Long non-coding RNAs as emerging regulators of miRNAs and epigenetics in diabetes-related chronic kidney disease

Diabetes is one of the major cause of chronic kidney disease (CKD), including "diabetic nephropathy," and is an increasingly prevalent accelerator of the progression of non-diabetic forms of CKD. The long non-coding RNAs (lncRNAs) have come into the limelight in the past few years as one of the emerging weapons against CKD in diabetes. Available data over the past few years demonstrate the interaction of lncRNAs with miRNAs and epigenetic machinery. Interestingly, the evolving data suggest that lncRNAs play a vital role in diabetes-associated CKD by regulation of epigenetic enzymes such as DNA methyltransferase, histone deacetylases, and histone methyltransferases. LncRNAs are also engaged in the regulation of several miRNAs in diabetic nephropathy. Hence this review will elaborate on the association between lncRNAs and their interaction with epigenetic regulators involved in different aspects and thus the progression of CKD in diabetes.

Phloretin: a comprehensive review of its potential against diabetes and associated complications

OBJECTIVES

Phloretin is ubiquitous in apples (Malus domestica) and other fruits and has potential antidiabetic properties. Considering the preclinical potential of phloretin, its transition to clinical observations has unintentionally been neglected, particularly within the diabetic population. Furthermore, a comprehensive understanding of its pharmacokinetics remains elusive. This review seeks to offer valuable insights into phloretin's physical properties, pharmacokinetics, and pharmacodynamics, aiming to unveil opportunities for additional research on its therapeutic potential in the context of diabetes.

KEY FINDINGS

All pharmacokinetic reports of phloretin confirm that the utilization of phloretin gets enhanced during diabetic conditions. Phloretin targets pathomechanisms such as glucose transporter 4 (GLUT4) and peroxisome proliferator's activity-activated receptor-γ (PPAR-γ) to decrease insulin resistance in diabetic conditions. Moreover, phloretin targets inflammatory, oxidative, and apoptotic signaling to minimize the progression of diabetes-associated macro- and microvascular complications.

SUMMARY

The pleiotropic antidiabetic action of phloretin is mainly dependent on its pharmacokinetics. Nevertheless, further investigation into the altered pharmacokinetics of phloretin during diabetic conditions is essential. Additionally, the results derived from clinical studies utilized apples, apple extract, and supplements containing phloretin. Greater emphasis should be placed on future clinical studies to assess the potential of phloretin as a standalone compound.

ER stress modulated Klotho restoration: A prophylactic therapeutic strategy against acute kidney injury-diabetes comorbidity

Klotho is a renoprotective factor that is at the forefront of research as a potential therapeutic agent and biomarker of acute kidney injury (AKI). Endoplasmic reticulum (ER) stress and Klotho downregulation are the critical hallmarks of AKI progression. Importantly, the crosstalk between ER and Klotho is still elusive in AKI under diabetic condition. Therefore, this study aimed to elucidate the affiliation between ER stress and Klotho regulation by using the ischemia-reperfusion renal injury (IRI) model based on male Wistar rats and the hypoxia-reperfusion injury (HRI) using NRK52E cells. Study outcomes demonstrated that the expression of AKI biomarkers: plasma creatinine, neutrophil gelatinase-associated lipocalin, kidney-injury molecule 1, and ER stress markers such as binding immunoglobulin binding protein (BiP), R/PKR-like ER kinase (PERK), and eukaryotic initiation factor-2 (eIF2α), were observed during AKI. Increased ER stress was associated with apoptosis induction as depicted by increased levels of Poly (ADP-ribose) polymerase (PARP) and caspase-7 and decreased tubular Klotho expression. Under diabetic settings, ER stress and apoptosis were exacerbated by additional Klotho downregulation. Treatment with Tauroursodeoxycholic acid (TUDCA) inhibited the ER stress, apoptosis, restored endogenous Klotho levels and ameliorated AKI under diabetic and non-diabetic conditions. ER stress and Klotho appear to be shared factors involved in the pathogenesis of AKI-diabetes comorbidity and targeting them could prove a novel therapeutic approach.

Voclosporin: Unique Chemistry, Pharmacology and Toxicity Profile, and Possible Options for Implementation into the Management of Lupus Nephritis

Calcineurin inhibitors (CNI) can suppress allo- and autoimmunity by suppressing T cell function but also have anti-proteinuric effects by stabilizing the cellular components of the kidney's filtration barrier. Therefore, CNI are used in autoimmune kidney diseases with proteinuria. However, the traditional CNI, cyclosporine A and tacrolimus, have a narrow therapeutic range, need monitoring of drug levels, and their use is associated with nephrotoxicity and metabolic alterations. Voclosporin (VOC), a novel CNI, no longer requires drug level monitoring and seems to lack these adverse effects, although hypertension and drug-drug interactions still occur. VOC demonstrated efficacy superior to standard-of-care in controlling active lupus nephritis in the phase 2 AURA-LV and the phase 3 AURORA-1 trials and was approved for the treatment of active lupus nephritis. However, how to implement VOC into the current and changing treatment landscape of lupus nephritis is still debated. Here, we review the unique chemistry, pharmacology, and toxicity profile of VOC, summarize the efficacy and safety data from the AURA-LV and AURORA-1 trials, and discuss the following four possible options to implement VOC into the management of lupus nephritis, namely regarding B cell-targeting therapy with belimumab (BEL). These include: 1. patient stratification to either VOC or BEL, 2. VOC/BEL combination therapy, 3. VOC-BEL sequential therapy, or 4. alternative options for the rapid antiproteinuric effect of VOC.

