Pregnancy outcomes for women with pre-existing renal disease and the role of a dedicated joint maternal medicine and renal clinic: A retrospective cohort study

OBJECTIVE

To reaffirm the value of a joint obstetric and renal clinic on obstetric outcomes in patients with high-risk pregnancies due to chronic kidney disease (CKD).

METHODS

This was a retrospective cohort study of patients who attended the clinic between 2005 and December 2021. The hospital is a regional tertiary unit for renal medicine and a maternal medicine hub. The data included all women with pre-existing renal conditions who were cared for in a dedicated renal and obstetric clinic. Datasets were extracted from hospital notes, the renal database, clinical data and maternity electronic health records. The data analyzed included pre-existing renal conditions, biochemical parameters related to the renal condition, pregnancy outcomes included miscarriages, gestation, mode of delivery, postpartum hemorrhage (PPH), loss, birth weight and neonatal admission.

RESULTS

The results were as follows: Lupus nephritis: four term deliveries; three had pre-eclampsia; two PPH and two miscarriages. Four estimated glomerular filtration rates (eGFRs) returned to baseline levels within 12 months. With regard to IgA nephropathy there were five live births, four term deliveries, two pre-eclampsia (PE) and five cesarean sections (CS). All eGFRs returned to baseline within 12 months. With regard to patients with adult polycystic kidney disease (APKD), there were six live births, two had pre-eclampsia and there were five term vaginal deliveries.

CONCLUSION

Patients with lupus nephritis, APKD, and IgA demonstrated a higher incidence of adverse pregnancy outcomes as compared with our local pregnant population. Our findings reflect those of larger studies and support the role of combined renal/obstetric clinics. More research and larger scale studies are needed into specific CKD conditions and their outcomes.

Managing couples with recurrent miscarriage: A narrative review and practice recommendations

There is significant variation in practice when managing couples with recurrent miscarriage (RM), with guidelines differing on the definition of RM, recommended investigations, and treatment options. In the absence of evidence-based guidance, and following on from a paper by the authors-FIGO Good Practice Recommendations on the use of progesterone in the management of recurrent first-trimester miscarriage-this narrative review aims to propose a global holistic approach. We present graded recommendations based on best available evidence.

Tamsulosin Versus Mirabegron in Relieving Ureteric Stent-Related Symptoms: A Prospective, Double-Blinded, Randomized Controlled Trial

Introduction Alpha-adrenergic blockers like tamsulosin are widely used in the treatment of stent-related symptoms due to ureteric stents. Recently, mirabegron has emerged as a potential alternative. So, our study aimed to compare the effect of mirabegron and tamsulosin on ureteric stent-related morbidity. Methods In this randomized controlled study, 80 patients undergoing uncomplicated ureteroscopic lithotripsy with double J stenting for ureteric stones were enrolled. They were divided into two groups: Group A (n=40) received mirabegron (25mg) and Group B (n=40) received tamsulosin (0.4mg). Outcomes were assessed using the Ureteral Stent Symptom Questionnaire (USSQ), International Prostate Symptoms Score (IPSS), and the visual analog pain scale. The t-test and the Chi-square test were utilized to study the efficacy of the interventions across both groups. Results The USSQ urinary symptom score (25.5 vs 33.45; p < 0.001) and body pain score (16.15 vs 26.02; P < 0.001) were significantly lower in the mirabegron group. However, the general health score (17.0 vs 17.28; p = 0.62) and work performance score (7.6 vs 8.0; p = 0.28) did not show a significant difference. The storage symptom score was significantly lower in the mirabegron group (3.98 vs 5.1; p = 0.001). Furthermore, the mirabegron group reported a better quality of life score (2.18 vs 3; p < 0.001). Conclusion Mirabegron has been shown to reduce urinary symptoms associated with ureteric stents and also results in a better quality of life when compared with tamsulosin. However, large-scale, prospective, multicentric studies are further required to holistically evaluate and comprehend the beneficial effects of mirabegron on stent-related morbidity.

Role of Posterior Acoustic Shadow Width in Ultrasound in Determining Stone Size in Urolithiasis

Introduction Ultrasound (US) is frequently the initial diagnostic tool for urolithiasis, though computed tomography (CT) remains the imaging modality of choice. However, due to potential overestimations, the accuracy of US in gauging stone size has been a point of contention. This study aims to compare the accuracy of stone size measurements in US, specifically evaluating the utility of the posterior acoustic shadow (PAS) width, against the CT measurements. Methods We conducted a cross-sectional study where 120 adult patients (aged >18 years) with confirmed urolithiasis through CT participated. Stone sizes were assessed via both CT and US, with the PAS width also being measured in the latter. Statistical analysis compared stone size discrepancies between both CT and US measurement techniques. Results The study enrolled 73 males and 47 females with various stone locations. The average stone sizes were 15.93 ± 4.59 mm (CT), 18.60 ± 4.80 mm (US), and 16.69 ± 4.61 mm (PAS width). There was a mean difference of 2.67 mm (p < 0.0001) between CT and US sizes, whereas the difference between the PAS width and CT sizes was only 0.75 mm (p = 0.203). Stone size miscalculation by US was 16.77%, whereas it was only 4.77% for PAS width. Conclusion US tends to significantly overestimate stone size when compared to CT. Conversely, the measurement of the PAS width in US presents a more aligned estimation to CT outputs. Integrating PAS width into routine US reporting can enhance the accuracy of stone size estimation, optimizing urolithiasis management and patient counseling.

