Obstetric outcomes in Jehovah's Witnesses: case series over nine years in a London teaching hospital

OBJECTIVES

The aim of the study is to assess obstetric and fetal outcomes of Jehovah's Witnesses (JWs) mothers in an inner city teaching hospital, as well as to examine the acceptance rates of various blood fractions and blood transfusion alternatives.

METHODS

Case series to evaluate the maternal and fetal outcomes of JWs over a nine period between 2013 and 2021.

RESULTS

There were 146 pregnancies extracted from our database, of which 10 were early pregnancy losses. Data from 136 deliveries > 24 weeks' gestation were assessed, with a mean maternal age and gestational age of 30.26 (± 5.4) years and 38.7 (± 5.3) weeks, respectively. 57% had normal vaginal deliveries, 8% had instrumental births and 35% had caesarean births. Mean estimated blood loss at caesarean was 575 (± 305.6) mls, while the overall mean estimated loss was 427.8 (± 299.8) mls. Cell salvage was performed in all caesarean sections but autologous transfusion was only necessary for 26%. Consultant presence was documented in 62% of caesarean births. The mean birthweight and 5-min Apgar scores were 3.31 (± 0.05) kg and 9.1 (± 0.09), respectively. There were no maternal deaths or admissions to the adult intensive care unit and the most serious complication was a uterine rupture following a trial of scar, after which the baby required cooling for hypoxic ischaemic encephalopathy.

CONCLUSIONS

Pregnant JWs received obstetric care led by senior clinicians, with optimisation of haematinics, minimizing of blood loss at delivery and access to technology such as cell salvage.

Prophylactic Use of Uterine Artery Embolization to Decrease Bleeding in Laparoscopic Myomectomy: A Case Report

Uterine fibroids, or leiomyomas, are the most frequent benign tumors affecting the female reproductive system, particularly during the reproductive years. The case report that follows presents the diagnosis and treatment of uterine fibroids in a female patient. The 33-year-old female patient in this instance arrived at the tertiary rural hospital with an abnormally large, bloated belly. Upon examination and imaging, it was discovered that the patient had multiple fibroids growing inside her uterus. Here, we present a successful management of uterine leiomyoma with laparoscopic myomectomy where we performed uterine artery embolization before surgical management in order to minimize blood loss during surgery. The case highlights the significance of collaboration between gynecologists, surgeons, and interventional radiologists. Thanks to their combined expertise, the patient was given a variety of treatment options, such as minimally invasive treatments, surgical interventions, and medication therapy. Decision considerations included the consequences of fibroids and the patient's age and desire to preserve fertility. The effect of fibroids on her life expectancy is taken into account. This case emphasizes how important it is to embolize the uterine arteries before having a myomectomy to cure large uterine leiomyomas successfully.

First-Trimester Pregnancy Loss Due to Condyloma Acuminata: A Twisted Tale of Gravidity

The human papillomavirus can induce condyloma acuminata, a benign papillomatous squamous growth with a fibrovascular core that arises in the vaginal canal. These illnesses typically afflict women who are fertile and are frequently encountered during pregnancy, manifesting with a variety of symptoms. The influences of hormones and vaginal secretions cause the lesion to expand quickly during pregnancy. Viral infections are known to be one risk factor for threatening abortions. Infection with human papillomavirus (HPV) during pregnancy has been associated with a risk for spontaneous abortion, preterm delivery, and abnormalities in the placenta. There are many therapeutic approaches available to address the disease; however, it is still unclear which one is the most successful. Additionally, organogenesis is crucial throughout the first trimester, and treatment during this period may elevate the risk of spontaneous abortion. Here, we describe the case of a young woman who experienced vaginal lesions during the first trimester of her pregnancy.

An Incidental Diagnosis of Herlyn-Werner-Wunderlich Syndrome in a Young Female: A Case Report of a Rare Entity

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome, a rare genetic condition of the urogenital system, is characterized by distinctive features such as ipsilateral renal agenesis, obstructed hemivagina, and uterus didelphys. It is also referred to as Herlyn-Werner-Wunderlich (HWW) syndrome. Its clinical manifestations include dysmenorrhea, consistent abdominal pain, and infrequent periods. It is typically diagnosed after menarche. We report a case of a 20-year-old female who was admitted to the casualty ward following a road accident. She was Incidentally found to have uterine didelphys with hemorrhagic cystic lesion and left renal agenesis on ultrasonography (USG). She also had gallbladder stones, along with the findings mentioned above. Clinicians should exclude HWW syndrome in cases where uterine didelphys and unilateral renal agenesis coexist. Prompt identification and treatment of the condition can help avoid potential untoward pregnancy-related issues in the future.

