Mosaic Turner Variant Adult Female Presenting with XO/XY Karyotype

Turner syndrome (TS) is the most frequently detected chromosomal abnormality in females caused by the partial or complete absence of second X chromosome. Due to varied phenotypical presentation, the diagnosis of TS can create a spectrum of clinical concerns related to morbidity and mortality. At least 10% of Turner females exhibit the presence of Y chromosome or Y-derived sequences. Patients with 45,X/46,XY mosaicism may have a phenotypic variation of the external genitalia and exhibit features ranging from normal male to ambiguous to female genitalia with features of TS. Turner mosaic variants with Y chromosome components have increased risk for gonadoblastoma. Although the risk is not exactly quantifiable, according to the 2016 Cincinnati International TS Meeting Clinical Practice guidelines, bilateral prophylactic gonadectomy is mandatory if Y chromosomal component is identified in mosaic Turner. We describe a rare case of an adult female patient detected as mosaic Turner variant with the presence of Y chromosome and reconfirmed by an aneuploidy FISH probe.

Unravelling the Impact of an Additional Sex Chromosome in an Adult Female

Women with Triple X syndrome (TXS) appear to be at increased risk for decreased ovarian reserve; however, available data are limited. We present an asyndromic adult female with features of recurrent pregnancy loss and decreased ovarian reserve detected with mosaic Triple X syndrome (TXS). The patient was initially evaluated by a low-cost peripheral blood (PB) conventional karyotyping using standard cytogenetic protocols. Interphase fluorescence in situ hybridisation was performed to confirm the diagnosis. Chromosomal microarray, which is a more expensive test, substantiated the presence of additional X chromosomes but failed to detect the presence of low level of mosaicism. Our case study emphasised the recommendation of performing a strategy-based cost-effective cytogenetic evaluation of all cases of decreased ovarian reserve or low anti-Müllerian hormone levels in a resource-constrained setting. It also highlighted the need for additional research to understand the natural history of ovarian function in TXS affected women throughout their lifespans.

Leveraging Structure-Based Drug Design to Identify Next-Generation MAT2A Inhibitors, Including Brain-Penetrant and Peripherally Efficacious Leads

Inhibition of the S-adenosyl methionine (SAM)-producing metabolic enzyme, methionine adenosyltransferase 2A (MAT2A), has received significant interest in the field of medicinal chemistry due to its implication as a synthetic lethal target in cancers with the deletion of the methylthioadenosine phosphorylase (MTAP) gene. Here, we report the identification of novel MAT2A inhibitors with distinct in vivo properties that may enhance their utility in treating patients. Following a high-throughput screening, we successfully applied the structure-based design lessons from our first-in-class MAT2A inhibitor, AG-270, to rapidly redesign and optimize our initial hit into two new lead compounds: a brain-penetrant compound, AGI-41998, and a potent, but limited brain-penetrant compound, AGI-43192. We hope that the identification and first disclosure of brain-penetrant MAT2A inhibitors will create new opportunities to explore the potential therapeutic effects of SAM modulation in the central nervous system (CNS).

Prevalence of polycystic ovarian syndrome, phenotypes and their ovulation response to sequential letrozole dose escalation among infertile women at a tertiary care centre in Southern India

Background:

Women with polycystic ovarian syndrome (PCOS) often have anovulatory infertility requiring ovulation induction with letrozole.

Aims:

This study aimed to determine the prevalence and phenotypic categorisation of infertile PCOS women and to assess ovulatory response and pregnancy rates of PCOS phenotypes with sequential letrozole dose escalation.

Study Setting and Design:

This was a prospective observational study.

Materials and Methods:

One hundred seventy-five infertile PCOS women were enrolled. One hundred fifty-six women received ovulation induction as per the protocol with sequential letrozole dose escalation in each subsequent cycle (2.5 mg, 5 mg and 7.5 mg). Responses were assessed by ovulation and/or pregnancy.

