A very rare case of bacteraemia in a 4-year-old girl with osteopetrosis with probable Leuconostoc lactis infection

Leuconostoc lactis (LLac) is a Gram-positive coccus of the family Leuconostocaceae . It can be found in a variety of vegetables and dairy products. LLac is an opportunistic pathogen with intrinsic resistance to vancomycin and teicoplanin. In this case report, we discuss a rare case of LLac-associated bacteraemia in a patient with osteopetrosis. A 4-year-old girl was admitted to the paediatric emergency department with acute fever without other signs. Blood culture revealed an infection with LLac. Using the streptococcus antibiogram, the isolate was resistant to vancomycin, teicoplanin, rifampicin and sulfamethoxazole-trimethoprim but sensitive to β-lactams, gentamicin, streptomycin, azithromycin, clarithromycin, lincomycin, clindamycin and erythromycin. The patient was treated with intravenous ceftriaxone and gentamicin, and subsequently with oral amoxicillin. After a favourable course, she was discharged from the hospital on the 10th day. The modes of transmission and physiopathology of LLac remain unknown. Factors associated with this infection include compromised immunity, previous antibiotic therapy especially with vancomycin, and application of a central venous catheter. In our patient, the risk factors for infection were pancytopenia and multiple transfusions used to treat bone marrow failure. The source of the bacteraemia could have been the cutaneous route, but it could also have been digestive due to the reservoir of the bacteria. LLac is known as an opportunistic bacterium. Further studies on its pathogenesis and other risk factors are needed to understand the true prevalence of this potentially fatal bacterium in compromised individuals, such as the case of our patient.

Use of traditional medicine and control of hypertension in 12 Sub-Saharan African countries: the EIGHT cross-sectional study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Camille Lassale is supported by a fellowship from “La Caixa” Foundation (ID 100010434). The fellowship code is LCF/BQ/PR21/11840003

Background

Use of traditional medicine (TM), is widespread in Sub-Saharan Africa as treatment option for a wide range of disease. We aimed to describe the profile of TM users and estimate the association with blood pressure (BP) and control of hypertension among hypertensive patients in a pan-African study.

Methods

We included 2128 participants in the cross-sectional EIGHT study, who attended an outpatient consultation in the cardiology departments of 12 Sub-Saharan African countries (Benin, Cameroon, Congo, Democratic Republic of the Congo, Gabon, Guinea, Côte d’Ivoire, Mauritania, Mozambique, Niger, Senegal, Togo). We describe patients’ characteristics according to TM use. We modelled the odds of uncontrolled hypertension, severe hypertension, and complications of hypertension by multivariable mixed logistic regression, and the linear association with systolic and diastolic BP by linear regression, all adjusted for age, sex, individual wealth index, adherence to hypertension conventional treatment, and country.

Results

A total of 512 (24%) of participants reported using TM, and this percentage varied drastically across countries from 10% in the Congo to 48% in Guinea. TM users were more likely to be male, with poor treatment adherence, reporting missing treatment because it is too expensive, and presenting any complication of hypertension. TM use was associated with greater odds of hypertension (OR=1.30; 95% confidence interval: 0.99, 1.70), severe hypertension (OR=1.34; 1.04, 1.74) and of any complication of hypertension (OR=1.27; 1.01, 1.60), driven by renal complication (OR=1.57; 1.07, 2.29). Use of TM was associated with a 3.87 mmHg higher systolic BP and 1.75 mm Hg higher diastolic BP compared to no use.

Conclusions

In this cross-sectional study of patients with hypertension in 12 Sub-Saharan African countries, we identified that the use of traditional medicine was associated with a poorer control of hypertension and more complications.