Filling the Gaps in Oncofertility Care by Addressing Challenges Faced by Patients and Providers

With enhanced technology and upcoming treatment strategies in the cancer field, the survival rates of patients have increased. We have now reached a stage in the treatment of cancer where we not only address the disease but also address complications that arise due to the disease and the side effects that present in the post-survival population due to its treatment. One of the primary consequences after oncotherapy is infertility, which is a major reason for distress for patients' post-survival, as they are afraid they may be deemed as less desirable, be rejected by their existing partner, or cannot grapple with the fact that they cannot have children of their own. This can be avoided by the implementation of proper oncofertility practices. The subject of oncofertility involves interactions between experts in the domains of cancer diagnosis, therapy, fertility preservation, and reproductive health. It attempts to investigate and broaden the possibilities for cancer survivors' reproductive future in order to suit their needs according to their ethical religious and sociocultural beliefs. However, these practices are often not implemented effectively due to ineffective doctor-patient communication, lack of knowledge, or partial knowledge of clinicians themselves regarding fertility care. This leads to a feeling of insecurity among clinicians hence resulting in them not referring patients. Lack of awareness among doctors of different oncofertility procedures available especially for patient groups like women and younger patients, hence leading to reduced referral in these groups. Improper coordination across health departments, patient ignorance regarding procedures, financial instability especially in a country with a lower sociodemographic index like India, and neglect or less importance given to the related ethical, social, and legal issues. In this article, we cover the effects of cancer and cancer treatment on fertility, the options available to adult and pediatric cancer patients to preserve their fertility like oocyte/ovarian tissue cryopreservation in females and sperm cryopreservation in males, techniques undergoing experimental studies that could be implemented in the future like spermatogonial stem culture and transplantation of testicular tissue, the obstacles that we face that hinder the proper implementation of such practices and what measures can we take to overcome these obstacles to improve patient care and be better healthcare providers.

The Atacama Rover Astrobiology Drilling Studies (ARADS) Project

With advances in commercial space launch capabilities and reduced costs to orbit, humans may arrive on Mars within a decade. Both to preserve any signs of past (and extant) martian life and to protect the health of human crews (and Earth's biosphere), it will be necessary to assess the risk of cross-contamination on the surface, in blown dust, and into the near-subsurface (where exploration and resource-harvesting can be reasonably anticipated). Thus, evaluating for the presence of life and biosignatures may become a critical-path Mars exploration precursor in the not-so-far future, circa 2030. This Special Collection of papers from the Atacama Rover Astrobiology Drilling Studies (ARADS) project describes many of the scientific, technological, and operational issues associated with searching for and identifying biosignatures in an extreme hyperarid region in Chile's Atacama Desert, a well-studied terrestrial Mars analog environment. This paper provides an overview of the ARADS project and discusses in context the five other papers in the ARADS Special Collection, as well as prior ARADS project results.

Bell's Palsy Unmasked: A Compelling Case Study of Facial Nerve Palsy During Pregnancy

Facial paralysis occurs more frequently in pregnant individuals, affecting them two to four times more often than those who are not pregnant, making it the most frequent unilateral cranial nerve pathology in pregnancy. This case report describes a 29-year-old primigravida's presentation, examination, and treatment of left-sided (unilateral) facial nerve palsy during 32 weeks of gestation. Concerns regarding possible underlying reasons were raised when the patient suddenly developed left-side facial weakness. We examined her history, clinical assessment, and diagnosis methods, which included laboratory and neuro-imaging tests. The difficulties of managing this illness during pregnancy are explored, taking into account the well-being of the developing fetus and mother. There are several causes for facial nerve palsy during pregnancy, including idiopathic causes, vascular problems, and viral infections. Here, we emphasize the value of a multidisciplinary approach comprising obstetricians, neurologists, and other medical professionals to guarantee the best possible care. The paper also underscores the necessity for prompt diagnosis and suitable interventions to reduce problems and foster a successful outcome. This case report adds to the limited literature on facial nerve palsy in pregnancy by highlighting individualized medical care and teamwork in addressing this uncommon but serious condition.

Novel Advances in the Role of Selective Estrogen Receptor Modulators in Hormonal Replacement Therapy: A Paradigm Shift

Estrogen is a key regulatory hormone in the functioning of a female reproductive system. Estrogen hormone regulates many complex physiological processes, which has its role in reproduction and skeletal and cardiovascular systems by acting on estrogen receptors alpha (ERα) and beta (ERβ), which are nuclear transcription factors. Selective estrogen receptor modulators (SERMs) are now being used to treat bone loss, breast carcinoma, and menopausal symptoms, metabolic neurodegenerative because of their characteristics that allow them to function as both estrogen agonists and antagonists, depending on the target tissue. First-generation SERMs, such as Tamoxifen, are used in the management protocol for breast cancer, which is estrogen receptor (ER-positive). Raloxifene is a second-generation SERM that is a valuable adjunct used to treat and prevent osteoporosis in postmenopausal women and prevent compression fractures of the vertebral column. Novel SERM molecules are on the horizon, proven more potent and efficacious in preventing and treating osteoporosis. These include Ospemifene, lasofoxifene, bazedoxifene and arzoxifene. The benefits of Raloxifene versus that of Bazedoxifene are under trial. Despite their therapeutic benefits and actions, these medications are not without adverse effects, such as thromboembolic disorders. Increased risk of uterine cancer has been linked to Tamoxifen. This article delves into the world of SERMs, including their development and discovery. The newer SERMs in late development, ospemifene, lasofoxifene, bazedoxifene, and arzoxifene, are described in detail.

