Development of video tutorials to help parents manage children with acute illnesses using a modified Delphi method

AIM

Children often fall sick, which causes concern among parents. Online health information can be confusing and difficult to understand. We aimed to produce simple, informative video tutorials on the symptoms ill children present.

METHODS

We used a modified Delphi method to produce video tutorials on the symptoms fever, vomiting & diarrhea, abdominal pain, breathing difficulties, sore throat, red eyes, earache, and rash. We identified the most common symptoms in acutely ill children. During the first consensus round, experts rated statements on out-of-hospital management from existing health information. Video tutorials were produced from statements rated to be included. Second consensus involved video showings and editing. Two videos were evaluated in focus groups by parents.

RESULTS

During the first round, experts rated median 79 (40-154) statements for each symptom. Panels consisted of median seven (6-11) experts, primarily. Panels reached consensus on inclusion, neutral, or exclusion in 83% of statements. Second round led to adjustments to the videos and final approval by experts. Most parents evaluated the videos as "informative, easy to understand, and calming".

CONCLUSION

We produced video tutorials on the common symptoms ill children present using a modified Delphi method. Feedback from parents in focus groups was positive.

Pegbovigrastim use in periparturient embryo-recipient cows: Effects on health and reproduction

The objective of this randomized clinical study was to evaluate the effects of periparturient administration of pegbovigrastim (recombinant bovine granulocyte colony stimulating factor; PEG) on postpartum health and reproductive outcomes in dairy cows carrying transferred embryos. A total of 60 multiparous Jersey cows (second parity n = 21, >second parity n = 39) that were in vitro-fertilized embryo recipients were enrolled. Animals were selected from a commercial herd and assigned to 1 of 2 treatments: (1) PEG (n = 31), which received a subcutaneous injection of 15 mg of PEG 7 d before expected calving and a second dose within 1 h of parturition; or (2) CON, untreated control (n = 29). Parturition was induced pharmacologically in all cows at 280 d of pregnancy with 500 μg of cloprostenol and 25 mg of dexamethasone intramuscularly. Cow health was monitored daily during the periparturient period and included assessment for retained fetal membranes within 24 h after calving and metritis until 20 d in milk. Descriptive statistics were calculated, to determine the incidence of postpartum diseases, causes of culling, and early-lactation reproductive outcomes, including number of inseminations, days to first heat, days to first service, and interval from calving to conception. The Wilcoxon rank sum test was used to assess treatment effects on early-lactation reproductive performance outcomes. The overall incidence of metritis in this cohort of cows was 17.14%. Animals treated with PEG tended to have more cases of metritis (25%) compared with CON (8.8%). Mastitis incidence in PEG was 19.35% compared with CON at 27.59%. These data suggest that in this dairy, with embryo-recipient cows induced to calve at 280 d of pregnancy, the administration of 2 doses of PEG tended to increase postpartum metritis but had no effect on mastitis incidence, culling rate, or early-lactation reproductive outcomes.

P-468 Organotypic culture of testicular tissue from infant boys with cryptorchidism

Study question

Can organotypic culture support the survival and maturation of germ cells and niche-related cells within testicular tissue from infant boys with cryptorchidism?

Summary answer

The testicular structure and the number of germ cells were maintained during organotypic culture, whereas Sertoli cells and peritubular myoid cells (PTMCs) matured.

What is known already

Testicular tissue cryopreservation (TTC) is a strategy to safeguard the fertility of prepubertal boys who face a risk of infertility. Organotypic culture of immature testicular tissue from mice achieved production of spermatozoa. Similarly, the culture of human fetal gonads resulted in the generation of competent spermatids. However , in vitro spermatogenesis by organotypic culture of human prepubertal testicular tissue has not been achieved. It is also unknown whether germ cells as well as its niche-related cells, in testicular tissue from infant boys with cryptorchidism, can maintain and mature under in vitro conditions.

Study design, size, duration

Testicular tissue was cryopreserved from four infant boys with bilateral cryptorchidism undergoing orchidopexy (age range: 0.5-1.4 years), as part of a fertility preservation program. Culture media with and without retinoic acid were tested. Testicular fragments were harvested at 30 days and 60 days after culture and evaluated by histological assessment of tissue structure, germ cell development, and immunohistochemical staining for germ cell and somatic cell markers.

Participants/materials, setting, methods

Cryopreserved-thawed testicular tissue was cut into fragments (1-2 mm3) and placed on top of agarose gel stands and cultured at 34oC with 5% CO2 in Minimum Essential Medium-alpha supplemented with knockout serum replacement, human umbilical cord plasma, Activin A, hormones, growth factors, with or without retinoic acid. Immunohistochemical analyses were performed using germ cell markers (MAGE-A, GAGE, and VASA), Sertoli cell maturation markers (AMH, AR, SOX9), PTMC marker (alpha-SMA).

Main results and the role of chance

Following the 60-day culture, the lumen of the seminiferous tubules had developed. The number of germ cells per tubule remained stable during this period. However, no further germ cell maturation was observed. Germ cells showed different phenotypes of MAGEA, GAGE, and VASA expression with no significant difference in number. The number of SOX9-positive Sertoli cells was significantly increased from 30 days to 60 days of culture (p <0.0001). No difference in AMH expression was observed, while AR expression in Sertoli cells was induced during culture. Alpha-SMA expression was detected in the PTMCs surrounding the seminiferous tubules. The two different culture conditions, with and without retinoic acid in the culture media, did not affect cell survival or maturation.

Limitations, reasons for caution

The small number of testicular biopsies available is a limitation.

Wider implications of the findings

Our organotypic culture conditions support the long-term survival of germ cells in testicular tissue from infant boys with cryptorchidism. Thus, further studies are needed to induce the maturation of germ cells under similar experimental conditions.

Trial registration number

not applicable

O-189 Male fertility restoration by direct transplantation of human infant testicular cells into infertile recipient mouse testis

Study question

Is colonization of human gonocytes and spermatogonial stem cells (SSCs) directly transplanted to seminiferous tubules of busulfan sterilised mice testis during an 8-week period feasible? 

Summary answer

Gonocytes and SSCs from infant boys can settle on the basal membrane and form germline stem cell colonies in the seminiferous tubules of recipient mice.