Assessment of deep learning algorithms to predict histopathological diagnosis of breast cancer: first Moroccan prospective study on a private dataset

Objective

Breast cancer is a critical public health issue and a leading cause of cancer-related deaths among women worldwide. Its early diagnosis and detection can effectively help in increasing the chances of survival rate. For this reason, the diagnosis and classification of breast cancer using Deep learning algorithms have attracted a lot of attention. Therefore, our study aimed to design a computational approach based on deep convolutional neural networks for an efficient classification of breast cancer histopathological images by using our own created dataset. We collected overall 328 digital slides, from 116 of surgical breast specimens diagnosed with invasive breast carcinoma of non-specific type, and referred to the histopathology department of the National Institute of Oncology in Rabat, Morocco. We used two models of deep neural network architectures in order to accurately classify the images into one of three categories: normal tissue-benign lesions, in situ carcinoma or invasive carcinoma.

Results

Both Resnet50 and Xception models achieved comparable results, with a small advantage to Xception extracted features. We reported high degrees of overall correct classification accuracy (88%), and sensitivity (95%) for detection of carcinoma cases, which is important for diagnostic pathology workflow in order to assist pathologists for diagnosing breast cancer with precision. The results of the present study showed that the designed classification model has a good generalization performance in predicting diagnosis of breast cancer, in spite of the limited size of the data. To our knowledge, this approach can be highly compared with other common methods in the automated analysis of breast cancer images reported in literature.

Percutaneous Transhepatic Radiologic Intervention of Biliary Complications following Liver Transplantation: A Single-center Experience

Background

Biliary complications are the leading cause of morbidity and mortality in patients undergo¬ing Liver Transplantation (LT). Post-biliary transplantation strictures (BSs) are a severe problem with a high risk of graft failure. However, management of these BSs has remained controversial, and consid¬erable variability has been reported in Percutaneous Transhepatic Radiological Interventions (PTRIs) related to broad differences in technical procedures.

Objective

This study aimed to evaluate the efficacy of percutaneous treatments in managing post-LT BSs in a center in Shiraz.

Methods

PTRIs including balloon dilatation, metallic stent, and internal or internal-external hand-made plastic stent insertion were done for 34 transplanted patients with BSs referring to the Interventional Radiology Unit of Shiraz Namazi Hospital. Technical success rate, patency rates, and complications were evaluated.

Results

The. In this study, 31 strictures were successfully treated without any significant difference between the anastomotic and non-anastomotic types of stricture (success rate: 91.2%). Based on the results, 12- , 24-, and 36-month primary patency rates were 90.1%, 84.5%, and 76.8%, respectively. The secondary patency rate was 100% at 12 and 24 months and 93.3% at 36 and 60 months. The rate of minor complica¬tions (mild cholangitis and hemobilia) was 6.4%, and no major complications were detected.

Conclusion

According to the findings, PTRI is an effective method for treating anastomotic and non-anas- tomotic strictures with a high success rate and low complications.

Inhibiteurs du système-rénine-angiotensine au cours de la covid-19 : protecteurs ou dangereux ?

La COVID-19 est liée de près au système rénine-angiotensine (SRA), puisque la pénétration du SARS-CoV-2 dans les cellules se fait via l’enzyme de conversion de l’angiotensine 2 (ACE2). L’ACE2 tire son nom d’une homologie de séquence avec l’angiotensin-converting enzyme1 (ACE1) qui clive l’Ang I en Ang II et est inhibée par les IEC qui en revanche n’inhibent pas l’ACE2. L’ACE2 clive l’Ang II en Ang (1-7) et l’Ang I en Ang (1-9), qui est ensuite convertie en Ang (1-7) par l’ACE1. L’Ang (1-7) s’oppose aux actions de l’Ang II. L’infection par le SARS-CoV-2 entraine une baisse de l’ACE-2, internalisé pour permettre au virus d’entrer dans les cellules. Ceci a pour conséquence une dérégulation de l’équilibre entre l’Ang II et l’Ang (1-7), entrainant une augmentation de l’inflammation, une endothélite avec une dysfonction endothéliale, responsable d’un phénotype vasculaire pro-thrombotique, et une fibrose tissulaire accélérée. Après une inquiétude initiale, il a été montré que les bloqueurs du SRA ne favorisent ni l’infection par le SARS-CoV-2, ni en aggravent le pronostic. Il est donc recommandé par toutes les sociétés savantes de ne pas arrêter les IEC ou ARA2 chez les patients atteints de COVID-19, en dehors des indications d’arrêt classiques (insuffisance rénale aigüe, déshydratation sévère, état de choc). Il reste à élucider un éventuel effet bénéfique chez les patients initialement sans indication pour un traitement par IEC ou ARA2 atteints de COVID-19.