Postabortal Bleeding: A Diagnostic Dilemma Resolved As Arteriovenous Malformation and Successfully Managed With Uterine Artery Embolization

Uterine arteriovenous malformations (AVM) are rare and may be missed in routine clinical practice, often concealing their existence until dire consequences emerge. This potentially lethal condition can manifest abruptly, with torrential postabortal bleeding, as a grim reminder of its risky nature. Here, we present a rare case of para 1, living 1, abortion 2, initially subjected to dilatation and evacuation due to a missed abortion at a peripheral healthcare facility, subsequently developing torrential bleeding despite all the conservative measures. So she was referred to our hospital in view of heavy vaginal bleeding following the earlier instrumentation; the differential diagnosis of molar pregnancy and AVM was made clinically. As per speculum examination, the presence of remnants of abortion was seen, and the possibility of an invasive mole was suspected. Ultrasonography with color Doppler showed uterine AVM, which was further confirmed by magnetic resonance imaging (MRI). In order to save her life while preserving the uterus, a multidisciplinary approach was involved in managing this patient, consisting of interventional radiologists to perform uterine artery embolization (UAE).

Primary Fallopian Tube Carcinoma Presenting as a Broad Ligament Fibroid: A Rare Case

Primary fallopian tube carcinomas (PFTCs) are quite rare with the incidence ranging from 0.3% to 1.1% amongst all the gynaecological malignancies. Here, we present a rare case of a 44-year-old female (parity-2, live-2 and abortion-2), with one previous classical caesarean section and one vaginal birth after caesarean section (VBAC), bilateral tubal ligation done referred to our gynaecology OPD with complaints of pain in the abdomen since the past six days. The patient also had complaint of spotting per vagina for the past two months. Her ultrasonography and contrast-enhanced CT abdomen and pelvis were suggestive of broad ligament fibroid, which turned out to be a PFTC. Primary fallopian tube malignancies are so rare that this entity may be missed in routine clinical practice and surprisingly noticed during operative procedure or on histopathology reports. Thus, one must be aware of this rare clinical entity and keep it in mind while taking patients on the operating table.

Therapeutic Management of Giant Uterine Fibroid: A Case Report

The most common benign tumor that affects female reproductive system is a uterine fibroid or leiomyomas, especially during their reproductive years. The prevalence is around 20-40% women in the age group of 14-45 years. The following case report proffers the diagnosis and management of a female diagnosed with uterine fibroids. In this case a 45-year-old woman presented to the tertiary rural hospital with an unusually large distended abdomen which on examination and imaging revealed a big fibroid growing inside the uterus. The case highlights the significance of a collaborative approach involving gynecologists, interventional radiologists, and surgeons. Their combined expertise provides patients with various treatment options: medical management, minimally invasive procedures, and surgical interventions. During the decision-making process, factors such as the patient's age, desire for fertility preservation, and impact of fibroids on her quality of life are taken into account. This particular case showcases successful pre-hysterectomy uterine artery embolization of large uterine leiomyoma while emphasizing the importance of personalized care and shared decision making for optimal patient outcomes.

A Case of Chemical Pregnancy in a Female With Turner Syndrome

Turner syndrome (TS) is a genetic anomaly that is characterized by the absence of an X chromosome, either completely or partially. Primary amenorrhea, short stature, webbed neck, cubitus valgus, and a little intellectual disability are some of the characteristics. Infertility is also one of the most common clinical symptoms of TS-affected females. With the advent of assisted reproductive technology (ART), chances of childbearing possibilities for TS females have risen. Infertility issues in females with TS are challenging, but they can be managed with proper counseling and ART by artificial implantation, oocyte donation, and others. This case report aims to present the case of a 27-year-old female who had not attained her menarche and wanted to conceive. She was diagnosed with TS on the basis of clinical and laboratory investigations. The patient was, thereafter, treated for infertility by oocyte donation and conceived successfully.

