Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group

The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Dual growth factor delivery from degradable oligo(poly(ethylene glycol) fumarate) hydrogel scaffolds for cartilage tissue engineering

This work describes the development of a non-invasive means of simultaneously delivering insulin-like growth factor-1 (IGF-1) and transforming growth factor-beta1 (TGF-beta1) to injured cartilage tissue in a controlled manner. This novel delivery technology employs the water-soluble polymer, oligo(poly(ethylene glycol) fumarate) (OPF), in the fabrication of biodegradable hydrogels which encapsulate gelatin microparticles. Release studies first examined the effect of gelatin isoelectric point (IEP) and crosslinking extent on IGF-1 release from these microparticles. In the presence of collagenase, highly crosslinked, acidic gelatin (IEP=5.0) provided sustained release of IGF-1, 95.2+/-2.9% cumulative release at day 28, while less crosslinked microparticles and microparticles of alternate IEP exhibited similar release values after only 6 days. Encapsulation of these highly crosslinked microparticles in a network of OPF provided a means to further control release, reducing final cumulative release to 70.2+/-4.7% in collagenase-containing PBS. Final release values from OPF-gelatin microparticle composites could be altered by incorporating less crosslinked, non-loaded microparticles within these constructs. Finally, this technology was extended to the dual delivery of IGF-1 and TGF-beta1 by loading these growth factors into either the OPF hydrogel phase or gelatin microparticle phase of composites. Release profiles were successfully manipulated by altering the phase of growth factor loading and microparticle crosslinking extent. For instance, by loading TGF-beta1 into the gelatin microparticle phase, a burst release of 10.8+/-0.7% was achieved, while loading this growth factor into the OPF hydrogel phase resulted in a burst release of 25.2+/-1.5%. With either system, simultaneous, slow release of IGF-1 over a 4-week period was accomplished by selectively loading this protein into highly crosslinked, encapsulated microparticles. These results demonstrate the utility of these systems in future studies to assess the interplay and time course of multiple growth factors in cartilage repair.

Delivery of TGF-β1 and chondrocytes via injectable, biodegradable hydrogels for cartilage tissue engineering applications

In this work, novel hydrogel composites, based on the biodegradable polymer, oligo(poly(ethylene glycol) fumarate) (OPF) and gelatin microparticles (MPs) were utilized as injectable cell and growth factor carriers for cartilage tissue engineering applications. Specifically, bovine chondrocytes were embedded in composite hydrogels co-encapsulating gelatin MPs loaded with transforming growth factor-beta1 (TGF-beta1). Hydrogels with embedded cells co-encapsulating unloaded MPs and those with no MPs served as controls in order to assess the effects of MPs and TGF-beta1 on chondrocyte function. Samples were cultured up to 28 days in vitro. By 14 days, cell attachment to embedded gelatin MPs within the constructs was observed via light microscopy. Bioassay results showed that, over the 21 day period, there was a statistically significant increase in cellular proliferation for samples containing gelatin MPs, but no increase was exhibited in samples without MPs over the culture period. The release of TGF-beta1 further increased cell construct cellularity. Over the same time period, glycosaminoglycan content per cell remained constant for all formulations, suggesting that the dramatic increase in cell number for samples with TGF-beta1-loaded MPs was accompanied by maintenance of the cell phenotype. Overall, these data indicate the potential of OPF hydrogel composites containing embedded chondrocytes and TGF-beta1-loaded gelatin MPs as a novel strategy for cartilage tissue engineering.

Soft and hard tissue response to photocrosslinked poly(propylene fumarate) scaffolds in a rabbit model

The treatment of large cranial defects may be greatly improved by the development of precisely formed bone tissue engineering scaffolds. Such scaffolds could be constructed by using UV laser stereolithography to photocrosslink a linear, biodegradable polymer into a three-dimensional implant. We have previously presented a method to photocrosslink the biodegradable polyester, poly(propylene fumarate) (PPF). To ensure the safety and effectiveness of this technique, the soft and hard tissue response to photocrosslinked PPF scaffolds of different pore morphologies was investigated. Four classes of photocrosslinked PPF scaffolds, constructed with differing porosities (57-75%) and pore sizes (300-500 or 600-800 microm), were implanted both subcutaneously and in 6.3-mm-diameter cranial defects in a rabbit model. The rabbits were sacrificed at 2 and 8 weeks, and the implants were analyzed by light microscopy, histological scoring analysis, and histomorphometric analysis. Results showed the PPF scaffolds elicit a mild tissue response in both soft and hard tissues. Inflammatory cells, vascularization, and connective tissue were observed at 2 weeks; a decrease in inflammatory cell density and a more organized connective tissue were observed at 8 weeks. Scaffold porosity and scaffold pore size were not found to significantly affect the observed tissue response. Evidence of scaffold surface degradation was noted both by histology and histomorphometric analysis. Bone ingrowth in PPF scaffolds implanted into cranial defects was <3% of the defect area. The results indicate that photocrosslinked PPF scaffolds are biocompatible in both soft and hard tissues and thus may be an attractive platform for bone tissue engineering.

