A Roadmap for Training in Urogynecology: IUGA International Initiative

INTRODUCTION AND HYPOTHESIS

Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission.

METHODS

The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities.

RESULTS

The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors.

CONCLUSION

The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.

Systematic Review and Meta-analysis of the Prevalence of Levator Ani Avulsion with Obstetric Anal Sphincter Injury and its Effects on Pelvic Floor Dysfunction

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the prevalence of levator ani avulsion (LAA) among primiparous women with obstetric anal sphincter injury (OASI) and how this association could affect future pelvic floor dysfunction.

METHODS

Three electronic databases (MEDLINE/PubMed/EMBASE) were searched in December 2018 and again in October 2022. Nine full-text articles were included in the analysis. The exclusion criteria were language other than English, studies not based on primiparous women only, conference abstracts, and evaluation without ultrasound or MRI.

RESULTS

The overall prevalence of LAA was 24% (95% CI: 18-30%). Those with OASI, were at a higher risk of LAA, OR 3.49 (95% CI: 1.46 to 8.35). In women with LAA + OASI versus OASI alone, Three of Five studies showed worsened AI symptoms. Three of Five studies assessing urinary incontinence (UI) reported no significant difference in UI, whereas two reported increased UI. All studies that looked at pelvic organ prolapse reported a higher incidence of symptomatic prolapse and reduced pelvic floor muscle strength in women with LAA + OASI compared with those without LAA.

CONCLUSION

Levator ani avulsion is prevalent following vaginal birth and is strongly associated with OASI. Incidence of AI does not increase in women with LAA and OASI, but they had greater symptom bother. OASI with LAA appears to increase the incidence of pelvic floor weakness and pelvic organ prolapse. There is no consensus agreement on the effect of LAA + OASI on UI.

Plasma cell rich acute rejection: Risk factors, treatment and outcomes

Plasma cell-rich rejection is a rare and poorly defined entity. Its treatment is not clearly defined and has universally poor prognosis. More data should be published from various transplant centers around the world to identify the treatment that has the best outcomes and to formulate treatment guidelines for these cases. It is a retrospective analysis of kidney biopsies form 2008 to 2018. Four hundred biopsied were screened and 55 were found to have features of rejection and among them, 13 had plasma cell-rich rejection. Data of treatment given and the graft survival outcomes in these cases were retrieved by medical records. One patient had complete recovery, three had graft loss and the remaining nine had permanent decline in glomerular filtration rate. Decrease in immunosuppression and presence of infection are risk factors for plasma cell-rich acute rejection (PCAR). It can be acute cell-mediated rejection (ACR)/antibody-mediated rejection (AMR)/ACR+AMR. Resistant rejection, ACR+AMR, C4d positivity, and severe interstitial inflammation are poor prognostic factors. Overzealous decrease in immunosuppression should not be done. Management of immunosuppression during infection is most critical for the development of PCAR. Bortezomib is emerging as a therapeutic modality for the treatment of PCAR.

POS0606 DISEASE ACTIVITY AND PATIENTS-REPORTED OUTCOMES AFTER SWITCHING BETWEEN IL-6 RECEPTOR INHIBITORS AND JAK INHIBITORS: AN ANALYSIS FROM THE CORRONA REGISTRY

Background:

Rheumatoid arthritis (RA) patients who fail therapy may be switched to any of the five classes of biological disease-modifying antirheumatic drugs (DMARDs) and targeted synthetic DMARDs, to meet treatment goals. Physicians may hesitate to switch between Janus Kinase inhibitors (JAKi) and interleukin-6 receptor inhibitors (IL-6Ri) since they both impact IL-6 signalling and due to limited data on switching between the two classes.

Objectives:

This retrospective, observational study based on the real-world Corrona RA registry aimed to describe the response in RA patients switching between IL-6Ri and JAKi.

Methods:

Adult RA patients who initiated either IL-6Ri or JAKi after November 2012 and had a six-month post-initiation follow-up visit were eligible. Patients in ‘Cohort A’ initiated an IL-6Ri following discontinuation of a JAKi and those in ‘Cohort B’ initiated a JAKi following discontinuation of an IL-6Ri. Disease activity measures and patient-reported outcomes (PROs) were evaluated at baseline and at six-month follow-up. Within each group, change from baseline was assessed for Clinical Disease Activity Index (CDAI), Health Assessment Questionnaire (HAQ), pain, fatigue, tender joint count (TJC), swollen joint count (SJC), physician global assessment (MDGA), patient global assessment (PtGA) and morning stiffness duration. Proportion of patients achieving CDAI low disease activity (LDA), CDAI remission and minimal clinically important difference (MCID) for HAQ, pain, fatigue, MDGA, PtGA were assessed. Adjusted linear and logistic regression models were performed for between-group comparisons (Cohort A vs Cohort B) excluding initiators who switched therapy prior to six-month visit.