Type 2 Diabetes Mellitus in Patients With Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a multisystemic disorder usually seen in females who are in their reproductive age (15-49 years of age). PCOS exhibits insulin resistance and hyperinsulinemia, which make it a pre-diabetic state. The syndrome has many overt changes, like dyslipidemia and hypertension, which increase the risk of cardiovascular diseases. There is also an increased risk of development of hepatic steatosis. Resistance to insulin, increased amount of insulin, and dysfunction of beta-cells are frequent in PCOS, although they are not the only cause for diagnosis. Type 2 diabetes and glucose resistance may result from total or compared insulin insufficiency, which can happen if the beta cells' compensatory response slows down. Pregnancy challenges such as miscarriage, gestational diabetes mellitus (DM), hypertensive disorders of pregnancy, more excellent rates of cesarean birth, and abnormalities in fetal development may be more common in women with PCOS. In studies investigating the glucose-insulin system compared to control groups with similar age and weight, glycemic intolerance, which includes both decreased glucose tolerance and type 2 diabetes, was more common in PCOS women. In the short-term therapy of insulin resistance in PCOS, the potential use of insulin-sensitizing medications has recently been studied. Controlled studies have demonstrated that metformin treatment can lower fasting and stimulate plasma insulin levels by encouraging body weight reduction. These findings provide insulin-sensitizing drugs as a unique method in treating ovarian hyperandrogenism and irregular ovulation in PCOS and indicate a new prescription for Metformin. They further assert that long-term metformin treatment may assist in addressing insulin resistance, reducing the risk of type 2 diabetes and cardiovascular-related disease in people who take it.

Under-Representation for Female Cancers in Commercial Auto-Segmentation Solutions and Open-Source Imaging Datasets

PURPOSE/OBJECTIVE(S)

Auto-segmentations methods to aid radiation therapy (RT) workflows have recently emerged with the increasing availability of commercial solutions for organs at risk (OARs) in addition to open-source imaging datasets that support training for new auto-segmentation algorithms. Here, we explored whether female and male cancer sites are equally represented among these solutions.

MATERIALS/METHODS

Inquiries were sent out to five major RT vendors regarding their currently available auto-segmentation solutions. Additionally, The Cancer Imaging Archive (TCIA) was screened for publicly available imaging datasets pertaining to female and male tumor sites.

RESULTS

The five commercial solutions provided a median of 103 (range: 60-120) OAR auto-segmentations of which the majority concerned the head and neck (45 (24-55)) and thorax (34 (27-43)) and were provided by all vendors (Table). Prostate as a site was also provided by all vendors and included 17 (9-20) auto-segmentations. A total of 23 publicly available TCIA imaging datasets involved the female anatomy (breast: 19; cervix: 2; ovarian: 1; uterus: 1) while 11 imaging datasets involved the male anatomy (prostate). No OARs segmentations were available for the 23 female-specific datasets while 27% of the 11 prostate datasets included segmented OARs. Three vendors and two TCIA datasets provided organs involved in the male sexual function apparatus (neurovascular bundle and penile bulb), whereas nipple or areola segmentations were not available among the commercial solutions for breast or among the TCIA breast datasets. None of the TCIA datasets or any of the five commercial solutions provided OARs for the female pelvis such as organs involved in reproduction (ovaries), sexual health (clitoris, vagina) or the cervix and uterus. Further, auto-segmentations provided for OARs trained exclusively on the male pelvis are likely inadequate for female cancers given the substantial anatomical differences between genders.

CONCLUSION

Commercial auto-segmentation solutions and open-source imaging datasets together include considerably more datasets, tumor sites and consequently more OAR auto-segmentations pertaining to male cancers compared to female cancers. Despite a 1.4 times higher incidence for female cancers (breast: 300,590; female pelvis: 114,810; male cancer: 299,540; Siegel RL et al CA Cancer J Clin 2023), auto-segmentation models are lacking, and this gender disparity is likely to lead to suboptimal care for female-specific cancers.

Pre-Brachytherapy Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) Response as Predictor of Local Control in the Definitive Treatment of Cervical Cancer

PURPOSE/OBJECTIVE(S)

Chemoradiation consisting of external beam radiotherapy (EBRT) followed by brachytherapy (BT) is the standard of care for Stage IB2-IVA cervical cancer (CC). Multi-parametric MRI (mpMRI) is a valuable tool for initial staging, treatment planning and response assessment. In this study, we aim to explore the potential of mpMRI, in particular DW-MRI, to predict overall tumor control following chemoradiation in CC.

MATERIALS/METHODS

We identified 78 consecutive patients treated with chemoradiation for FIGO IB2-IVA CC between 2012-2020, who had an MRI at baseline (MRb) and post-EBRT prior to brachytherapy boost (MRpb) that included DW-MRI (b-value = 0 and 800 s/mm2). Median age was 53 years, most patients had squamous cell carcinoma (76.9%) and advanced-stage disease (56.4% stage IIIA-IVA). Median time from completion of EBRT to MRpb was 3 days. Regions of interest (ROI) in primary tumor were delineated on DW image (b = 0 s/mm2) using ITK-SNAP software. DW-MRI data were fitted to a monoexponential model to calculate apparent diffusion coefficient (ADC) values using in-house software platform (MRI-QAMPER). MRpb mean ADC values (n = 78) and relative changes (%) in mean ADC values between MRb and MRpb (n = 64) were correlated with outcomes, including local failure (LF), regional or distant failure (RDF), and failure at any site (FAS), with death without failure as a competing risk. Median follow-up time was 45 months (95% CI 38, 53).