Degradable hydrogel scaffolds for in vivo delivery of single and dual growth factors in cartilage repair

OBJECTIVE

As our population ages, treatment for joint pain associated with articular cartilage damage is becoming a prevalent challenge. Accordingly, this work investigates local delivery of two regulatory proteins - transforming growth factor-beta1 (TGF-beta1) and insulin-like growth factor-1 (IGF-1) - to cartilage defects from degradable scaffolds as a potential strategy for improving cartilage repair.

METHOD

The effects of TGF-beta1 and/or IGF-1 delivery on osteochondral repair in adult rabbits were examined through histomorphometric analysis of 11 markers of osteochondral repair.

RESULTS

Complete scaffold degradation occurred allowing for assessment of the healing response at 12 weeks post-surgery. When compared to untreated defects, higher scores were observed with IGF-1-treated defects for the six markers of neo-surface repair: neo-surface morphology, cartilage thickness, surface regularity, chondrocyte clustering, and the chondrocyte/glycosaminoglycan content of the neo-surface and the cartilage surrounding the defect. Surprisingly, the benefits of IGF-1 delivery were not maintained when this growth factor (GF) was co-delivered with TGF-beta1, despite numerous in vitro reports of the combinatory actions of these GFs.

CONCLUSIONS

While localized delivery of IGF-1 may be a promising repair strategy, further in vivo assessment is necessary, since fibrous tissue was commonly observed in the neo-surface of all treatment groups. More importantly, this study highlights the need to rigorously examine GF interactions in the wound healing environment and demonstrates that in vitro observations do not directly translate to the in vivo setting.

In vitro release of transforming growth factor-beta 1 from gelatin microparticles encapsulated in biodegradable, injectable oligo(poly(ethylene glycol) fumarate) hydrogels

This research investigates the in vitro release of transforming growth factor-beta1 (TGF-beta1) from novel, injectable hydrogels based on the polymer oligo(poly(ethylene glycol) fumarate) (OPF). These hydrogels can be used to encapsulate TGF-beta1-loaded-gelatin microparticles and can be crosslinked at physiological conditions within a clinically relevant time period. Experiments revealed that OPF formulation and crosslinking time may be adjusted to influence the equilibrium swelling ratio, elastic modulus, strain at fracture, and mesh size of these hydrogels. Studies with OPF-gelatin microparticle composites revealed that OPF formulation and crosslinking time, as well as microparticle loading and crosslinking extent, influence composite swelling. In vitro TGF-beta1 release studies demonstrated that burst release from OPF hydrogels with a mesh size of 136 A was approximately 53%, while burst release from hydrogels with a mesh size of 93 A was only 34%. For hydrogels with a large mesh size (136 A), encapsulation of loaded gelatin microparticles allowed burst release to be reduced to 29-32%, depending on microparticle loading. Likewise, final cumulative release after 28 days was reduced from 71% to 48-66% by encapsulation of loaded microparticles. However, inclusion of gelatin microparticles within OPF hydrogels of smaller mesh size (93 A) was seen to increase TGF-beta1 release rates. The equilibrium swelling ratio of the microparticle component of these composites was shown to be greater than the equilibrium swelling ratio of the OPF component. Therefore, increased release rates are the result of disruption of the polymer network during swelling. These combined results indicate that the kinetics of TGF-beta1 release can be controlled by adjusting OPF formulation and microparticle loading, factors affecting the swelling behavior these composites. By systematically altering these parameters, in vitro release rates from hydrogels and composites loaded with TGF-beta1 at concentrations of 200 ng/ml can be varied from 13 to 170 pg TGF-beta1/day for days 1-3 and from 7 to 47 pg TGF-beta1/day for days 6-21. Therefore, these studies demonstrate the potential of these novel hydrogels and composites in the sustained delivery of low dosages of TGF-beta1 to articular cartilage defects.

Transforming growth factor-β1 release from oligo(poly(ethylene glycol) fumarate) hydrogels in conditions that model the cartilage wound healing environment

This research demonstrates that controlled material degradation and transforming growth factor-beta1 (TGF-beta1) release can be achieved by encapsulation of TGF-beta1-loaded gelatin microparticles within the biodegradable polymer oligo(poly(ethylene glycol) fumarate) (OPF), so that these microparticles function as both a digestible porogen and a delivery vehicle. Release studies performed with non-encapsulated microparticles confirmed that at normal physiological pH, TGF-beta1 complexes with acidic gelatin, resulting in slow release rates. At pH 4.0, this complexation no longer persists, and TGF-beta1 release is enhanced. However, by encapsulating TGF-beta1-loaded microparticles in a network of OPF, release at either pH can be diffusionally controlled. For instance, after 28 days of incubation at pH 4.0, final cumulative release from non-encapsulated microparticles crosslinked in 10 and 40 mM glutaraldehyde (GA) was 75.4+/-1.6% and 76.6+/-1.1%, respectively. However, when either microparticle formulation was encapsulated in an OPF hydrogel (noted as OPF-10 mM and OPF-40 mM, respectively), these values were reduced to 44.7+/-14.6% and 47.4+/-4.7%. More interestingly, release studies, in conditions that model the expected collagenase concentration of injured cartilage, demonstrated that by altering the microparticle crosslinking extent and loading within OPF hydrogels, TGF-beta1 release, composite swelling, and polymer loss could be systematically altered. Composites encapsulating less crosslinked microparticles (OPF-10 mM) exhibited 100% release after only 18 days and were completely degraded by day 24 in collagenase-containing phosphate-buffered saline (PBS). Hydrogels encapsulating 40 mM GA microparticles did not exhibit 100% release or polymer loss until day 28. Hydrogels with no microparticle component demonstrated only 79.3+/-9.2% release and 89.2+/-3.4% polymer loss after 28 days in enzyme-containing PBS. Accordingly, these studies confirm that the rate of TGF-beta1 release and material degradation can be controlled by altering key parameters of these novel, in situ crosslinkable biomaterials, so that TGF-beta1 release and scaffold degradation may be tailored to optimize cartilage repair.