Results:

Cohorts A and B included 122 and 144 initiators, respectively. Patients who switched to

IL-6Ri (vs JAKi) were younger (mean [SD] age, 56.2 [11.3] vs 58.9 [12.6] years), had higher baseline CDAI (23.2 [12.9] vs 20.2 [12.8]), had higher prior use of ≥2 csDMARDs (75% vs 65%), and were less likely to initiate therapy as monotherapy (44% vs 50%).

In Cohort A, significant changes from baseline were observed for all continuous outcomes except HAQ and fatigue. In Cohort B, a significant improvement was observed only for patient-reported pain (Table 1).

Table 1.

Unadjusted Within-Group Change from Baseline to Six Months, Mean (95% CI), n

OutcomesCohort A, N = 122Cohort B, N = 144CDAI-4.7 (-7.6, -1.9), 109-2.4 (-5.2, 0.4), 116HAQ-0.0 (-0.1, 0.1), 105-0.1 (-0.1, 0.0), 118Patient-reported pain-8.2 (-13.4, -3.0), 109-5.9 (-11.5, -0.2), 120Patient-reported fatigue-4.4 (-9.0, 0.2), 109-1.7 (-6.6, 3.3), 117TJC-1.6 (-3.0, -0.1), 112-1.2 (-2.6, 0.3), 117SJC-1.5 (-2.5, -0.4), 112-0.4 (-1.3, 0.6),117MDGA-10.9 (-15.6, -6.3), 112-4.3 (-8.7, 0.2), 117PtGA-6.0 (-11.2, -0.8), 109-4.8 (-10.5, 0.8), 120Morning stiffness durationa-1.3 (-2.2, -0.5), 109-0.1 (-1.1, 0.8), 118

aAmong those reporting morning stiffness at baseline.

In the adjusted between-group comparison (data not shown) of change from baseline, there were no significant differences in clinical outcomes between Cohorts A and B.

In both cohorts, patients achieved CDAI LDA, CDAI remission, and MCIDs across other PROs (Figure 1). In the adjusted between-group comparison (data not shown), the results were similar with the exception of achievement of CDAI LDA among patients with moderate to high disease activity at baseline.

Figure 1.

Rates of CDAI LDA, CDAI Remission, and MCID for PROsa at Six Months

Conclusion:

In general, in both cohorts a substantial proportion of patients achieved CDAI LDA and MCID across PROs. Despite some overlap of JAKi and IL-6Ri therapies’ on the IL-6 pathway, there are some distinct mechanisms of action which may result in meaningful improvements for a subset of patients.

Acknowledgements:

Amy Praestgaard (Sanofi) contributed to the interpretation of the statistical analysis for this abstract. Medical writing support for this abstract was provided by Nupur Chaubey (Sanofi).

Disclosure of Interests:

Anisha Dua Speakers bureau: AbbVie, Consultant of: Consulting/advisory board for AbbVie, Novartis, and Chemocentryx, Employee of: Board member of Vasculitis foundation and Chicago Rheumatism Society, Kerri Ford Shareholder of: Sanofi, Employee of: Sanofi, Stefano Fiore Shareholder of: Sanofi, Employee of: Sanofi. In addition, Stefano Fiore has a patent EP 19306553.9; USPTO #s 62/799,698; 62/851,474; 62/935,395 issued, Dimitrios A Pappas Shareholder of: Corrona LLC, Consultant of: Sanofi, AbbVie, Gtech, Roche Hellas, and Novartis, Employee of: Corrona LLC. Board of directors, Corrona Research Foundation, Judson Janak: None declared, Taylor Blachley: None declared, Carla Roberts-Toler: None declared, Kelechi Emeanuru: None declared, Joel Kremer Consultant of: AbbVie, Lilly, Novartis, Pfizer, BMS, Genentech, Regeneron, Sanofi, and Corrona, Grant/research support from: AbbVie, Lilly, Novartis, and Pfizer, Alan Kivitz Shareholder of: Pfizer, Sanofi, GlaxoSmithKline, Gilead Sciences, Inc., and Novartis, Speakers bureau: Celgene, Merck, Lilly, Novartis, Pfizer, Sanofi, Flexion, and AbbVie, Consultant of: AbbVie, Boehringer Ingelheim, Flexion, Janssen, Pfizer, Sanofi, Regeneron, SUN Pharma Advanced Research, Gilead Sciences, Inc. In addition, Alan Kivitz reports other from Altoona Center for Clinical Research, PC, during the conduct of the study.