Statistical Analysis Used:

Descriptive statistics were elaborated by means, medians, frequencies and percentages. Group comparisons and linear correlation between two continuous variables were done using appropriate statistical tests.

Results:

Eighty-seven (49.7%) women were Phenotype A; 11 (6.3%) were Phenotype B; 20 (11.4%) were Phenotype C and 57 (32.6%) were Phenotype D in our study. After excluding the lost to follow up participants in each induction cycle, 33.3% (2.5 mg dose); 62.8% (5 mg dose) and 78.9% (7.5 mg dose) women responded to letrozole. A significant increase in ovulation to escalating letrozole doses was noted (Phenotype A: 35.1% to 2.5 mg, 53.7% to 5 mg and 72.7% to 7.5 mg; Phenotype B: 30% to 2.5 mg and 80% to 5 mg; Phenotype C: 35.3% to 2.5 mg and 87.5% to 5 mg and Phenotype D: 30.8% to 2.5 mg, 65.6% to 5 mg and 87.5% to 7.5 mg). Fifty-six of 156 (35.9%) infertile PCOS women achieved pregnancy; increase in pregnancy rates with escalated doses of letrozole was noted.

Conclusion:

All PCOS phenotypes show a similar response to escalating doses of letrozole. The role of phenotypic sub-categorisation for variable response to letrozole as an ovulation-inducing agent is uncertain.

Selective Vulnerability to Pyrimidine Starvation in Hematologic Malignancies Revealed by AG-636, a Novel Clinical-Stage Inhibitor of Dihydroorotate Dehydrogenase

Agents targeting metabolic pathways form the backbone of standard oncology treatments, though a better understanding of differential metabolic dependencies could instruct more rationale-based therapeutic approaches. We performed a chemical biology screen that revealed a strong enrichment in sensitivity to a novel dihydroorotate dehydrogenase (DHODH) inhibitor, AG-636, in cancer cell lines of hematologic versus solid tumor origin. Differential AG-636 activity translated to the in vivo setting, with complete tumor regression observed in a lymphoma model. Dissection of the relationship between uridine availability and response to AG-636 revealed a divergent ability of lymphoma and solid tumor cell lines to survive and grow in the setting of depleted extracellular uridine and DHODH inhibition. Metabolic characterization paired with unbiased functional genomic and proteomic screens pointed to adaptive mechanisms to cope with nucleotide stress as contributing to response to AG-636. These findings support targeting of DHODH in lymphoma and other hematologic malignancies and suggest combination strategies aimed at interfering with DNA-damage response pathways.

Characteristics of Empty Follicular Syndrome during In vitro Fertilization Embryo Transfer and its Association with Various Etiologies in Comparatively Young Patients

Background:

Nearly 0.6%–7% of patients undergoing in vitro fertilization embryo transfer (IVF ET) will not be able to yield any oocyte despite successful ovarian stimulation and this condition is called as empty follicular syndrome (EFS). EFS is a dreadful situation for clinicians as well as patients, seems to be an unavoidable clinical condition despite a proper ovarian stimulation.

Materials and Methods:

This was a retrospective observational study conducted at a tertiary hospital; 1103 patients who underwent IVF ET between January 2016 and May 2017 were included in the study.

Study Outcome:

To estimate the incidence of empty follicle syndrome (EFS) and to study the associated factors.

Results:

There were 53 (4.8%) cases of EFS out of 1103 cycles of IVF ET; 43 (3.9%) cases were false EFS and 10 (0.9%) cases were genuine EFS. Mean age of EFS group and oocyte retrieved group was 30.17 years and 29.12 years respectively. Recurrence rate of EFS during the next IVF cycle was 36.8%. Decreased ovarian reserve was associated with an increased chance of EFS (54.7%) with a recurrence rate as high as 57%.

Conclusion:

The incidence of EFS is not an uncommon clinical scenario; it depends upon ovarian reserve to a great extent. Young age is not immune for the occurrence of EFS as there is a similar incidence in comparatively younger age group in our study. EFS is seen in all etiological groups of infertility, but only respite is that there is a chance of about 63.2% oocyte retrieval during repeat IVF cycle.