Osteochondral repair in the rabbit model utilizing bilayered, degradable oligo(poly(ethylene glycol) fumarate) hydrogel scaffolds

In this study, hydrogel scaffolds, based on the polymer oligo(poly(ethylene glycol) fumarate) (OPF), were implanted into osteochondral defects in the rabbit model. Scaffolds consisted of two layers-a bottom, bone forming layer and a top, cartilage forming layer. Three scaffold formulations were implanted to assess how material composition and transforming growth factor-beta1 (TGF-beta1) loading affected osteochondral repair. Critical histological evaluation and scoring of the quantity and quality of tissue in the chondral and subchondral regions of defects was performed at 4 and 14 weeks. At both time points, no evidence of prolonged inflammation was observed, and healthy tissue was seen to infiltrate the defect area. The quality of this tissue improved over time with hyaline cartilage filling the chondral region and a mixture of trabecular and compact bone filling the subchondral region at 14 weeks. A promising degree of Safranin O staining and chondrocyte organization was observed in the newly formed surface tissue, while the underlying subchondral bone was completely integrated with the surrounding bone at 14 weeks. Material composition within the bottom, bone-forming layer did not appear to affect the rate of scaffold degradation or tissue filling. However, no bone upgrowth into the chondral region was observed with any scaffold formulation. TGF-beta1 loading in the top layer of scaffolds appeared to exert some therapeutic affect on tissue quality, but further studies are necessary for scaffold optimization. Yet, the excellent tissue filling and integration resulting from osteochondral implantation of these OPF-based scaffolds demonstrates their potential in cartilage repair strategies.

Synthesis and properties of photocross-linked poly(propylene fumarate) scaffolds

The photocross-linking of poly(propylene fumarate) (PPF) to form porous scaffolds for bone tissue engineering applications was investigated. PPF was cross-linked using the photoinitiator bis(2,4,6-trimethylbenzoyl) phenylphosphine oxide (BAPO) and exposure to 30 min of long wavelength ultraviolet (UV) light. The porous photocross-linked PPF scaffolds (6.5 mm diameter cylinders) were synthesized by including a NaCl porogen (70, 80, and 90 wt% at cross-linking) prior to photocross-linking. After UV exposure, the samples were placed in water to remove the soluble porogen, revealing the porous PPF scaffold. As porogen leaching has not been used often with cross-linked polymers, and even more rarely with photoinitiated cross-linking, a study of the efficacy of this strategy and the properties of the resulting material was required. Results show that the inclusion of a porogen does not significantly alter the photoinitiation process and the resulting scaffolds are homogeneously cross-linked throughout their diameter. It was also shown that porosity can be generally controlled by porogen content and that scaffolds synthesized with at least 80 wt% porogen possess an interconnected pore structure. Compressive mechanical testing showed scaffold strength to decrease with increasing porogen content. The strongest scaffolds with interconnected pores had an elastic modulus of 2.3+/-0.5 MPa and compressive strength at 1% yield of 0.11+/-0.02 MPa. This work has shown that a photocross-linking/porogen leaching technique is a viable method to form porous scaffolds from photoinitiated materials.

Risk of severe ovarian hyperstimulation syndrome in GnRH antagonist versus GnRH agonist protocol: RCT including 1050 first IVF/ICSI cycles

STUDY QUESTION

Is the risk of severe ovarian hyperstimulation syndrome (OHSS) similar in a short GnRH antagonist and long GnRH agonist protocol in first cycle IVF/ICSI patients less than 40 years of age?.

SUMMARY ANSWER

There is an increased risk of severe OHSS in the long GnRH agonist group compared with the short GnRH antagonist protocol. WHAT IS KNOWN ALREADY?: In the most recent Cochrane review, the GnRH antagonist protocol was associated with a similar live birth rate (LBR), a similar on-going pregnancy rate (OPR), and a lower incidence of OHSS (odds ratio (OR) = 0.43 95% confidence interval (CI): 0.33-0.57) compared with the traditional GnRH agonist protocol. Previous trials comparing the two protocols mainly included selected patient populations, a limited number of patients and the applied OHSS criteria differed, making direct comparisons difficult. In two recent large meta-analyses, no significant differences in LBR (OR = 0.86; 95% CI: 0.72-1.02) or in the incidence of severe OHSS were reported, while others found a lower LBR (OR = 0.82; 95% CI: 0.68-0.97) and a reduced risk of severe OHSS using the GnRH antagonist protocol (OR = 0.60; 95% CI: 0.40-0.88).