What is known already

The neonatal or immature animal provides higher populations of gonocytes and/or SSCs than adults, and the number of transplanted donor SSCs directly affects the colonization rate of the recipient testes. Along with SSC transplantation restoring the recipient’s spermatogenesis, donor gonocyte was also reported to be capable of establishing spermatogenesis in rodents.

Study design, size, duration

Transplantation of human testicular cells including gonocytes and SSCs into seminiferous tubules of infertile recipient mice. We included 10 infant testis biopsies from which single-cell suspension was transplanted individually into the seminiferous tubules of 10 immunodeficient mice. The immunodeficient mouse testes were injected with busulfan to deplete germ cells. Four weeks later, we did the xenotransplantation. Then after eight weeks, we collected all mouse testes to do further analysis.

Participants/materials, setting, methods

Testis biopsies were obtained from cryptorchid boys undergoing orchidopexy. After enzymatic digestion of the testis biopsies, dissociated single-cell suspensions were pre-labeled with a green fluorescent dye. Then the single-cell suspensions were transplanted into seminiferous tubules of the infertile recipient mice. Eight weeks later, the presence of gonocytes and SSCs was determined by immunohistochemistry and whole-mount immunofluorescence.

Main results and the role of chance

Without in vitro propagation, naturally enriched human germline stem cells settled on the basal membrane of seminiferous tubules and survived in the mouse testes at least for two months demonstrating that human gonocytes and SSCs were capable of colonizing the recipient mouse seminiferous tubules.

Limitations, reasons for caution

The study samples were from infant boys with undescended testes that were more likely to contain gonocytes. It was not possible to determine which germ-cell type at transplantation resulted in the detected gonocytes and SSC colonies after xenotransplantation. Transplantation of gonocytes may include the potential risk of stem cell-related malignancy.

Wider implications of the findings

Without in vitro propagation, male germline stem cell-based transplantation could provide a relatively safe therapeutic treatment for prepubertal boys with cryptorchidism and boys diagnosed with cancer. This method could also facilitate clinical translation.

Trial registration number

not applicable

Are Danish doctors comfortable teaching in English?

Background

From 2012–2015, the Departments of Obstetrics and Gynecology and of Pediatrics at the University of Copenhagen conducted a project, “Internationalization at Home ”, offering clinical teaching in English. The project allowed international students to work with Danish speaking students in a clinical setting. Using semi-quantitative questionnaires to 89 clinicians about use of English and need for training, this paper considers if Danish clinical doctors are prepared to teach in English.

Results

The majority self-assessed their English proficiency between seven and eight on a 10 unit visual analogue scale, with 10 equivalent to working in Danish, while 15 % rated five or less. However, one-fourth found teaching and writing in English to be twice as difficult than in Danish, and 12 % rated all teaching tasks in English at four or less compared to Danish. The self-assessed need for additional English skills was perceived low.

Conclusion

Teaching in English was rated as 30 % more difficult than in Danish, and a significant subgroup of doctors had difficulties in all forms of communication in English, resulting in challenges when introducing international students in non-native English speaking medical departments.

Newborn regional body composition is influenced by maternal obesity, gestational weight gain and the birthweight standard score

AIM

This study investigated whether newborn body composition is influenced by prepregnancy obesity and gestational weight gain (GWG) and explored any associations between body composition and birthweight standard score (z-score), categorised by size for gestational age.

METHODS

We recruited 231 obese and 80 normal weight mothers and their newborn infants and assessed the babies' body composition using dual-energy X-ray absorptiometry.

RESULTS

The total and abdominal fat masses of infants born to mother who were obese before pregnancy were 135 g (p < 0.001) and 18 g (p < 0.001) higher than the offspring of normal weight mothers. The infants' fat mass increased by 11 g (p < 0.001) for every kilogram of GWG. There were no associations between prepregnancy obesity and fat-free mass. The fat percentage was significantly higher in infants who were large for gestational age (15.3%) than small for gestational age (5.2%) and appropriate for gestational age (9.8%) (p < 0.001). Lower birthweight z-score was associated with a higher proportion of abdominal fat mass (p = 0.009).

CONCLUSION

Infants born to obese mothers had higher fat mass at birth, with abdominal fat accumulation. Low birthweight was associated with a lower crude abdominal fat mass, but a higher proportion of total fat mass placed abdominally.

Experience with the NICE guidelines for imaging studies in children with first pyelonephritis

PURPOSE

This retrospective study evaluates the applicability of a selective approach for imaging in children aged 0-15 years with a first episode of pyelonephritis, based on the UTI guidelines of the National Institute for Health and Clinical Excellence (NICE).

MATERIAL AND METHODS

A total of 96 consecutive patients were included (age range: 0.1-14.9 years, median age: 0.7 years), treated for a first episode of confirmed culture-positive pyelonephritis. At initial hospitalization all patients underwent ultrasound examination of the kidneys and urinary tract (US) and technetium-99m mercaptoacetyltriglycine scinti- and renography ( (99m)Tc MAG3). If vesicoureteral reflux (VUR) was suspected, then prophylactic antimicrobial therapy was prescribed and the patients were referred to a surgeon for further evaluation including voiding cystoureterography (VCU). Patients with known urological anomalies including antenatally diagnosed anomalies were excluded. All patients were followed up for a median of 5.2 years (3.5-8.6 years).

RESULTS

Initially, US findings were abnormal in 29 (30%) patients and (99m)Tc MAG3 findings were abnormal in 20 (21%) cases. At follow-up, prophylactic antimicrobial therapy was prescribed for 19 (20%), and VUR was diagnosed by VCU in 9 patients. Surgery was carried out in 7 (7%) patients, primarily for VUR. If the NICE guidelines had been initially followed, 5 of our 9 patients with VUR would not have been identified. VUR surgery was performed in 4 of these cases. Moreover, 9 cases with urological anomalies subsequently prescribed prophylactic antimicrobial therapy would have been missed.

CONCLUSION

We do not recommend following the imaging strategies of the NICE guidelines for children with a first episode of pyelonephritis. Our most important argument is that at follow-up, after a minimum of 3.5 years, the initial diagnosis of VUR would have been missed in 4 out of the 5 patients who underwent VUR surgery.