Epigenetic regulation of mitochondrial-endoplasmic reticulum dynamics in kidney diseases

Kidney diseases are serious health problems affecting >800 million individuals worldwide. The high number of affected individuals and the severe consequences of kidney dysfunction demand an intensified effort toward more effective prevention and treatment. The pathophysiology of kidney diseases is complex and comprises diverse organelle dysfunctions including mitochondria and endoplasmic reticulum (ER). The recent findings prove interactions between the ER membrane and nearly all cell compartments and give new insights into molecular events involved in cellular mechanisms in health and disease. Interactions between the ER and mitochondrial membranes, known as the mitochondria-ER contacts regulate kidney physiology by interacting with each other via membrane contact sites (MCS). ER controls mitochondrial dynamics through ER stress sensor proteins or by direct communication via mitochondria-associated ER membrane to activate signaling pathways such as apoptosis, calcium transport, and autophagy. More importantly, these organelle dynamics are found to be regulated by several epigenetic mechanisms such as DNA methylation, histone modifications, and noncoding RNAs and can be a potential therapeutic target against kidney diseases. However, a thorough understanding of the role of epigenetic regulation of organelle dynamics and their functions is not well understood. Therefore, this review will unveil the role of epigenetic mechanisms in regulating organelle dynamics during various types of kidney diseases. Moreover, we will also shed light on different stress origins in organelles leading to kidney disease. Henceforth, by understanding this we can target epigenetic mechanisms to maintain/control organelle dynamics and serve them as a novel therapeutic approach against kidney diseases.

Nutraceuticals and network pharmacology approach for acute kidney injury: A review from the drug discovery aspect

Acute kidney injury (AKI) has become a global health issue, with ~12 million reports yearly, resulting in a persistent increase in morbidity and mortality rates. AKI pathophysiology is multifactorial involving oxidative stress, mitochondrial dysfunction, epigenetic modifications, inflammation, and eventually, cell death. Hence, therapies able to target multiple pathomechanisms can aid in AKI management. To change the drug discovery framework from "one drug, one target" to "multicomponent, multitarget," network pharmacology is evolving as a next-generation research approach. Researchers have used the network pharmacology approach to predict the role of nutraceuticals against different ailments including AKI. Nutraceuticals (herbal products, isolated nutrients, and dietary supplements) belong to the pioneering category of natural products and have shown protective action against AKI. Nutraceuticals have recently drawn attention because of their ability to provide physiological benefits with less toxic effects. This review emphasizes the nutraceuticals that exhibited renoprotection against AKI and can be used either as monotherapy or adjuvant with conventional therapies to boost their effectiveness and lessen the adverse effects. Additionally, the study sheds light on the application of network pharmacology as a cost-effective and time-saving approach for the therapeutic target prediction of nutraceuticals against AKI.

Hippo signaling in acute kidney injury to chronic kidney disease transition: current understandings and future targets

Acute kidney injury (AKI)-to-chronic kidney disease (CKD) transition is a slow but persistent progression toward end-stage kidney disease. Earlier reports have shown that Hippo components, such as Yes-associated protein (YAP) and its homolog TAZ (Transcriptional coactivator with PDZ-binding motif), regulate inflammation and fibrogenesis during the AKI-to-CKD transition. Notably, the roles and mechanisms of Hippo components vary during AKI, AKI-to-CKD transition, and CKD. Hence, it is important to understand these roles in detail. This review addresses the potential of Hippo regulators or components as future therapeutic targets for halting the AKI-to-CKD transition.

Concomitant inhibition of TLR-4 and SGLT2 by phloretin and empagliflozin prevents diabetes-associated ischemic acute kidney injury

Toll-like receptor-4 (TLR4) and sodium-glucose co-transporter 2 (SGLT2) signaling is involved in the pathogenesis of diabetes-associated kidney diseases. The purpose of this study was to explore the role and effect of phloretin, a TLR4 inhibitor, as an adjuvant therapy to empagliflozin, an SGLT2 inhibitor, in ischemic acute kidney injury (AKI) under diabetic conditions. To achieve this, firstly we induced type 1 diabetes using streptozotocin (55 mg per kg per intraperitoneally (i.p.)) followed by performing bilateral ischemia-reperfusion kidney injury to induce AKI in male Wistar rats. Treatment with phloretin (50 and 100 mg per kg per orally) and empagliflozin (10 mgper kg per orally) alone or in combination was administered to the diabetic rats for 4 days and 1 h before surgery. Moreover, a hypoxia-reperfusion injury was induced using sodium azide in NRK52E cells under a hyperglycemic environment to mimic the in vivo model. The cells were treated with phloretin (50 μM) and empagliflozin (100 nM) for 24 h. For biochemical analysis, plasma and urine samples were used. The kidney tissues were used to perform immunoblotting, histopathology, and immunohistochemistry. Other experiments like immunofluorescence, cell viability assay, and flow cytometry analysis were performed using the in vitro samples. The study outcomes revealed that compared to monotherapy, combination therapy of phloretin and empagliflozin was significantly effective. Phloretin and empagliflozin target the HMGB1/TLR4/MyD88/IK-β/α/NF-κB pathway to reduce inflammation and apoptosis, in addition to their antihyperglycemic effect. Thus, phloretin, a natural dietary supplement, as an adjuvant therapy to empagliflozin can be helpful to reduce empagliflozin-associated side effects, by reducing its clinical dose and increasing its therapeutic efficacy in AKI-diabetes comorbidity.

Lupus Nephritis: New and Emerging Biologic and Targeted Therapies

Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE), a polyclonal systemic autoimmunity directed against nuclear and other self-antigens. SLE/LN affects mostly females during childbearing age, which puts them at risk for the progression of chronic kidney disease (CKD), cardiovascular disease, and pregnancy complications. The current management of LN involves the use of drugs with significant toxicities, and despite many attempts at novel drug interventions, the overall treatment efficacy has remained low. In this article, we discuss recent drug approvals and the upcoming pipeline of novel medications tested in clinical trials to improve effectiveness in terms of LN disease activity, LN relapse, and progression of LN-related CKD. In this context, we discuss (1) drugs with the potential to achieve these treatment goals by modulating SLE activity as the driving force for LN (e.g., belimumab, obinutuzumab, anifrolumab, and others); (2) drugs with SLE-non specific renoprotective effects by targeting non-immune mechanisms of LN progression (dapagliflozin, empagliflozin); and (3) drugs with dual immunosuppressive and antiproteinuric effects (voclosporin). Increasing the number of possible drug options will help to improve the management of LN in terms of efficacy and safety, and enable a more personalized treatment approach.