STUDY DESIGN, SIZE, DURATION

Phase IV, dual-centre, open-label, RCT including 1050 women allocated to either short GnRH antagonist or long GnRH agonist protocol in a 1:1 ratio and enrolled over a 5-year period using a web-based concealed randomization code. This is a superiority study designed to detect a difference in severe OHSS, the primary outcome, between the two groups with a power of 80% and stratified for age, assisted reproductive technology (ART) clinic and planned fertilization procedure (IVF/ICSI). The secondary aims were to compare rates of mild and moderate OHSS, positive plasma (p)-hCG, on-going pregnancy and live birth between the two arms. None of the women had undergone previous ART treatment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All infertile women referred for their first IVF/ICSI at two public fertility clinics, less than 40 years of age and with no uterine malformations were asked to participate. A total of 1099 subjects were randomized, including women with poor ovarian reserve, polycystic ovary syndrome and irregular cycles. A total of 49 women withdrew their consent, thus 1050 subjects were allocated to the GnRH antagonist (n = 534) and agonist protocol (n = 516), respectively. In total 1023 women started recombinant human follitropin-β (rFSH) stimulation, 528 in the GnRH antagonist group and 495 in the GnRH agonist group. All subjects were given a fixed rFSH dose of 150 IU or 225 IU according to age ≤36 years or >36 years, with the option to adjust dose at stimulation day 6. Clinical OHSS parameters were collected at oocyte retrieval, and Days 3 and 14 post-transfer. On-going pregnancy was determined by transvaginal ultrasonography at gestational weeks 7-9. In the intention-to-treat (ITT) analysis for reproductive outcomes, 1050 subjects were included. For the ITT analyses on OHSS 1023 subjects who started gonadotrophin stimulation were included.

MAIN RESULTS AND THE ROLE OF CHANCE

The incidence of severe OHSS [5.1% (27/528) versus 8.9% (44/495) (difference in proportion percentage point (Δpp) = -3.8pp; 95% CI: -7.1 to -0.4; P = 0.02)] and moderate OHSS [10.2% (54/528) versus 15.6% (77/495) (Δpp = -5.3pp; 95% CI: -9.6 to -1.0; P = 0.01) ] was significantly lower in the GnRH antagonist group compared with the agonist group, respectively. In the GnRH antagonist and agonist group, respectively, 4.7% (25/528) versus 8.5% (42/495) women were seen by a physician due to OHSS (P = 0.01), and 1.7% (9/528) versus 3.6% (18/495) were admitted to hospital due to OHSS (P = 0.06). No women had ascites-puncture in the GnRH antagonist group versus 2.0% (10/495) in the GnRH agonist group (P < 0.01). LBRs were 22.8% (122/534) versus 23.8% (123/516) (Δpp = -1.0pp; 95% CI: -6.3 to 4.3; P = 0.70) and OPRs were 24.9% (133/528) versus 26.2% (135/516) (Δpp = -1.3pp; 95% CI: -6.7 to 4.2; P = 0.64) per randomized subject in the GnRH antagonist versus agonist group, with a mean number of 1.1 versus 1.2 embryos transferred in the two groups. Pregnancy rates (PR) per randomized subject, per started gonadotrophin stimulation and per embryo transfer were all similar in the two groups.

LIMITATIONS, REASONS FOR CAUTION

A possible limitation is the duration of the trial, with new methods, such as 'freeze all' and 'GnRH agonist triggering', being developed during the trial, the new methods were sought avoided, however a total number of 32 women had 'freeze all' and 'GnRH agonist triggering' was performed in three cases. Ultrasonic measurements were performed by different physicians and inter-observer bias may be present. Measures of anti-Mullerian hormone and antral follicle count, to estimate ovarian reserve and thus predict risk of OHSS, were not performed. Finally, the physicians were not blinded to GnRH treatment group after randomization.

WIDER IMPLICATIONS OF THE FINDINGS

The short GnRH antagonist protocol should be the protocol of choice for patients undergoing their first ART cycle in females <40 years of age including both low and high responders when an age-dependent initially fixed gonadotrophin dose is used, as an increased risk of severe OHSS and the associated complications is seen in the long GnRH agonist group and as PRs and LBRs are similar in the two groups. Patients at risk of OHSS particularly benefit from the short GnRH antagonist treatment as GnRH agonist triggering can be used.

STUDY FUNDING/COMPETING INTERESTS

An unrestricted research grant is funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA (MSD). The funders had no influence on the data collection, analyses or conclusions of the study. No conflict of interests to declare.

TRIAL REGISTRATION NUMBER

EudraCT #: 2008-005452-24. ClinicalTrial.gov: NCT00756028. Trial registration date: 18 September 2008. Date of first patient's enrolment: 14 January 2009.