RESULTS

At first post treatment assessment, 72 patients (92.3%) had a complete response (CR) in the cervix and 68 patients (87.2%) had CR in all disease sites. Of patients who had CR in the cervix (n = 72), only 1 patient had local recurrence. Of patients who had CR in all disease sites, 10 later recurred (1 LF only, 1 LF&RDF, 8 RDF only). Overall, 7 patients (9%) had LF, and 19 patients (24.4%) had FAS. A higher mean ADC value in MRpb was associated with LF (HR 4.3, 95% CI 1.32, 14.6; P = 0.016), but not with RDF (P = 0.4) or FAS (P = 0.5). A higher relative change in the mean ADC value between MRb and MRpb was associated with a lower risk of LF (HR 0.94, 95% CI 0.90, 0.98; P = 0.002), but not with RDF (P = 0.8) or FAS (P = 0.4).

CONCLUSION

Treatment response as measured on prebrachytherapy DW-MRI is a significant predictor of local control in patients undergoing chemoradiation for stage IB2-IVA CC. ADC values, a quantitative imaging biomarker on MRpb may be instrumental in dose intensification/de-escalation efforts in CC.

Air Embolism: A Rare Lethal Complication of Hysteroscopy in a Young Woman Undergoing Infertility Workup

Compared to operative hysteroscopy, diagnostic hysteroscopy rarely leads to issues. However, one very uncommon yet potentially fatal complication is air embolism, with an incidence rate of three in 17,000 cases. This report describes an unexpected complication discovered during diagnostic hysteroscopy surgery. In the course of routine infertility testing, a 29-year-old woman underwent a diagnostic hysteroscopy under general anesthesia. Intraoperatively, her end-tidal carbon dioxide (EtCO2) levels decreased, oxygen saturation dropped, and heart rate increased, leading the anesthesiologists and critical care team to terminate the procedure and manage her further. Subsequent transesophageal echocardiography confirmed the diagnosis of air embolism. She was managed with 100% oxygen and inotropes and cardiopulmonary resuscitation but despite aggressive medical interventions, her condition did not improve, and she unfortunately passed away. To diagnose, prevent, and manage the potentially devastating consequences associated with diagnostic hysteroscopy, gynecologists and surgical teams must maintain vigilance. The focus should be on proper patient selection, optimal surgical techniques, and the use of high-quality equipment to mitigate the risk of air embolism.

Successful Pregnancy Outcome in an Operated Case of Budd-Chiari Syndrome Having Fetal Growth Restriction: A Twisted Tale of Gravid

Budd-Chiari Syndrome (BCS) primarily affects women in the reproductive age group, with an ever-increasing incidence in the general population. Due to its rarity, it is not known precisely how a pregnancy progresses in a woman with BCS and what can happen to the baby. A rare condition known as Budd-Chiari syndrome causes the hepatic veins in the liver to constrict and become blocked. The challenges in pregnancy, such as decreasing hepatic function, a rise in thrombotic and bleeding events, or ascites, have historically made pregnancy inappropriate in these people. Here, we present a case of an unbooked 24-year-old female, a known case of treated BCS with 36 weeks and three days gestation period. She was referred from a peripheral hospital to our hospital's emergency department because of having fetal growth restriction. By presenting this rare case, we expect more extensive studies will be conducted on the effect of pregnancy on BCS and the effect of BCS on pregnancy which will help obstetricians to turn this rare possibility of conception into a fair possibility.

Unveiling the Unprecedented: An Astonishing Rarity of Metoclopramide Hydrochloride-Triggered Nystagmus in a Pregnant Woman

Metoclopramide hydrochloride is a widely used medication for the treatment of gastrointestinal disorders such as nausea, vomiting, and gastroparesis. However, it has been associated with extrapyramidal side effects (EPS) such as tardive dyskinesia, nystagmus, and other locomotive disorders on rare occasions. These reactions are commonly seen in children and females, particularly in young people. In this article, we report a rare case of a 15-week pregnant woman who was prescribed metoclopramide hydrochloride in view of nausea and vomiting, which was later diagnosed as vomiting in pregnancy not relieved with first-line medications, and has later developed drug-induced nystagmus, highlighting its unpredictable nature and shortcomings of management in the pregnant woman. This article will draw the attention of obstetricians and gynecologists to wisely prescribe metoclopramide hydrochloride for treating nausea and vomiting in pregnant women.