Chengai Nomogram: A Comprehensive Study of Uroflow Parameters and Characteristics in Healthy Adult Males From South India

Introduction Uroflowmetry is a widely accepted non-invasive diagnostic modality used in the evaluation of lower urinary tract dysfunction. While various nomograms have been established for different populations and races, there has been a lack of studies that focus on the South Indian populations. Consequently, the objective of the study was to investigate the urinary flow parameters in a healthy adult male South Indian population using uroflowmetry and identify the variations in flow rates. Additionally, the study sought to assess the influence of age and voided volume (VV) on flow rates and create a representative nomogram. Methods A total of 500 uroflowmetry tests were prospectively performed on healthy adult males. The gravimetric method was utilized for uroflowmetry. Flow charts and parameters were analyzed for correlation and linear regression models, and statistical calculations were employed to generate uroflow nomograms. Results The mean age of the participants was 37.77±9.91 years. The mean values for maximum flow rate (Qmax), average flow rate (Qavg), and VV were 23.42±6.64 mL/s, 11.71±3.77 mL/s, and 229.90±59 mL, respectively. A significant correlation was observed between flow rates (Qmax and Qavg) and VV, which indicated that increased VV leads to higher flow rates. Additionally, a significant negative correlation between the flow rates and age was noted. Conclusion The findings provide insight into the uroflow parameters of the South Indian adult male population and contribute to the development of nomograms, establishing normal reference ranges for flow rates across varying VVs. As a tribute to the hospital and the study participants, the nomogram was named the "Chengai Nomogram."

A Comparison Between Silodosin and Tamsulosin for Medical Expulsive Therapy of Distal Ureteric Calculus

INTRODUCTION

Medical expulsive therapy (MET) is an established treatment option for distal ureteric stones. Tamsulosin, a selective alpha-1 blocker, has been used for MET with good results, while silodosin, a more selective alpha-1a blocker, is more effective than tamsulosin for MET. Thus, this study aimed to compare the efficacy of silodosin with tamsulosin.

METHODS

This prospective randomized study was conducted at the Department of Urology, Government Chengalpattu Medical College Hospital, Tamil Nadu, India. Eighty patients who presented with ureteric colic and were radiologically diagnosed with distal ureteric calculus of size <10mm were included. Participants in the silodosin group received tablet silodosin 8mg OD until the passage of the stone, not more than two weeks, and analgesics as per demand. And participants in the tamsulosin group received tablet tamsulosin 0.4mg OD until the passage of the stone, not more than two weeks, and analgesics as per demand.

RESULTS

A total of 80 patients were included in the study. Forty patients in the silodosin group and forty patients in the tamsulosin group were included. In the silodosin group, out of 40 patients, 38 expelled the calculus. In the tamsulosin group, out of 40 patients, 28 expelled the calculus. The silodosin group had a significantly higher rate of expulsion, with a p-value of 0.003. Stone expulsion time was shorter in the silodosin group when compared with the tamsulosin group (10.15 vs. 13.4 days). Analgesic usage during medical expulsive therapy was lower in the silodosin group (5.68 vs. 8.4). We observed significant differences in comparing the outcome, stone expulsion time, and analgesic requirement between the silodosin and tamsulosin groups. We observed no significant difference between the groups for age-wise and gender-wise comparisons. Furthermore, non-expulsion of calculus in four patients and pain in eight patients were the reasons for intervention in the tamsulosin group. The reason for intervention in the silodosin group was the non-expulsion of calculus in two patients.

CONCLUSION

Using silodosin for MET of distal ureteric calculus, we found to have a better stone expulsion rate, early expulsion time, and reduced analgesic requirement.

An Unusual Case of Inflammatory Pseudotumor of Paratesticular Region

Inflammatory pseudotumors (IPT) are rare benign tumors that can develop in various regions of the body. Notably, IPTs have been uncommonly described in the Genitourinary system including occasional reports from the paratesticular region. This origin from this area is significant because of the ambiguity in differentiating this pathology from malignant lesions arising from the testis. We would like to report a case of a 32-year-old male who presented with a painless left scrotal mass for two years. Ultrasonography was done followed by a radical orchidectomy and histopathological examination of the excised lesion showed features suggestive of inflammatory pseudotumor from the paratesticular region. We feel this case merits reporting owing to the rarity of IPT occurring in the paratesticular region and the essential need for increased awareness and differentiation from the malignant counterparts.

Beyond the Breaking Point: A Unique Case Report of a Penile Fracture With a Distal Urethral Injury

A penile fracture is a rare urological emergency, often resulting from blunt trauma to the erect penis. This case report describes a 30-year-old male who presented with penile swelling during sexual intercourse, raising suspicion of a penile fracture. The patient underwent surgical exploration, revealing a rent in the tunica albuginea and an additional laceration in the corpus spongiosum with the Foley catheter exposed. The lacerations were closed using Vicryl sutures over a Foley catheter. The patient experienced an uneventful postoperative course, and follow-up assessments showed satisfactory healing of the urethra. This case underlines the need for clinicians to consider the possibility of urethral involvement in cases of penile fracture, as timely surgical intervention can prevent long-term sequelae such as erectile dysfunction and urethral strictures. By sharing this case, we hope to further emphasize the need for vigilance and swift action when faced with potential penile fractures in clinical practice.

Maternal and perinatal outcomes of dichorionic diamniotic twins in women after spontaneous and assisted conception

OBJECTIVE

Twin pregnancies have been shown to be associated with numerous maternal and perinatal complications. Published data shows conflicting reports on whether assisted conception influences these risks. The purpose of this study was to assess the impact of mode of conception on maternal and perinatal outcomes of dichorionic diamniotic twin pregnancies.

STUDY DESIGN

This was a large retrospective study of 497 women with dichorionic diamniotic twins that were conceived spontaneously or with assisted conception in a single centre over a 10-year period.

