycin (pirarubicin) in head and neck carcinoma

BACKGROUND

4'-0-tetrahydropyranyladriamycin (Pirarubicin, Meiji Seika (USA) Inc., New York, NY) may be less toxic than doxorubicin.

METHODS

A Phase II trial of Pirarubicin was done in 26 patients who had not previously had chemotherapy and who had measurable and incurable head and neck carcinoma. All patients received an intravenous bolus dose of 60 mg/m2 Pirarubicin in the first cycle without any prophylactic antiemetic. The cycles were repeated every 3 weeks. Based on tumor response, nadir counts, or complications of myelosuppression, the doses were escalated or de-escalated by 10 mg/m2, if necessary, in the second cycle to achieve mild leukopenia (3000-4000 leukocytes/microliters).

RESULTS

Leukopenia was mild, moderate (2000-2999 leukocytes/microliters), severe (1000-1999 leukocytes/microliters), and life threatening (less than 1000 leukocytes/microliters) in 13%, 31%, 27%, and 9% of the first two courses, respectively. The median interval to nadir leukopenia was 13 days (range, 7-21 days), with a median of 8 days (range, 5-13 days) to recover to normal. One patient with a leukocyte count of 800/microliters and an absolute granulocyte count (AGC) of 488/microliters died of sepsis 15 days after the first course. All patients had at least one course that resulted in leukopenia. One episode each of mild (100,000-150,000 platelets/microliters) and severe (25,000-49,999 platelets/microliters) thrombocytopenia occurred in the first two courses. Leukocyte, granulocyte, and platelet counts were not done routinely after the second cycle. Six patients who received four or more courses with cumulative doses of 310, 610, 340, 260, 660, and 550 mg/m2 had decrements of 0%, 1%, 7%, 10%, 12%, and 13%, respectively, in radionuclide left ventricular ejection fraction (LVEF). All other toxic effects were mild.

CONCLUSIONS

In the 24 patients with disease evaluable for response to Pirarubicin therapy, 1 had a complete response that lasted 5 months and 4 had a partial response of 2, 3, 6, and 8 months. The median survival time in patients with disease that responded to Pirarubicin therapy was 27 months; in patients with disease that did not respond to Pirarubicin therapy, the median survival time was 4 months, and in the total cohort, it was 5 months. Pirarubicin was well tolerated and was an active agent in head and neck squamous cell carcinoma.