Selective Inhibition of Calcium Entry Induced by Benzylisoquinolines in Rat Smooth Muscle

The mechanism of relaxant activity of six benzylisoquinolines was examined in order to determine the minimal structural requirements that enable these compounds to have either a non-specific action like papaverine or an inhibitory activity on calcium entry via potential-operated channels. All the alkaloids tested totally or partially relaxed KCl-depolarized rat uterus and inhibited oxytocin-induced rhythmic contractions. Only glaucine and laudanosine inhibited K+-induced uterine contractions more than oxytocin-induced uterine contractions. In Ca+-free medium, sustained contractions induced by oxytocin or vanadate were relaxed by the alkaloids tested except for glaucine and laudanosine indicating no inhibitory effect on intracellular calcium release. Those alkaloids containing an unsaturated heterocyclic ring (papaverine, papaverinol, papaveraldine, N-methylpapaverine and dehydropapaverine) exhibited a more specific activity than those with a tetrahydroisoquinoline ring.

The challenge of early surgery for cryptorchidism

OBJECTIVE

In congenital cryptorchidism, a recent Nordic Consensus report recommends surgical correction at 6-12 months of age to prevent male infertility. In published series of orchiopexies the median age at surgery is often 3 years or more. The aim of this study was to evaluate whether early surgery is technically safe.

MATERIAL AND METHODS

The study included 356 boys with 418 orchiopexies and median 1 year of follow-up.

RESULTS

At follow-up 367 testes were in the scrotum without iatrogenic atrophy. Eight testes were atrophied and in 43 cases a redo operation was performed to achieve a scrotal position of the testis. All acquired undescended testes had a successful result. The age at operation for the group with congenital undescended testes in the intracanalicular position or in a position close to the external inguinal annulus was 4 months to 14.5 years. In the latter group the median age at operation for the 41 failures was 2 years and 4 months, which is significantly younger than the median age for the more successful operations (3 years and 9 months).

CONCLUSION

The standard orchiopexy is technically demanding in small boys. Focus on successful operative results in specialist centres is important when treating cryptorchidism with early surgery, otherwise the positive beneficial biological impact on fertility potential may be lost due to treatment failure.

Severe iron intoxication treated with exchange transfusion

An 18-month-old previous healthy girl who had ingested 442 mg elemental iron/kg was admitted to a paediatric intensive care unit. The child was treated with gastric lavage, whole bowel irrigation and intravenous deferoxamine. After 2 h of standard therapy serum iron had risen threefold to 1362 microg/dl (244 micromol/l). The child was treated with exchange transfusion (ET; 52 ml/kg) and serum iron fell to 134 microg/dl (24 micromol/l). The patient made an uncomplicated recovery. ET should be considered in severe iron poisoning when standard therapy is inadequate.

Nordic consensus on treatment of undescended testes

AIM

To reach consensus among specialists from the Nordic countries on the present state-of-the-art in treatment of undescended testicles.

METHODS

A group of specialists in testicular physiology, paediatric surgery/urology, endocrinology, andrology, pathology and anaesthesiology from all the Nordic countries met for two days. Before the meeting, reviews of the literature had been prepared by the participants.

RECOMMENDATIONS

The group came to the following unanimous conclusions: (1) In general, hormonal treatment is not recommended, considering the poor immediate results and the possible long term adverse effects on spermatogenesis. Thus, surgery is to be preferred. (2) Orchiopexy should be done between 6 and 12 months of age, or upon diagnosis, if that occurs later. (3) Orchiopexy before age one year should only be done at centres with both paediatric surgeons/urologists and paediatric anaesthesiologists. (4) If a testis is found to be undescended at any age after 6 months, the patient should be referred for surgery--to paediatric rather than general surgeons/urologists if the boy is less than one year old or if he has bilateral or non-palpable testes, or if he has got relapse of cryptorchidism.

The relation of germ cells per tubule in testes, serum inhibin B and FSH in cryptorchid boys

At bilateral orchiopexy bilateral biopsies may be indicated to determine fertility potential. It is currently unknown if the serum inhibin B levels at time of orchiopexy reflect the testicular status of the bilaterally cryptorchid child. The aim of this study was to relate the results of inhibin B and FSH measurements with testicular biopsy parameters in bilateral cryptorchid boys. Included were 25 boys with bilateral cryptorchidism, median 2.5 years (9 months to 5.5 years) at surgery for bilateral cryptorchidism with simultaneous testicular biopsies, and blood sample for inhibin B and FSH. The number of spermatogonia and gonocytes was measured in 100 tubular transverse sections, the S/T and the mean-S/T of the patient was found, and expressed as percent of lowest normal value. Inhibin B and FSH were measured and related to age-specific values. Forty percent (10/25) of the patients had very low mean-S/T (mean-S/T<10% of lowest normal-value). Inhibin B was decreased in 24% (6/25) of the patients, all with decreased mean-S/T, predominantly with a mean-S/T<10% of lowest normal-value (p<0.05). There was a negative correlation between inhibin B and FSH (p<0.05). In cases of mean-S/T<10% of lowest normal-value and decreased inhibin B, we found increased FSH in 9% (2/22) of the patients and hypergonadotropic hypogonadism was suspected. Low FSH was found in 5% (1/22) of the patients and hypogonadotropic hypogonadism was suspected. Low inhibin B predicts a serious condition in respect of infertility. Low FSH and inhibin B indicates examination for hypogonadotropic hypogonadism. In bilateral cryptorchid boys inhibin B levels correlated negatively to FSH.

The incidence of bilateral cryptorchidism is increased and the fertility potential is reduced in sons born to mothers who have smoked during pregnancy

PURPOSE

Recent studies have demonstrated a high prevalence of cryptorchidism, decreasing semen quality and increasing incidence of testicular cancer. These changes seem to be interrelated, and may be symptoms of a common underlying entity with foundations in fetal life. We investigated the influence of maternal smoking on fertility status in offspring cryptorchidism.

MATERIALS AND METHODS

We prospectively studied consecutive patients presenting to the pediatric surgery department between 1996 and 2005. A total of 157 boys 1 to 5.9 years old underwent surgery for cryptorchidism with simultaneous testicular biopsy, and exhibited well preserved testicular parenchyma. Only white patients with Danish-speaking mothers who had reported pregnancy history including smoking habits during pregnancy and history of the offspring were included. The patients had cryptorchidism only and none received hormonal treatment before surgery. The number of spermatogonia and gonocytes per tubule cross-section was assessed and compared to normal values from autopsy material.