Deep Vein Thrombosis as a Rare Post-procedural Complication After Uterine Artery Embolization: A Case Report

When a patient is undergoing uterine artery embolization (UAE) which is considered a modality that is safer than surgical management for abnormal uterine bleeding (AUB), one must acknowledge as a surgeon the existence of rare but serious complications such as deep vein thrombosis (DVT). We encountered such a case where a 34-year-old female (para-3 living-3) with AUB and severe anemia because of heavy bleeding required multiple blood transfusions and was treated with UAE. The procedure was uneventful and the patient was discharged. However, later she presented with DVT of the right lower limb which was promptly managed with an inferior vena cava filter implant and thrombolysis, which prevented life-threatening sequelae such as pulmonary embolism and, potentially, death. Therefore, one must be vigilant about such complications despite UAE being a safer alternative to surgical management for gynecological complaints.

0422 Apocalypse Tau: The Relationship Between Inflammaging and Local Sleep Disruption in Older Adults is Mediated by Tau Burden

Introduction

Chronic inflammation in aging is independently associated with tau burden and sleep disruption, though the mechanism linking inflammation with sleep disruption remains unknown. Recent evidence associates tau burden with deficits in local expression of sleep spindles and slow wave activity (SWA). Here we test the hypothesis that age-related central inflammation disrupts local sleep by influencing tau pathology.

Methods

Cognitively asymptomatic older adults from the Wisconsin Alzheimer’s Disease Research Center underwent overnight polysomnography with high-density electroencephalography (hdEEG; 256 channels) at the University of Wisconsin-Madison (n=33, 61.9±6.7 years, 23 female). EEG data were subjected to multitaper spectral analysis (0.5-40Hz) to yield topographic maps of SWA (SWA1:0.5-1Hz, SWA2:1-4.5Hz) and spindle (sigma1:11-13Hz; sigma2:13-16Hz) power during NREM sleep. Cerebrospinal fluid assay-based measurements of YKL-40 (indicating glial activation), phosphorylated tau (Ptau), and total tau (Ttau), were correlated with SWA and sigma topographical power employing Holm-Bonferroni correction. Multiple linear regression models were implemented controlling for age, apnea-hypopnea index (AHI), and sex at significant derivations. Finally, Sobel testing was employed to assess whether tau burden mediated YKL-40-sleep associations.

Results

Age was associated with YKL-40 (r=0.53, p=0.002), and YKL-40 was associated with both Ptau (r=0.66, p<0.001) and Ttau (r=0.68, p<0.001). Correlations between sigma2 activity and both Ptau and Ttau were detected at 14 derivations, 12 of which remained significant after controlling for age, sex, and AHI. YKL-40 was associated with sigma2 power (r=-0.39, p=0.025) across derivations expressing peak significance with tau. Sobel mediation analyses indicated that both Ptau (t=-2.15, p=0.031) and Ttau (t=-2.36, p=0.018) mediated the relationship between YKL-40 and sigma2 activity at these derivations. SWA was not associated with Ttau, Ptau, or YKL-40.

Conclusion

These results suggest that age-related increases in central glial activation may disrupt local expression of fast spindles by increasing tau burden, highlighting a potential role for chronic inflammation in sleep deficits observed in aging and Alzheimer’s disease.

Support

Supported by R56 AG052698, P50AG033514

0335 Frontal Expression of NREM Sleep Oscillations are Associated with Executive Function in Children and Adolescents

Introduction

The prefrontal cortex, an area known for executive functioning (including inhibition and self-monitoring) develops during childhood and adolescents, with a pattern of posterior to anterior brain development. Slow-wave activity (SWA) in NREM sleep, tracks brain development with high SWA power migrating from occipital to frontal region as brain maturation occurs. This pilot study aimed to examine whether slow wave topography is correlated with executive function in youth.

Methods

Seventeen healthy children and adolescents (ages 11-17; 10 females) underwent overnight polysomnography (PSG) with high-density electroencephalography (hdEEG). Behavior Rating Inventory of Executive Function (BRIEF) was administered to assess executive function. SWA (SWA1: 0.5-1 Hz; SWA2: 1-4.5 Hz) and spindle (slow sigma: 11-13 Hz; fast sigma: 13-16 Hz) activity was analyzed with spectral analysis using Welch’s method. BRIEF subscales of inhibition and monitor were correlated with SWA and sigma power across all derivations, with Holm-Bonferroni correction (126 channels). Significant derivations were then controlled for sex and self-reported Tanner stage using multiple regression

Results

BRIEF-Inhibition scale (i.e., ability to repress impulsivity) and SWA1 in anterior frontal derivations were negatively correlated (R2=0.58, p=0.047 corrected). BRIEF-Monitor scale (i.e., self-perception of one’s own behavior and interpersonal awareness) was negatively correlated with fast sigma in anterior frontal derivations (R2=0.65, p=0.013 corrected). These associations were significant after controlling for sex and Tanner stage.

Conclusion

These results support the hypothesis that NREM sleep oscillations are associated with executive function and reflect changes in neuroplasticity related to “back-to-front” brain maturation. Future longitudinal studies should combine multi-modal neuroimaging of brain structure and local sleep with comprehensive assessments of executive function to evaluate the possible link between local sleep and development of higher-order cognition in frontal brain regions in youth.