RESULTS

This study showed no significant difference in mode of delivery (OR 1.40 95% CI 0.88 - 2.24), need for admission to neonatal unit (OR 1.56 95% CI 0.88-2.77), or preterm births between dichorionic twin pregnancies conceived following assisted conception when compared to spontaneously conceived dichorionic twin pregnancies. Women who conceived twins by assisted conception that did not have an elective caesarean section were more likely to go into spontaneous labour than have an induction of labour (OR 0.54 95% CI 0.3 - 0.99). They also had a higher chance of having an estimated blood loss of more than 1L than women who conceived naturally (OR 1.70 95% CI 1.06 - 2.73).

CONCLUSIONS

In the case of dichorionic twins, this study showed that assisted conception does not seem to be associated with adverse obstetric and perinatal outcomes when compared with spontaneous conception. These results should be considered reassuring to women undergoing assisted conception, and may assist clinicians when counselling patients for assisted conception treatment. Further research is needed to assess the impact of assisted conception on postpartum blood loss.

Abstract 2851: A rapid and an efficient method to remove unreacted small-molecules using a versatile resin packed in a convenient Spin-and-Go format

A rapid and an efficient method to remove unreacted small-molecules using a versatile resin packed in a convenient Spin-and-Go format. Removal of unreacted or residual compounds in the sample-preparation workflow is a key success factor for downstream analysis and processing of biomolecules. For example, during sample preparation of biomolecules such as proteins or nucleic acids, there is often a need to label the biomolecules with dyes, affinity tags, radioactive labels, and mass tags. In other instances, there is a need to chemically modify biomolecules such as to reduce, oxidize, methylate, etc. During these treatments, some amount of the labeling or chemical agent remains in the sample as an unreacted label/chemical. These unreacted small molecules can cause several issues during downstream analysis or use of the biomolecule. For example, free unreacted fluorescent dyes after bioconjugation of protein cause non-specific binding of free-dye resulting in high background issues during fluorescent imaging. Commonly used clean-up methods following sample preparation, such as dialysis, are tedious and lengthy with multiple buffer exchanges sometime resulting in loss of protein due to aggregation. Alternatively, size-exclusion chromatography requires expensive instrumentation in addition to lengthy set up time. We have developed the Thermo Scientific™ PierceTM Dye and Biotin Removal Spin Columns, a novel resin that is packed in an easy to use “Spin and Go” format of varying spin column sizes (0.5 mL, 2mL, 5 mL and 10 mL) to accommodate a range of sample volumes (100 uL- 4 mLs). The resin is highly specialized to produce exceptional protein recovery and can be used effectively to remove 4 different class of small molecules: non-conjugated fluorescent dyes, biotinylation reagents, reducing agents, and crosslinkers. It is a multimodal resin with size exclusion properties and proprietary surface chemistry that allows removal of the above-mentioned small molecules, while the size exclusion property allows for the biomolecule to be efficiently recovered. Our results indicate efficient dye removal and protein recovery from fluorescent conjugated antibodies. The results also indicate removal of reducing agents such as TCEP at a concentration as high as 25 mM from protein samples, while recovering &gt;90% of the added protein. Results also indicate &gt;90% removal of biotinylated molecules and crosslinkers from Protein samples with &gt;90% protein recovery. Our results show that the efficiency and binding capacity for removal of small molecules using this resin is better than any resin in the market. This is exemplified by immunofluorescent analysis of ZO-1 monoclonal antibody conjugated Alexa Fluor™ 488 which was purified using PierceTM Dye and Biotin Removal Spin columns and shows high intensity and lesser background in Caco-2 cells than the non-purified conjugate.

Citation Format: Deven Kent Etnyre, Ramesh Ganapathy, Marie Nlend, Chris Etienne, Atul M. Deshpande. A rapid and an efficient method to remove unreacted small-molecules using a versatile resin packed in a convenient Spin-and-Go format [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2851.

Successful versus unsuccessful instrumental deliveries-Predictors and obstetric outcomes

OBJECTIVE

The purpose of this study was to examine instrumental births in a multi-ethnic population to assess the factors associated with success and failure in instrumental births.

STUDY DESIGN

This was a large retrospective study of 7954 women that underwent either a successful or an unsuccessful instrumental delivery in a single centre over a 10 year period.

RESULTS

Logistic regression analysis showed that women with a BMI of more than 30, attempted Forceps delivery, having a prolonged second stage, Macrosomia (birth weight more than 4 kg) and a senior obstetrician performing the procedure increase the risk of a failed instrumental delivery. While age, ethnicity, type of anaesthesia, use of oxytocin or induction of labour did not provide a significant outcome. Results also showed that patients are likely to bleed more and neonates need admission in failed instrumental deliveries when compared to successful attempts.

CONCLUSION

This is one of a very few studies comparing a large cohort of successful instrumental births with unsuccessful attempts at an instrumental birth. The rate of failure has been difficult to reduce, and the analysis shows that many of the factors associated with failure are not modifiable in labour. We should consider studies with use of ultrasound assessment before application or consideration of instruments to facilitate birth. This will allow us to objectively come up with an algorithm to predict success or failure and consider if it is suitable to attempt an instrumental birth. Our data can be used to counsel women about the difficulty in predicting success and failure rate of instrumental births.