Management of mid-urethral tape complications: a retrospective study

Background/purpose of the study

Following mid-urethral tape insertion, for stress urinary incontinence (SUI), a proportion of women experience complications such as voiding dysfunction or tape erosion which fail to respond to conservative management approaches. These women thus require further surgical treatment. Our objective was to describe the outcomes of the surgical management of complications in these women.

Methods

This retrospective study describes the results obtained following the surgical management of mid-urethral tape complications. Twenty-nine consecutive women who required mid-urethral tape lysis, loosening or excision for tape-related complications in the period 2007-2017 were included. Primary outcomes were improvement in voiding dysfunction and resolution of pain, while secondary outcomes were evaluation of the recurrence of stress urinary incontinence and patient satisfaction. Patient outcomes were measured using the Patient Global Impression of Improvement questionnaire.

Results

There were 1459 mid-urethral tape procedures performed in the study period. Twenty-nine women (1.99%) who had revision surgery for tape complication were identified. Interventions included tape loosening or lysis in 19 women and tape excision in ten women. Twenty-three of the 29 patients reported a significant improvement in their symptoms postoperatively. Two women had a recurrence of SUI in the tape excision cohort; all patients following tape loosening or lysis remained continent.

Conclusions

Tape revision surgery is a safe and effective treatment for mid-urethral tape complications with the majority of women maintaining continence following revision. Early intervention and proactive management of complications, by the appropriate specialist, will improve outcomes.

Hypothyroidism-induced reversible dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is an idiopathic condition that results from impaired ventricular systolic function. Thyroid diseases have been known to cause myriad changes in the structure and function of the heart. Diastolic dysfunction is a common abnormality reported in hypothyroidism. However, hypothyroidism-induced DCM and systolic dysfunction is an uncommon phenomenon, especially as the initial presenting manifestation of hypothyroidism. The current article describes the case of a young female who presented with symptoms of heart failure and was diagnosed as having DCM as echocardiography revealed left ventricular global hypokinesia and severely depressed systolic function. Thyroid profile revealed a grossly elevated thyroid-stimulating hormone (TSH) value of 313 μIU/ml; free thyroxine (fT4) was 0.220 ng/dl. The present case presented with DCM as the initial presentation of hypothyroidism and improved significantly after five months of levothyroxine replacement therapy.

Should maximal urethral closure pressure be performed before midurethral sling surgery for stress incontinence? A time to revisit

INTRODUCTION AND HYPOTHESIS

Maximum urethral closure pressure (MUCP) provides an objective assessment of urethral integrity, but its role in predicting outcome after midurethral sling (MUS) placement is debatable and current practice in the UK is variable. The study was carried out to determine if lower preoperative MUCP is associated with poor outcome following MUS.

METHOD

The study was a retrospective review of the British Society of Urogynaecology (BSUG) database and urodynamics (UDS) data. Patients who reported outcome as "no improvement", "worse" or "much worse" on the Patient Global Impression of Improvement (PGII) scale were identified as having a poor outcome. Patients who reported "a little improvement", "improved" and "very much improved" on the PGII were thought to have a good outcome. The preoperative demographics, UDS findings and quality of life (International Consultation of Incontinence questionnaires [ICIQ-SF]) data of the two groups were compared.

RESULT

A total of 236 women were identified for the study. Of these, 24 women (10.2 %) had a poor outcome. Of the remaining women reporting a good outcome, 50 cases were randomly selected. All urodynamic parameters, including mean functional urethral length (FUL), bladder capacity, and Qmax, were similar, except for mean MUCP 37.05 cm H2O, which was significantly lower in group 1 (poor outcome 37.05 cm H2O) compared with a mean MUCP of 50.6 cm H2O in group 2 (good outcome; p = 0.005).

CONCLUSION

We conclude that failure following MUS is associated with preoperatively lower MUCP, which can be used as a predictor of failure.

