Transcutaneous Temperature Controlled Radiofrequency: Groundbreaking Technology - Female Stress Urinary Incontinence and Overactive Bladder Can Be Treated Noninvasively and with Vulvovaginal Rejuvenation?

It has long been difficult to treat vulvovaginal laxity, genitourinary syndrome of menopause, stress urine incontinence, overactive bladder (OAB), and other indications of sexual dysfunction because women traditionally find it difficult to discuss these difficulties with clinicians and because society generally accepts these diseases. Originating in esthetic medicine, noninvasive feminine rejuvenation that targets vaginal tissue with energy-based methods has recently become more popular. A more youthful-looking vulva, the restoration of vaginal elasticity and "tightness," a significant improvement in stress urinary incontinence, a reduction in symptoms of OAB, and a decrease in sexual dysfunction are all benefits of transcutaneous temperature-controlled radiofrequency (TTCRF) therapy at the vulvovaginal region. It is also becoming more popular as a mild-to-moderate stress urinary incontinence and OAB noninvasive therapy option. Women will likely always be appreciative of their gynecologist for managing stress urinary incontinence with TTCRF therapy without making an incision, it would appear.

COVID-19 Pandemic Research Opportunities in India: What the Pandemic Is Teaching Us About Transplantation

Coronavirus disease (COVID-19) has engulfed the whole world, and India has been the second worst-hit nation. Organ transplant services were halted in both the public and private care sectors of India, with public care sectors more adversely affected. Deceased donations were disproportionately more affected, with unfavorable rates at the peak of the pandemic. Mortality outcomes of COVID-19 among different organ transplant recipients in India have been lower compared with the Western world, with younger age and less comorbidities among Indian populations partly responsible for the lower mortality. Mortality and graft loss were mostly associated with older age and those with chronic graft dysfunction. During the pandemic, invasive fungal infections, like mucormycosis, have been reported, illustrating the need for multidisciplinary management. The Indian transplant societies have formulated and timely revised guidelines for transplantation in the COVID-19 era. Living donor transplants (both liver and kidney) after recovery from COVID-19 were both first described in India, providing a guiding tool for the world. Follow-up reports of recovered solid-organ transplant recipients have also been reported in Indian studies, showing reassuring long-term outcomes. Data of breakthrough COVID-19 cases after vaccination among both transplant recipients and waitlist candidates and research in vaccine efficacy for solid-organ transplant recipients is still underway. We suggest continuing and intensifying research activities for a better plan and strategy in case of a future pandemic.

Management strategies and outcomes in renal transplant recipients recovering from COVID-19: A retrospective, multicentre, cohort study

Background

There is an enormous knowledge gap on management strategies, clinical outcomes, and follow-up after kidney transplantation (KT) in recipients that have recovered from coronavirus disease (COVID-19).

Methods

We conducted a multi-center, retrospective analysis in 23 Indian transplant centres between June 26, 2020 to December 1, 2021 on KT recipients who recovered after COVID-19 infections. We analyzed clinical and biopsy-confirmed acute rejection (AR) incidence and used cox-proportional modeling to estimate multivariate-adjusted hazard ratios (HR) for predictors of AR. We also performed competing risk analysis. Additional outcome measures included graft loss, all-cause mortality, waiting time from a positive real-time polymerase test (RT-PCR) to KT, laboratory parameters, and quality of life in follow-up.

Findings

Among 372 KT which included 38(10·21%) ABO-incompatible, 12(3·22%) sensitized, 64(17·20%) coexisting donors with COVID-19 history and 20 (5·37%) recipients with residual radiographic abnormalities, the incidence of AR was 34 (9·1%) with 1(0·26%) death censored graft loss, and 4(1·07%) all-cause mortality over a median (interquartile range) follow-up of 241 (106-350) days. In our cox hazard proportional analysis, absence of oxygen requirement during COVID-19 compared to oxygen need [HR = 0·14(0·03-0·59); p-value = 0·0071], and use of thymoglobulin use compared to other induction strategies [HR = 0·17(0·03-0.95); p-value = 0·044] had a lower risk for AR. Degree of Human leukocyte antigen (HLA) DR mismatch had the highest risk of AR [HR = 10.2(1·74-65·83); p-value = 0·011]. With competing risk analysis, with death as a competing event, HLA DR mismatch, and oxygen requirement continued to be associated with AR. Age, gender, obesity, inflammatory markers, dialysis vintage, steroid use, sensitization and ABO-incompatibility have not been associated with a higher risk of AR. The median duration between COVID-19 real time polymerase test negativity to transplant was 88(40-145) days (overall), and ranged from 88(40-137), 65(42-120), 110(49-190), and 127(64-161) days in World Health Organization ordinal scale ≤ 3, 4, 5, and 6-7, respectively. There was no difference in quality of life, tacrolimus levels, blood counts, and mean serum creatinine assessed in patients with a past COVID-19 infection independent of severity.

Interpretation

Our findings support that the outcomes of KT after COVID-19 recovery are excellent with absence of COVID-19 sequelae during follow-up. Additionally, there does not seem to be a need for changes in the induction/immunosuppression regimen based on the severity of COVID-19.

Funding

Sanofi.

Clinical Profiles and Outcomes of COVID-19 in Kidney Transplant Recipients: Experience From a High-Volume Public Sector Transplant Center in India

OBJECTIVES

Data are so far limited on outcomes of kidney transplant recipients with COVID-19 seen at public sector hospitals in developing countries with limited resources.