A chemical biology screen identifies a vulnerability of neuroendocrine cancer cells to SQLE inhibition

Aberrant metabolism of cancer cells is well appreciated, but the identification of cancer subsets with specific metabolic vulnerabilities remains challenging. We conducted a chemical biology screen and identified a subset of neuroendocrine tumors displaying a striking pattern of sensitivity to inhibition of the cholesterol biosynthetic pathway enzyme squalene epoxidase (SQLE). Using a variety of orthogonal approaches, we demonstrate that sensitivity to SQLE inhibition results not from cholesterol biosynthesis pathway inhibition, but rather surprisingly from the specific and toxic accumulation of the SQLE substrate, squalene. These findings highlight SQLE as a potential therapeutic target in a subset of neuroendocrine tumors, particularly small cell lung cancers.

Structure and inhibition mechanism of the catalytic domain of human squalene epoxidase

Squalene epoxidase (SQLE), also known as squalene monooxygenase, catalyzes the stereospecific conversion of squalene to 2,3(S)-oxidosqualene, a key step in cholesterol biosynthesis. SQLE inhibition is targeted for the treatment of hypercholesteremia, cancer, and fungal infections. However, lack of structure-function understanding has hindered further progression of its inhibitors. We have determined the first three-dimensional high-resolution crystal structures of human SQLE catalytic domain with small molecule inhibitors (2.3 Å and 2.5 Å). Comparison with its unliganded state (3.0 Å) reveals conformational rearrangements upon inhibitor binding, thus allowing deeper interpretation of known structure-activity relationships. We use the human SQLE structure to further understand the specificity of terbinafine, an approved agent targeting fungal SQLE, and to provide the structural insights into terbinafine-resistant mutants encountered in the clinic. Collectively, these findings elucidate the structural basis for the specificity of the epoxidation reaction catalyzed by SQLE and enable further rational development of next-generation inhibitors.

Correlation between Serum Progesterone Level on the Day of Ovulation Trigger During In vitro Fertilization and Its Effect on Treatment Outcome

Background:

Premature luteinization (PL) is defined as a premature rise in serum progesterone concentration on or before the day of ovulation trigger with human chorionic gonadotropin. The incidence of PL varies between 5% and 30% during in vitro fertilization and embryo transfer (IVF-ET).

Materials and Methods:

The prospective observational study comprising 380 patients undergoing IVF-ET. Blood samples were collected for serum progesterone level estimation on the day of ovulation trigger. Ovum pickup was done 36 h later and serum progesterone levels were correlated with IVF-ET outcome.

Study Outcome:

To correlate serum progesterone level on the day of ovulation trigger during IVF and its effect on treatment outcome.

Results:

Mean serum progesterone level in the positive pregnancy group and negative pregnancy group was 0.892 ± 0.752 ng/ml and 0.91 ± 0.688 ng/ml, respectively (P = 0.961). The overall incidence of PL was 12.8% with 12.7% and 13.6% in the agonist and antagonist protocol respectively (P = 0.9001). PL incidence was 13.5% and 13.4% in positive pregnancy and negative pregnancy group (P = 0.223).

Conclusion:

PL has been associated with 12.8% of the IVF cycles. There was no statistically significant difference observed in the incidence of PL between different IVF stimulation protocols. PL does not seem to affect IVF outcome.

A study on cervical cancer screening in asymptomatic women using Papanicolaou smear in a tertiary care hospital in an urban area of Mumbai, India

Introduction:

Cervical cancer is the most common cause of death among women in developing countries. Among the Indian women, cervical cancer is the most common genital tract cancer. Papanicolaou (Pap) smear test plays a vital role in the detection of cervical cancer even in its premalignant condition. The aim of this study to evaluate the role of Pap smear in detecting premalignant and malignant lesions as well as nonneoplastic lesions of the cervix and to determine the prevalence of various lesions.