Support

NCATS grant #UL1TR001414 & PERC Systems Biology Fund

Association of bilirubin and malondialdehyde levels with retinopathy in type 2 diabetes mellitus

INTRODUCTION

Bilirubin as an antioxidant and malondialdehyde (MDA) as an oxidant have been shown to be associated with various complications of type 2 diabetes mellitus (DM).

AIMS AND OBJECTIVES

The aim was to measure the levels of serum bilirubin and MDA in type 2 DM patients with and without diabetic retinopathy (DR) and to correlate them with severity of DR.

MATERIALS AND METHODS

A total number of 120 subjects out of which 40 were controls without type 2 DM and the rest 80 were type 2 DM patients were included in the study. Of those 80 diabetics, 44 patients did not have DR and 36 patients had DR.

RESULTS

The total bilirubin, direct bilirubin, indirect bilirubin were higher in controls as compared to cases (P = 0.017, 0.033, 0.024). Serum MDA levels were found to be higher in diabetics as compared to controls (P = 0.00). The values of all the three parameters, that is, total bilirubin, direct bilirubin and indirect bilirubin were lower in patients with retinopathy as compared to those without retinopathic changes (P = 0.00, 0.020, and 0.007). Subjects were assigned to quartiles based on serum total bilirubin concentration. The prevalence of DR was significantly lower among persons with the highest bilirubin quartile compared to those with the lowest quartile. The severity of DR was inversely proportional to the total bilirubin levels (P = 0.001). The multiple logistic regression analysis showed total bilirubin to be associated with prevalence of DR (P = 0.035).

CONCLUSIONS

The levels of total bilirubin were significantly lower in patients with DR and also in the late stages of retinopathy as compared to those without retinopathy and in controls but MDA levels did not show any association with DR.

Subcutaneous insulin B:9-23/IFA immunisation induces Tregs that control late-stage prediabetes in NOD mice through IL-10 and IFNgamma

AIMS/HYPOTHESIS

Subcutaneous immunisation with the 9-23 amino acid region of the insulin B chain (B:9-23) in incomplete Freund's adjuvant (IFA) can protect the majority of 4- to 6-week-old prediabetic NOD mice and is currently in clinical trials. Here we analysed the effect of B:9-23/IFA immunisation at later stages of the disease and the underlying mechanisms.

METHODS

NOD mice were immunised once s.c. with B:9-23/IFA at 5 or 9 weeks of age, or when blood glucose reached 10 mmol/l or higher. Diabetes incidence was followed in addition to variables such as regulatory T cell (Treg) induction, cytokine production (analysed by Elispot) and emergence of pathogenic CD8(+)/NRP-V7(+) cells.

RESULTS

A single B:9-23/IFA immunisation protected the majority of NOD mice at advanced stages of insulitis, but not after blood glucose reached 13.9 mmol/l. It increased Treg numbers and lost its protective effect after IFNgamma or IL-10 neutralisation, but not in the absence of IL-4. CD4(+)CD25(+) and to a lesser extent IFNgamma-producing cells from mice protected by B:9-23/IFA induced tolerance upon transfer into new NOD animals, indicating that a dominant Treg-mediated effect was operational. Reduced numbers of CD8(+)/NRP-V7(+) memory T cells coincided with protection from the disease.

CONCLUSIONS/INTERPRETATION

Protection from diabetes after B:9-23/IFA immunisation cannot be achieved once diabetes is fully established, but can be achieved at most prediabetic stages of the disease. Protection is mediated by Tregs that require IFNgamma and IL-10. These findings should provide important guidance for ongoing human trials, especially for the development of suitable T cell biomarkers.

Why me? A missing girl

Demographic imbalance created because of the declining sex ratio in India is a cause of concern to policy makers, implementers, demographers and social reformers. To take situation under control, Pre Natal Diagnostic Techniques (PNDT) Act is operational since 1996. Authors have critically reviewed the status of women and socio-cultural factors influencing their status based on data from NFHS III and census 2001 and challenges faced in the operationalisation of PNDT Act in India.

Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) as a predictor of response in head and neck squamous cell carcinoma (HNSCC)