[Congenital cutis laxa: a case study]

Les « cutis laxa » (CL) sont des affections rares du tissu élastique, caractérisées par une hyperlaxité cutanée. Elles peuvent être congénitales ou acquises. Les formes héréditaires constituent un groupe hétérogène par la gravité de leurs atteintes viscérales et leur mode de transmission. Trois groupes ont été individualisés sur la base de la transmission génétique: autosomique dominante, autosomique récessive et récessive liée à l'X. La sévérité des atteintes viscérales conditionne le pronostic des CL héréditaires qui peut être fatal à brève échéance en cas d'atteinte cardiaque ou pulmonaire. L'objectif de notre travail est de rappeler aux praticiens cette affection rarissime, ceci à travers l'observation d'un nourrisson suivi depuis son seizième jour de vie pour une détresse respiratoire.

P4554Central-acting aminopeptidase a inhibitors for new treatment of hypertension: from discovery to clinical trial

Acknowledgement/Funding

INSERM, College de France, ANR LabCom, Quantum Genomics

P4567Factors associated with poor adherence to medication among hypertensive patients in twelve low and middle income sub-Saharan countries

Background

Over the past few decades, the prevalence of hypertension has dramatically increased in Sub-Saharan Africa. Poor adherence has been identified as a major cause of failure to control hypertension. Scarce data are available in Africa.

Purpose

We assessed adherence to medication and identified socioeconomics, clinical and treatment factors associated with low adherence among hypertensive patients in 12 sub-Saharan African countries.

Methods

We conducted a cross-sectional survey in urban clinics of both low and middle income countries. Data were collected by physicians on demographics, treatment and clinical data among hypertensive patients attending the clinics. Adherence was assessed by questionnaires completed by the patients. Factors associated with low adherence were investigated using logistic regression with a random effect on countries.

Results

There were 2198 individuals from 12 countries enrolled in the study. Overall, 678 (30.8%), 738 (33.6%), 782 (35.6%) participants had respectively low, medium and high adherence to antihypertensive medication. Multivariate analysis showed that the use of traditional medicine (OR: 2.28, 95% CI [1.79–2.90]) and individual wealth index (low vs. high wealth: OR: 1.86, 95% CI [1.35–2.56] and middle vs. high wealth: OR: 1.42, 95% CI [1.11–1.81]) were significantly and independently associated with poor adherence to medication. In stratified analysis, these differences in adherence to medication according to individual wealth index were observed in low-income countries (p<0.001) but not in middle-income countries (p=0.17). In addition, 26.5% of the patients admitted having stopped their treatment due to financial reasons and this proportion was 4 fold higher in the lowest than highest wealth group (47.8% vs 11.4%) (p<0.001).

Conclusion

This study revealed the high frequency of poor adherence in African patients and the associated factors. These findings should be useful for tailoring future programs to tackle hypertension in low income countries that are better adapted to patients, with a potential associated enhancement of their effectiveness.

Figure 1. Percentage of patients according to their adherence level by patient wealth index stratified by country-level income.

1405Sequential nephron blockade with diuretics improves diastolic dysfunction in patients with resistant hypertension, a substudy a the PHARES trial

Introduction

Hypertension is one of the major contributors to cardiac diastolic dysfunction as observed in patients with heart failure and preserved ejection fraction. Different therapeutics strategies have been proposed to control blood pressure (BP) but their independent impact on cardiac function remain undetermined. In patients referred to our center for uncontrolled hypertension, we compared changes in cardiac parameters between two strategies consisting of sequential nephron blockade with intensive diuretics (NBD) or sequential renin angiotensin blockade (RAB).