Mechanism of Action of G-Quadruplex-Forming Oligonucleotide Homologous to the Telomere Overhang in Melanoma

T-oligo, a guanine-rich oligonucleotide homologous to the 3'-telomeric overhang of telomeres, elicits potent DNA-damage responses in melanoma cells; however, its mechanism of action is largely unknown. Guanine-rich oligonucleotides can form G-quadruplexes (G4), which are stabilized by the hydrogen bonding of guanine residues. In this study, we confirmed the G4-forming capabilities of T-oligo using nondenaturing PAGE, nuclear magnetic resonance, and immunofluorescence. Using an anti-G-quadruplex antibody, we showed that T-oligo can form G4 in the nuclei of melanoma cells. Furthermore, using DNase I in a nuclease degradation assay, G4-T-oligo was found to be more stable than single-stranded T-oligo. G4-T-oligo had decreased antiproliferative effects compared with single-stranded T-oligo. However, G4-T-oligo has similar cellular uptake as single-stranded T-oligo, as shown by FACS analysis. Inhibition of JNK, which causes DNA damage-induced apoptosis, partially reversed the antiproliferative activity of T-oligo. T-oligo also inhibited mRNA expression of human telomerase reverse transcriptase, a catalytic subunit of telomerase that was reversed by JNK inhibition. Furthermore, two shelterin complex proteins TRF2/POT1 were found to be up-regulated and bound by T-oligo, suggesting that T-oligo may mediate dissociation of these proteins from the telomere overhang. These studies show that T-oligo can form a G-quadruplex and that the antitumor effects of T-oligo may be mediated through POT1/TRF2 and via human telomerase reverse transcriptase inhibition through JNK activation.

Gestational diabetes-Predictors of response to treatment and obstetric outcome

OBJECTIVE

Evaluate patient characteristics that are predictors of treatment response and outcomes in gestational diabetes STUDY DESIGN: Retrospective cohort of 265 women with gestational diabetes treated with diet/metformin and/or insulin in a single centre over 2 years.

RESULTS

Multinomial logistic regression showed that (after adjusting for age and ethnicity) women who were of normal weight were more likely to be on diet and women who were obese were more likely to be on metformin or metformin and insulin(p=0.014). Women who were obese were twice more likely to have labour induced than those with normal weight. Onset of labour was the only parameter significantly associated with a treatment modality among the three groups (p<0.001). There was no difference in the incidence of large for gestational age, neonatal admission, shoulder dystocia or still birth between the three groups.

CONCLUSIONS

Maternal BMI appears to be the only parameter that is predictive of need for treatment with metformin/insulin and the modality of treatment does not have an effect on maternal and neonatal outcomes.

Echocardiographic Structure and Function in Hypertensive Disorders of Pregnancy

Background—

Echocardiography is commonly used to direct the management of hypertensive disorders in medical patients, but its application in pregnancy is unclear. Our objective was to define the use of echocardiography in pregnancies complicated by gestational hypertension (GH) and preeclampsia.

Methods and Results—

We performed a systematic review of articles using an electronic search of databases from inception to March 2015, prospectively registered with PROSPERO (CRD42015015700). Eligible studies included pregnant women with GH or preeclampsia, evaluating left ventricular structure and function using echocardiography. The search strategy identified 36 studies, including 745 women with GH and 815 women with preeclampsia. The populations were heterogeneous with respect to clinical characteristics, parity, and risk of bias. Increased vascular resistance and left ventricular mass were the most consistent findings in GH and preeclampsia. Differentiating features from normal pregnancy were left ventricular wall thickness of ≥1.0 cm, exaggerated reduction in E/A, and lateral e′ of <14 cm/s. There was disagreement between studies with regard to cardiac output because of the timing of echocardiography, although reduced stroke volume was an indicator of adverse prognosis. Diastolic dysfunction and left ventricular remodeling are most marked in severe and early-onset preeclampsia, but are also markers of preeclampsia before clinical manifestation, and are associated with adverse outcomes.

Conclusions—

Echocardiography is a valuable tool to stratify risk and can guide management and counseling in the preclinical and clinical phases of GH and preeclampsia. Changes in cardiac function and morphology are recognizable at an asymptomatic early stage and correlate with disease severity and adverse outcomes.

Remote monitoring of blood pressure to reduce the risk of preeclampsia related complications with an innovative use of mobile technology

OBJECTIVE

Assess suitability of remote self-monitoring of blood pressure with an innovative use of technology in detecting raised blood pressure in pregnancy.

STUDY DESIGN

Assess ease of use and safety of the newly developed kit which included a Bluetooth enabled blood pressure machine and an android based mobile phone. The phone was modified to have only one application in it which showed the blood pressure readings with a traffic light system. The study was a proof of concept for wider use of the kit. We provided 50 women who were admitted with the kit. We assessed ease of use of the blood pressure machine and accuracy of readings including remote transfer to a computer.

MAIN OUTCOME MEASURE

Technological feasibility and acceptance by women.

RESULTS

The technology provides accurate data and visual cues including safe remote transfer instantaneously. 90% of the women agreed that the Kit was simple to use and 78% would prefer this model of testing at home.

CONCLUSION

In a relatively resource rich setting the machine can reduce the number of patient visits for women who are at risk for preeclampsia. In resource poor settings it helps to triage resources to women who need it the most. It also is a valuable tool for research. Studies of the Kit in both developed and developing world will be needed to show reduction in perinatal and maternal morbidity or mortality secondary to preeclampsia.

A systematic review and meta-regression analysis of aggression during the first episode of psychosis

OBJECTIVE

The First Episode of Psychosis (FEP) represents a period of heightened risk for aggression. However, it is not known whether this risk is significantly altered following contact with mental health services.

METHOD

Meta-analytic methods were used to estimate pooled prevalence of 'any' and 'serious' aggression during FEP, while meta-regression analyses were conducted to explore reasons for heterogeneity between studies.