Adrenal suppression and steroid supplementation in renal transplant recipients

The use of increased dosages of glucocorticoids during periods of physiologic stress in allograft recipients represents a clinical dilemma in that the short-term exogenous therapy required may significantly impair wound healing and immunocompetence. To investigate whether "stress steroids" are actually necessary, a prospective study was conducted in 40 renal allograft recipients admitted with significant physiologic stress. Stress categories included sepsis, metabolic abnormalities, and surgery. These patients received only their baseline prednisone immunosuppression (5-10 mg/day) and no supraphysiologic or stress doses of glucocorticoids. The clinical course of the patients revealed no evidence of adrenal insufficiency. There was no mortality, increase in hospital stay, or eosinophilia. Five episodes of hyponatremia and seven instances of hypotension were attributed to primary disease processes and responded promptly to specific treatment without steroid supplementation. Biochemical evaluation during stress revealed suppression of ACTH levels in 74.5% of episodes, elevation of urinary free cortisol levels in 79.1% of episodes, and elevation of isolated serum cortisol levels in 55.9% of episodes. This suggested that these patients had physiologically adequate adrenal function. The cosyntropin stimulation test overestimated the incidence and degree of clinically significant adrenal dysfunction (63% of patients) and was not a useful indication of a requirement for additional glucocorticoids. We conclude that functional adrenal suppression is uncommon in renal allograft recipients receiving baseline prednisone immunosuppression (5-10 mg/day) and that the demands of physiologic stress are met by a combination of endogenous adrenal function plus exogenous, baseline, immunosuppressive doses of glucocorticoids. Supra-physiologic or high doses of so-called "stress steroids" are not required. The cosyntropin stimulation test has significant clinical limitations and did not serve to alter clinical care.

Analysis of formaldehyde in the headspace of urine from bladder and prostate cancer patients using selected ion flow tube mass spectrometry

We have used selected ion flow tube mass spectrometry (SIFT-MS) to determine the concentration of formaldehyde in the headspace of urine from patients suffering from bladder and prostate cancer and from several healthy subjects as controls. We address the potential problems associated with the use of ion chemistry to quantify formaldehyde in the presence of the relatively large number densities of water molecules and show that formaldehyde can be quantified in urine headspace using analysis by SIFT-MS. These studies show that formaldehyde is clearly elevated in the headspace of the urine from the cancer patients as compared with urine from the healthy controls. Thus, with further improvements in the methodology and the sensitivity of our SIFT-MS technique, formaldehyde quantification in urine headspace using this new analytical method could be a valuable non-invasive indicator of the presence of early-stage tumours in the body.

Advances in drug delivery for articular cartilage

The complex structure of articular cartilage, the connective tissue lining diarthrodial joints, enables this tissue to dissipate compressive loads but also appears to hinder its repair ability. At best, both natural and surgical repair attempts replace the highly ordered extracellular matrix of native articular cartilage with fibrous repair tissue of inferior mechanical properties. Numerous bioactive molecules closely regulate the cellular processes in healthy and degenerative articular cartilage. Accordingly, this review outlines the roles of important signaling molecules in cartilage tissue. In addition, drug delivery strategies, aimed at utilizing these bioactive agents to prevent inflammation, to regulate extracellular matrix metabolism, and to control cellular activities, are discussed. As scientists gain further insight into the complex signaling cascades of articular cartilage, continued refinement of drug delivery systems is necessary to develop effective clinical therapies for articular cartilage repair.

Subcellular localisation of cyclin D1 protein in colorectal tumours is associated with p21(WAF1/CIP1) expression and correlates with patient survival

We investigated the expression of the cell cycle regulatory proteins cyclin D1 and p21(WAF1/CIP1) (p21) in human colorectal carcinomas using immunohistochemistry. Cyclin D1 was not detected in normal colonic epithelium; however, expression was observed in 74/126 (58.7%) of the tumour samples studied. Protein was detected in the nucleus in 22/126 (17.4%) and exclusively in the cytoplasm in 52/126 (41.3%) tumours. Nuclear expression of cyclin D1 was associated with poorly differentiated tumours (p = 0.035) and was more common in right- than in left-sided tumours (p = 0.005). Tumours displaying either, expression of cytoplasmic, (p = 0.05, HR 0.56, 95% CI 0.31-1.0) or nuclear (p = 0.021, HR 0.24, 95% CI 0.07-0.81) cyclin D1 were associated with improved patient survival compared with tumours negative for cyclin D1. p21 protein was strongly expressed mainly in the upper crypts of normal colonic epithelial cells, but in 63/126 (50%) of the tumour samples studied p21 expression was absent. Patients with tumours in which >50% of cells expressed p21 had improved survival compared to patients whose tumours were negative or had < or =50% of cells expressing p21 (p = 0.06, HR 0.33, 95% CI 0.1-1.0). We also observed a significant association between cyclin D1 subcellular localisation and p21 expression: 21/22 (95.5%) tumours expressing cyclin D1 in the nucleus also expressed p21, whereas only 17/52 (32.7%) of the tumours displaying exclusive cytoplasmic cyclin D1 staining were positive for p21 (p < 0.001). These data highlight the significance of exclusive cytoplasmic expression of cyclin D1 in colorectal cancer and lend support to recent in vitro studies suggesting that p21 protein may modulate the subcellular localisation of the cyclin D1 protein. Thus, deregulated expression of the cyclin D1 and p21 proteins are important in colorectal tumourigenesis and have implications for patient prognosis.