How to use COVID-19 antiviral drugs in patients with chronic kidney disease

Antiviral drugs such as Remdesivir (Veklury), Nirmatrelvir with Ritonavir (Paxlovid), Azvudine, and Molnupiravir (Lagevrio) can reduce the risk for severe and fatal Coronavirus Disease (COVID)-19. Although chronic kidney disease is a highly prevalent risk factor for severe and fatal COVID-19, most clinical trials with these drugs excluded patients with impaired kidney function. Advanced CKD is associated with a state of secondary immunodeficiency (SIDKD), which increases the susceptibility to severe COVID-19, COVID-19 complications, and the risk of hospitalization and mortality among COVID-19 patients. The risk to develop COVID-19 related acute kidney injury is higher in patients with precedent CKD. Selecting appropriate therapies for COVID-19 patients with impaired kidney function is a challenge for healthcare professionals. Here, we discuss the pharmacokinetics and pharmacodynamics of COVID-19-related antiviral drugs with a focus on their potential use and dosing in COVID-19 patients with different stages of CKD. Additionally, we describe the adverse effects and precautions to be taken into account when using these antivirals in COVID-19 patients with CKD. Lastly, we also discuss about the use of monoclonal antibodies in COVID-19 patients with kidney disease and related complications.

Diabetes and Cardiorenal Complications: A Clinical Review of Existing Therapies and Novel Combinations, Focusing on SGLT2 Inhibitors

Type 2 diabetes mellitus (T2DM) is a set of metabolic disorders specified by hyperglycemia as a result of abnormalities in insulin secretion or sensitivity. Chronic kidney disease (CKD) and cardiovascular disease (CVD) are the widespread co-morbidities of T2DM and share risk factors for onset and progression. Despite numerous mono- and combination therapies exist, the progression of diabetes complications remains a global health concern. Treatment options for diabetic- CKD and CVD include drugs targeting hyperglycemia, hypertension, albuminuria, hyperlipidemia and the renin-angiotensin aldosterone system (RAAS). The sodium-glucose co-transporter 2 channel (SGLT2) is abundantly present in proximal tubules of the kidney and its capacity to recover glucose and sodium from the glomerular filtrate limits urinary glucose and sodium excretion. SGLT2 inhibitors (SGLT2i) reduce sodium and glucose reabsorption in the proximal and thus increase urinary glucose excretion in T2DM. SGLT2i monotherapy can improve but dual SGLT2/RAAS inhibition or SGLT2i along with other classes of drugs are more effective in protecting the kidneys and the cardiovascular system in patients with and without diabetes. Combinations such as empagliflozin and linagliptin, ertugliflozin and metolazone, dapagliflozin and sacubitril- valsartan and many more show promising results. Here, we have reviewed the ongoing and completed clinical trials, addressed current theories, and discussed necessary future research to explain the possible risks and benefits of using an SGLT2i alone and in combination with existing antidiabetic drugs and drugs acting on the cardiovascular system.

Role of endoplasmic reticulum stress and autophagy in the transition from acute kidney injury to chronic kidney disease

Acute kidney injury (AKI) and chronic kidney disease (CKD) are global health concerns with increasing rates in morbidity and mortality. Transition from AKI-to-CKD is common and requires awareness in the management of AKI survivors. AKI-to-CKD transition is a main risk factor for the development of cardiovascular disease and progression to end-stage kidney disease. The mechanisms driving AKI-to-CKD transition are being explored to identify potential molecular and cellular targets for renoprotective drug interventions. Endoplasmic reticulum (ER) stress and autophagy are involved in the process of AKI-to-CKD transition. Excessive ER stress results in the persistent activation of unfolded protein response, which is an underneath cause of kidney cell death. Moreover, ER stress modulates autophagy and vice-versa. Autophagy is a degradation defensive mechanism protecting cells from malfunction. However, the underlying pathological mechanism involved in this interplay in the context of AKI-to-CKD transition is still unclear. In this review, we discuss the crosstalk between ER stress and autophagy in AKI, AKI-to-CKD transition, and CKD progression. In addition, we explore possible therapeutic targets that can regulate ER stress and autophagy to prevent AKI-to-CKD transition to improve the long-term prognosis of AKI survivors.

Surgical Treatment of Catamenial Chest Pain: Excision of diaphragmatic endometriosis during robot-assisted laparoscopic surgery

Background

10% of women of reproductive age are affected by endometriosis, and diaphragmatic endometriosis represents 1-1.5% of these cases. Diaphragmatic endometriotic lesions often require surgical treatment.

Objective

This video aims to demonstrate the appearance of diaphragmatic endometriosis and describe our experience with robot-assisted laparoscopic excision of full thickness diaphragmatic endometriosis.

Materials and Methods

The patient was a 37-year-old female with the complaint of cyclical right shoulder pain (for 1 year). She previously had caesarean section scar and umbilical endometriosis excision procedures. The magnetic resonance imaging (MRI) of the abdomen highlighted three endometriotic nodules, one of which was described as full thickness on the right hemi-diaphragm. The patient underwent a robot-assisted laparoscopic endometriosis surgery as a joint procedure between the gynaecology and general surgery teams. The falciform ligament was completely divided to obtain full views of the endometriotic lesions on the diaphragm. Superficial diaphragmatic lesions were first excised. The larger deep nodule, which was described on the MRI, was then excised with the full thickness of diaphragm. Pleural cavity was entered intentionally to achieve complete excision of the nodule. Laparoscopic assessment of the right lower pleural cavity through this opening did not show any endometriotic lesions. After the excision, the diaphragm was repaired with a barbed suture. Negative pressure suction of the pleural cavity was performed at the end of this repair instead of using a chest tube.

Results

The patient was discharged on the 3rd day with no complications encountered. Histopathological examination confirmed endometriosis. The patient was asymptomatic three months after surgery.

Conclusion

Robotic-assisted surgery is an easy and safe choice especially in such challenging dual compartment surgeries by providing a 3D view that abolishes sensory loss and increases depth perception, providing better manoeuvrability with tremor absence.