Long-term follow-up after colpocleisis: regret, bowel, and bladder function

INTRODUCTION AND HYPOTHESIS

Colpocleisis is not a popular option amongst surgeons, possibly due to concern about long-term regret. This study assessed a cohort of women who underwent colpocleisis 2-5 years previously to determine the regret rate, the effect on quality of life (QOL) and bladder and bowel function.

METHODS

This was a longitudinal study of patients who underwent colpocleisis at least 2 years previously. Participants were asked to complete the Prolapse QOL (P-QOL), International Consultation on Incontinence-Urinary Incontinence (ICIQ-UI Short Form) and Colorectal Anal Distress Inventory questionnaires (CRADI). Two additional questions were asked: (1) Do you regret having vaginal closure surgery for prolapse? (never, sometimes, often, all the time), and (2) Would you recommend this surgery to a relative or friend who is not sexually active? (yes, no.)

RESULTS

Thirty-four women were identified. Six had died by the time of follow-up, and five declined to answer the questionnaires because of ill health. Twenty-three women responded (67 %). Mean age was 78.68 years. One woman regretted having had the surgery, as the colpocleisis had failed. Twenty-one women (91.3 %) would recommend this surgery; one would not (4.3 %), and another was not sure (4.5 %). Low P-QOL [8 (0-37) ± 9.41), ICIQ-UI (7 (0-17) ± 5.44) and CRADI (10; 0-28 ± 8.13] scores suggest a positive impact on QOL, bladder and bowel function.

CONCLUSION

In this cohort, colpocleisis produced a good outcome with low regret rate (4.3 %), good QOL and minimal effect on bladder and bowel function at 2-5 years.

The effect of prolapse repair on sexual function in women

INTRODUCTION

Sexual dysfunction is common in women with pelvic organ prolapse (POP). Treatment of symptomatic prolapse often requires surgery. The outcome of prolapse symptoms following surgery is well studied and reported, but evidence on outcomes of sexual function following pelvic reconstructive surgeries is limited.

AIM

The objective of this study was to assess the impact of different forms of surgery for POP on sexual function using prospectively collected data.

METHODS

In this ethically approved project, data were collected prospectively for women undergoing prolapse repair between 2008 and 2010 and were stratified into four groups: "posterior repair,""anterior repair,""anterior repair with vaginal hysterectomy," and "combined anterior and posterior repair." The electronic personal assessment questionnaire-pelvic floor (ePAQ-PF) was used to assess symptoms. The sexual dimension of ePAQ-PF computes domain scores for sexual dysfunction secondary to vaginal symptoms and dyspareunia on a scale of 0-100 (0 = best possible and 100 = worst possible health status). ePAQ-PF was completed in 123 sexually active women both pre- and 3-6 month postoperatively. Results were analyzed using SPSS (SPSS Inc., Chicago, IL, USA). Pre- and postoperative scores for each domain were compared in all groups (Student's t-test). Individual symptoms in these domains were compared using Wilcoxon signed-rank test.

MAIN OUTCOME MEASURES

Change in sexual symptoms and dyspareunia following prolapse surgery in each group.

RESULTS

Women undergoing anterior repair or anterior repair and vaginal hysterectomy reported significant improvement in sexual symptoms and dyspareunia. Women undergoing a posterior repair in isolation had improved sexual function following surgery though improvement in dyspareunia was not significant. Women undergoing combined anterior and posterior repair had the least improvement in sexual function.

CONCLUSIONS

Sexual function improves in women following pelvic reconstructive surgery, but the improvement is more substantial following anterior repair either alone or in combination with a vaginal hysterectomy when compared with posterior repair.

The effect of posterior colporrhaphy on anorectal function

INTRODUCTION AND HYPOTHESIS

The objective of this study is to determine the effect of posterior colporrhaphy on bowel symptoms.

METHODS

Comprehensive pelvic floor data were collected prospectively for 60 women undergoing posterior colporrhaphy. The electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF) was completed at initial assessment and 3-6 months post-operatively. The bowel dimension of ePAQ-PF computes domain scores for IBS, constipation, evacuation, continence and QoL on a scale of 0-100. Preoperative bowel domain scores were compared with post-operative scores (Student t test).

RESULTS

Significant improvement was seen in bowel evacuation (42%), continence (37%) and bowel-related QoL (61%) scores. IBS score improved by 28%, but this did not reach significance. There was no significant change noted in constipation (0.5%). All individual symptoms relating to bowel evacuation and continence improved significantly other than painful evacuation and incontinence to solid stool.