Materials and Methods:

We screened 1100 women in the age group of 21–65 years who attended our medical camp organized by the hospital in outdoor patient department. All women was willing to give consent for screening by Pap smear test were included.

Results:

Of 1100 cases, majority of the cases were benign comprising negative for intraepithelial neoplasia (NILM) of about 581 (52.8%) cases, 203 (18.4%) inflammatory, atypical squamous cells of undetermined significance 45 (4%), low-grade squamous intraepithelial lesion (LSIL) in 75 (6.8%), and high-grade squamous intraepithelial lesion (HSIL) in 74 (6%) women. Overall sensitivity and specificity for the detection of LSIL were 75.8% and 94.6% and those for the detection of HSIL were 68.9% and 98.6%.

Conclusions:

Pap smear test is a very easy, noninvasive, useful, simple, safe, and very economical tool to detect preinvasive cervical epithelial lesions. It is evident and proven that every woman above the age of 30–35 years must be subjected to cervical screening and this must be continued even in the postmenopausal period.

Diagnostic Office Vaginohysteroscopy in Evaluation of Infertility Prior to IVF: A Retrospective Analysis of 1000 Cases

AIM

The aim of this study was to analyze the utility of routine use of diagnostic office vaginohysteroscopy in the evaluation of uterine cavity in infertility patients prior to IVF-ET.

MATERIALS AND METHODS

We conducted a retrospective analysis of 1000 women who had undergone routine diagnostic office vaginohysteroscopy as an institutional protocol in the evaluation of infertility prior to IVF-ET cycle at a tertiary care hospital. They were divided into two groups: primary infertility (group I) and secondary infertility (group II). The primary outcome was the finding of an abnormal uterine cavity (congenital abnormality vs acquired abnormality).

RESULTS

One thousand women underwent routine diagnostic office vaginohysteroscopy in the evaluation of infertility prior to IVF-ET. There were no intraoperative or postoperative complications. Vaginohysteroscopy revealed an abnormal uterine cavity in 13.8% (1000 patients) of women. Primary infertility group (I) had 13.19% (811 patients), and secondary infertility group (II) had 16.4% (189 patients) abnormal uterine cavities.

CONCLUSION

Diagnostic office vaginohysteroscopy has a definite role in the uterine cavity evaluation in infertility patients prior to IVF, but routine use should not be recommended considering the low incidence of abnormal uterine cavity findings. Moreover, the majority of these uterine cavity abnormalities can be detected by less invasive tests such as HSG, TVS, SSG and 3D ultrasound.

SAR studies of non-zinc-chelating MMP-13 inhibitors: improving selectivity and metabolic stability

SAR studies to improve the selectivity and metabolic stability of a class of recently discovered MMP-13 inhibitors are reported. Improved selectivity was achieved by modifying interactions with the S1' pocket. Metabolic stability was improved through reduction of inhibitor lipophilicity. This translated into lower in vivo clearance for the preferred compound.

Measurement of tissue hardness: can this be a method of diagnosing compartment syndrome noninvasively in children?

In order to assess the feasibility of using the measurement of tissue hardness as a method of diagnosing compartment syndrome noninvasively in children, a simple hand-held device to measure tissue hardness was fabricated. The relationship between hardness and compartmental pressure was studied in an experimental model and in three fresh amputated lower limbs. Normal tissue hardness of the forearm was measured in 189 children and 20 adults to identify the factors that influence normal tissue hardness. The reproducibility of measurement of tissue hardness was assessed on the experimental model, on the amputated limbs and in normal individuals. Experimental data from this study suggest that there is a nonlinear relationship between intracompartmental pressure and tissue hardness. The study also shows that tissue hardness can be measured reproducibly in the forearm of children with the device. Several factors influence tissue hardness such as the age of the child, the site of measurement on the limb, the hand dominance and active muscle contraction. These factors may affect the specificity of this measure as a screening tool for diagnosing compartment syndrome. Further refinement of the measuring device and well designed clinical trials are needed to establish whether compartmental syndrome can be diagnosed reliably by measuring tissue hardness noninvasively.