Purpose

To determine evolution of BNP levels and echocardiographic (TTE) parameters of diastolic dysfunction according to strategies to control BP.

Methods

After 4-weeks treatment with 300mg irbesartan + 12.5mg hydrochlorothiazide + 5mg amlodipine, 140 patients with uncontrolled hypertension were randomized to either complete nephron blockade with sequential introduction of 25mg spironolactone, 20 to 40mg furosemide and 5mg amiloride (NBD group, n=74) or complete RAAS blockade with 5 to 10mg ramipril and 5 to 10mg bisoprolol (RAB group, n=67). BNP levels and TTE parameters according to ESC guidelines were assessed at baseline and week 12.

Results

BNP levels were not significantly different in the two groups at baseline (mean±SD 30.1±37.0pg/mL in NBD versus 22.6±22.3pg/mL in RAB, p=0.147) but significantly decreased in NBD at week 12 (20.1±22.7pg/mL in NBD versus 55.2±60.4pg/mL in RAB, p<0.0001). At week 12, only 9 (12%) patients in NBD presented BNP levels >35pg/mL versus 37 (55%) in RAB (p<0.001).

Concordantly, TTE parameters such as left ventricular end-diastolic diameter (mean±SD, 49±4mm in NBD and 52±5mm in RAB, p=0,004) and left atrial area (16.9±3.6cm2 in NBD and 19.1±3.7cm2 in RAB, p=0,003) improved significantly in NBD group. The proportions of patients presenting ≥2 criteria of diastolic dysfunction according to ESC guidelines in NBD and RAB group respectively were 31.2% and 19.3% at baseline vs. 3.1% and 32.2% after 12 weeks (p=0.001). In a multivariate analysis, NBD treatment was significantly associated with a decline in BNP levels (p<0.01) even after adjustment on daytime systolic BP lowering, heart rate, renal function, age and gender.

Conclusion

In patients with uncontrolled hypertension, intensive nephron blockade with sequential addition of diuretics improves markers of diastolic dysfunction independently of BP lowering.

Bothersome menopausal symptoms amongst postmenopausal Iranian women

OBJECTIVES

This study was undertaken to determine the impact of menopause on middle-eastern women.

METHODS

This was a cross-sectional study of 1520 women, aged 40-64 years, living in Sari, Northern Iran, recruited by multistage cluster sampling between October 2016 and April 2017. All women completed the Menopause Quality of Life Questionnaire (MENQOL) and Beck Depression Inventory-II (BDI-II).

RESULTS

Of all the women, 54.5% were perimenopausal or postmenopausal. The prevalences of any vasomotor symptom (VMS) and moderate-severely bothersome VMS were greatest for postmenopausal women aged <55 years (66.4%, 95% confidence interval (CI) 59.9-72.3% and 13.5%, 95% CI 9.6-18.6%, respectively). Having moderate-severe VMS was associated with moderate-severe depressive symptoms (adjusted odds ratio (AOR) 2.9; 95% CI 1.6-5.2; p < 0.001). Symptoms of vulvovaginal atrophy (VVA) were reported by 41.1% (95% CI 37.4-45.0%) of perimenopausal and postmenopausal women, with 22.9% (95% CI 19.8-26.3%) reporting their symptoms as moderate-severely bothersome. In women with moderate-severe VMS, the proportion with both moderate-severe depressive symptoms and moderate-severe VVA symptoms (12.1%) was four times that in women with no or mild VMS (3.3%) (p < 0.001).

CONCLUSION

One in seven perimenopausal and postmenopausal women has moderate-severely bothersome VMS and few women receive appropriate therapy. The reporting of moderate-severe VMS should alert clinicians to the likelihood of significant concurrent VVA and depressive symptoms.