RESULTS

Fifteen studies comprising 3, 294 FEP subjects were analysed. Pooled prevalence of 'any aggression' before service contact was 28% (95% CI: 22-34) and following contact 31% (95% CI: 20-42). Pooled prevalence of 'serious aggression' was 16% (95% CI: 11-20) before service contact and 13% (95% CI: 6-20) following contact. Four studies reporting repeated assessments within the same cohort revealed that aggression rates did not significantly differ post and pre service contact: Odds Ratios for any aggression: 1.18 (95% CI: 0.46-2.99) and serious aggression: 0.61 (95% CI: 0.31-1.21).

CONCLUSION

Rates of aggression are high during FEP, both before and following initial service contact, and seem not to alter following contact. This conclusion remains tentative due to considerable heterogeneity between studies and a lack of prospective cohort studies.

Fallout from the Nuclear Explosion of 16 October 1964

Measurements of the concentrations of 20 fission products in a sample of rain collected at Fayetteville, Arkansas, on 26 October 1964, yielded two "mass-yield" curves; one for fresh debris from the Chinese nuclear explosion, and another for older debris. The former curve resembled the mass-yield curve for neutron-induced fission of uranium-235.

Evidence for a major meteorite impact on the Earth 34 million years ago: implication for eocene extinctions

A deep-sea core from the Caribbean contains a layer of sediment highly enriched in meteoritic iridium. This layer underlies a layer of North American microtektites dated at 34.4 million years ago and coincides with the extinction of five major species of Radiolaria. It is suggested that a massive, chemically undifferentiated meteorite collided with the earth, producing the tektites and leading to extinctions 34 million years ago.

A major meteorite impact on the Earth 65 million years ago: evidence from the cretaceous-tertiary boundary clay

Evidence for a major meteorite impact on the earth 65 million years ago is shown by the presence of meteoritic debris in the "fish clay" from Denmark representing the Cretaceous-Tertiary boundary. Noble metals (iridium, osmium, gold, platinum, rhenium, ruthenium, palladium, nickel, and cobalt), which are sensitive indicators of meteorites and are normally depleted on the terrestrial surface by factors of 10(4) to 10(2) relative to cosmic abundances, are enriched in this boundary clay by factors of 5 to 100 over the expected abundances. With the exception of rhenium, all the enriched noble metals in the clay are present in cosmic proportions, indicating that the impacting celestial body had not undergone gross chemical differentiation. The major extinction of life on the earth at the end of the Cretaceous Period may be related to the meteorite impact.

Secondary repair of the perineum following childbirth

The aim of the study was to evaluate secondary repair of the perineum following perineal trauma at childbirth. Patients who underwent secondary repair reported with symptoms of superficial dyspareunia, vulvo-vaginal pain, vaginal stenosis and broken or gaping wound. The study included 103 women over a 16-year period that underwent refashioning of the perineum at Northwick Park Hospital by the same surgeon. Among the cases, 81.6% were nulliparous and 18.4% were multiparous. Labour was induced in 30.1%, and 38% of the women required instrumental delivery. The length of the second stage of labour was 89 +/- 60 min for nulliparae and 50 +/- 48 min for multiparae. In 53.4% of the women, an episiotomy was performed. Catgut sutures were used in 69% of primary repairs. Predisposing factors for the need for secondary repair included nulliparity, forceps delivery, episiotomy, prolonged second stage of labour, surgeons' inexperience and the choice of suture material. Secondary repair is associated with a good result. A majority of women who required refashioning of the perineum for superficial dyspareunia presented late after the onset of the problem. In carefully selected women, such cases of superficial dyspareunia are easily treatable and surgery needs to be considered as an option.

Pelvic tuberculosis reactivated by in vitro fertilization egg collection?

OBJECTIVE

To report a case of pelvic tuberculosis, presenting a few months after an unsuccessful IVF cycle.

DESIGN

Case report and discussion.

SETTING

District General Hospital with National Health Service, United Kingdom.

PATIENT(S)

A 40-year-old nulliparous woman.

INTERVENTION(S)

Drainage of the ovarian abscess and biopsy.

MAIN OUTCOME MEASURE(S)

Histology confirmed the diagnosis of tuberculosis.

RESULT(S)

Patient has been diagnosed with tuberculosis and is now undergoing treatment.

CONCLUSION(S)

Although pelvic tuberculosis is rare in the developed world, it should be considered as a differential in the high-risk population.

Effect of heparin and fractionated heparin on trophoblast invasion

BACKGROUND

Heparin can significantly reduce pregnancy complications in women with certain thrombophilias, such as antiphospholipid syndrome. Recent reports suggest that heparin may act by mechanisms other than anticoagulation. However, the effect of heparin on trophoblast biology in the absence of thrombophilia has not been extensively investigated. Therefore, this study aimed to evaluate trophoblast invasion, using an established cell line and primary extravillous trophoblasts (EVTs), following exposure to heparin and fractionated heparin.

METHODS

An EVT cell line (SGHPL-4) was used to study invasion in the presence of hepatocyte growth factor (HGF) and varying concentrations of fractionated and unfractionated heparin. These experiments were repeated using first trimester primary EVTs.

RESULTS

Both forms of heparin significantly reduced HGF-induced invasion in the SGHPL-4 cell line. This suppression of invasion appeared to be dose-dependent for fractionated heparin. In primary EVT cells, fractionated heparin also demonstrated significant suppression of invasion.

CONCLUSIONS

Heparin has the potential to reduce trophoblast invasion in cell lines and first trimester EVT cells. This article highlights the need for further evaluation of these medications in vitro and in vivo, especially when used in the absence of thrombophilic disorders.