Prevalence of criminal offending by men and women with intellectual disability and the characteristics of offenders: implications for research and service development

The investigation of the relationship between criminal offending and the presence of an intellectual disability (ID) is problematic for two main reasons. First, because of problems associated with the definition of 'ID' and secondly, because much criminal offending goes undetected or unreported, and studies can only investigate those already involved with the criminal justice process. Studies using IQ as a continuous variable indicate that significantly below-average intellectual ability is an independent predictor of future offending. Whilst people with ID may be over-represented in parts of the criminal justice system, given the intellectual and other psychosocial disadvantages which they experience, the level of offending behaviour in this particularly vulnerable group is strikingly low. The present authors propose that two broad groups of people can be identified. The first, broader, group is one of people for whom social disadvantage and mental ill health (particularly substance abuse), coupled with a significant intellectual impairment, are the main characteristics. Secondly, there is a smaller group of people, usually already known to ID services as service users, but for whom the process whereby what might have been conceptualized as 'challenging behaviour' becomes 'offending' is far from clear. The distinction the present authors make between challenging behaviour and offending is important for understanding how 'difficult' behaviour becomes identified as 'antisocial/criminal behaviour'. They argue that research needs to move from prevalence and descriptive studies to investigating the processes which determine movement in and out the criminal justice system. The present political emphasis on public protection and proposals for significantly broader mental health legislation raise the danger of a re-expansion of institutional models of care, rather than the development of multi-agency support networks. The present paper underscores a note of caution, particularly where choices have to be made between expanding institutional models on the one hand and providing more integrated services on the other. Over and above policy decisions, these are social and political choices.

Optimal nitrogen supply as a key to increased and sustained production of a monoclonal full-size antibody in BY-2 suspension culture

Plant cell cultures have been used as expression hosts for recombinant proteins for over two decades. The quality of plant cell culture-produced proteins such as full-size monoclonal antibodies has been shown to be excellent in terms of protein folding and binding activity, but the productivity and yield fell short of what was achieved using mammalian cell culture, in which the key to gram-per-liter expression levels was strain selection and medium/process optimization. We carried out an extensive media analysis and optimization for the production of the full-size human anti-HIV antibody 2G12 in N. tabacum cv. BY-2. Nitrogen source and availability was found to be one key factor for the volumetric productivity of plant cell cultures. Increased amounts of nitrate in the culture medium had a dramatic impact on protein yields, resulting in a 10-20-fold increase in product accumulation through a combination of enhanced secretion and higher stability. The results were scalable from shake flasks to stirred-tank bioreactors, where the maximum yield per cultivation volume was 8 mg L(-1) over 7 days. During the stationary phase, antibody levels were 150-fold higher in nitrogen-enriched medium compared to standard medium. The enhanced medium appeared not to affect antibody quality and activity, as determined by Western blots, surface plasmon resonance binding assays and N-glycan analysis.

Photoinitiated cross-linking of the biodegradable polyester poly(propylene fumarate). Part II. In vitro degradation

This study investigated the in vitro degradation of both solid PPF networks and porous PPF scaffolds formed by photoinitiated cross-linking of PPF polymer chains. Three formulations of scaffolds of differing porosity and pore size were constructed by varying porogen size and content. The effects of pore size and pore volume on scaffold mass, geometry, porosity, mechanical properties, and water absorption were then examined. Throughout the study, the solid networks and porous scaffolds exhibited continual mass loss and slight change in length. Porogen content appeared to have the greatest effect upon physical degradation. For example, scaffolds initially fabricated with 80 wt % porogen content lost approximately 30% of their initial PPF content after 32 weeks of degradation, whereas scaffolds fabricated with 70 wt % porogen content lost approximately 18% after 32 weeks of degradation. For all scaffold formulations, water absorption capacity, porosity, and compressive modulus were maintained at constant values following porogen leaching. These results indicate the potential of photo-cross-linked PPF scaffolds in tissue engineering applications which require maintenance of scaffold structure, strength, and porosity during the initial stages of degradation.

Photoinitiated cross-linking of the biodegradable polyester poly(propylene fumarate). Part I. Determination of network structure

In this work, we investigated the mechanism involved in the photoinitiated cross-linking of the polyester poly(propylene fumarate) (PPF) using the initiator bis(2,4,6-trimethylbenzoyl) phenylphosphine oxide (BAPO). It was hypothesized that BAPO has the ability to cross-link PPF into solid polymer networks, without the use of a cross-linking monomer, because two pairs of radicals, both involving a fast adding phosphinoyl radical, were formed upon UV irradiation of BAPO. Spectroscopic investigation first confirmed the addition of BAPO derived radicals to the PPF olefin. Investigations of fumarate conversion and bulk network properties were then undertaken, using the BAPO initiator and a monoacylphosphine oxide (MAPO) initiator which contains a single photolabile bond. Results show that a single BAPO phosphinoyl radical was primarily responsible for the formation of a highly cross-linked PPF network and the additional radical pair which may be formed does not dramatically alter fumarate conversion or bulk network properties. From these results, the network structure of BAPO initiated, photo-cross-linked PPF may be deduced. Finally, this study demonstrates a method for inferring cross-linked network structures by contrasting properties of bulk materials formed from similar cross-linking initiators.