Effects of breast milk on pain severity during muscular injection of hepatitis B vaccine in neonates in a teaching hospital in Iran

INTRODUCTION AND AIMS

Human breast milk is a natural pain reliever that contains endorphins. The aim of this study was to compare the effects of breast milk and powdered milk on pain severity after a muscular injection in 1-day-old neonates.

MATERIALS AND METHODS

One hundred neonates admitted to a teaching hospital in Ilam city, Iran, participated in a randomized clinical trial in 2016. One-day-old neonates were divided into four equal groups including: the control group (no feeding); the breastfed group; the bottle-fed mother's milk group and the powdered formula group. All infants received the hepatitis B vaccine by muscle injection in the same position of the thigh. The severity and duration of pain were compared among all groups during and after injection using the DAN scoring method (evaluation behavioral scale of acute pain in newborn infant).

RESULTS

One hundred neonates (57% boys) participated in this study. The mean±SD age and weight for participants were 39.15±0.05 weeks and 3016±28g, respectively. Crying duration either during or after the injection in breastfed infants was significantly shorter compared to the control and powdered formula groups (9.2±3.9 and 16±4.6s vs. 38.2±8.9 and 30.0±4.4s, respectively, during injection, P<0.003); (11.8±3.4 and 20.6±5.1s vs. 56.2±6.5 and 49.8±9.6s, respectively, after injection, P<0.006). There was also a significant relationship between behavioral variations and pain during injection (P<0.0001).

CONCLUSIONS

The results of this study showed that breastfeeding decreases pain severity during painful experiences in neonates, which is in accordance with other reports. Based on this finding, neonates are advised to be breastfed if a painful intervention such as vaccination is needed. The pain-relieving effect of breast milk could also be added to its other suitable effects.

Long-term evaluation of osteoarthritis sheep knee, treated with TGF-β3 and BMP-6 induced multipotent stem cells

BACKGROUND

Hyaline articular cartilage, which protects the bones of diarthrodial joints from forces associated with load bearing, frictions, and impacts has very limited capacities for self-repair. Over the years, the trend of treatments has shifted to regenerations and researchers have been on the quest for a lasting regeneration. We evaluated the treatment of osteoarthritis by chondrogenically induced ADSCs and BMSCs for a long time functional recovery.

METHODS

Osteoarthritis was induced at the right knee of sheep by complete resection of ACL and medial meniscus. Stem cells from sheep were induced to chondrogenic lineage. Test sheep received 5 mls single doses of 2 × 10⁷ autologous PKH26-labelled ADSCs or BMSCs, while controls received basal medium. Functional recovery of the knees was evaluated via electromyography.

RESULTS

Induced ADSCs had 625, 255, 393, 908, 409, 157 and 1062 folds increases of collagen I, collagen II, aggrecan, SOX9, cartilage oligomeric protein, chondroadherin and fibromodullin compare to uninduced cells, while BMSCs had 702, 657, 321, 276, 337, 233 and 1163 respectively; p = .001. Immunocytochemistry was positive for these chondrogenic markers. 12 months post-treatment, controls scored 4 in most regions using ICRS, while the treated had 8; P = .001. Regenerated cartilages were positive to PKH26 and demonstrated the presence of condensing cartilages on haematoxylin and eosin; and Safranin O. OA degenerations caused significant amplitude shift from right to left hind limb. After treatments, controls persisted with significant decreases; while treated samples regained balance.

CONCLUSIONS

Both ADSCs and BMSCs had increased chondrogenic gene expressions using TGF-β3 and BMP-6. The treated knees had improved cartilage scores; PKH26 can provide elongated tracking, while EMG results revealed improved joint recoveries. These could be suitable therapies for osteoarthritis.

Depressive symptoms and their risk factors in midlife women in the Middle East: a systematic review

INTRODUCTION

Women may experience different menopausal symptoms across different cultures around the world. The purpose of this study was to determine the prevalence and contributing factors of depression in midlife women in the Middle East.