Structure of mesh phases in a cationic surfactant system with strongly bound counterions

We report the observation of an intermediate mesh phase with rhombohedral symmetry, corresponding to the space group Rm, in a mixed surfactant system formed by the cationic surfactant cetyltrimethylammonium bromide (CTAB) and the organic salt 3-sodium-2-hydroxy naphthoate (SHN). It occurs between a random mesh phase (L(alpha)(D)) and a lamellar phase (L(alpha)) at low temperatures; at higher temperatures, the (L(alpha)(D)) phase transforms continuously into the (L(alpha)) phase with an increasing surfactant concentration (phi(s)). To separate the effects of salt and phi(s) on the phase behavior, the ternary system consisting of cetyltrimethylammonium 3-hydroxy-naphthalene-2-carboxylate (CTAHN), sodium bromide (NaBr), and water was studied. The intermediate mesh phase is found in this system at high NaBr concentrations. The micellar aggregates, both in the intermediate and random mesh phases, are found to be made up of a two-dimensional network of rod-like segments, with three rods meeting at each node. The average mesh size increases with phi(s), and the transition from the random mesh phase to the intermediate phase is found to occur when it is approximately 1.5 times the lamellar periodicity. The intermediate mesh phase is absent in the equimolar dodecyltrimethylammonium bromide (DTAB)-SHN system, indicating the role of the surfactant chain length in the formation of this phase. This system exhibits a random mesh phase over a very wide range of water content, with the average mesh size decreasing upon an increasing phi(s), contrary to the trend seen in the CTAB-SHN system.

Unexplained elevated maternal serum β-HCG concentration and adverse pregnancy outcome

OBJECTIVE

To investigate the association between unexplained elevated maternal serum beta-Human chorionic gonadotrophin (HCG) in the second trimester of pregnancy and adverse pregnancy outcome.

METHODS

In a case-controlled study of 3463 women who opted for second-trimester serum screening for Down syndrome, 142 were found to have a serum beta-HCG of > or =3.5 multiples of the median (MoM), 56 of whom had a serum beta-HCG of > or =5.0 MoM. These women were compared with a control group of women with serum beta-HCG within the 95% confidence interval around the median.

RESULTS

In the elevated beta-HCG group (> or =5 MoM) significantly more babies required admission to the special care baby unit (p = 0.02) and were small for gestational age (SGA) (p = 0.03). The mean birth weight was also significantly lower in the group with elevated beta-HCG. Women with a serum beta-HCG of > or =5, > or =6, > or =7 or > or =8 MoM were associated with SGA babies in 40, 44, 64 and 86% respectively. All babies born to the six women with beta-HCG of 8.75-24.1 MoM were SGA.

CONCLUSION

Increased surveillance is necessary in pregnancies where the maternal serum beta-HCG in the second trimester is inexplicably elevated to > or =5 MoM.

Intussusception: a rare cause of abdominal pain in pregnancy

A 34-year-old woman presented at 19 weeks in her third pregnancy with abdominal pain and hyperemesis. This was her third admission during the pregnancy for similar complaints. A few days after admission an exacerbation in her pain was noted, in particular on eating or lying down, and a firm and mobile epigastric mass could be palpated separate from her uterus. The differential diagnosis was a hernia or a degenerating pedunculated fibroid. Sonography revealed a mass separate from the uterus with an appearance consistent with intussusception. Magnetic resonance imaging confirmed the diagnosis. A limited right hemicolectomy was performed. The final diagnosis was adenocarcinoma of the colon. It is difficult to diagnose intussusception during pregnancy. The presenting symptoms of nausea, vomiting, abdominal pain and constipation are common in pregnancy and the displacement of the bowel by the gravid uterus hampers examination. Intussusception is very rare in adults and generally it is associated with tumors. Preoperative diagnosis is difficult but possible with accurate imaging.

Anti-proliferative effects of sorafenib in clear cell renal cell carcinoma (CCRCC) cell lines: Relationship to von Hippel Lindau protein (pVHL) expression and hypoxia

4601

Background: Sorafenib, a multikinase inhibitor targeting raf kinase and several receptor tyrosine kinases including VEGFR-2 and PDGFR, has demonstrated clinical activity in the treatment of metastatic CCRCC. To further characterize the molecular basis of response to this agent, we tested the functional role of pVHL and hypoxia in the anti-tumor activity of sorafenib in a panel of CCRCC cell lines. Methods: CCRCC cell lines CAKI-1 (wild-type pVHL), CAKI-2 (mutant VHL) and the isogenic pair, 786–0-neo (vector control) and 786–0-VHL (pVHL expressing) cells were treated with sorafenib (2.5 - 20 μM) for 24 - 96 hours at 37°C in a atmosphere of either normoxia (21% oxygen) or hypoxia (1% oxygen), 5% carbon dioxide and remainder nitrogen. Gene expression analysis of control and sorafenib treated CCRCC cell lines was carried out using a custom cancer cDNA array containing probes to 9240 cDNA clones corresponding to 4900 Unigenes or unclustered ESTs relevant to cancer or kidney development. Results: Anti-proliferative effects of sorafenib were both concentration and time of treatment dependent; the IC50 of sorafenib (inhibitory concentration for 50% cell kill) ranged from 7.5-10 μM and required continuous treatment for at least 48-72 hours for maximal cell kill. In contrast to CAKI-2 and 786–0-neo cells harboring mutant VHL, both CAKI-1 and 786–0-VHL cells expressing wild type VHL were ∼2-fold more resistant to the anti-proliferative effects of sorfaenib when treated under hypoxic conditions. No difference in resistance was observed under normoxic conditions. In contrast to 786–0-neo cells, there were ∼40 genes overexpressed (>5-fold) under hypoxia in control 786–0-VHL cells, that were predominantly related to anti-apoptosis (e.g. bcl2-associated athanogene) or angiogenesis (e.g. PDGF beta). Bcl2-associated athanogene and PDGF beta were down regulated >2-fold in hypoxia with sorafenib treatment. Conclusions: CCRCC with wild type VHL under hypoxic conditions can promote overexpression of anti-apoptotic and angiogenesis genes that attenuate the anti-proliferative effects of sorafenib. pVHL and hypoxia related genes may be important biomarkers for assessing the clinical efficacy of sorafenib in CCRCC.