Association between ultrasound features of adenomyosis and severity of menstrual pain

OBJECTIVE

To investigate the association between the ultrasound features of adenomyosis and the severity of menstrual pain.

METHODS

This was a prospective observational study set in the general gynecology clinic of a university teaching hospital between January 2009 and January 2010. A total of 718 consecutive premenopausal women aged between 17 and 55 years attended the clinic and underwent structured clinical and transvaginal ultrasound examinations in accordance with the study protocol. Morphological features of adenomyosis on ultrasound scan were recorded systematically. A quantitative assessment of menstrual pain was made by completion of a numerical rating scale (NRS).

RESULTS

One hundred and fifty-seven (21.9% (95% CI, 18.8-24.9%)) women were diagnosed with adenomyosis on ultrasound. Multiple linear regression analysis showed that an ultrasound diagnosis of adenomyosis and ultrasound and laparoscopic diagnoses of endometriosis were significantly associated with menstrual pain when measured by an NRS. In addition, there was a statistically significant positive correlation between the severity of menstrual pain and the number of ultrasound features of adenomyosis seen.

CONCLUSIONS

Women with ultrasound features of adenomyosis have more severe menstrual pain than do women without these features. The positive correlation between the number of ultrasound features of adenomyosis and the severity of menstrual pain could form the basis of a clinically relevant grading system for adenomyosis. A classification of severity of adenomyosis based on the number of ultrasound features present is a novel concept that should be evaluated prospectively in different populations. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Accuracy of ultrasound subjective 'pattern recognition' for the diagnosis of borderline ovarian tumors

OBJECTIVES

To assess the value of pattern recognition for the preoperative ultrasound diagnosis of borderline ovarian tumors (BOTs).

METHODS

This was a prospective study of women who were referred to our regional cancer center with the diagnosis of an adnexal mass on a Level II (routine) gynecological ultrasound scan. Women with lesions of uncertain nature were referred for a Level III (expert) ultrasound scan in our tertiary center. The tumor pattern recognition method was used to differentiate between various types of ovarian tumors. Morphological features suggestive of BOTs were: unilocular cyst with a positive ovarian crescent sign and extensive papillary projections arising from the inner wall, or a cyst with a well defined multilocular nodule. The ultrasound findings were compared with the final histological diagnosis.

RESULTS

A total of 224 women with an adnexal mass of uncertain nature were referred for an expert scan, 166 (74.1%) of whom underwent surgery. In this group of women the final histological diagnoses were: 99 (60%) benign lesions, 32 (19%) invasive ovarian cancer and 35 (21%) BOTs. Using pattern recognition combining the different morphological features, a correct preoperative diagnosis of BOT was made in 24/35 (68.6%) women: area under the receiver-operating characteristics curve 0.812 (standard error 0.049; 95% CI, 0.716-0.908), sensitivity 0.69 (95% CI, 0.52-0.81), specificity 0.94 (95% CI, 0.88-0.97), positive likelihood ratio 11.3 (95% CI, 5.53-22.8) and negative likelihood ratio 0.34 (95% CI, 0.21-0.55).

CONCLUSIONS

Ultrasound diagnosis of BOTs is highly specific. However, typical features are absent in one-third of cases, which are typically misdiagnosed as benign lesions.

A balanced chromosomal translocation partially co-segregating with psychotic illness in a family

Psychotic illness was associated with an apparently balanced 6;11 chromosomal translocation in a three-generation family. The mother and son carrying the translocation suffer from a chronic psychotic illness, a daughter who was a translocation carrier committed suicide, and her twin daughters who both carry the translocation have not yet reached the age of risk for developing this psychiatric illness, although one has attempted suicide. Two older members of the family have the translocation and have never suffered from a psychiatric disorder. The pattern of dominant inheritance of the psychotic illness only occurring in individuals carrying the translocation suggests that there may be a major genetic component in the etiology of the psychosis in this family. Genes at the chromosomal break points may be candidate genes implicated in this particular form of psychotic illness.