METHODS

Electronic databases including PubMed, Medline, PsycINFO, CINAHL, Web of Science, SCOPUS, and Google scholar were searched. The quality of articles was assessed by using the risk of bias tool.

RESULTS

Sixteen articles were used for this review. The prevalence for depressive symptoms in perimenopausal women is higher than in premenopausal women. The overall data also suggest that depressive symptoms may be more prevalent in postmenopausal women than in premenopausal women. Studies reported sociodemographic, physical, psychological, cultural and sexual risk factors for depressive symptoms in middle-aged women. Risk of bias for a majority of the studies conducted in the Middle Eastern region on depression in midlife was moderate.

CONCLUSION

Consistent with other areas in the world, midlife women in the Middle East region are at higher risk for depression due to the presence of different factors. High-quality longitudinal studies of representative samples, using validated questionnaires, are needed to provide more accurate prevalence data and the association between menopause and menopausal symptoms in women in the Middle East.

Protective effects of Smyrnium cordifolium boiss essential oil on pentylenetetrazol-induced seizures in mice: involvement of benzodiazepine and opioid antagonists

Smyrnium cordifolium as a wild plant is used in traditional medicine in Iran for the treatment of anxiety and insomnia. The anticonvulsant effect of this plant has not been studied to date, therefore this study aimed to evaluate the anticonvulsant effects of its essential oil and curzerene on seizure. Essential oil of the Smyrnium cordifolium plant was prepared by the hydro-distillation method. Gas chromatography and gas chromatography-mass spectroscopy analysis of the essential oil revealed its main components. Anticonvulsant effects of Smyrnium cordifolium essential oil (SCEO) and curzerene were examined on mice using the pentylentetrazole model (PTZ). Flumazenil (2 mg/kg, i.p) and naloxone (5 mg/kg, i.p) were injected into the relevant groups of mice to realize the anticonvulsant mechanism of SCEO and curzerene, respectively. The main identified components of the plant were curzerene (65.26%), δ-Cadinene (14.39%) and γ-elemene (5.15%), which comprised approximately 85.28% of SCEO. The ED50 values of SCEO and curzerene in the PTZ model were 223±15 and 0.25±0.09 mg/kg, respectively. Curzerene at the dosage of 0.4 mg/kg prolonged the onset time of seizure and decreased the duration of seizure among treated group compared to the saline group. At the dosage of 0.4 mg/kg, seizure and mortality protection rates for the treated group were 100%. Flumazenil and naloxone could suppress the anticonvulsant effects of SCEO and curzerene. It seems that SCEO and curzerene are useful for the treatment of absence seizure and this effect may be related to their effects on GABAergic and opioid systems.

Interindividual variability in dabigatran and rivaroxaban exposure: contribution of ABCB1 genetic polymorphisms and interaction with clarithromycin

Essentials Rivaroxaban and dabigatran are substrates of the P-glycoprotein (P-gp) encoded by the ABCB1 gene. We tested the effect of ABCB1 polymorphisms and of a P-gp inhibitor on both drugs' pharmacokinetics. The ABCB1 genotype was not a clinically relevant determinant of both drugs' pharmacokinetics. Administration of P-gp inhibitors with dabigatran or rivaroxaban should be exercised with caution.