V-NOTES hysterectomy under spinal anaesthesia: A pilot study

Background: Spinal anaesthesia has not been widely adopted for laparoscopic surgeries until now. There are a few studies that have shown that spinal anaesthesia is at least as safe as general anaesthesia. The need for additional analgesics can be reduced by utilising early postoperative analgesic effects of spinal anaesthesia, and maximum benefit can be obtained from minimally invasive approaches when V-NOTES surgery is performed under spinal anaesthesia. Objective: Combining V-NOTES with spinal anaesthesia to improve minimally invasive surgical techniques and provide maximum benefit to patients. Materials and methods: Patients who were found to have benign pelvic organ pathologies, required a hysterectomy and were considered suitable for V-NOTES hysterectomy under spinal anaesthesia were included in this study. Spinal anaesthesia was achieved with 12.5 mg 0.5% hyperbaric bupivacaine in the sitting position. Perioperative events and complications related to spinal anaesthesia were noted. Postoperatively, the pain was evaluated using a visual analogue scale at the 6th, 12th, and 24th hours. Main outcome measures: To evaluate the feasibility and safety of spinal anaesthesia in VNOTES hysterectomy and to increase the advantages of minimally invasive surgical procedures. Results: No conversion to conventional laparoscopy or laparotomy was required in all six operated patients. Conversion from spinal anaesthesia to general anaesthesia was unnecessary, and no major perioperative incident occurred in any of the cases. Conclusion: In the current study by our team, we demonstrated that V-NOTES hysterectomy could be performed safely under spinal anaesthesia in well-selected patients. The need for additional analgesics can be reduced by utilising early postoperative analgesic effects of spinal anaesthesia, and maximum benefit can be obtained from minimally invasive approaches when VNOTES surgery is performed under spinal anaesthesia. What is new? V-NOTES hysterectomy could be performed safely under spinal anaesthesia in well-selected patients.

Obturator nerve endometriosis: A systematic review of the literature

BACKGROUND

Symptomatic obturator nerve endometriosis is a rare condition. In this paper, we aim to review and discuss the characteristics of obturator nerve endometriosis in light of current literature.

METHODS

An electronic search was conducted using the PubMed/Medline database.

RESULTS

Symptomatic obturator nerve endometriosis is rare; only 8 cases have been reported in the literature. Symptoms including difficulty walking, weak thigh adduction and pain in the inner thigh, which are all related to obturator nerve function, could be seen in the case of the entrapment of the nerve by endometrial nodules. A history of recurrent symptoms during menstrual cycles and physical examination, combined with appropriate radiologic imaging, led to a suspicion of obturator nerve involvement.

CONCLUSION

Early diagnosis and surgical treatment of obturator nerve endometriosis is essential to minimise the nerve damage caused by recurrent cycles of bleeding and fibrosis, which are characteristics of endometriosis. The laparoscopic minimally invasive technique is feasible for the surgery of obturator nerve endometriosis. It offers the advantage of precise discrimination of vital structures and excellent access to deep anatomic sites.

WHAT IS NEW?

Obturator nerve endometriosis may be a severe cause of chronic pelvic pain in women of reproductive age. Treatment may be achieved surgically and in experienced hands, laparoscopic surgery would be the preferred choice.

Klotho restoration via ACE2 activation: A potential therapeutic strategy against acute kidney injury-diabetes comorbidity

Acute kidney injury (AKI) is a collection of clinical syndromes with persistent increases in morbidity and mortality rates. Hyperglycemia is a risk factor for AKI development. Renin-angiotensin-aldosterone system (RAS) disequilibrium and Klotho downregulation also play a pivotal role in the pathogenesis of AKI. Moreover, the relationship between Klotho and ACE2 (a component of non-conventional RAS) regulation in AKI remains an unexplored area of research. Hence, in this study, we investigated ACE2 and Klotho regulation in AKI using ischemic Wistar rats and NRK52E cells under normal and hyperglycemic conditions. Our findings suggested that hyperglycemia exacerbates renal ischemia-reperfusion injury (IRI)/hypoxia-reperfusion injury (HRI) induced AKI. Systemic and renal Klotho deficiency is a novel hallmark of AKI. Additionally, ACE2 is a protective component of the RAS, and its inhibition/deficiency leads to inflammation, apoptosis, Klotho downregulation, and thus AKI development. However, ACE2 activation resulted in the amelioration of AKI. Importantly, ACE2 plays an important role in Klotho upregulation, which might act as an intermediate for ACE2-mediated reno-protection. In conclusion, ACE2 activator i.e. DIZE restored endogenous ACE2-Ang-(1-7)-Klotho level, inhibited apoptosis and inflammation, and ameliorates IRI/HRI induced AKI under diabetic and non-diabetic conditions. Hence, in future, targeting ACE2-Ang-(1-7)-Klotho axis may prove a novel therapeutic strategy against AKI, where further preclinical and clinical investigations are required to verify the clinical potential of this finding.

Receptor-mediated mitophagy: An emerging therapeutic target in acute kidney injury

Acute kidney injury (AKI) is a global health concern associated with high morbidity and mortality. AKI etiology is linked to mitochondrial dysfunction along with oxidative stress and inflammation. The defective mitochondria are removed via mitophagy for maintaining cellular integrity. The main regulatory mechanisms of mitophagy in response to different stressors are Phosphatase and tensin homolog-induced kinase 1 (PINK1)/Parkin and receptor-mediated. Receptors like B-cell lymphoma 2/adenovirus E1B-interacting protein (BNIP3), BNIP3L, prohibitin2, tacrolimus (FK506)-binding protein8 (FKBP8), autophagy-beclin1-regulator1 (AMBRA1) and SMAD-ubiquitination regulatory factor1 (SMURF1), etc. participate in receptor-mediated mitophagy. In recent studies, receptor-mediated mitophagy showed protective effects in AKI. This review summarizes the evidence related to mitophagy in AKI and outlines the significance of receptor-mediated mitophagy modulation as a possible therapeutic approach in AKI.

Diabetes and Cardiorenal Complications: A Clinical Review of Existing Therapies and Novel Combinations, Focusing on SGLT2 Inhibitors

Type 2 diabetes mellitus (T2DM) is a set of metabolic disorders specified by hyperglycemia as a result of abnormalities in insulin secretion or sensitivity. Chronic kidney disease (CKD) and cardiovascular disease (CVD) are the widespread co-morbidities of T2DM and share risk factors for onset and progression. Despite numerous mono- and combination therapies exist, the progression of diabetes complications remains a global health concern. Treatment options for diabetic- CKD and CVD include drugs targeting hyperglycemia, hypertension, albuminuria, hyperlipidemia and the renin-angiotensin aldosterone system (RAAS). The sodium-glucose co-transporter 2 channel (SGLT2) is abundantly present in proximal tubules of the kidney and its capacity to recover glucose and sodium from the glomerular filtrate limits urinary glucose and sodium excretion. SGLT2 inhibitors (SGLT2i) reduce sodium and glucose reabsorption in the proximal and thus increase urinary glucose excretion in T2DM. SGLT2i monotherapy can improve but dual SGLT2/RAAS inhibition or SGLT2i along with other classes of drugs are more effective in protecting the kidneys and the cardiovascular system in patients with and without diabetes. Combinations such as empagliflozin and linagliptin, ertugliflozin and metolazone, dapagliflozin and sacubitril-valsartan and many more show promising results. Here, we have reviewed the ongoing and completed clinical trials, addressed current theories, and discussed necessary future research to explain the possible risks and benefits of using an SGLT2i alone and in combination with existing antidiabetic drugs and drugs acting on the cardiovascular system.