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Influence of parity on first trimester endovascular trophoblast invasion

OBJECTIVE

To assess the effect of parity on endovascular trophoblastic invasion in early pregnancy.

DESIGN

Observational study.

SETTING

Teaching hospital.

PATIENT(S)

Healthy women at 10-14 weeks of gestation.

INTERVENTION(S)

Surgical termination of pregnancy for nonmedical reasons.

MAIN OUTCOME MEASURE(S)

Products of conception were blindly examined histologically with regard to the extent of decidual endovascular trophoblast invasion.

RESULT(S)

Samples were obtained from 20 nulliparous and 10 parous women. The presence of normal intradecidual endovascular trophoblast invasion was identified with a similar frequency in both groups (P=.28). However, the proportion of decidual vessels with endovascular trophoblast invasion was significantly higher in parous women (60%) compared with nulliparous women (32%, P<.001).

CONCLUSION(S)

Endovascular trophoblast invasion in early pregnancy is more extensive in parous women who already had an uncomplicated pregnancy than in nulliparous women.

Effect of first-trimester serum from pregnant women with high-resistance uterine artery Doppler resistance on extravillous trophoblast invasion

BACKGROUND

Abnormal uterine artery Doppler indices are associated with pregnancy complications such as pre-eclampsia and intrauterine growth restriction. Poor trophoblast invasion may be a consequence of, or be associated with, abnormal Doppler indices.

OBJECTIVE

To evaluate in vitro trophoblast function following exposure to first-trimester serum from pregnancies with high uterine artery Doppler resistance indices.

METHODS

Doppler ultrasound examination of the maternal uterine arteries was performed on women at 10-14 weeks' gestation. Serum was collected from women with bilateral uterine artery notches with resistance indices above the 95th centile and from patients with normal uterine artery indices. The effect of serum on trophoblast invasion was determined using an established in vitro model from the extravillous trophoblast-derived cell line SGHPL-4.

RESULTS

Trophoblastic invasion was significantly reduced when treated with serum from women with high-resistance compared with normal-resistance uterine artery Doppler indices (P < 0.05).

CONCLUSION

Maternal serum in the first trimester of pregnancy from patients with high-resistance uterine artery Doppler indices appears to inhibit trophoblast invasion. This experimental model allows further investigation of factors responsible and the evaluation of therapeutic strategies.

Neonatal outcome of antenatally diagnosed congenital cystic adenomatoid malformations

OBJECTIVE

To investigate the natural history and outcome of antenatally diagnosed congenital cystic adenomatoid malformation (CCAM) of the lung.

METHODS

This was a retrospective study of all cases of fetal CCAM of the lung diagnosed antenatally. All cases were referred to a tertiary center for further management. A computer search identified all referred cases, and the records of these patients were examined to determine the pregnancy outcome.

RESULTS

In a 4-year period, 34 cases of fetal CCAM were referred for further management. At presentation, all the cases were noted to be unilateral CCAMs and the majority (79%) were microcystic in nature. The CCAMs were complicated by varying degrees of mediastinal shift (79%) and hydrops fetalis (18%). During the course of the pregnancy, the lung lesion was seen to reduce in size or resolve spontaneously in 76% of cases without any prenatal intervention (including resolution of hydrops in three cases). The overall survival rate into infancy was 88%. One pregnancy was terminated for persisting hydrops fetalis and another resulted in infant death from complications of neonatal cardiac surgery for an associated aortic coarctation.

CONCLUSION

The outcome of antenatally detected CCAM is much better than previously reported even when complicated by hydrops fetalis at presentation. The latter seems to be related to the high spontaneous regression rate of this tumor. Despite the antenatal resolution of CCAMs on ultrasound, postnatal follow-up is recommended in view of the long-term complications of this malformation.

Characterization and analysis of osteopontin-immobilized poly(2-hydroxyethyl methacrylate) surfaces

A wide array of technologies exist for the characterization and quantification of molecules present at surfaces. We have used several of these experimental and instrumental techniques for the analysis of a novel biomaterial surface. Osteopontin, an extracellular matrix molecule involved in wound-healing processes, has been chosen as a relevant model protein to immobilize onto poly(2-hydroxyethyl methacrylate) [poly(HEMA)]. Electron spectroscopy for chemical analysis and time-of-flight secondary ion mass spectrometry were used to verify the surface chemistry and the presence of protein. Iodination of osteopontin yielded quantitative data supportive of dose-dependent immobilization. Enzyme-linked immunosorbent assay was also used to investigate the presence of osteopontin on poly(HEMA). Finally, the cell adhesive properties of immobilized osteopontin were confirmed by using a bovine aortic endothelial cell adhesion assay. The use of multiple tools to characterize the many facets of a biomaterial surface will undoubtedly improve our understanding of the surface and facilitate the amelioration of in vivo performance.

The longitudinal variation in uterine artery blood flow pattern in relation to birth weight

OBJECTIVE

To investigate the relationship between the timing of disappearance of high-resistance uterine artery waveforms between the first and second trimester of pregnancy and birth weight.

METHODS

Uterine artery Doppler recordings were obtained in a cohort of singleton pregnancies at 11-14 weeks of gestation and subsequently at 18-23 weeks. At each examination, the presence or absence of an early diastolic notch was recorded for each side. An abnormal pattern of blood flow was defined as the presence of bilateral notches. Cases complicated by preeclampsia or preterm delivery were excluded.