SUMMARY

Background The direct oral anticoagulants (DOACs) dabigatran and rivaroxaban are both substrates of the P-glycoprotein (P-gp) transporter, encoded by the ABCB1 gene. Rivaroxaban is metabolized by cytochrome P450 A4 (CYP3A4). Interindividual variability in DOAC exposure and frequent P-gp-associated drug-drug interactions have been described in patients. Objective To assess the influence of ABCB1 polymorphisms on the pharmacokinetics of dabigatran and rivaroxaban, associated or not with clarithromycin, a P-gp and CYP3A4 inhibitor. Methods Sixty healthy male volunteers, selected according to ABCB1 genotype (20 homozygous mutated, 20 heterozygous mutated, and 20 wild-type for haplotype 2677-3435), were included in this randomized, two-center, crossover study. All received sequentially a single dose of dabigatran etexilate (300 mg) and rivaroxaban (40 mg) associated or not with clarithromycin. Peak plasma concentration and area under the curve (AUC) were compared across the three ABCB1 genotypes. The effect of clarithromycin on dabigatran or rivaroxaban pharmacokinetics was assessed. Results Interindividual coefficients of variation for AUC were 77% for dabigatran and 51% for rivaroxaban. ABCB1 genotype did not significantly affect drug pharmacokinetics: AUC ratios between mutant-allele carriers and wild-type volunteers were 1.27 (95% confidence interval [CI] 0.84-1.92) and 1.20 (95% CI 0.96-1.51) for dabigatran and rivaroxaban, respectively. Clarithromycin coadministration led to a two-fold increase in both drugs' AUC, irrespective of ABCB1 genotype: ratios of geometric means were 2.0 (95% CI 1.15-3.60) and 1.94 (95% CI 1.42-2.63) for dabigatran and rivaroxaban, respectively. Conclusions ABCB1 genotype is not a significant determinant of interindividual variability in dabigatran and rivaroxaban pharmacokinetics. The levels of one drug did not predict the levels of the other. Coadministration of a P-gp/CYP3A4 inhibitor with dabigatran or rivaroxaban may warrant caution in patients at risk of overexposure.

Effect of fibrous separators on the performance of lithium–sulfur batteries

In this paper we systematically investigated effect of separator morphology on the performance of Li–S batteries.

Accessing targeted nanoparticles to the brain: the vascular route

The blood-brain barrier (BBB), formed by brain capillary endothelial cells, prevents the entry of several drug molecules to the brain, especially molecules hydrophilic in nature. Advanced drug carriers like nanoparticles share the potential to allow entry of therapeutic proteins and genetic molecules into the central nervous system (CNS). Taking a targeting approach by conjugating molecules acting as ligands or monoclonal antibodies with affinity for proteins expressed on the luminal side of brain capillary endothelial cells, the nanoparticles can be designed to enable transport into the brain endothelium, or perhaps even through the endothelium leading to blood to brain transport. Currently, the iron-binding protein transferrin or antibodies raised against the transferrin receptor denote the most feasible molecule for targeting purposes at the BBB. This manuscript reviews the targetability of nanoparticles to the brain capillary endothelial cells, how nanocarriers may enter and transfer through the brain endothelium, and how likely restraints denoted by the threedimensional mesh of the extracellular proteins forming the brain capillary basement membrane challenge the possibilities for enabling transport of large molecules through the BBB encapsulated in nanoparticles.

Decreased ovarian reserve: any new hope?

While diminished ovarian reserve (DOR) predicts decreased ovarian response to stimulation, it does not necessarily foretell about the fecundity cycle. According to Bologna's criteria laid down by the European Society of Human Reproduction and Embryology, old age, abnormal ovarian reserve tests such as antral follicle count (AFC) and anti-mullerian hormone (AMH) as well as prior suboptimal response to stimulation are the main factors representing DOR. Unfavorable response to maximal stimulation on two previous occasions may also represent DOR. Among the ovarian reserve tests, AMH and AFC are the most predictive values for DOR. Factors which may give rise to DOR include environmental factors, autoimmune or metabolic disorders, infections, genetic abnormalities, and iatrogenic causes (such as smoking, chemotherapy, radiation and gynecologic surgeries). Besides, studies have proposed endometriosis as a key contributor to DOR and hence emphasized on its proper management to prevent additional damages leading to compromised fertility. In summary, DOR is found to be a clinical challenge in the practice of fertility care with controversial countermeasures to prevent or treat the condition. Nevertheless, some promising measure such as: oocyte, embryo and tissue cryopreservation, ovarian transplantation, dietary supplementation and the transfer of mitochondria have offered hopes towards ameliorating the burden of DOR. This review attempts to discuss DOR from different perspectives and summarize some existing hopes in clinical practice.