Cyproheptadine, a SET7/9 inhibitor, reduces hyperglycaemia-induced ER stress alleviating inflammation and fibrosis in renal tubular epithelial cells

CONTEXT

Persistent hyperglycaemia increases SET7/9 expression and endoplasmic reticulum (ER) stress which causes inflammation, apoptosis, and fibrosis in renal tubular epithelial cells leading to diabetic kidney disease (DKD).

OBJECTIVE

Current study explores the renoprotective potential of a novel SET7/9 inhibitor, Cyproheptadine, and the underlying molecular mechanisms in hyperglycaemia-induced renal tubular epithelial cell injury.

METHODS

Change in expression of SET7/9, histone H3 lysine (K4) monomethylation (H3K4Me1), inflammatory, fibrotic, and ER stress proteins were evaluated in-vivo and in-vitro. NRK-52E cells were used to study the preventive effect of Cyproheptadine against hyperglycaemia-induced ER stress and subsequent inflammation and fibrosis.

RESULTS

SET7/9 and H3K4Me1 expression significantly increased with ER stress, inflammation, apoptosis, and fibrosis, in-vivo and in-vitro under hyperglycaemia. However, the cells treated with Cyproheptadine showed significant suppression of H3K4Me1 and reduction in ER stress, inflammation, apoptosis, and fibrosis.

CONCLUSION

Cyproheptadine prevented hyperglycaemia-induced renal fibrosis and inflammation by reducing H3K4Me1 expression and ER stress.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Epigenetic regulation of Toll-like receptors 2 and 4 in kidney disease

Kidney disease affects more than 10% of the worldwide population and causes significant morbidity and mortality. Epigenetic mechanisms such as DNA methylation, histone modifications, and non-coding RNAs (ncRNAs) play a pivotal role in the progression of kidney disease. These epigenetic mechanisms are reversible and majorly involved in regulating gene expression of inflammatory, fibrotic, and apoptotic proteins. Emerging data suggest that the Toll-like receptor 2 and Toll-like receptor 4 (TLR2 and TLR4) are expressed by almost all types of kidney cells and known for promoting inflammation by recognizing damage-associated molecular proteins (DAMPs). Epigenetic mechanisms regulate TLR2 and TLR4 signaling in various forms of kidney disease where different histone modifications promote the transcription of the TLR2 and TLR4 gene and its ligand high mobility group box protein 1 (HMGB1). Moreover, numerous long non-coding RNAs (LncRNAs) and microRNAs (miRNAs) modulate TLR2 and TLR4 signaling in kidney disease. However, the precise mechanisms behind this regulation are still enigmatic. Studying the epigenetic mechanisms involved in the regulation of TLR2 and TLR4 signaling in the development of kidney disease may help in understanding and finding novel therapeutic strategies. This review discusses the intricate relationship of epigenetic mechanisms with TLR2 and TLR4 in different forms of kidney diseases. In addition, we discuss the different lncRNAs and miRNAs that regulate TLR2 and TLR4 as potential therapeutic targets in kidney disease.

Inhibition of endoplasmic reticulum stress combined with activation of angiotensin-converting enzyme 2: novel approach for the prevention of endothelial dysfunction in type 1 diabetic rats

Persistent hyperglycemia in type 1 diabetes triggers numerous signaling pathways, which may prove deleterious to the endothelium. As hyperglycemia damages the endothelial layer via multiple signaling pathways, including enhanced oxidative stress, downregulation of angiotensin-converting enzyme 2 signaling, and exacerbation of endoplasmic reticulum (ER) stress, it becomes difficult to prevent injury using monotherapy. Thus, the present study was conceived to evaluate the combined effect of ER stress inhibition along with angiotensin-converting enzyme 2 activation, two major contributors to hyperglycemia-induced endothelial dysfunction, in preventing endothelial dysfunction associated with type 1 diabetes. Streptozotocin-induced diabetic animals were treated with either diminazene aceturate (5 mg·kg-1 per day, p.o.) or tauroursodeoxycholic acid, sodium salt (200 mg·kg-1 per day i.p.), or both for 4 weeks. Endothelial dysfunction was evaluated using vasoreactivity assay, where acetylcholine-induced relaxation was assessed in phenylephrine pre-contracted rings. Combination therapy significantly improved vascular relaxation when compared with diabetic control as well as monotherapy. Restoration of nitrite levels along with prevention of collagen led to improved vasodilatation. Moreover, there was an overall reduction in aortic oxidative stress. We conclude that by simultaneously inhibiting ER stress and activating angiotensin-converting enzyme 2 deleterious effects of hyperglycemia on endothelium were significantly alleviated. This could serve as a novel strategy for the prevention of endothelial dysfunction.

Klotho in kidney diseases: A crosstalk between the renin-angiotensin system and endoplasmic reticulum stress

Klotho is a transmembrane anti-ageing protein that exists in three forms, i.e., α-Klotho, β-Klotho, and γ-Klotho with distinct organ-specific expression and functions in the body. Here we focus on α-Klotho (mentioned as 'Klotho' only), abundantly expressed by the distal and proximal convoluted tubules of the kidney. Significant decline in systemic and renal Klotho level is a new hallmark for kidney disease progression. Emerging research portrays Klotho as a promising diagnostic as well as a therapeutic target for diabetic and non-diabetic kidney disease. Even so, the underlying mechanisms of Klotho regulation and the strategies to restore its systemic as well as the renal level are still lacking. Angiotensin-converting enzyme inhibitors (ACEi) and/or angiotensin receptor blockers (ARBs) are the current standard of care for kidney diseases where the molecular mechanisms for their nephroprotective action are still ambiguous. Moreover, endoplasmic reticulum stress (ER stress) also plays a crucial role in kidney disease progression. Few studies have claimed that RAAS has a direct relation with ER stress generation and vice versa in kidney disease. Interestingly, RAAS and ER stress modulation is associated with Klotho regulation in kidney disease. Here we focus on how the RAAS and ER stress connects with Klotho regulation in kidney disease. We also discuss Klotho and ER stress in an alliance with the concept of hemodynamic and metabolic overload in kidney disease. In addition, we highlight novel approaches to implement Klotho as a therapeutic target via RAAS and ER stress modulation for the treatment of diabetic and non-diabetic kidney disease.