A recent decrease in the time to development of monomorphous and polymorphous posttransplant lymphoproliferative disorder

We have noted a decrease in the time to development of posttransplant lymphoproliferative disorder (PTLD) over the last two and one-half years in our multiorgan transplant program. From February 1965 until December 1990, 1622 transplants were performed including 1489 kidneys (KTxp), 87 livers (LTxp), and 46 pancreata. Between February 1965 and July 1988 (group 1), there were 1260 transplants performed and nine cases of either monomorphous PTLD (M-PTLD, n = 8) or polymorphous PTLD (P-PTLD, n = 1) were diagnosed. The mean time to development of PTLD was 163 +/- 128 weeks, all after KTxp. Five of these nine patients received haploidentical living-related grafts. All patients had presented with advanced disease, none had transplant nephrectomy, and all died of their disease. Between July 1988 and December 1990 (group 2), 362 transplants were performed, and four cases of M-PTLD and three cases of P-PTLD were recognized. Of the seven cases of PTLD in group 2, six developed within 90 days posttransplant (early PTLD). The mean time to development of PTLD was 11 +/- 16 weeks. This was significantly earlier than group 1 (P less than .01). Four of the five cases after KTxp had a 1 or 2 DR-matched donor. Five of these seven patients had serological evidence of recent Epstein-Barr Virus infection, and four of these five had received OKT3 and then developed early PTLD. In group 2, three patients are alive 7-15 months after KTxp nephrectomy, the remaining four have died. We hypothesize that risk factors for the development of PTLD may include heavy immunosuppression, including the use of OKT3, good DR matching, and active EBV infection. Treatment should include graft removal, if applicable, and reduction or cessation of immuno-suppression.

Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome?

OBJECTIVE

The aim of this study was to assess the natural history of ultrasonically diagnosed ovarian dermoid cysts in a large group of women who were managed expectantly, and to assess the factors that were associated with failure of expectant management.

METHODS

Our database was searched for dermoid cysts diagnosed on ultrasonography by a single expert operator between 2001 and 2007 in this retrospective study. In women who opted for expectant management, demographic data including age, gravidity and parity were recorded. Indications for scan, site of cysts, dimensions and the outcomes of expectant management were also recorded.

RESULTS

Two hundred and eighty-nine women were diagnosed with a total of 323 dermoid cysts by a single expert ultrasound operator. 93/289 (32.2%; 95% CI, 26.8-37.6%) women with 105/323 (32.5%; 95% CI, 27.4-37.6%) ovarian dermoid cysts were managed expectantly for longer than 3 months. The mean age at diagnosis was 33.8 (range, 13-79) years and the median duration of follow up was 12.6 (interquartile range, 7.6-29.3) months. The mean growth rate of dermoid cysts during follow up was 1.67 mm/year. There were no demographic or morphological features that could be used to predict the growth rate of dermoid cysts. After a period of expectant management, 24/93 (25.8%; 95% CI, 16.9-34.7%) women had surgical intervention. The risk of surgical intervention was significantly increased in younger women, those of parity > or = 2 and in women with bilateral cysts or larger-diameter cysts, and reduced in women with a past history of ovarian cyst.

CONCLUSIONS

The success rate of expectant management of dermoid cysts is high and this approach should be considered as a viable alternative to surgical management.

Biodegradable polymeric scaffolds. Improvements in bone tissue engineering through controlled drug delivery

Recent advances in biology, medicine, and engineering have led to the discovery of new therapeutic agents and novel materials for the repair of large bone defects caused by trauma, congenital defects, or bone tumors. These repair strategies often utilize degradable polymeric scaffolds for the controlled localized delivery of bioactive molecules to stimulate bone ingrowth as the scaffold degrades. Polymer composition, hydrophobicity, crystallinity, and degradability will affect the rate of drug release from these scaffolds, as well as the rate of tissue ingrowth. Accordingly, this chapter examines the wide range of synthetic degradable polymers utilized for osteogenic drug delivery. Additionally, the therapeutic proteins involved in bone formation and in the stimulation of osteoblasts, osteoclasts, and progenitor cells are reviewed to direct attention to the many critical issues influencing effective scaffold design for bone repair.

Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section

OBJECTIVES

To investigate the prevalence and location of pelvic adhesions in women with a history of Cesarean section and to identify risk factors for their formation and symptoms associated with their presence.

METHODS

This was a prospective observational study of women in whom one or more Cesarean sections had been performed > 12 months previously and who attended for a gynecological ultrasound examination. In all women, both transvaginal and transabdominal scans were performed in order to identify the presence of pelvic adhesions. Medical and surgical history was recorded and a structured questionnaire was used to enquire about any history of pelvic pain and urinary symptoms.

RESULTS

A total of 308 women were recruited into the study. On ultrasound examination, 139 (45.1% (95% CI, 39.7-50.7%)) women showed evidence of adhesions within the pelvis. Adhesions in the vesicouterine pouch were the most common and were found in a total of 79 (25.6% (95% CI, 20.7-30.5%)) women. In women with a history of no surgery other than Cesarean section(s) (n = 220), an increasing number of Cesarean sections (odds ratio (OR) 3.4 (95% CI, 2.1-5.5)) and a postoperative wound infection (OR 11.7 (95% CI, 3.5-39.5)) increased the likelihood of adhesions developing in the anterior pelvic compartment. There was a significant association between the presence of anterior compartment adhesions and chronic pelvic pain. Multivariable logistic regression analysis identified anterior abdominal wall adhesions (OR 2.4 (95% CI, 1.0-5.9)) and any adhesions present on ultrasound scan (OR 2.6 (95% CI, 1.2-5.7)) as independent predictors of chronic pelvic pain.

CONCLUSIONS

Pelvic adhesions are present in more than a third of women with a history of Cesarean section and they are associated with chronic pelvic pain.