MATERIALS AND METHODS

We retrospectively investigated a cohort of 157 kidney transplant recipients (75% living and 25% deceased donors) seen at a public sector transplant hospital in India from March to December 2020 who had reverse-transcriptase polymerase chain reaction tests that confirmed COVID-19. Demographic data, immunosuppression regimens, clinical profiles, treatments, and outcomes were analyzed. In our center, maintenance immunosuppression was reduced according to disease severity and case-by-case evaluations. There were also 53 patients with asymptomatic or mild COVID-19 symptoms who received home care to optimize the utilization of scarce resources during travel restrictions.

RESULTS

In our kidney transplant recipient group, median age was 43 years (133 male; 24 female patients); recipients presented at a median of 4 years after transplant. The most common comorbidities included arterial hypertension (73%) and diabetes (24%); presenting symptoms at the time of COVID-19 positivity included cough (49%), fever (58%), and sputum production (32%). Clinical severity ranged from asymptomatic (4%), mild (45%), moderate (31%), and severe (20%) disease. Statistically significant risk factors for mortality included older age, dyspnea, severe disease, obesity, allograft dysfunction prior to COVID-19, acute kidney injury, higher levels of inflammatory markers (C-reactive protein, interleukin 6, procalcitonin), abnormality in chest radiography, and intensive care/ventilator requirements (P < .05). Overall patient mortality was 9.5% (15/157) in hospitalized patients, 21% (15/71) in patients in the intensive care unit, 100% (15/15) in patients who required ventilation, and 0% among those in home treatment.

CONCLUSIONS

The mortality rate in kidney transplant recipients with COVID-19 was higher than in the nonimmunosuppressed general population (1.2%) in India. To our knowledge, this is a largest single-center study of kidney transplant recipients with COVID-19 so far.

Consequences of the first and second COVID-19 wave on kidney transplant recipients at a large Indian transplant centre

Background

There is a scarcity of data comparing the consequences of first and second COVID‐19 waves on kidney transplant recipients (KTRs) in India.

Methods

We conducted a single‐centre retrospective study of 259 KTRs with COVID‐19 to compare first wave (March 15–December 31 2020, n = 157) and second wave (April 1–May 31 2021, n = 102).

Results

KTRs during second wave were younger (43 vs. 40 years; p‐value .04) and also included paediatric patients (0 vs. 5.9%; p‐value .003). Symptoms were milder during the second wave (45 vs. 62.7%; p‐value .007); COVID‐19 positive patients had less frequent cough (32 vs. 13.8%; p‐value .001), fever was less frequent (58 vs. 37%; p‐value .001), and we observed fewer co‐morbidities (11 vs. 20.6%; p‐value .04). The percentages of neutrophils (77 vs. 83%; p‐value .001) and serum ferritin (439 vs. 688; p‐value .0006) were higher during second wave, while lymphocyte counts were reduced (20 vs. 14%; p‐value .0001). Hydroxychloroquine (11 vs. 0%; p‐value .0001) and tocilizumab (7 vs. 0%; p‐value .004) were more frequently prescribed during first wave, while utilization of dexamethasone (6 vs. 27%; p‐value .0001) and remdesivir (47 vs. 65%; p‐value .03) increased during the second wave. Mucormycosis (1.3 vs. 10%; p‐value .01) and ICU admissions (20 vs. 37.2%; p‐value .002) were more frequent during second wave. The 28‐day mortality rate (9.6 vs. 10%; p‐value 1) was not different.

Conclusions

There has been a different clinical spectrum of COVID‐19 amongst KTR with similar mortality between the two waves at a large Indian transplant centre.

A large single centre study from India reporting on the health outcomes of COVID‐19 infected kidney transplant recipients during the two waves of between 2020 and 2021. The rate of intensive care admission was more frequent during the second wave of infection although mortality rates were similar in both waves.

The Impact of COVID-19 Pandemic on Nephrology and Transplant Services and Clinical Training in India

OBJECTIVES

COVID-19 has emerged as a global pandemic with significant impacts on health care systems. The present study was conducted to analyze the effects of the COVID-19 pandemic on nephrology and transplant services and clinical training at our center.

MATERIALS AND METHODS

This observational study was conducted at the Institute of Kidney Disease and Research Centre (Ahmedabad, India). Our institute is one of the largest tertiary care centers of its kind in India with around 400 total inpatient beds for nephrology, urology, and transplant patients. In 2019, our center had annual outpatient and inpatient numbers of 132 181 and 7471, respectively, and conducted 412 renal transplant procedures. For this study, monthly data on number of outpatients, inpatients, and patients undergoing renal transplant, as well as various nonelective procedures, conducted in 2019 and 2020 were collected and analyzed. We investigated the impact of the COVID-19 pandemic on various non-COVID-19-related health care facilities and on clinical training and research activities at our institute.

RESULTS

During the 2020 COVID-19 period, the number of outpatients and inpatients was greatly reduced compared with data from 2019. A similar decrease was seen in patients undergoing hemodialysis, renal transplant, and nonelective procedures at our center. The COVID-19 period also greatly affected clinical training of residents enrolled at our institute and research activities, as a result of focus on COVID-19 as a priority.

CONCLUSIONS

The effects of reduced numbers of outpatients and inpatients on workflow, as well as reduced numbers of renal transplants and nonelective procedures on the health of our patients, are unknown. Hence, a strategic scheme is needed to develop new health care models that can help manage the COVID-19 pandemic at present and any further waves arising in the future.

Clinical Profile and Outcome of COVID-19 in 250 Kidney Transplant Recipients: A Multicenter Cohort Study From India

BACKGROUND

There is a scarcity of data on the consequences of coronavirus disease-19 (COVID-19) infections in kidney transplant recipients (KTRs) from emerging countries.