Klotho: A possible mechanism of action of SGLT2 inhibitors preventing episodes of acute kidney injury and cardiorenal complications of diabetes

Diabetes and cardiorenal comorbidities are major global health concerns, with high economic burdens and mortality rates. Sodium glucose co-transporter-2 inhibitors (SGLT2is) are novel US Food and Drug Administration (FDA)-approved antihyperglycemics with unexpected protective potential against cardiorenal diseases in patients with or without type 2 diabetes mellitus (T2DM). Despite initial concerns, the incidence of episodes of acute kidney injury (AKI) was significantly lower in patients taking SGLT2i compared with other therapies or placebo. Evolving data suggest a link between SGLT2is and the anti-aging protein Klotho in the amelioration of diabetes and cardiorenal diseases. Here, we consider Klotho and SGLT2is as a novel therapeutic approach for the management of AKI and other cardiorenal complications in patients with or without diabetes.

Epigenetic and non-epigenetic regulation of Klotho in kidney disease

Klotho is a novel renoprotective anti-aging protein available in membrane-bound or soluble form. Klotho is expressed in brain, pancreas, and other solid organs but shows highest expression levels in the kidney. Klotho sustains normal kidney physiology but Klotho regulation also contributes to the progression of kidney disease. Systemic and intrarenal levels of Klotho fall drastically during acute kidney injury, kidney fibrosis, diabetic nephropathy, and other forms of chronic kidney disease, etc. Moreover, exogenous supplementation or overexpression of endogenous Klotho attenuates kidney disease. The regulation of endogenous Klotho expression involves epigenetic as well as non-epigenetic mechanisms. The epigenetic modifications such as DNA methylation, post-translational histone modifications, miRNAs regulate the change in Klotho expression in kidney disease. Non-epigenetic mechanisms such as ER stress, Wnt signaling, activation of the renin angiotensin system (RAS), excessive reactive oxygen species and cytokine generation, albumin overload, and PPAR-γ signaling also contribute to Klotho regulation. Evolving evidence highlight the capacity of natural products to regulate Klotho expression in kidney disease. All these preclinical data suggest that Klotho could be a novel biomarker as well as therapeutic target. Here we review the different mechanisms of Klotho regulation in the context of Klotho as a biomarker and potential therapeutic agent.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Evidence for Use or Disuse of Renin-Angiotensin System Modulators in Patients Having COVID-19 With an Underlying Cardiorenal Disorder

Coronavirus disease 19 (COVID-19) originated in Wuhan, China, in December 2019 has been declared pandemic by World Health Organization due to an exponential rise in the number of infected and deceased persons across the globe. Emerging reports suggest that susceptibility and mortality rates are higher in patients with certain comorbidities when compared to the average population. Cardiovascular diseases and diabetes are important risk factors for a lethal outcome of COVID-19. Extensive research ensuing the outbreak of coronavirus-related severe acute respiratory syndrome in the year 2003, and COVID-19 recently revealed a role of renin-angiotensin system (RAS) components in the entry of coronavirus wherein angiotensin-converting enzyme 2 (ACE2) had garnered the significant attention. This raises the question whether the use of RAS inhibitors, the backbone of treatment of cardiovascular, neurovascular, and kidney diseases could increase the susceptibility for coronavirus infection or unfortunate outcomes of COVID-19. Thus, currently, there is a lack of consensus regarding the effects of RAS inhibitors in such patients. Moreover, expert bodies like American Heart Association, American College of Cardiology, and so on have now released official statements that RAS inhibitors must be continued, unless suggested otherwise by a physician. In this brief review, we will elaborate on the role of RAS and ACE2 in pathogenesis of COVID-19. Moreover, we will discuss the potential effect of the use and disuse of RAS inhibitors in patients having COVID-19 with cardiometabolic comorbidities.

New method: Are tumor markers in vaginal-washing fluid significant in the diagnosis of primary ovarian carcinoma?

OBJECTIVE

Ovarian cancer is the seventh most common cancer in women worldwide, with nearly a quarter of a million women diagnosed every year. The serum tumor markers cancer antigens CA 125, CA 19-9, and carcinoembryonic antigen (CEA) are potentially of clinical value for the diagnosis of ovarian cancer. A diagnostic tool that is noninvasive, simple to perform, and specific is needed to predict primary ovarian cancer. The purpose of this study was to evaluate the diagnostic sensivitity and specificity of vaginal-washing tumor markers CA 125, CA 19-9, and CEA for diagnosis of primary ovarian cancer.

MATERIALS AND METHODS

In the current prospective study, 30 patients with advanced primary ovarian cancer and 30 patients with benign ovarian cysts were enrolled. The vaginal-washing fluid samples were obtained the day before surgery and were immediately centrifuged and stored at -80 degrees C until analysis. Measurements of CA 125, CA 19-9, and CEA were determined using fully-automated chemiluminescent microparticle immunoassays.

RESULTS

The vaginal fluid concentrations of CA 125, CA 19-9, and CEA in patients with primary ovarian carcinoma were significantly higher (p < 0.001) compared to those in patients with benign adnexal masses (p < 0.001). In the ROC curve analysis, the optimal cut-off values for the detection of primary ovarian cancer were >295 for CA 125 (p < 0.001), > 101 for CA 19-9 (p < 0.001), and >135 for CEA (p < 0.001).

CONCLUSION

Vaginal-washing tumor markers CA 125, CA 19-9, and CEA are simple, noninvasive, and reliable diagnostic tests for the detection of primary ovarian cancer.