CONCLUSIONS

Bowel evacuation and continence improve significantly 3-6 months following posterior colporrhaphy and are associated with parallel improvement in QoL.

Necrotising fasciitis of the cervicofacial region: a bizarre presentation

The following paper presents the case of a middle-aged woman, who presented with a necrotising soft tissue infection of the cervicofacial region with maggots in situ. She was managed with aggressive surgical debridement, but eventually succumbed to the disease because of erosion of the great vessels of the neck by the maggots. The purpose of this case report is to emphasise the severity of this disease and also to present an unusual case, which had a fatal outcome.

Genetic variability analysis of Giant river catfish (Sperata seenghala) populations from Indus river system by RAPD-PCR

The Giant river catfish, Sperata seenghala (Sykes) is commercially very important fish species of South Asia. Genetic variability between its populations collected from two rivers i.e. river Sutlej and river Beas of Indus river system in India were examined using randomly amplified polymorphic DNA analysis. Total 38 fish samples were collected from river Sutlej whereas 46 fish samples were collected from river Beas. Total 40 primers were screened, out of these 7 were selected for studying polymorphism which produced a total of 64 RAPD loci in two populations. Percentage polymorphic loci calculated following 95% criterion was 89.06% for Beas population as compared to 95.31% for Sutlej population. Moderate level of genetic divergence (genetic distance of 0.0486) between both the populations suggests distinct population substructure of giant river catfish in both the rivers.

Apotemnophilia: ethical considerations of amputating a healthy limb

Apotemnophilia is a condition that causes those who have it to not feel "correct" in their own bodies. As a result, an intense obsession develops with removing the limb; this obsession hinders tremendously the patients' social behaviour and societal integration. These patients, in some respects resembling transgendered individuals, feel that the body part (limb) in question is simply "not a part of themselves", causing them to feel uncomfortable in their own bodies. Whether amputations should be performed on apotemnophiles or not is a question that poses a significant medical ethical dilemma. It is argued that observing an apotemnophile's request for amputation is the ethical action. The major arguments opposing such amputations and supporting such amputations are examined and critically analysed with regard to ethical principles-namely, patient autonomy, beneficence, non-maleficence and justice with regard to every person's "right to happiness". Finally, a discourse on how the accepted notion of harm does not apply to apotemnophilia is developed to justify the position that amputation is indeed medically the ethical choice.

An investigation into the applicability of customised charts for the assessment of fetal growth in antenatal population at Blackburn, Lancashire, UK

The antenatal population at Blackburn, Lancashire, UK is diverse, with 35% non-Caucasian, mainly of Indo-Pakistani origin. The department currently uses standard growth charts, based on the Caucasian population for assessment of fetal growth. This study was designed to ascertain whether the use of customised growth charts (CGCs) in our antenatal population can improve the identification of true growth restriction and decrease the number of interventions for suspected growth restriction. CGCs were generated for 109 women induced for intrauterine growth retardation (IUGR) and fetal biometry plotted. The centile range on the CGC was compared with standard charts. Results showed that women of Indian and Pakistani origin were greatly over-represented in the study group. A total of 58% of the cases induced for IUGR had babies within the normal range on CGC. Had CGC been used 54.4% of growth scans and 53% of antenatal day unit (ADU) appointments for fetal monitoring would have been unnecessary. Our study shows that introduction of CGC in our practice could lead to a very significant reduction in interventions for suspected growth restriction.

Mercury toxicology as assessed through fish scales

Increasing pollution in water bodies is directly or indirectly related to increasing urbanization and indiscriminate disposal of agrochemical & industrial effluents. Heavy metals are one of the important categories of such pollutants and are causing serious hazards to non target species (Mwachiro and Druve1997). Their salts constitute a serious type of pollution in fresh water and being stable compounds; they are not readily removed by oxidation, precipitation or other processes and affect the activity in recipient animal (Jagadeesan and Vijayalakshmi 1998). Increase in the concentration of heavy metals has been reported in water of Vasai Creek, Maharastra and surface as well as groundwater of Delhi (Lokhande and Kelker 1999; Dixit et al. 2003). Recently, Food and Drug Adminstration (USFDA) and Environmental Protection Agency (USEPA) (2004) in their combined report recommended that pregnant women and lactating mothers should not eat shark, sword fish and king Mackerel as these fishes contain high levels of mercury.