METHODS

Here, we present a cohort study of 13 transplant centers in India including 250 KTR (226 living and 24 deceased donors) with polymerase chain reaction-confirmed COVID-19 positivity from March 23, 2020, until September 15, 2020. We detailed demographics, immunosuppression regimen, clinical profile, treatment, and outcomes.

RESULTS

Median age of transplant recipients was 43 years, and recipients presented at a median of 3.5 years after transplant. Most common comorbidities (94%) included arterial hypertension (84%) and diabetes (32%); presenting symptoms at the time of COVID-19 included fever (88%), cough (72%), and sputum production (52%). Clinical severity ranged from asymptomatic (6%), mild (60%), and moderate (20%) to severe (14%). Strategies to modify immunosuppressants included discontinuation of antimetabolites without changes in calcineurin inhibitors and steroids (60%). Risk factors for mortality included older age; dyspnea; severe disease; obesity; allograft dysfunction before COVID-19 infection; acute kidney injury; higher levels of inflammatory markers including C-reactive protein, interleukin-6 level, and procalcitonin; chest X-ray abnormality, and intensive care unit/ventilator requirements. Overall patient mortality was 11.6% (29 of 250), 14.5% (29 of 200) in hospitalized patients, 47% (25 of 53) in intensive care unit patients, and 96.7% (29 of 30) in patients requiring ventilation. KTRs with mild COVID-19 symptoms (n = 50) were managed as outpatients to optimize the utilization of scarce resources during the COVID-19 pandemic.

CONCLUSIONS

Mortality rates in COVID-19-positive KTR appear to be higher than those in nonimmunosuppressed patients, and high mortality was noted among those requiring intensive care and those on ventilator.

Non-simultaneous kidney exchange cycles in resource-restricted countries without non-directed donation - a prospective single-center cohort study

Recent reports suggest that bridge-donor reneging is rare (1.5%) in non-simultaneous kidney exchange chains. However, in developing countries, the non-directed donors who would be needed to initiate chains are unavailable, and furthermore, limited surgical space and resources restrain the feasibility of simultaneous kidney exchange cycles. Therefore, the aim of this study was to evaluate the bridge-donor reneging rate during non-simultaneous kidney exchange cycles (NSKEC) in a prospective single-center cohort study (n = 67). We describe the protocol used to prepare co-registered donor-recipient pairs for non-simultaneous surgeries, in an effort to minimize the reneging rate. In addition, in order to protect any recipients who might be left vulnerable by this arrangement, we proposed the use of standard criteria deceased-donor kidneys to rectify the injustice in the event of any bridge-donor reneging. We report 17 successful NSKEC resulting in 67 living-donor kidney transplants (LDKT) using 23 bridge-donors without donor renege and no intervening pairs became unavailable. We propose that NSKEC could increase LDKT, especially for difficult-to-match sensitized pairs (25 of our 67 pairs) in countries with limited transplantation resources. Our study confirms that NSKEC can be safely performed with careful patient-donor selection and non-anonymous kidney exchanges.

Feasibility of Convalescent Plasma Therapy in Kidney Transplant Recipients With Severe COVID-19: A Single-Center Prospective Cohort Study

OBJECTIVES

There are limited clinical data on feasibility and safety of convalescent plasma therapy in kidney transplant recipients with severe COVID-19. The present study was conducted to explore the feasibility of convalescent plasma treatment in 10 kidney transplant recipients with severe COVID-19.

MATERIALS AND METHODS

The prospective observational cohort study was conducted at the Institute of Kidney Disease and Research Centre, Ahmedabad, India. All patients were admitted to the intensive care unit and received antiviral therapy, glucocorticoids, and other supportive care. Two doses of 200 mL each of convalescent plasma with neutralization activity of >1:640 were transfused into patients 24 hours apart following the World Health Organization blood transfusion protocol. The endpoints were the improvement of clinical symptoms and laboratory parameters within 1 day and 7 days after convalescent plasma transfusion.

RESULTS

The patients showed resolution of clinical symptoms, and there was a significant decrease in inflammatory markers (P < .05) within 7 days of convalescent plasma transfusion. Of the 10 patients, 9 patients had full recovery and 1 patient died.

CONCLUSIONS

Convalescent plasma therapy is highly safe and clinically feasible and reduces mortality in kidney transplant recipients with severe COVID-19. Larger clinical registries and randomized clinical trials should be conducted to further explore the clinical outcomes associated with convalescent plasma use in kidney transplant recipients with severe COVID-19.

Bladder Perforation: A Missed Diagnosis Posttransobturator Tape

The advent of transobturator tape (TOT) in 2001 reduced the risk of bladder perforation to 1% in TOT as compared to 5% in tension-free vaginal tape (TVT). We present a case of bladder perforation in TOT where the diagnosis was missed for 5 years. This patient presented with dysuria and dyspareunia repeatedly and was treated for repeated urinary tract infection. The mesh was excised by cystoscopy, following which the symptoms were relieved. Thus, bladder perforation through a rare complication of TOT should always be ruled out in patients presenting with the failure of surgery or irritable detrusor activity such as dysuria and urgency.

A Case of Primary Amenorrhea with Swyer Syndrome

Swyer syndrome with complete gonadal dysgenesis is associated with an absence of testicular differentiation in a phenotypic female with a 46, XY karyotype. A 14-year-old unmarried girl was referred with complaints of primary amenorrhea and nondevelopment of breast. Her built was normal. Examination of her secondary sexual characteristics revealed no breast development, absent axillary hairs, and sparse pubic hairs. External genitalia was of female type. Karyotype showed genotype of 46, XY. Magnetic resonance imaging revealed hypoplastic uterus with absent fallopian tubes and ovaries. A diagnosis of Swyer syndrome was made. Laparoscopy showed infantile uterus, normal fallopian tubes, and streak gonads. Laparoscopic removal of streak gonads was done as there is a risk of gonadoblastoma in such cases. The patient was started on hormonal replacement therapy. Swyer syndrome results mainly due to mutation in certain genes such as SRY gene, which leads to failure of development of testis.