Single-port access total laparoscopic hysterectomy with Korean-made OCTO Port: Turkish surgeons' initial experience

We present our initial experience with single-port access total laparoscopic hysterectomy (TLH) surgery using a Korean-made laparoscopic port (OCTO™ Port). In a retrospective study, single-port access TLH (SPA-TLH) with the OCTO Port was performed on 34 patients with benign gynaecological indications from July 2013 to May 2014 by two surgeons (Ahmet Kale and Hasan Terzi). All patients were divided into two groups. The first 15 patients who underwent SPA-TLH were classified as Group 1, and the second 19 patients who underwent SPA-TLH were classified as Group 2. Patient data were analyzed for age, body mass index (BMI, kg/m(2)), weight of uterus, vaginal cuff suturation time, estimated blood loss, operation time, hysterectomy indications and operative outcomes. The median time needed for the surgery was 75 min in both groups. The duration of suturing of the vaginal cuff was shorter in Group 2 compared with that in Group 1. The estimated blood loss was less in Group 2 compared with Group 1: Four patients in Group 1 required blood transfusion while none of the patients in Group 2 required blood transfusion. The OCTO Port has soft and flexible instrumental movements, which can reduce crowding of instruments during surgery, and the cap rotates 360 degrees. The OCTO Port might facilitate the learning curve of single-port laparoscopic hysterectomy surgery.

Uterine artery ligation at the beginning of total laparoscopic hysterectomy reduces total blood loss and operation duration

The purpose of this study was to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom uterine arteries were not ligated at the beginning of TLH. In our prospective study, a total of 60 women underwent TLH. Uterine artery ligation (UAL) was done at the beginning of the procedure. Women were divided into TLH + UAL (n = 30) and TLH (n = 30) groups. In TLH group, TLH was done without ligating the uterine arteries at the beginning of the procedure. In TLH + UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. The mean operating time was longer for the TLH group (99.16 ± 7.01) than TLH + UAL group (63.27 ± 7.16). The median total blood loss was higher in TLH group (109.38 ± 33.03 mL) than TLH + UAL group (47.50 ± 8.12 mL). UAL at the beginning of TLH is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure and length of hospital stay.

Effects of ROCK inhibitor Y27632 and EGFR inhibitor PD168393 on human neural precursors co-cultured with rat auditory brainstem explant

Hearing function lost by degeneration of inner ear spiral ganglion neurons (SGNs) in the auditory nervous system could potentially be compensated by cellular replacement using suitable donor cells. Donor cell-derived neuronal development with functional synaptic formation with auditory neurons of the cochlear nucleus (CN) in the brainstem is a prerequisite for a successful transplantation. Here a rat auditory brainstem explant culture system was used as a screening platform for donor cells. The explants were co-cultured with human neural precursor cells (HNPCs) to determine HNPCs developmental potential in the presence of environmental cues characteristic for the auditory brainstem region in vitro. We explored effects of pharmacological inhibition of GTPase Rho with its effector Rho-associated kinase (ROCK) and epidermal growth factor receptor (EGFR) signaling on the co-cultures. Pharmacological agents ROCK inhibitor Y27632 and EGFR blocker PD168393 were tested. Effect of the treatment on explant penetration by green fluorescent protein (GFP)-labeled HNPCs was evaluated based on the following criteria: number of GFP-HNPCs located within the explant; distance migrated by the GFP-HNPCs deep into the explant; length of the GFP+/neuronal class III β-tubulin (TUJ1)+ processes developed and phenotypes displayed. In a short 2-week co-culture both inhibitors had growth-promoting effects on HNPCs, prominent in neurite extension elongation. Significant enhancement of migration and in-growth of HNPCs into the brain slice tissue was only observed in Y27632-treated co-cultures. Difference between Y27632- and PD168393-treated HNPCs acquiring neuronal fate was significant, though not different from the fates acquired in control co-culture. Our data suggest the presence of inhibitory mechanisms in the graft-host environment of the auditory brainstem slice co-culture system with neurite growth arresting properties which can be modulated by administration of signaling pathways antagonists. Therefore the co-culture system can be utilized for screens of donor cells and compounds regulating neuronal fate determination.

Morphometric analysis of the infraorbital foramen and its localization relative to surgical landmarks

AIM

The infraorbital foramen (IOF) is an important anatomic landmark for maxillofacial surgery; therefore, its location should be well documented. In morphometric analyses of the IOF, various methods have been applied and differences have been found among the results of the measurements. The aim of this study was to facilitate localization of the IOF during clinical practice.

METHODS

In the current study, in order to perform anatomic and morphometric analyses of the IOF, 112 skulls were used. The shortest distance from each IOF to certain determined points was identified and measured by digital calipers.

RESULTS

The longest and the shortest diameters of the IOF were measured as 4.21±0.91 mm and 3.11±0.62 mm, respectively. The shortest distances between the IOF and the landmarks were measured as follows: the maxillary mid-line (ML) as 28.47±2.49 mm; the supraorbital foramen/supraorbital notch (SOF/SON) as 43.43±3.39 mm; the lower end of the nasomaxillary suture (LENS) as 26.47±3.05 mm; the lower end of the alveolar juga of the canines (LAJC) as 31.62±3.09 mm; the infra-orbital margin (IOM) as 6.98±1.72 mm; and the opposite IOF as 56.85±3.89 mm.

CONCLUSION

Among the landmarks, the most useful ones in clinical practice might be the distances between the IOF and the IOM, IOF and LAJC, and even IOF and ML. SOF/SON and LENS provide more accurate localization when they are used together with the other parameters. Moreover, their importance increases when other parameters are not available for use (because of fractures or damage).

Amniotic fluid amino acid concentrations in fetal skeletal dysplasia

The authors' objective was to measure amniotic fluid amino acid concentrations in pregnant women diagnosed as having fetuses with skeletal dysplasia in the second trimester of pregnancy. Eighteen pregnant women who had fetuses with with skeletal dysplasia detected by ultrasonography (skeletal dysplasia) in the second trimester and 35 women who had abnormal triple screenings indicating an increased risk for Down syndrome, but had healthy fetuses (control group), were enrolled in the study. Amniotic fluid was obtained by amniocentesis. The chromosomal analysis of the study and control groups was normal. Levels of free amino acids and non-essential amino acids were measured in amniotic fluid samples using GC/FID free (physiological) amino acid kit by gas chromatography. The mean levels of essential amino acids (histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine) in amniotic fluid were found to be significantly lower in fetuses with skeletal dysplasia than in the control group (p < 0.05). The detection of significantly lower amino acid concentrations in the amniotic fluid of fetuses with a skeletal dysplasia compared to healthy fetuses suggests amino acid deficiency may play an etiological role in the pathogenesis of skeletal dysplasia.