Messenger ribonucleic acid encoding interferon-inducible guanylate binding protein 1 is induced in human endometrium within the putative window of implantation

The putative window of embryo implantation in the human opens between days 19--24 of the menstrual cycle. During this period, the endometrium undergoes distinctive structural and functional changes orchestrated by steroid hormones, growth factors, and cytokines to attain a receptive phase in which it acquires the ability to implant the developing embryo. A major challenge in the study of human reproduction is to identify the molecular signals that participate in the establishment of this critical receptive phase in the context of the natural cycle. Toward this goal, we analyzed human endometrial biopsies at various days of the menstrual cycle by employing messenger RNA (mRNA) differential display technique. We isolated several complementary DNAs representing genes that are either up- or down-regulated within the putative window of implantation. We identified one of these genes as that encoding interferon (IFN)-inducible guanylate-binding protein 1 (or GBP1), which possesses GTPase activity. Analysis of endometrial biopsies by Northern blotting and RT-PCR demonstrated that GBP1 mRNA is specifically induced at the midsecretory phase of the menstrual cycle. In situ hybridization analysis revealed that GBP1 mRNA expression is localized in the glandular epithelial cells as well as in the stroma in the immediate vicinity of the glands. We observed that treatment of human endometrial adenocarcinoma cell, Ishikawa, with IFN-gamma or IFN-alpha markedly induced the expression of GBP1 mRNA. IFN-gamma was, however, a more potent inducer of GBP1 than IFN-alpha. Consistent with this finding, the temporal profile of GBP1 expression during the menstrual cycle resembled that of IFN-gamma mRNA more closely than that of IFN-alpha, predicting a regulatory role of IFN-gamma in GBP1 expression in midsecretory human endometrium. Although the precise function of GBP1 in the receptive human uterus remains unclear, its unique expression overlapping the putative window of implantation suggests that it might serve as a useful marker of uterine receptivity in the human.

Underutilization and clinical benefits of angiotensin-converting enzyme inhibitors in patients with asymptomatic left ventricular dysfunction

Despite evidence of therapeutic benefit of angiotensin-converting enzyme (ACE) inhibitors for congestive heart failure and asymptomatic left ventricular (LV) dysfunction, recent studies suggest that in heart failure patients, rates of ACE inhibitor usage in clinical practice remain low. In this study, the medical records of 107 patients with documented LV dysfunction were investigated for patterns of ACE inhibitor usage; 6-month and 1-year outcomes and event rates were evaluated. At index admission, 48% patients did not receive ACE inhibitor treatment, 32% were initiated on treatment, 19% continued on a prior regimen, and 1% were discontinued. Patients seen by a cardiologist were more likely to receive ACE inhibitor treatment (53% vs 35%, p = 0. 172), as were patients with histories of hypertension (60% vs 40%, p = 0.044) or myocardial infarction (56% vs 44%, p = 0.221). Significantly shorter hospitalizations (5.9 vs 9.5 days, p = 0.001) were noted for patients with on-going ACE inhibitor treatment compared with those receiving newly initiated treatment or no treatment. At time of hospital discharge, 102 patients were alive. Of 54 patients who received ACE inhibitors, 67% received an insufficient dose. At a 6-month follow-up, of 51 patients on ACE inhibitors, 23% died or were readmitted to hospital compared with 55% of nonusers (p = 0.001). At 1 year, this event rate was 31% among ACE inhibitor users versus 71% among nonusers (p < 0.0001). Bivariate and multivariate analysis revealed absence of ACE inhibitor use as the only significant variable associated with the event rate (p < 0.0011). Thus, about half of patients with asymptomatic LV dysfunction received ACE inhibitors; 2/3 of these did not receive a sufficient dose. ACE inhibitor usage increased with involvement of a cardiologist, presence of coexistent hypertension, or prior myocardial infarction. Ongoing ACE inhibitor therapy was associated with shorter hospitalizations and fewer hospital readmissions or deaths.