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Background: We wish to assess on a preliminary basis whether pretreatment DCE-MRI predicts response to chemoradiation in HNSCC. Methods: Tumor perfusion was assessed in 14 patients (median age, 56y; 13 M, 1 F; squamous cell cancer 13, poorly differentiated carcinoma 1; base of tongue 6; tonsil 6; larynx 1; nasopharynx 1) with nodal metastases (size >1 cc for DCE-MRI; N1, 3; N2a, 2; N2b, 4; N2c, 4; N3, 1; Stage III, 3; Stage IVa, 10; Stage IVb, 1) prior to platin-based concurrent chemoradiation therapy. Data were acquired on a 1.5 Tesla clinical scanner with a standard MRI protocol using a clinical contrast agent (Gd-DTPA). The two compartment model analysis measured the rate constants of the contrast agent transfer between the lesion and plasma compartments (kep) and elimination by the plasma (kel). Each patient was assigned a single MR imaging parameter of uptake slope and compartmental model (Akep) on the basis of the histogram analysis of all individually fit tumor voxels. Histogram analysis calculated the amplitude (a), width (s), and median (μ) of the distribution from the fitting procedure. Overall response was determined approximately 2–5 months post treatment. Results: DCE-MRI data showed a rapid rise in the time intensity curves for viable appearing tumor, whereas muscle showed minimal signal enhancement. The mean Akep value was higher for complete responders (CR/near CR, n = 7) than for incomplete responders (ICR, n = 7; 3 partial response, 4 no response) (12.29/min±4.09 vs 7.11/min±2.51 [P = 0.04]. The preliminary histogram analysis for the slope showed that the width and median were able to differentiate between CR and ICR, P=0.039 and P=0.013 respectively, while amplitude was not significant (P=0.150). Conclusions: These preliminary data suggest that DCE-MRI may prove to be a useful predictor of response in HNSCC patients, and thus may enhance prognostication, patient selection, and treatment outcomes.

No significant financial relationships to disclose.

Sudden cardiac arrest in a neonate with congenital adrenal hyperplasia

We describe a 6-day-old male who developed cardiac arrest due to hyperkalemia secondary to congenital adrenal hyperplasia and was successfully resuscitated. This case illustrates the importance of considering congenital adrenal hyperplasia as one of the causes of sudden cardiac arrest in a neonate. A literature review revealed only one similar case in a 3-month-old with a fatal outcome.

Complicated stent supported cerebrovascular angioplasty: case analyses and review of literature

BACKGROUND

Hemodynamic lesions of the cervicocerebral vasculature are currently being treated with stent supported percutaneous transluminal angioplasty. These procedures have met with increasing success when compared to the risks and morbidity of more invasive surgical approaches. The versatility of stent-supported angioplasty as a primary therapeutic modality is examined in the following complex cases.

CASE DESCRIPTION

We present four cases involving cervical angioplasty with emergent or adjunctive stent placement. Two cases involved the subclavian arteries, whereas the others involved the vertebral and internal carotid arteries. In our experience, complications of cervicocerebral artery angioplasty have been successfully managed by stent placement.

CONCLUSION

Our cases demonstrate the emerging role of cervical angioplasty and stent implantation as a successful therapeutic modality, highlighted in these complex cases.

Effect of pulmonary artery stenoses on the cardiopulmonary response to exercise following repair of tetralogy of Fallot

Data from exercise tests, echocardiograms, and lung perfusion scans were analyzed to determine whether the excessive minute ventilation (VE) often encountered among patients with tetralogy of Fallot is due to ventilation-perfusion mismatch secondary to branch pulmonary artery stenoses. Patients with branch PA stenoses had lower peak oxygen consumptions and higher VE during exercise than did patients without stenoses, and a strong correlation existed between the degree of pulmonary blood flow maldistribution on lung perfusion scan and the amount of excessive VE during exercise.

Expression of retinoic acid receptor beta in human renal cell carcinomas correlates with sensitivity to the antiproliferative effects of 13-cis-retinoic acid

The differentiation and growth suppressive effects of retinoic acid are mediated through retinoic acid nuclear receptors (RARs and RXRs), which are ligand-activated transcription factors. Recent data suggest that both altered and regulated expression of RARs are linked to retinoic acid response in a cell context-dependent manner. This study examined the antiproliferative effects of 13-cis-retinoic acid (cRA) on 12 renal cancer cell lines and correlated these findings with the basal and induced expression of RAR-alpha, -beta and -gamma. Eleven of 12 renal cancers that were either resistant to or only minimally inhibited by cRA did not basally express RAR-beta as determined by Northern blot analysis. In these cells, cRA treatment did not induce RAR-beta expression. In contrast, 1 of 12 cell lines (SK-RC-06) was >90% inhibited by cRA and basally expressed RARbeta. Furthermore, RAR-beta mRNA in SK-RC-06 cells was up-regulated by cRA treatment. Amplification of cDNA using PCR and RAR-beta isoform-specific primer pairs revealed that only SK-RC-06 cells expressed the RAR-beta1 isoform. Expression of RAR-alpha transcripts was abundant in all 12 cell lines examined, whereas low levels of RAR-gamma transcripts were detectable in 6 of 10 renal cancers. Expression of RAR-alpha and RAR-gamma was not affected by cRA. These data showing that the majority of renal cancer cell lines are resistant to cRA suggest that: (a) resistance to the antiproliferative action of cRA correlates with repressed RAR-beta mRNA expression; and (b) the antiproliferative effects of cRA in renal cancer cells are mediated through RAR-beta1.