A Study on Balanced Chromosomal Translocations in Couples with Recurrent Pregnancy Loss

Background:

Recurrent pregnancy loss (RPL) is an obstetric complication that affects couples in their reproductive age. Chromosomal abnormalities, mainly balanced rearrangements, could commonly be present in couples with RPL.

Aim:

The purpose of this study is to evaluate the contribution of chromosomal abnormalities and balanced reciprocal translocations, in particular occurring in either of the partners, resulting in RPL.

Materials and Methods:

A retrospective cytogenetic study was carried out on 152 individuals (76 couples) having a history of RPL. The cases were analyzed using G-banding and fluorescence in situ hybridization, wherever necessary.

Results:

Chromosomal abnormalities were observed in 3.2% of the total RPL cases, of which balanced translocations were observed in 4 (80%) individuals and marker chromosome was detected in 1 (20%) individual. All balanced translocations comprised reciprocal translocations, and no cases of Robertsonian translocations were detected in our study. Among reciprocal translocation carriers, three were male and one was female. Polymorphic variants were noted in 8 (5.3%) individuals.

Conclusions:

Chromosomal analysis is an important etiological investigation in couples with RPL. Balanced translocations are the most commonly detected chromosomal abnormalities in such couples. Thus, these couples are the best candidates for offering prenatal genetic diagnosis, thereby ensuring a better reproductive outcome.

Evaluation of Spot Urinary Albumin-Creatinine Ratio as Screening Tool in Prediction of Pre-eclampsia in Early Pregnancy

Objective

The aim of this study was to establish whether a spot urinary albumin/creatinine ratio (ACR) measured between 20 and 28 weeks of gestation can predict subsequent pre-eclampsia in asymptomatic pregnant women.

Design

Prospective observational study.

Subjects

The patients included sixty-two women with singleton pregnancy, normal renal function and no evident proteinuria, attending antenatal clinics between 20 and 28 weeks of gestation in a tertiary care hospital.

Methods

The ACR was determined from midstream urine sample taken between 20 and 28 weeks of gestation. Estimation of albumin was done by immunoturbidimetric microalbumin method and creatinine by modified Jaffe's method.

Results

Incidence of pre-eclampsia in the study group was 12.90%. The cut-off value for ACR was taken as 35.5 mg/mol. The mean ACR in normotensive group was 19.26 ± 7.99, and in pre-eclampsia group it was 51.95 ± 18.78. For pre-eclampsia, screening in early pregnancy, spot ACR cut-off ≥35.5 mg/mol has sensitivity of 87.5%, specificity of 96.30%, PPV of 77.78% and NPV of 98.11%.

Conclusions

Spot urinary ACR values are higher in asymptomatic women in early pregnancy, who developed pre-eclampsia later on. When measured early in the second trimester, an ACR ≥ 35.5 mg/mmol predicted pre-eclampsia well before the onset of clinical manifestations with high sensitivity and specificity. It can be used as a good screening tool for predicting pre-eclampsia in early pregnancy.

Pregnancy Outcome in Patients with Solitary Kidney

BACKGROUND

Solitary kidney may be congenital or as a result of nephrectomy. There is a lot of literature available on quality of life in these patients, but there is limited data on pregnancy outcome.

OBJECTIVES

To study pregnancy outcome in patients with solitary kidney either congenital or due to nephrectomy.

MATERIALS AND METHODS

Study Design This is a retrospective observational study conducted at tertiary health center in Ahmedabad, from 2011 to 2014. Sample Size There were 164 patients of solitary kidney, out of which two patients had congenital solitary kidney and the remaining had solitary kidney due to nephrectomy. Among 164 patients, 96 (58.53 %) patients had completed family, 37 (22.56 %) patients did not try for pregnancy, 15 (9.14 %) patients have conceived, 12 (7.3 %) were lost to follow up and 4 (2.43 %) patients were infertile. Method Patients in reproductive age group (20-40 years), with solitary kidney either congenital or due to nephrectomy, were included. Maternal and fetal outcome was studied, and patients were followed up till 2 years postpartum. Exclusion Criteria Patients with solitary kidney due to post-renal transplant were excluded.

RESULTS

There were 15 (9.14 %) patients who had conceived, out of which 11 (73.33) patients delivered and 4 (26.67 %) patients had spontaneous abortion. Two patients developed gestational hypertension and one had preeclampsia. On follow-up, all babies were normal and none of them had delayed developmental milestones.

CONCLUSION

Preconceptional counseling should be done in these patients regarding risk of developing preeclampsia during pregnancy and preterm delivery. These patients can have good pregnancy outcome with close monitoring during antenatal period.

Prevalence, Clinical and Laparoscopic Features of Endometriosis Among Infertile Women

OBJECTIVE

To study the prevalence, clinical and laparoscopic characteristics of endometriosis in infertile women.

STUDY DESIGN

This is a hospital-based prospective study.

PATIENTS

Five hundred and two (502) patients underwent diagnostic laparoscopy for evaluation of cause for infertility. Staging of endometriosis was done according to the rAFS scoring system.

RESULTS

Out of 502 women, 276 (54.98 %) showed the presence of endometriosis, while 226 (45.01 %) did not have endometriosis. One hundred and eighty-three (66.3 %) women had stage I endometriosis, 49 (17.77 %) had stage II, 23 (8.33 %) had stage III and 21 (7.6 %) had stage IV endometriosis.