RESULTS

The group of boys with cryptorchidism whose mothers had smoked heavily during pregnancy (ie more than 10 cigarettes daily throughout the pregnancy) had a significantly increased risk of bilateral cryptorchidism (52%, or 11 of 21 patients), and a decreased number of spermatogonia and gonocytes per tubule cross-section, which was absolute (0.097 [0 to 0.75]) and age related (14% [0% to 198%] of normal for age) compared to boys whose mothers did not smoke (20%, or 22 of 112 patients, 0.140 [0 to 2.14] and 37% [0% to 563%] of normal for age, p <0.01, p <0.05 and p <0.05, respectively).

CONCLUSIONS

A close relationship between maternal smoking during pregnancy and adverse trends in offspring reproductive health in relation to cryptorchidism was observed.

The results of 15 years of consistent strategy in treating antenatally suspected pelvi-ureteric junction obstruction

OBJECTIVE

To determine how to select patients for surgery among those with antenatally detected pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

The study comprised 100 consecutive children with antenatally detected suspected unilateral PUJ obstruction and a normal contralateral kidney. The correct diagnosis was made using postnatal ultrasonography, intravenous urography and renal scintigraphy, the last also being used for the follow-up.

RESULTS

Four patients had poor function in the hydronephrotic kidney, treated in three by nephrectomy; 61 had normal function in the hydronephrotic kidney, with 49 followed for 1-10 years with no change in kidney function and no symptoms. Twelve patients in this group had later surgery (at 0.7-8 years old) because of pyelonephritis (four), pain and/or renal functional impairment (eight, three of whom had normal function afterward). Thirty-five patients had moderately impaired function of the hydronephrotic kidney; 29 had primary surgery at a median age of 4 months. The median hydronephrotic renal function increased from 32% before to 42% after surgery, with 15 kidneys having normal function. In one other patient the kidney was lost before surgery. Five other patients were initially treated conservatively and the hydronephrotic renal function increased from 32% to 35% at the 1-year follow-up, significantly less than in the surgical group. The overall operative complication rate was 4%.

CONCLUSIONS

With our management programme more than half the patients can avoid surgery in childhood. Although the follow-up was intense there was moderate and irreversible functional kidney deterioration in 5%. In contrast, after successful reconstructive surgery, only a few follow-up procedures causing possible discomfort to the child are needed in most. The risk of surgical complications cannot be neglected. The present results are useful for advising parents deciding whether their antenatally detected hydronephrotic child should undergo surgery or not.

Infertility despite surgery for cryptorchidism in childhood can be classified by patients with normal or elevated follicle-stimulating hormone and identified at orchidopexy

OBJECTIVE

To analyse infertility despite orchidopexy in childhood.

PATIENTS AND METHODS

The study comprised patients with cryptorchidism (70 bilateral and 65 unilateral) who had a simultaneous biopsy taken at orchidopexy in childhood, and in adulthood had analyses of semen and FSH. In adulthood 42 formerly bilateral cryptorchid boys had repeat testicular biopsies taken. Infertility was suspected in men with < 5 million sperm/mL in the best sample of semen and concomitant poor sperm motility, and who were classified by follicle-stimulating hormone (FSH) values. At orchidopexy the number of spermatogonia/tubule and the germ cell differentiation were measured. In adulthood the percentage of tubules with complete spermatogenesis, spermatogenic arrest and Sertoli-cell only status was assessed.

RESULTS

Infertility was suspected in 38 of 70 (54%) of formerly bilateral and six of 65 (9%) formerly unilateral cryptorchid patients. High FSH values were expected in these suspected infertile patients, but 15 of 38 (59%) formerly bilateral and five of six formerly unilateral cryptorchid patients had normal FSH values. These patients were identified in childhood at orchidopexy; those with bilateral cryptorchidism generally presented with germ cells, but the mean number of spermatogonia per tubule was < 30% of the lowest normal value, and the germ cells were seldom normally differentiated, whereas those with unilateral cryptorchidism generally lacked germ cells in the biopsies. No patients had a decreased FSH value.

CONCLUSION

Despite surgery for cryptorchidism, infertility was probable in a third (44 of 135) of the patients. We expected high FSH values in these patients, but in 45% (20/44) the FSH values were normal. These patients may have relative FSH deficiency. At orchidopexy these patients were identified to be bilaterally cryptorchid with few germ cells and those unilaterally cryptorchid had none in the biopsy. After orchidopexy in childhood, additional hormonal treatment, e.g. recombinant FSH or buserelin, may be indicated in these patients.

Erythropoietin may reduce the risk of germ cell loss in boys with cryptorchidism

PURPOSE

In boys with cryptorchidism older than 2 years a testicular biopsy at time of orchiopexy shows lack of germ cells in 10-40% of the cases. The number of spermatogonia per tubule is prognostic for subsequent fertility potential. A biopsy without germ cells is associated with 33-100% risk of infertility. In order to increase the number of germ cells, and thereby the fertility potential, additional hormonal therapy has been attempted before surgery. In a study, small doses of the gonadotropin-releasing hormone analogue buserelin before orchiopexy caused higher values. Others have found that hormonal treatment with human chorionic gonadotropin or gonadotropin releasing hormone analogue may harm the germ cells in cryptorchidism. The aim of the study is to demonstrate that additional hormonal therapy with erythropoietin has a positive effect on the number of germ cells.

MATERIALS AND METHODS

Erythropoietin (Eprex) 100 IU/kg were administered subcutaneously weekly for 3 months prior to surgery in two cryptorchid boys, 6 months old and 1 year 9 months old, respectively, with renal function impairment.

RESULTS

The number of spermatogonia per tubular cross-section in testicular biopsies was unusually high in both erythropoietin- treated cryptorchid cases compared to the control material of biopsies from the undescended testes of 698 cryptorchid patients and compared to the normal values.

CONCLUSION

There are several hypothetic mechanisms that can explain the elevated number of spermatogonia seen in our erythropoietin treated cryptorchid patients. Erythropoietin may have a positive effect on germ cell proliferation in cryptorchidism.

Cryptorchidism: aspects of fertility and neoplasms. A study including data of 1,335 consecutive boys who underwent testicular biopsy simultaneously with surgery for cryptorchidism

PURPOSE

An attempt to make a rational strategy for treatment of cryptorchidism.