An expanded histatin gene polymorphism and test of a possible disease resistant phenotype

Histatins are small molecular weight salivary proteins that are important in the non-immune host defense system. Two frequent cis-linked coding-change mutations were previously described in exon 5 of the HIS2 gene of Blacks. The polymorphic mutant allele was termed HIS2(2) and the wild-type allele HIS2(1). We here describe two new non-coding change polymorphisms of the HIS2 gene: a deletion in intron 5 (7183-7198 del) and a C-->T mutation in exon 5 [C-->T (7104)] that characterize two new HIS2 alleles, HIS2(3) and HIS2(4) respectively. Both mutations occur on a HIS2(1) background. The HIS2(3) allele occurred only in Afro-Americans, but not in 67 Japanese, 51 Chinese and 50 Whites. Among 66 random DNA samples from Afro-Americans, frequencies of HIS2(1), HIS2(2), HIS2(3) and HIS2(4) were 0.67, 0.22, 0.05 and 0.07 respectively, with a heterozygosity of 0.45. The frequencies of the HIS2(4) allele in 50 Whites and 50 Chinese were 0.06, and 0.1 respectively. In a comparison of 60 matched saliva and DNA samples from the Afro-American population, the DNA-based mutation analysis reliably identified salivary histatin phenotypes. The salivary histatin polymorphism (inferred from PCR analysis) was used to test a biologically plausible hypothesis, that the mutant histatin phenotype (coded by the HIS2(2) allele) confers relative resistance to severe and fatal malaria. In a study of 185 Black Tanzanian subjects, there were no significant differences in HIS2(2) allelic frequencies between the various test groups: for 86 cerebral malaria subjects, 54 uncomplicated malaria subjects, and 45 combined asymptomatic parasitemia and health controls, HIS2(2) frequencies were 0.16, 0.17 and 0.17 respectively. Thus, there was no support for the hypothesis in this population.

Progesterone induces calcitonin gene expression in human endometrium within the putative window of implantation

The human endometrium acquires the ability to implant the developing embryo within a specific time window that is thought to open between days 19-24 of the secretory phase of the menstrual cycle. During this period the endometrium undergoes pronounced structural and functional changes induced by the ovarian steroids, estrogen and progesterone, that prepare it to be receptive to invasion by the embryo. The identification of reliable biochemical markers to assess this critical receptive phase in the context of the natural cycle remains one of the major challenges in the study of human reproduction. Our previous studies in a rat model system demonstrated that the expression of calcitonin, a peptide hormone involved in calcium homeostasis, is transiently induced by progesterone in the glandular epithelium at the onset of implantation. Attenuation of calcitonin synthesis in the uterus during the preimplantation phase by administration of calcitonin antisense oligodeoxynucleotides severely impairs implantation of rat embryos, suggesting that this peptide hormone plays a critical role in uterine receptivity. To investigate whether calcitonin is also expressed in the human endometrium during implantation, we monitored the spatio-temporal expression of calcitonin on various days of the menstrual cycle. Our studies employing RT-PCR showed that calcitonin messenger ribonucleic acid is expressed in human endometrium during the postovulatory midsecretory phase (days 17-25) of the menstrual cycle, with maximal expression occurring between days 19-21. Very little calcitonin expression was detected in the endometrium in either the preovulatory proliferative (days 5-14) or the late secretory (days 26-28) phase. In situ hybridization and immunocytochemical analyses localized the calcitonin expression predominantly in the glandular epithelial cells of the endometrium. Our studies further showed that calcitonin expression in the human endometrium is under progesterone regulation. Treatment of women with an antiprogestin, mifepristone (RU-486), drastically reduced calcitonin expression in the endometrium. Collectively, these findings reveal that progesterone-induced expression of calcitonin in the secretory endometrium temporally coincides with the putative window of implantation in the human.

Relationships of plasma leptin levels to changes in plasma free fatty acids in women who are lean and women who are abdominally obese

Regulation of leptin production by the hormonal and metabolic milieu is poorly understood. Because abdominal obesity is commonly associated with elevated plasma free fatty acid (FFA) flux, we examined the effects of augmenting FFA on plasma leptin levels in women who were lean and of suppressing FFA in women with abdominal obesity. In study 1, nine subjects who were lean, after a 12-hour overnight fast, received either intravenous saline or Intralipid plus heparin to increase the plasma FFA concentration to approximately 1000 mumol/ L. After 3 hours of additional fasting, subjects underwent 3-hour hyperglycemic clamps. In study 2, seven subjects with abdominal obesity were evaluated by a similar protocol, but lipolysis and plasma FFA flux were instead maximally suppressed by acipimox. In the individuals who were lean, leptin levels were unchanged during clamping. Increasing plasma FFA reduced plasma leptin from 7.66 +/- 0.66 to 7.05 +/- 0.66 (p = 0.03), but 3 hours of hyperglycemia plus hyperinsulinemia had no additional effect on leptin levels (7.15 +/- 0.71). Basal leptin levels, 4-fold higher in the subjects with obesity, were reduced from 34.6 +/- 2.4 micrograms/L to 32.3 +/- 1.1 micrograms/L (p = 0.004) during the clamp period. When plasma FFA flux was suppressed, however, plasma leptin levels after clamped hyperglycemia/hyperinsulinemia were increased to 38.9 +/- 1.2 micrograms/L (p = 0.014 vs. time 0 and 0.001 vs. saline protocol). Changes in leptin concentrations are not correlated with changes in FFA. These results suggest that plasma FFA concentration does not regulate plasma leptin levels in basal, extended fasting, or hyperglycemic/hyperinsulinemic states.