Sublingual misoprostol is better for cervical ripening prior to hysteroscopy in post-menopausal women

BACKGROUND

The aim of the present study was to evaluate the efficacy of misoprostol administered sublingually, vaginally or rectally on cervical ripening before hysterescopic surgery in post-menopausal women.

MATERIALS AND METHODS

Post-menopausal women were randomised to receive either 400 ug of misoprostol, administered sublingually, vaginally or rectally six hours and 12 hours prior to operative hysterescopy.

RESULTS

Patients were randomized to receive receive sublingual (n = 30), rectal (n = 30) or vaginal (n = 30) misoprostol. The control group did not receive misoprostol (n = 30). The four groups were comparable in terms of preoperative cervical width after misoprostol administration. The mean cervical widths for control group was 9.0 +/- 1.1 mm and the mean post-treatment cervical widths for the sublingual, vaginal, and rectal groups were 7.1 +/- 1.1 mm, 8.9 +/- 1.3 mm, and 8.6 +/- 1.5 mm, respectively. The cervical widths of sublingual group were significantly different from control, vaginal; and rectal groups (p < 0.001).

CONCLUSION

Four hundred micrograms of sublingual misoprostol, 12 and six hours prior to operative hysteroscopy has a significant cervical ripening effect compared with vaginal, rectal, and control groups in post-menopausal women.

Examination of the effect of melatonin use in Pomeroy method of tubal ligation on ovarian histology in rats

OBJECTIVE

To examine the effects of melatonin use in the unilateral Pomeroy method of tubal ligation on ovarian histology in rats.

SETTING

Firat University Medical School, Obstetrics and Gynecology Department, Elaziğ.

MATERIAL AND METHOD

Thirty adult, female rats of Wistar albino species with regular cycles were randomly allocated to three groups in the estrus phase: G1 (n: 10): The abdomen was opened and closed. G2 (n: 10): The group where the abdomen was opened, and the Pomeroy method of tubal ligation was performed. G3 (n: 10): The group where the abdomen was opened, and Pomeroy method of tubal ligation was performed 15 min after 10 mg/kg/ip melatonin administration. Abdomens of all rats were opened six months later and left oophorectomy was performed. Samples of the left ovary were fixed in formaldehyde. The preparations were stained with hematoxylin eosin, and primordial, primary, secondary and tertiary follicles were counted. All the numbers were added up to determine the ovarian follicle reserve. An atretic follicle count was made. The corpus luteum and corpus albicans were counted, and the number of total corpuses were calculated. Regression of angiogenesis within the corpus luteum was examined. Presence of fibrosis on ovarian stroma was examined. An ordinal scale was formed for the regression of angiogenesis within the corpus luteum and presence of fibrosis (none: 0p, present: 1p, markedly present: 2). Follicle cysts in the ovary were counted. Kruskal Wallis variance analysis was used in the statistical analysis of data; p < 0.05 were considered significant.

RESULTS

The comparison between G1 and G3 showed that all values were similar (p > 0.05, Kruskal Wallis variance analysis). When G2 was compared with G1 and G3, regression of angiogenesis in the corpus luteum was found to be significantly lower (p < 0.05, Mann Whitney U test), while atretic follicle count and fibrosis were significantly higher in G2 (p < 0.05, Mann Whitney U test).

CONCLUSION

The Pomeroy method of tubal ligation reduces regression of angiogenesis in the corpus luteum, and increases atretic follicles and fibrosis development. Melatonin use restores these harmful effects. Melatonin can be used to refrain from this negative effect of the Pomeroy method of tubal ligation on the ovary.

The role of amino acids in spina bifida

Our objective was to measure amniotic fluid amino acid concentrations in pregnant women diagnosed as having fetuses with spina bifida in the second trimester of pregnancy. Fifteen pregnant women who had fetuses with spina bifida detected by ultrasonography (spina bifida group) in the second trimester and 19 women who had abnormal triple screenings indicating an increased risk for Down's syndrome but had healthy fetuses (control group) were enrolled in the study. Amniotic fluid was obtained by amniocentesis. The chromosomal analysis of the study and control groups was normal. Levels of free amino acids were measured in amniotic fluid samples using EZ: fast kits (EZ: fast GC/FID free (physiological) amino acid kit) by gas chromatography (Focus GC AI 3000 Thermo Finnigan analyzer). The mean levels of alanine, cystathionine, cysteine, phenylalanine, tryptophane, and tyrosine amino acids were found to be significantly higher in fetuses of the control group than in the spina bifida group (p<0.05). The detection of significantly higher amino acid concentrations in the amniotic fluid of healthy fetuses suggests loss of amino acids from the fetus through the spinal cord may contribute to the etiology of spina bifida.

Are alanine, cysteine, glycine and valine amino acids the cause of non-immune hydrops fetalis?

Our objective was to measure amniotic fluid amino acid concentrations in pregnant women diagnosed as having fetuses with non immune hydrops fetalis in the second trimester of pregnancy. Twenty-three pregnant women who had fetuses with non immune hydrops fetalis detected by ultrasonography (non immune hydrops fetalis group) in the second trimester and 19 women who had healthy fetuses (control group) were enrolled in the study. Amniotic fluid was obtained by amniocentesis. The chromosomal analysis of the study and control groups was normal. Levels of free amino acids were measured in amniotic fluid samples using EZ: fast kits (EZ: fast GC/FID free (physiological) amino acid kit) by gas chromatography (Focus GC Al 3000 Thermo Finnigan analyzer). The mean levels of alanine, cysteine, glycine and valine amino acids were found to be significantly higher in fetuses with non immune hydrops fetalis than in the control group (p<0.05). The detection of significantly higher amino acid concentrations in the amniotic fluid of fetuses with a non immune hydrops fetalis in healthy fetuses suggests loss of amino acids from the fetus through capillary permeability or/and the lymphatic system through the amniotic fluid may contribute to the etiology of non-immune hydrops fetalis.