MATERIALS AND METHODS

1,335 cryptorchid boys with biopsy at surgery (1,638 specimens). We studied: frequency of no germ cells in biopsies from 698 patients <12 years at surgery; fertility potential of 140 patients who were now adults, and apperance of testicular neoplasia in all biopsies.

RESULTS

Lack of germ cells appeared from 18 months. The frequency increased with increasing age. It appeared in 30% (61/202) bilateral, and 18% (88/496) unilateral cases. In men who had undergone bilateral or unilateral orchiopexy, respectively, there was normal sperm count in 19% (14/75) and 83% (54/65), and infertility was suspected in 56% (42/75) and 8% (5/65) (FE, p < 0.00005, p < 0.00005), respectively. The lowest, the mean, and the highest age-matched spermatogonia count per tubule at orchiopexy was associated with sperm count (Spearman test, p < 0.0001, p < 0.005, p < 0.05). Isolated, this was demonstrated for the 75 formerly bilateral (Spearman, p < 0.0001, p < 0.0001, p < 0.0001), but not the 65 formerly unilateral cases (Spearman, p = 1.0). No germ cells at orchiopexy was associated with suspected infertility. Risk was 78-100% in bilateral (dependent on one or both testes affected), and 33% in unilateral cryptorchidism. There was one invasive germ cell tumor, six cases of carcinoma in situ testis, and one Sertoli cell tumor. Three neoplasms were diagnosed in intra-abdominal testes, four in boys with abnormal external genitalia, and two in boys with known abnormal karyotype. Risk of neoplasia was 5% (7/150) in patients with intra-abdominal testis, abnormal external genitalia or diagnosed abnormal karyotype, versus 0% (0/1,185) in patients without these characteristics (FE, p < 0.00005).

CONCLUSION

We recommend surgery for cryptorchidism before 15-18 months of age because: (a) lack of germ cells is very rare before, and (b) lack of germ cells is associated with subsequent risk of infertility. At primary surgery for cryptorchidism, we recommend examination for testicular neoplasia in cases of intra-abdominal testis, abnormal external genitalia or known abnormal karyotype.

Cytotoxic compounds from Annonaceus species as DNA topoisomerase I poisons

BACKGROUND

In the search for cytotoxic natural products as DNA topoisomerase poisons, we have assessed six annonaceus compounds (the acetogenins annonacin and rolliniastatin-1, the styryl-lactones etharversin and altholactone and the alkaloids thaligrisine and cepharanone-B) for cytotoxic activity against three human cancer cell lines and then we evaluated these compounds as DNA topoisomerase poisons.

MATERIALS AND METHODS

The cytotoxicity parameters were determined following protocols established by the National Cancer Institute (NCI) using the SRB assay. In the topoisomerase assay, the supercoiled DNA produces open circle forms that are stabilised in the presence of DNA topoisomerase poisons and can be detected after a denaturation step by proteinase K-SDS.

RESULTS

The six compounds showed cytotoxic activity, with cepharanone B being the most cytotoxic one, even more than the antineoplastic agent etoposide on two cancer cell lines, although it is the only one that does not act as a DNA topoisomerase poison.

CONCLUSION

These results could justify the traditional use of the studied annonaceus species and topoisomerase-mediated DNA damage might be a possible mechanism by which five of these compounds exert their cytotoxicity.

Enantioselective Syntheses of Dopaminergic (R)- and (S)-Benzyltetrahydroisoquinolines

Optically pure (1S,R)- and (1R,S)-benzyltetrahydroisoquinolines (BTHIQs), 12a,b as the major diastereomers, were prepared by stereoselective reduction of the isoquinolinium salt possessing (R)- and (S)-phenylglycinol as the chiral auxiliary, respectively. The absolute configurations of (1S,R)-13a hydrochloride (O-debenzoylated derivative from 12a) and (1R,S)-12b diastereomers were unambiguously determined by single-crystal X-ray analysis. Reductive removal of the chiral auxiliary group, subsequent N-propylation, and cleavage of the methylenedioxy group furnished the optically active catecholamines (1S)-16a and (1R)-16b in good overall yield. We have separately prepared for the first time pairs of dopaminergic 1-BTHIQs enantiomers through a classical methodology in asymmetric synthesis. The (1S)-enantiomers (14a-16a) bind to D1 and D2 dopamine receptors with affinities 5-15 times higher than those of the corresponding (1R)-enantiomers (14b-16b). Moreover, (1S)-14a inhibits [3H]dopamine uptake with high affinity. It appears that synthesis and testing of (S)-enantiomers of BTHIQ are very important for the search for new active drugs at dopamine receptors.

Gamma-lactone-Functionalized antitumoral acetogenins are the most potent inhibitors of mitochondrial complex I

To study the relevance of the terminal alpha,beta-unsaturated gamma-methyl-gamma-lactone moiety of the antitumoral acetogenins of Annonaceae for potent mitochondrial complex I inhibition, we have prepared a series of semisynthetic acetogenins with modifications only in this part of the molecule, from the natural rolliniastatin-1 (1) and cherimolin-1 (2). Some of the hydroxylated derivatives (1b, 1d and 1e) in addition to two infrequent natural beta-hydroxy gamma-methyl gamma-lactone acetogenins, laherradurin (3) and itrabin (4), are more potent complex I inhibitors than any other known compounds.

Dieulafoy's disease of the bronchus in association with a paravertebral neurilemoma

Dieulafoy's disease is a vascular anomaly characterized by the presence of a dysplastic artery that is related to an epithelial ulcer. While it is most frequently a GI condition, occurrence in the bronchus has been reported previously in six cases. We present the case of a 51-year-old man with severe hemoptysis and epistaxis. Chest radiographs showed diffuse density in the right base and a mass in the pedicle of T4. The results of bronchoscopy corroborated an active arterial bleeding point in the bronchus of the right middle lobe. A middle and lower lobectomy was performed with resection of the paravertebral mass. The final diagnoses were bronchial Dieulafoy's disease and paravertebral neurilemoma.