CONCLUSION

More than 50 % of patients in our study were asymptomatic; however, the presence of menorrhagia, dysmenorrhoea, dyspareunia and chronic pelvic pain are also clinically statistically significant. So, we would like to recommend the evaluation and treatment of a patient reporting in gynaecological OPD with the above-mentioned complaints with high suspicion of endometriosis.

A transvaginal removal and repair of vesicovaginal fistula due to mesh erosion

Vesicovaginal fistula (VVF) is a devastating social problem. It can either result from obstetric trauma or following gynecological surgeries, malignancy, or radiation. We present a case of a 70-year-old woman who had a VVF following mesh augmentation surgery for anterior compartment prolapse. She required a transvaginal removal of the eroded mesh followed by a transvaginal repair of VVF using a Martius flap, 6 weeks later. Transvaginal removal of mesh is technically feasible and a good approach. Timing and route of surgery should be individualized.

An Overview on Fertility Outcome in Renal Transplant Recipients

BACKGROUND

The number of patients undergoing renal transplant are increasing with time. Most of these patients fall in the reproductive age group, who are going to conceive sooner or later. But there are few recipients who either are infertile before transplant or became infertile due to underlying renal pathology responsible for transplantation.

OBJECTIVE

To study fertility outcome in female renal transplant recipients.

MATERIALS AND METHODS

STUDY DESIGN

This is a retrospective study conducted at tertiary health center in Ahmedabad, from 2004 to 2014.

INCLUSION CRITERIA

Renal transplant recipients in the reproductive age group (20-40 years of age) were followed up in gynecology outdoor patient department.

SAMPLE SIZE

There were 211 female renal transplant recipients, out of which 113 (53.5 %) patients had complete family, 3 (1.41 %) patients were infertile, 16 (7.58 %) patients have conceived, 33 (15.63 %) patients were lost to follow-up and remaining 46 (21.8 %) did not try for pregnancy.

EXCLUSION CRITERIA

Unmarried patients, divorced and widow patients were excluded.

RESULTS

Out of 19 patients, 16 patients conceived and 3 were infertile. The main cause of infertility in these patients was ovarian factor in 2 patients and tubal factor in 1 patient. Among 16 patients, 8 patients had missed abortion, 2 patients had preterm deliveries and 6 patients had term deliveries.

CONCLUSION

Peritransplant and preconceptional counseling plays an important role for renal transplant recipients to help them understand the effect of renal pathology and transplantation on their fertility. They can have good fertility and pregnancy outcome with optimum functioning graft.

Unusual presentation of twisted ovarian cyst

Ovarian torsion (also termed as adnexal torsion) refers to partial or complete rotation of the ovary and a portion of fallopian tube along its supplying vascular pedicle. It occurs commonly in reproductive age group; more on the right side (60%) and often presents with acute lower abdominal pain lasting for few hours and up to 24 h, accounting for 2.7% of acute gynecological conditions. It is one of the devastating conditions, hampering blood supply of ovary which may lead to total necrosis of ovarian tissue and complications, if not diagnosed and managed in time. Hence, we present a case on a twisted ovarian cyst in postmenopausal woman with unusual symptomatology leading to delayed diagnosis and loss of an ovary.

Endometrial and Subendometrial Vascularity by Three-Dimensional (3D) Power Doppler and Its Correlation with Pregnancy Outcome in Frozen Embryo Transfer (FET) Cycles

PURPOSE OF THE STUDY

To study the role of endometrial and subendometrial blood flow measured by 3D power Doppler as predictors of pregnancy in frozen embryo transfer (FET) cycles.

METHODS

A hospital-based prospective study of two hundred and twenty-one (221) women undergoing FET cycles with a triple-line endometrium ≥7 mm on day 14 endometrial and subendometrial blood flow was assessed using 3D power Doppler, and various indices endometrial volume, subendometrial volume and their vascularisation index (VI), flow index (FI) and vascularisation flow index (VFI) were obtained and compared between the pregnant and the non-pregnant group. Primary outcome was clinical pregnancy.

RESULTS

Out of 221 women, 97(43.89 %) became pregnant, while 124 (56.10 %) failed to become pregnant. The endometrial volume was comparable between the two groups. Endometrial VI, FI and VFI were significantly higher in the pregnant as compared to the non-pregnant group. There was a significant difference in subendometrial VI and VFI between the two groups, but FI was similar.

CONCLUSIONS

Endometrial and subendometrial vascularity by 3D power Doppler can be a useful parameter in predicting pregnancy in FET cycles.

Nonclassic congenital adrenal hyperplasia misdiagnosed as Turner syndrome

We present a patient with nonclassic congenital adrenal hyperplasia (NCAH) misdiagnosed as mosaic Turner syndrome. She presented with complaints of primary infertility. Short stature, the presence of facial hair and hoarse voice was also noted. She had primary amenorrhea and was advised for karyotype at 16 years of age, which was reported as 45, X[20]/46, XX[80], stating her as a case of mosaic Turner syndrome. Clitoroplasty was done at 21 years of age for clitoromegaly, which was noticed during puberty. The diagnosis of mosaic Turner could not explain the virilization. Therefore, we repeated the karyotype, which revealed 46, XX in more than 100 metaphases and was sufficient to exclude mosaicism. Furthermore, the endocrinological evaluation revealed high testosterone level with a normal 17 alpha-hydroxyprogesterone (17-OHP). The presence of pubertal onset virilization with a karyotype of 46, XX and raised testosterone level with normal 17-OHP level, raised the suspicion of NCAH for which adrenocorticotropic hormone stimulation test was done which confirmed the diagnosis of NCAH.