RESULTS

Four hundred eleven pregnancies showed absent or unilateral uterine artery notches at the 11-14-week scan (group 1). All these cases maintained a low-resistance uterine blood flow pattern at the second-trimester scan. Of the 251 pregnancies with bilateral notches at the 11-14-week scan, 222 subsequently displayed a low-resistance blood flow at 18-23 weeks (group 2) whereas only 29 maintained bilateral notches (group 3). The mean birth weight was higher in group 1 (3452 g) than in groups 2 (3310 g) and 3 (3224 g). This difference was confirmed after adjusting for confounding variables. Small-for-gestational-age fetuses were more common in groups 2 (14.9%) and 3 (14%) compared with group 1 (6.8%, P <.001). During the study period, severe preterm preeclampsia was observed in 6 cases only.

CONCLUSION

The longitudinal variation in uterine artery blood flow pattern has a statistically significant correlation with birth weight, likely reflecting the timing and degree of trophoblastic invasion of the maternal vessels.

LEVEL OF EVIDENCE

II-2

Natural history and outcome of prenatally diagnosed cystic hygroma

OBJECTIVE

To define the outcome in cases of cystic hygroma diagnosed from a routine obstetric population.

METHOD

This was a retrospective study of 42 cases of fetal cystic hygroma detected at 11 to 23 weeks' gestation in a routine obstetric population of 25 352 pregnancies. Fetal cystic hygroma was categorized according to position, severity, presence of cardiac defects and Hydrops fetalis.

RESULTS

There were 20 (47.6%) cases with aneuploidy (9 trisomies and 11 Turner's syndrome). Major congenital cardiac defects were identified in 12 (28.6%) cases. Regression of the hygroma was noted in 2/20 (10%) of the aneuploid pregnancies and 3/17 (17.6%) of the euploid pregnancies. The majority (90.0%) of the aneuploid fetuses were female. In contrast, 70.58% of the fetuses in the euploid group were male and all the surviving normal babies were also male (n = 3).

CONCLUSION

The findings of this study would support invasive prenatal diagnosis for an ultrasound finding of fetal cystic hygroma. Even in euploid pregnancies with cystic hygroma, there is a high mortality with associated abnormalities. The data also suggest a guarded pregnancy prognosis for the finding of fetal cystic hygroma, and that it is improved with spontaneous resolution, especially in male fetuses of normal karyotype.

Soliton propagation in an erbium-doped fiber with and without a continuous wave background

Considering ultrashort pulse propagation in a nonlinear resonant fiber governed by Hirota-Maxwell Bloch equations, the soliton interaction in an erbium-doped fiber system associated with higher-order dispersion, self-steepening, and self-induced transparency effects is studied for the case when the fiber is driven with and without a constant pumping source. Using auto-Bäcklund-transformation, one- and two-soliton solutions are generated. The significance of the results is discussed in detail.

Migraine with aura is not linked to the FHM gene CACNA1A or the chromosomal region, 19p13

Two microsatellite markers, tightly linked to CACNA1A, were genotyped in migraine with aura (MA) families to determine if this gene, which underlies the 19p13 linked forms of familial hemiplegic migraine, is also linked to MA. Two-point parametric lod and nonparametric linkage scores did not support linkage. Transmission disequilibrium testing provided no evidence for linkage of MA to CACNA1A. In a large dataset of 64 Canadian MA families, the authors did not find evidence to support an MA susceptibility gene in the region of 19p13.

Immobilization of papain on cold-plasma functionalized polyethylene and glass surfaces

Polyethylene and glass surfaces were functionalized under dichlorosilane-RF-cold-plasma environments and were employed as substrates for further in situ derivatization reactions and immobilization of papain. Surface functionality changes of RF-plasma-exposed surfaces were monitored under 40 kHz continuous discharge environments. The nature and morphology of derivatized substrates and the substrates bearing the immobilized enzyme were analyzed using survey and high resolution ESCA, ATR-FTIR, and fluorescence of chemical derivatization techniques. Spacer molecules intercalated between the substrates and the enzyme significantly increased the enzyme activity (comparable with the that of the free enzyme). Computer-aided conformational modeling of the substrate-spacer systems corroborated with experimental data indicated that an optimal distance might exist between the enzyme and the substrate. The activity of free and immobilized papain was monitored using benzoyl arginine ethyl ester assay. The pH data were recorded every 0.3 s over 25 min. The Michaelis-Menten kinetic constants were evaluated for immobilized enzymes. It was shown, that the immobilized papain retains most of its activity after several washing/assay cycles.

Immobilization of alpha-chymotrypsin on oxygen-RF-plasma functionalized PET and PP surfaces

In this contribution the immobilization of alpha-chymotrypsin on plasma activated PET and PP surfaces is investigated. The 'anchoring' C=O groups on polymer surfaces were created under RF-O2-plasma environments. The identity and relative concentrations of plasma-created functionalities were evaluated using survey and high resolution X-ray photoelectron spectroscopy, and differential attenuated total reflectance-FTIR spectroscopy. Surface morphology changes of plasma-exposed substrates were analyzed by atomic force microscopy. Enzyme assays were performed from both virgin and plasma modified samples which underwent the immobilization procedure. It was demonstrated that cold-plasma technique is suitable for generating functional, synthetic polymeric surfaces which can initiate enzyme coupling reactions. It also has been shown that the activity of the immobilized enzyme is lower in comparison to the free enzyme. Reduced conformational mobility resulting from multiple-point coupling process might be responsible for this behavior.