Semisynthesis of antitumoral acetogenins: SAR of functionalized alkyl-chain bis-tetrahydrofuranic acetogenins, specific inhibitors of mitochondrial complex I

The acetogenins of Annonaceae are known by their potent cytotoxic activity. In fact, they are promising candidates as a new future generation of antitumoral drugs to fight against the current chemiotherapic resistant tumors. The main target enzyme of these compounds is complex I (NADH:ubiquinone oxidoreductase) of the mitochondrial respiratory chain, a key enzymatic complex of energy metabolism. In an attempt to characterize the relevant structural factor of the acetogenins that determines the inhibitory potency against this enzyme, we have prepared a series of bis-tetrahydrofuranic acetogenins with different functional groups along the alkyl chain. They comprise several oxo, hydroxylimino, mesylated, triazido, and acetylated derivatives from the head series compounds rolliniastatin-1, guanacone, and squamocin. Our results suggest a double binding point of acetogenins to the enzyme involving the alpha,alpha'-dihydroxylated tetrahydrofuranic system as well as the alkyl chain that links the terminal alpha, beta-unsaturated-gamma-methyl-gamma-lactone. The former mimics and competes with the ubiquinone substrate. The latter modulates the inhibitory potency following a complex outline in which multiple structural factors probably contribute to an appropriate conformation of the compound to penetrate inside complex I.

Mechanism of vascular relaxation by thaligrisine: functional and binding assays

In the present study we examine the mechanism by which thaligrisine, a bisbenzyltetrahydroisoquinoline alkaloid, inhibits the contractile response of vascular smooth muscle. The work includes functional studies on rat isolated aorta and tail artery precontracted with noradrenaline or KCl. In other experiments rat aorta was precontracted by caffeine in the presence or absence of extracellular Ca2+. In order to assess whether thaligrisine interacts directly with calcium channel binding sites or with alpha-adrenoceptors we examined the effect of the alkaloid on [3H]-(+)-cis diltiazem, [3H]-nitrendipine and [3H]-prazosin binding to cerebral cortical membranes. The functional studies showed that the alkaloid inhibited in a concentration-dependent manner the contractile response induced by depolarization in rat aorta (IC50 = 8.9+/-2.9 microM, n=5) and in tail artery (IC50 = 3.04+/-0.3 microM, n=6) or noradrenaline induced contraction in rat aorta (IC50 = 23.0+/-0.39 microM, n=9) and in tail artery (IC50 = 3.8+/-0.9 microM, n=7). In rat aorta, thaligrisine concentration-dependently inhibited noradrenaline-induced contraction in Ca2+-free solution (IC50 = 13.3 microM, n=18). The alkaloid also relaxed the spontaneous contractile response elicited by extracellular calcium after depletion of noradrenaline-sensitive intracellular stores (IC50 = 7.7 microM, n=4). The radioligand receptor-binding study showed that thaligrisine has higher affinity for [3H]-prazosin than for [3H]-(+)-cis-diltiazem binding sites, with Ki values of 0.048+/-0.007 microM and 1.5+/-1.1 microM respectively. [3H]-nitrendipine binding was not affected by thaligrisine. The present work provides evidence that thaligrisine shows higher affinity for [3H]-prazosin binding site than [3H]-(+)-cis-diltiazem binding sites, in contrast with tetrandrine and isotetrandrine that present similar affinity for both receptors. In functional studies thaligrisine, acted as an alpha1-adrenoceptor antagonist and as a Ca2+ channel blocker, relaxing noradrenaline or KCl-induced contractions in vascular smooth muscle. This compound specifically inhibits the refilling of internal Ca2+-stores sensitive to noradrenaline, by blocking Ca2+-entry through voltage-dependent Ca2+-channels.

Synthesis of N-diisopropyl phosphoryl benzyltetrahydroisoquinoline, a new class of mitochondrial complexes I and III inhibitors

The synthesis of N-(O,O-diisopropylphosphoryl)-benzyltetrahydroisoquinoline (3) has been achieved in a 'one pot' procedure from imine (2) and diisopropyl-phosphorochloridate (1) generated in situ (POCl3 + iPrOH). Compound 3 is the first benzyltetrahydroisoquinoline derivative found to be a potent inhibitor of mitochondrial complexes I and III, and therefore it opens a new perspective with this series of compounds as they can be considered as new class of antitumor agents.

3-acetylaltholactone and related styryl-lactones, mitochondrial respiratory chain inhibitors

A novel furano-pyrone, 3-acetylaltholactone, and two other known styryl-lactones, altholactone and 5-acetoxyisogoniothalamin oxide, have been isolated from Goniothalamus arvensis (Annonaceae) stem bark. We report here the isolation and structural elucidation of these compounds with furane-pyrone and styryl-pyrone skeletons, postulating also for the first time their mechanism of cytotoxicity based on inhibition on mammalian mitochondrial respiratory chain.

Insecticidal and mutagenic evaluation of two annonaceous acetogenins

Annonaceous acetogenins represent a new class of bioactive compounds whose primary mode of action is the inhibition of NADH-ubiquinone oxidoreductase. Given the potential pesticidal use of such a class of compounds, we have further evaluated the antifeedant and insecticidal effects of squamocin and annonacin, two annonaceous acetogenins, on Spodoptera littoralis, Leptinotarsa decemlineata, and Myzus persicae. Additionally, to partially assess their environmental risk, we have also tested their mutagenicity in Salmonella typhimurium strains TA98, TA100, and TA102 in the presence and absence of a metabolic activation system. Among the test compounds, annonacin showed antifeedant effects on L. decemlineata, while squamocin was toxic to L. decemlineata and M. persicae. Neither acetogenin was mutagenic, although both were toxic in the absence of a metabolic activation system. We compared these results with those obtained with rotenone, a well-known respiratory inhibitor that was highly toxic to L. decemlineata and M. persicae and showed no mutagenicity/toxicity in the S. typhimurium strains tested up to a concentration of 1000 microg per plate.

Epoxy-acetogenins and other polyketide epoxy derivatives as inhibitors of the mitochondrial respiratory chain complex I

Annonaceous acetogenins (ACG), an extensive group of cytotoxic natural products, are antitumor agents whose main mode of action is inhibition of the mammalian mitochondrial complex I. Herein we describe the importance of the different chemical groups along the alkyl chain for optimal inhibitory potency, discussing the structurally relevant factors present in these compounds. For this purpose, a series of epoxide derivatives from alpha-linolenic acid were prepared and their activity compared with that of epoxy-acetogenins and tetrahydrofuranic (THF) acetogenins isolated from Rollinia membranacea.