Female sexual dysfunction in patients with endometriosis: Indian scenario

BACKGROUND

Female sexual dysfunction (FSD) in Indian women is often overlooked due to cultural beliefs and considered as social taboos. Sexuality is an important and integral part of life. There are many causes of sexual dysfunction, but the prevalence of FSD in endometriotic patients is still underdiagnosed.

MATERIALS AND METHODS

Study design - Cross-sectional observational study conducted at tertiary care center, from June 2015 to March 2016. Sample size - Fifty-one patients in reproductive age group (18-47 years) who were diagnosed with endometriosis on diagnostic laparoscopy were included. Methods - FSD was assessed with a detailed 19-item female sexual function index questionnaire. All six domains of sexual dysfunction, i.e., desire, arousal, lubrication, orgasm, satisfaction, and pain were studied. Exclusion - Patients with other gynecological, medical or surgical history were excluded.

RESULTS

Out of 51 patients with endometriosis, 47.06% of patients had sexual dysfunction. With the increase in staging of endometriosis, sexual dysfunction prevalence is also rising. FSD was 100% in patients with severe endometriosis as compared to 33.33% in minimal endometriosis.

CONCLUSION

Every individual deserves good sexual life. The sexual dysfunction associated with endometriosis should also be taken into consideration while managing these patients.

Prevalence of female sexual dysfunction among Indian fertile females

Background:

Female sexual dysfunction (FSD) is described as difficulty experienced by a female during any stage of a normal sexual activity including physical pleasure, desire, arousal, or orgasm. There are various factors responsible for FSD including psychological status of a person, gynecological or medical problems, long use of certain drugs, and social beliefs.

Objectives:

To study the prevalence and various factors associated with FSD.

Materials and Methods:

Study Design - This study design was a cross-sectional observational study conducted at Tertiary Care Centre, in Ahmedabad from June 2015 to March 2016. Sample Size - One hundred and fifty-three fertile females in reproductive age group (20–47 years) were included in the study. Written and informed consent was obtained from all the females. Methods - FSD was assessed with a detailed 19-item female sexual function index questionnaire. All six domains of sexual dysfunction, i.e., desire, arousal, lubrication, orgasm, satisfaction, and pain were studied. Various associated factors such as gynecological or psychological problems were also studied. Exclusion - Infertile patients were excluded from the study.

Results:

The prevalence of FSD was 55.55% among 153 fertile females. FSD was more prevalent in the age group of 26–30 years and with duration of marriage >16 years. FSD was also more common in females with middle education and those belonging to upper middle socioeconomic status. Psychological stress was significantly associated with FSD.

Conclusion:

It is right of every female to lead healthy sexual life as it is key to happiness in marriage. Females with FSD can be managed with proper counseling and treating the underlying etiology.

Prevalence; Characteristics and Management of Endometriosis Amongst Infertile Women: A One Year Retrospective Study

BACKGROUND

Endometriosis appears to affect every aspect of a women's reproductive system resulting in infertility and spontaneous pregnancy loss. This study aims to find out the prevalence & clinical characteristics of endometriosis amongst infertile women.

SETTINGS AND DESIGN

A Hospital based retrospective study over a period of one year.

MATERIALS AND METHODS

It is a retrospective study conducted in the gynaecology department in Institute of Kidney Diseases & Research Centre; Ahmedabad from April 2012 to March 2013 amongst women with a primary complaint of infertility (Primary/Secondary).A total of 372 patients underwent diagnostic hysterolaparoscopy and of these 180 patients who had laparoscopic evidence of endometriosis was included in the study. All of these patients and their findings were analysed with respect to the clinical signs and symptoms. The outcome after appropriate management was analysed in subsequent follow up.

STATISTICAL ANALYSIS

All collected data was entered into the SPSS version 20. Categorical data are expressed in frequency or percentage. Chi-Square test and Fisher-Exact test has been performed to carry out p-value for categorical data. P-value <0.05 shows statistically significant difference.

RESULTS

The frequency of endometriosis among women with infertility subjected to diagnostic hysterolaparoscopy was found to be 48.38%. Statistical significant association with severity of disease was associated with symptoms like dysmenorrhea, chronic pelvic pain, restricted uterine mobility and adnexal tenderness. (p <0.01) Ultrasound finding of endometrioma with ground glas appearance also had statistical significant association with staging of disease (p <0.01).

CONCLUSION

Endometriosis amongst infertile women is increasingly being detected due to greater use of laparoscopy in evaluation of infertility.Though most signs do not correlate with severity of disease however the presence of restricted uterine mobility, adnexal tenderness & chronic pelvic pain should always raise the suspicion of endometriosis. Laparoscopy remains the gold standard for diagnosing and staging endometriosis.

Acute renal failure in pregnancy: our experience

Acute renal failure (ARF) is a serious medical complication during pregnancy, and, in the post-partum period, is associated with significant maternal morbidity and mortality as well as fetal loss. The objective of our study is to find the etiology and maternal outcome of ARF during pregnancy. The study was conducted at the Obstetrics and Gynecology Department of the Institute of Kidney Disease and Research Center, Ahmedabad, India from January 2009 to January 2011. Fifty previously healthy patients who developed ARF, diagnosed on oliguria and serum creatinine >2 mg%, were included in the study. Patients with a known history of renal disease, diabetes and hypertension were excluded from the study. All patients were followed-up for a period of six months. Patient re-cords, demographic data, urine output on admission and preceding history of antepartum hemorrhage (APH), post-partum hemorrhage (PPH), septicemia, operative interventions and retained product of conception were noted and need for dialysis was considered. Patients were thoroughly examined and baseline biochemical investigations and renal and obstetrical ultrasound were performed on each patient and bacterial culture sensitivity on blood, urine or vaginal swabs were performed in selected patients. The age range was 19-38 years (mean 26 ± 3.8). The first trimester, second trimester and puerperal groups comprised of four (8%), 25 (50%) and 21 patients (42%), respectively. Hemorrhage was the etiology for ARF in 15 (30%), APH in ten (20%) and PPH in five (10%) patients. Eleven (22%) patients had lower segment cesarian section (LSCS) while 36 (78%) patients had normal vaginal delivery. In 20 (40%) patients, puerperal sepsis was the etiological factor, while pre-eclampsia, eclampsia and HELLP syndrome accounted for 18 (36%) patients. Two (4%) patients had disseminated intravascular coagulation on presentation while one (2%) patient was diagnosed with hemolytic uremic syndrome. Maternal mortality was 12% (n = 6). Of the 38 (88%) surviving patients, 21 (42%) had complete recovery of renal function, eight (16%) patients had partial and 15 (30%) patients required dialysis on a long-term basis. ARF in pregnancy is associated with poor maternal and renal outcome if not detected and treated in time.