Effects of free fatty acids and glucose on splanchnic insulin dynamics

The mechanism of hyperinsulinemia that accompanies insulin resistance in some abdominally obese and diabetic individuals is poorly understood. Both increased secretion of insulin and decreased clearance have been demonstrated. The present study was undertaken to examine the role of free fatty acids (FFAs) and glucose in regulating splanchnic insulin dynamics in vivo. Plasma FFA levels were raised approximately twofold via an intralipid/heparin infusion in eight lean women. Insulin dynamics were assessed using the individual's C-peptide kinetic coefficients. Studies were performed in the basal state and during two levels of glycemia, 7 and 11 mmol/l. Studies were repeated using saline, and thus each subject served as her own control. Under basal conditions, raising FFA flux resulted in a modest increase in plasma insulin concentration (PIC) secondary to an increase in insulin secretion rate (ISR); however, endogenous insulin clearance (EIC) was not influenced. During the 7 mmol/l hyperglycemic clamp, maintaining a high FFA flux resulted in a 30% increase in PIC above the effect produced by glucose alone. This represents the cumulative effects of stimulation of ISR and inhibition of EIC. Clamping plasma glucose at 11 mmol/l while maintaining a high FFA flux increased PIC twofold above that produced by glucose alone. This increase in PIC was mainly due to a significant reduction in EIC without an accompanying increase in ISR (392 +/- 159 and 787 +/- 187 ml/min with and without intralipid infusion, respectively). Analysis of variance indicated that the suppressive effect of FFA on EIC was independent of the effect of glucose. The effect of the two substrates seems to be additive.

Minimal change nephrotic syndrome associated with extrarenal neurilemmoma

Nephrotic syndrome may be associated not only with malignant neoplasia, but also rarely with benign solid tumours. Here we report a case of a young woman suffering from nephrotic syndrome, histologically classed as a minimal change glomerular lesion, associated with a posterior mediastinal neurilemmoma (ancient neurilemmoma). Surgical removal of the tumour led to complete cure of the nephrotic syndrome with total symptomatic improvement within 6 months. Scanning of the literature revealed only one case report of an association of spinal neurilemmoma with nephrotic syndrome.

Leptin: a significant indicator of total body fat but not of visceral fat and insulin insensitivity in African-American women

The recently cloned adipose tissue hormone leptin has been proposed to be involved in the neuroendocrine regulation of adiposity and its metabolic sequelae. Visceral fat is known to predict reduced insulin sensitivity and associated adverse metabolic profiles. In this study, we report the first evaluation of the relationships between leptin levels and total body fat, visceral fat, and insulin sensitivity in a cohort of premenopausal African-American women. Thirty-four subjects were analyzed for total fat mass and visceral fat by dual-energy X-ray absorptiometry and computerized axial tomography, respectively. Insulin sensitivity (SI) was assessed using Bergman's minimal model. Results showed that fasting leptin levels strongly correlated with total body fat mass (r = 0.797, P < 0.001). Correlations of leptin with visceral fat (r = 0.54, P < 0.001) and SI (r = -0.419, P = 0.02) were dependent on total body fat. In conclusion, leptin levels reflect total body fat mass, and although visceral fat is known to predict reduced insulin sensitivity independently, leptin did not. Our data thus suggest that diverse mechanisms are responsible for the regulation of total body versus visceral fat distribution, with its metabolic and health risks.

Sperm motility and morphology as changing parameters linked to sperm count variations

Variations in semen analyses of 177 males over a 1 year period were assessed. The average means of total counts, motility, morphology, total motile count and non-motile % were determined for 5 classes of patients ranging from azoospermic to normospermic. Positive relationships between a falling sperm count, a decrease in motility and total motile counts were seen. Also, increasingly, abnormal forms were found with lower sperm counts.