Preparation of dopaminergic N-alkyl-benzyltetrahydroisoquinolines using a 'one-pot' procedure in acid medium

The preparation of N-methyl-BTHIQ (4) from N-phenylethyl-phenacetamide (1) by cyclization, reduction and N-alkylation in acid medium has been achieved in good yield in a 'one-pot' procedure. Acylation of imine (2) intermediate afforded the Z and E stereoselectivity in the enamide formation. 6-Hydroxy-BTHIQ (7) shows selectivity for D2 dopamine receptors, while its N-methylated homologue (8) displays higher affinities for both D1 and D2 receptor types, with an unexpected increase in D1 dopamine receptor affinity.

Hormonal treatment may harm the germ cells in 1 to 3-year-old boys with cryptorchidism

PURPOSE

Hormonal treatment with human chorionic gonadotropin (HCG) or gonadotropin releasing hormone may be given initially for cryptorchidism. We evaluated whether hormonal treatment is safe for the germ cells in boys with cryptorchidism 1 to 3 years old in whom follicle-stimulating hormone, luteinizing hormone and testosterone values are normally low.

MATERIALS AND METHODS

We measured the number of spermatogonia per tubule at orchiopexy in 72 consecutive boys with cryptorchidism who underwent simultaneous testicular biopsy. In 19 patients gonadotropin releasing hormone was unsuccessful, while 8 received HCG and 45 underwent orchiopexy without hormonal therapy. Groups were otherwise equal.

RESULTS

Patients who underwent surgery only had a higher number of spermatogonia per tubule than those in whom hormonal treatment was unsuccessful (p<0.05). Spermatogonia per tubule values were normal only after surgery alone (p = 0.06). Gonadotropin releasing hormone and HCG influenced germ cells equally.

CONCLUSIONS

In 1 to 3-year-old boys with cryptorchidism gonadotropin releasing hormone or HCG given for testicular descent may suppress the number of germ cells.

Specific interactions of monotetrahydrofuranic annonaceous acetogenins as inhibitors of mitochondrial complex I

Annonaceous acetogenins (ACG) are a wide group of cytotoxic compounds isolated from plants of the Annonaceae family. Some of them are promising candidates to be a future new generation of antitumor drugs due to the ability to inhibit the NADH:ubiquinone oxidoreductase of the respiratory chain (mitochondrial complex I), main gate of the energy production in the cell. ACG are currently being tested on standard antitumor trials although little is known about the structure activity relationship at the molecular level. On recent studies, the relevance of several parts of the molecule for the inhibitory potency has been evaluated. Due to the great diversity of skeletons included in this family of natural products, previous studies on the presence and distribution of oxygenated groups along the alkyl chain only covered the compounds with different bis-tetrahydrofuranic (bis-THF) relative configurations. Therefore, we have investigated the inhibitory action of all the mono-tetrahydrofuranic (mono-THF) acetogenins available, which differ in the oxygenated arrangements along the molecule. Our results show that the hydroxyl and carbonyl groups, placed in the aliphatic chain that links the initial gamma-lactone moiety with the dihydroxylated tetrahydrofuranic ring system, significantly contribute for modulating the inhibitory potency of the ACG through specific effects.

[Eosinophilic cystitis in children]

Eosinophilic cystitis is an inflammatory disorder of the urinary bladder, characterised by irritative voiding symptoms, negative urine cultures, and eosinophilic infiltration of the bladder wall. Since 1960 only about 20 cases have been described in the English scientific reports, making it a rather rare entity. In children the disease appears to be shortlived and self-limited, requiring no specific treatment. We present a case with a 7.5-year-old boy, who experienced spontaneous remission of all symptoms, following an acute attack of eosinophilic cystitis.

Kinetic characterization of mitochondrial complex I inhibitors using annonaceous acetogenins

The NADH:ubiquinone oxidoreductase (complex I) of the mitochondrial respiratory chain is by far the largest and most complicated of the proton-translocating enzymes involved in the oxidative phosphorylation. Many clues regarding the electron pathways from matrix NADH to membrane ubiquinone and the links of this process with the translocation of protons are highly controversial. Different types of inhibitors become valuable tools to dissect the electron and proton pathways of this complex enzyme. Therefore, further knowledge of the mode of action of complex I inhibitors is needed to understand the underlying mechanism of energy conservation. This study presents for the first time a detailed exploration of the inhibitory action of the Annonaceous acetogenins, the most powerful inhibitors of the mammalian enzyme, taking as the head-series rolliniastatin-1, rolliniastatin-2, and corossolin. Despite their close chemical resemblance, each of them inhibits the complex I with different kinetic features reflecting differential binding to the enzyme.

Germ cells may survive clipping and division of the spermatic vessels in surgery for intra-abdominal testes

PURPOSE

Laparoscopy is a well described modality that provides an accurate visual diagnosis upon which further management of intra-abdominal testes may be based. Laparoscopic ligation of spermatic vessels as stage 1 of the procedure is a natural extension of laparoscopy. A staged approach provides adequate viability of the intra-abdominal testis. However, it is uncertain whether the more sensitive germ cells survive this procedure in addition to the Sertoli and interstitial cells of the human testis. Survival of germ cells is a prerequisite of later fertility potential.

MATERIALS AND METHODS

We studied 17 nonpalpable testes in 10 patients 1 year and 7 months to 13(1/2) years old. Results of testicular biopsies of 13 intra-abdominal testes taken at stages 1 and 2 of surgery were available for histological comparison.

RESULTS

Median number of spermatogonia per tubular cross section of the biopsies taken at stage 2 was slightly lower (0.03) compared to the median number at stage 1 (0.06) of the operation but this difference was not significant (p = 0.2031).

CONCLUSIONS

Our study shows that the spermatogonia may survive clipping and division of the spermatic vessels, although the number of spermatogonia per tubular transverse section decreases slightly.

Semisynthesis and cytotoxicity of styryl-lactone derivatives

The cytotoxicity and the cell-cycle action of altholactone (1), goniofufurone (2), and eight altholactone derivatives (5-12), were determined in vitro on L-1210 cells. Semisyntheses and structure-activity relationships of these compounds are described. The results of this study suggest that the cytotoxicity of altholactone (1), 11-nitro-altholactone (8), and 7-chloro-6,7-dihydroaltholactone (10) is due to the accumulation of the cells in the G2 + M phase of the cell cycle.