Oral contraceptive pills: A risk factor for retinal vascular occlusion in in-vitro fertilization patients

Retinal vascular occlusion is the most common cause of retinopathy leading to severe visual loss in all age groups. Central retinal vein occlusion (CRVO) is usually seen in older age group and is often associated with systemic vascular diseases. Although the exact cause and effect relationship has not been proven, central retinal vein occlusion has been associated with various systemic pathological conditions, hence a direct review of systems toward the various systemic and local factors predisposing the central retinal vein occlusion is advocated. We describe the development of central retinal venous occlusion with associated cystoid macular edema (CME) in two healthy infertile women who were recruited for in vitro fertilization cycle for infertility. Predisposing risk factors associated with central retinal vein occlusion are obesity, sedentary life style, smoking, and some systemic diseases such as hyperlipidemia, hypertension, associated autoimmune disorders e.g., antiphospholipid antibody syndrome, lupus, diabetes mellitus, cardiovascular disorders, bleeding or clotting disorders, vasculitis, closed-head trauma, alcohol consumption, primary open-angle glaucoma or angle-closure glaucoma. In our patients, they were ruled out afterdoing allpertaining investigations. The cases were managed with further avoidance of oral contraceptives and intra-vitreal injections of Bevacizumab (Avastin), an anti-vascular endothelial growth factor (anti-VEGF drug) and Triamcinolone acetonide (a long acting synthetic steroid). Hence, even if no systemic diseases are detected. Physical examinations are recommended periodically for young women on oral contraceptive pills.

Review: Toxicants in reproductive fluid and in vitro fertilization (IVF) outcome

Some of the physical, chemical, dietary, occupational and environmental factors are having adverse effect on human reproduction. Increasing trend in reproductive disorders in recent years at least in part might be associated with these factors. The data available suggests less success rate of in vitro fertilization (IVF) outcome of parents exposed to some of the reproductive toxic chemicals as compared to parents who were not exposed to such chemicals. However, data are very meager and require more studies as some debatable data also exists. But existing positive findings encourage in advising that sub-fertile subjects, who are planning to go for the IVF, should reduce toxic exposure well in advance by adopting positive life style and work environment. Further, clinician ought to be aware of occupational and environmental exposure history of the participating couple.

Successful Generation of Donor Specific Hematopoietic Stem Cell Lines From Co-Cultured Bone Marrow With Human Embryonic Stem Cell Line: A New Methodology

We report the generation of 30 healthy human embryonic stem cell (h-ESC) lines from 33 voluntary oocyte donors using a donor somatic cell nuclear transfer (SCNT) technique on 190 oocytes. Our aim was to coculture them with their own bone marrow (BM) to generate hematopoietic progenitor cells for therapeutic purposes. Pluripotency and undifferentiated stage were confirmed using molecular cell surface markers. Normal karyotype of these cell lines was confirmed. Here we demonstrate that SCNT-h-ESCs differentiate to hematopoietic precursors when cocultured with unmodified, nonirradiated donor BM. We did not use any xenogeneic material for this hematopoietic differentiation. Hematopoietic precursors derived from them expressed cell surface antigens CD45/34. When further cultured with hematopoietic growth factors these hematopoietic precursors formed characteristic myeloid, erythroid, and megakaryocyte lineages. Phenotypic CD34+ cells derived from NT-h-ESCs were functionally similar to their counterparts in primary hematopoietic tissues like BM, umbilical cord, and blood. More terminally differentiated hematopoietic cells derived from h-ESCs under these culture conditions also expressed normal surface antigens like glycophorin A on erythroid cells, CD15 on myeloid cells, and CD41 on megakaryocytes. We report generation of hematopoietic progenitor cells from h-ESC lines by a SCNT technique, with differentiation into further lineages with structural and functional similarities to their adult counterparts in vivo. This novel alternative source of CD34+ stem cells from h-ESC lines generated without any xenogeneic material might be used to create transplantation tolerance, to implement regenerative medicine, and to treat autoimmune disorders.

Embryonic stem cell derived and adult hematopoietic stem cell transplantation for tolerance induction in a renal allograft recipient:--a case report

We generated an human embryonic stem cell (hESC) line to augment chimerism-associated tolerance. A 40-year-old African with chronic glomerulonephritis-chronic renal failure with 100% G6PD enzyme deficiency presented for renal transplantation with a 27-year-old, 6/6 HLA-matched sister as a willing donor.

METHOD

We generated an hESC line from the donor's oocytes using long ovarian stimulation protocol simultaneously with tolerance induction protocol. A nuclear transfer (NT)-hESC line was derived by transferring a donor cumulus cell into an enucleated oocyte, subjected to electrical fusion, and cultured for 5 days. ESCs hatched from the blastocyst on day 6 were cocultured with her unmodified bone marrow for 2 days and suspended in Ringer's lactate. Five milliliters of suspension were collected for cell counting, viability, pluripotency, flow cytometry, and karyotyping. The remaining suspension was infused into the periphery of the recipient. Transplantation was performed 1 week later following a negative lymphocytotoxicity cross-match test using no immunosuppression. Peripheral blood chimerism (PBC) was studied using fluorescent in situ hybridization technique. Allograft biopsy was performed on day 7.

RESULTS

NT-hESC CD34+ count was 7.6%, viability 100%, karyotyping normal, pluripotency markers: SSEA-1, SSEA-4, OCT-3/4, TRA-1/60:positive; 12% PBC was noted at 1 week after transplantation. Serum creatinine was 1.2 mg%, graft biopsy was unremarkable, and G6PD enzyme deficiency was corrected to 0% at 100 days posttransplant. Liver function tests and hematology profile were unremarkable for graft-versus-host disease.

CONCLUSION

This is the first report of tolerance induction using NT-hESC-induced hematopoietic chimerism with synergistic use of adult bone marrow. It was safe and effective.

Oxidative stress status: possible guideline for clinical management of critically ill patients

BACKGROUND

Critical care medicine has developed in the last few years into a separate scientific discipline and studies related to the outcome after intensive care usually suggest a long hospital stay that becomes cost prohibitive. The majority of problems (death) amongst critically ill patients requiring critical care involve sepsis, inflammation, tissue damage-oxidative stress, oxygen tension PO2, lipid peroxidation. The present investigation involves monitoring of serum levels of MDA, SOD as a possible guideline for severity of clinical situations in critically ill patients.

METHODS

Fifty critically ill heterogeneous patients requiring intensive care in the ICU of IKDRC were selected as subjects with ages varying from 17 to 75 years. Serum levels of MDA (ng/ml), SOD (U/ml) were determined right from admission to discharge due to improvement / DAMA / death. MDA and SOD were estimated according to the methods of Buege and Aust et al. (1978), Nandi and Chatterji (1988).

RESULTS

Critically ill patients irrespective of the disease process indicated significantly very high serum levels of MDA and low levels of SOD at the time of admission (13.28+/-4.26 ng/ml, 3.80+/-2.60 U/ml, respectively) according to the severity of the prevalent clinical situation. The pattern of serum levels of MDA and SOD according to subsequent clinical performance did indicate a decreasing trend of MDA (oxidant) and fluctuating trend of SOD (antioxidant enzyme except in those who inevitably succumbed to death in spite of adequate clinical management.

CONCLUSIONS

The results of the present study have amply revealed the utility and relevance of monitoring oxidative stress in critically ill patients as biochemical markers, cost-effectiveness and role in decision making (withdrawal/continuation of different support modalities) as deemed fit.

Stress and women

Stress-tension-pain occur more often in health disorders of women than anywhere in the entire spectrum of human illness. No where is the effect of rapid change more apparent than in the changing role of today's women who are subjected to pressures from all sides. Now a days women virtually take part occupy positions, in day to day activities similar to their male counterparts. An outline of conceptual consideration, biochemical overview of stress and intricacies of coping mechanisms are delineated from the point of view of stress situations in female (during reproductive life span) peculiar to them only viz menarche, menstrual cycle, pregnancy-eventualities of pregnancy-labour-delivery, purperium, postpartum psychosis, abortions-induced, spontaneous, menopause. Lipid profile and oxidative stress status as biochemical responses in these stresses were investigated. As expected observed maximal/minimal biochemical responses well correlated with peak time and at termination of stress. Present day emphasis is on menstrual regulation by intake of oral contraceptive to improve health if women prefer not to bleed every month and hormone replacement therapy for elderly women to improve post menopausal quality of life and avoiding menstrual problems at the same time.

Iodinated contrast media induced oxidative stress status in patients undergoing urography

BACKGROUND

The present investigation is an extension of our earlier work on oxidative stress in a number of clinical situations and awareness of potential toxicity of contrast media. It was of interest to understand the relative safety (in terms of balance between oxidants/antioxidants) of the usage of iodinated contrast media in urography.

METHODS

Alterations in serum levels of oxidant lipid peroxidation and product malondialdehyde (MDA) and components of anti-oxidant have been studied in 125 patients (with renal calculus disease) to undergo intravenous urographic procedure before and 3 hours following intravenous administration of Trivideo-400 (Iothalmate Sodium 40 ml: 18 gm Iodine) and results of serum levels of MDA (nmol/ml), SOD (mu/ml), Vit-C and Vit-E (mg/dl) were also compared with 135 appropriately age matched controls.

RESULTS

The salient features of present investigation indicated definite pattern viz. Significant rise in serum levels of oxidant MDA (4.35 +/- 2.05) and fall in SOD (3.04 +/- 1.04), Vit-C (0.55 +/- 0.17), Vit-E (0.67 +/- 0.20) in patients at pre-IVU stage in comparison with those of controls viz MDA (4.35 +/- 2.05), SOD (3.77 +/- 1.55), Vit-C (0.71 +/- 0.25) and Vit-E (0.80 +/- 0.30). There occurred further elevation in serum levels of MDA (5.28 +/- 2.48) and fall in SOD (3.07 +/- 0.97), Vit-C (0.52 +/- 0.16), Vit-E (0.66 +/- 0.19) showing no significant alterations 3 hours following intravenous IVU procedure.

CONCLUSIONS

It is concluded that contrast media induced changes did remain within tolerable physiological limits and no significant changes in anti-oxidant components Vit-E and SOD were suggestive of relative safety of iodinated contrast media usage.