Anti-MIC2 as a tool in examination of testicular biopsies

MIC2 is a pseudoautosomal gene localized on X and Y chromosomes. The MIC2 gene product is a glycoprotein expressed on the cell membranes of a number of somatic cells, including Sertoli cells of the testis, but not on the cell membranes of germ cells. In cases of cryptorchidism, a testicular biopsy is recommended in order to evaluate future fertility potential. The spermatogonia are identified on histological sections and the number per tubular transverse section is compared with normal values for age. The patient is at 33-100% risk of subsequent infertility when the number of spermatogonia per tubular transverse section is lower than 1% of the lowest normal age-matched value. Besides Sertoli cells the seminiferous tubules in undescended testes contain only a few germ cells, and it may be difficult to pinpoint the germ cells in small biopsies. Especially in nonpalpable testes their number may be heavily reduced. A reliable identification of germ cells may also be difficult in cultures of testicular biopsies from undescended testes. Against this background, we tried the use of an immunohistochemical method with DAKO antibody to the MIC2 gene product (MIC2, 12 E7, code no. M3601) in order to obtain a "negative reaction" of germ cells, contrasting with the stained Sertoli cells. The material comprised: 44 specimens of testicular parenchyma taken at time of surgery for cryptorchidism from 24 cryptorchid boys with nonpalpable testes and 14 testicular biopsies from 13 cryptorchid patients with palpable testes which had been cultured in vitro for 7, 14 or 21 days. In all cases the immunohistochemical method with DAKO antibody to the MIC2 gene product was helpful for identification of Sertoli cells and germ cells, and we therefore recommend the use of anti-MIC2 in all testicular biopsies where it is difficult to pinpoint the germ cells.

[Renal and urinary tract abnormalities in small children]

The purpose of this study was to investigate frequency and pattern of urological abnormalities in children younger than two years of age in the county of Frederiksborg, Denmark, with a catchment area of about 350,000 people, and furthermore to investigate in which way the urological abnormalities were diagnosed. From 1994-1996 a total of 35 children younger than two years of age were found to have urological abnormalities. Fourteen patients had a ultrasonographical prenatally diagnosed urological abnormality, which was confirmed postnatally. Twenty-one children were diagnosed with urological abnormalities after presentry with their first urinary tract infection. The obstructive urological diagnoses: congenital hydronephrosis, congenital megaureter and posterior urethral valves made up to 57% (20/35) of the abnormalities. Nine boys were operated upon; three for unilateral hydronephrosis, two for posterior urethral valves, one for unilateral megaureter and three for phimosis. Two girls were treated with oestrogen for labial fusion. Urological abnormalities which were treated were found among the ultrasonographically diagnosed abnormalities, apart from phimosis and labial fusion. The frequency of urological abnormalities was 0.25% in children younger than two years of age in Frederiksborg county. In conclusion, in 1994-1996 the frequency and pattern of urological abnormalities in Frederiksborg county was in accordance with the figures in the literature. Urological abnormalities requiring treatment were diagnosed in 11 children; 55% (6/11) ultrasonographically and 45% (5/11) by examination of the external genitalia of children younger than two years of age at the time of the first diagnosed urinary tract infection.

[T validity of the diagnosis of urinary tract infection in children under two years of age]

In the Department of Paediatrics at Hillerød a valid diagnosis of urinary tract infection in children is defined to be at least 10.000 bacteria/ml. in two midstream specimens of urine or any bacterial growth in urine collected by a suprapubic aspiration or by bladder catheterisation. We decided to study if these criteria were fulfilled in our department, which takes care of urinary tract infections in children in the county of Frederiksborg with a catchment area of about 350.000 people. From 1994-1996 a total of 60 children younger than two years of age were treated for their first suspected urinary tract infection. The diagnosis was valid in 37% of the cases. Eighty-eight percent of the children received parenteral antibiotics for at least three days, and 86% were discharged with prophylactic antibiotics. All underwent urological ultrasonographic examination and 70% underwent an isotope micturition cystourethrography. Among patients with a valid diagnosis 68% were boys and 50% had urological abnormalities, whereas among patients without a valid diagnosis there were 33% boys (p < 0.025) and 24% had urological abnormalities (p = 0.0734). A valid diagnosis of a first urinary tract infection was established in 0.15% of children younger than two years of age in the county of Frederiksborg. This is lower than previously reported. The problem of false positive urinary tract infections thus may be important in general.

Enantiospecific semisynthesis of (+)-almuheptolide-A, a novel natural heptolide inhibitor of the mammalian mitochondrial respiratory chain

The development of novel styryl lactone derivatives as bioactive compounds and the semisynthesis of both 4,5-dialkoxylated eight-membered-ring lactones with a heptolide skeleton (almuheptolide-A (1) type) and 7-alkoxylated delta-lactones with a saturated furanopyrone skeleton (etharvensin (8) type) have been successfully achieved from the chiral unsaturated alpha-pyrone altholactone (7). This new method is a direct and one-step enantiospecific alkoxylation of altholactone (7) in concentrated acid medium, followed by formation of the eight-membered-ring zeta-lactone. The reaction mechanism operating in the synthesis of the heptolide skeleton is postulated to be a direct Michael-type addition. Concerted opening of both the alpha-pyrone and tetrahydrofuran rings and subsequent intramolecular rearrangement with the ring closure lead to almuheptolide-A (1). This compound (1) and its diacetated derivative (1a) showed potent and selective inhibitory activity toward mammalian mitochondrial respiratory chain complex I. This mechanism of action, reported here for the first time, provides a possible explanation for the cytotoxic and antitumor activities previously described for related natural compounds.

Is infertility after surgery for cryptorchidism congenital or acquired?

We evaluated whether deletions of the DAZ (deleted in azoospermia) gene, abnormal karyotypes or hypogonadotropic hypogonadism (HH) were demonstrable in infertile men who had undergone surgery in childhood for cryptorchidism with a simultaneous testicular biopsy that demonstrated no or almost no germ cells. In six men with infertility after surgery for cryptorchidism, the adult karyotype and analyses for the DAZ gene, serum follicle-stimulating hormone, luteinizing hormone, and testosterone were performed from a peripheral blood sample. Testicular volume was also measured. All patients exhibited a 46,XY karyotype. There were no deletions of the DAZ-gene, no HH and no testicular atrophy. The infertility was thus not proved to be congenital, and consequently, surgical treatment is indicated before the germ cells disappear from undescended testes. This appears to be before 15 months of age.