Circulating Placental Alkaline Phosphatase Expressing Exosomes in Maternal Blood Showed Temporal Regulation of Placental Genes.

Background: Analysis of placental genes could unravel maternal-fetal complications. However, inaccessibility to placental tissue during early pregnancy has limited this effort. We tested if exosomes (Exo) released by human placenta in the maternal circulation harbor crucial placental genes. Methods: Placental alkaline phosphate positive exosomes (ExoPLAP) were enriched from maternal blood collected at the following gestational weeks; 6-8th (T1), 12-14th (T2), 20-24th (T3), and 28th-32nd (T4). Nanotracking analysis, electron microscopy, dynamic light scattering, and immunoblotting were used for characterization. We used microarray for transcriptome and quantitative PCR (qPCR) for gene analysis in ExoPLAP. Results: Physical characterization and presence of CD63 and CD9 proteins confirmed the successful ExoPLAP enrichment. Four of the selected 36 placental genes did not amplify in ExoPLAP, while 32 showed regulations (n = 3-8/time point). Most genes in ExoPLAP showed significantly lower expression at T2-T4, relative to T1 (p < 0.05), such as NOS3, TNFSF10, OR5H6, APOL3, and NEDD4L. In contrast, genes, such as ATF6, NEDD1, and IGF2, had significantly higher expression at T2-T4 relative to T1. Unbiased gene profiling by microarray also confirmed expression of above genes in ExoPLAP-transcriptome. In addition, repeated measure ANOVA showed a significant change in the ExoPLAP transcriptome from T2 to T4 (n = 5/time point). Conclusion: Placental alkaline phosphate positive exosomes transcriptome changed with gestational age advancement in healthy women. The transcriptome expressed crucial placental genes involved in early embryonic development, such as actin cytoskeleton organization, appropriate cell positioning, DNA replication, and B-cell regulation for protecting mammalian fetuses from rejection. Thus, ExoPLAP in maternal blood could be a promising source to study the placental genes regulation for non-invasive monitoring of placental health.

Isolation and characterization of mesenchymal stem cells from human fetus heart.

BACKGROUND: Mesenchymal stem cells (MSCs) are promising cells for cardiovascular regenerative medicine. However, their potential may be limited, because of their restricted cardiovascular differentiation potential and decline in their number and functional characteristics with increasing donor age. We have previously shown that rat fetus heart harbors primitive MSCs and administration of these cells improved left ventricular (LV) function after ischemia/reperfusion injury in rats. To evaluate their potential as a new cell type for clinical cardiovascular cell therapy, we have undertaken this study on the isolation and characterization of human fetal cardiac MSCs (hfC-MSCs). METHODS: MSCs were isolated from the heart of five 14-16-week-old aborted human fetuses and studied for their growth characteristics, karyotypic stability and senescence over successive passages, expression of mesenchymal and embryonal markers by flow cytometry and immunocytochemistry, constitutive expression of cardiovascular genes by RT-PCR, differentiation into cells of the cardiovascular lineage and their immunomodulatory properties. RESULTS: The hfC-MSCs grew as adherent monolayer with spindle shaped morphology and exhibited rapid proliferation with an average population doubling time of 34 hours and expansion to up to more than 80 population doublings with maintenance of a normal karyotype and without senescence. Immunophenotyping showed that they had similar phenotype as human bone marrow mesenchymal stem cells (hBM-MSCs) expressing CD73, CD90, CD105 and lacking expression of CD31, CD34, CD45, HLA-DR. However, hfC-MSCs expressed significantly higher levels of CD117 and SSEA-4 compared to hBM-MSCs. In addition, hfC-MSCs expressed the embryonal markers Oct-4, Nanog and Sox-2 as compared to hBM-MSCs. Further, hfC-MSCs had significantly higher expression of the cardiovascular genes viz. ISL-1, flk-1, GATA-4, NKX2.5 and MDR-1 as compared to hBM-MSCs, and could be differentiated into major cardiovascular cells (cardiomyocytes, endothelial cells, smooth muscle cells). Interestingly, hfC-MSCs markedly reduced T-lymphocyte proliferation with an increased secretion of TGF-ß and IL-10. CONCLUSIONS: Our results show that human fetus heart is a novel source of primitive MSCs with cardiovascular commitment which may have a potential therapeutic application in cardiovascular regenerative medicine.

Molecular Characterization of FMR1 Gene by TP-PCR in Women of Reproductive Age and Women with Premature Ovarian Insufficiency.

BACKGROUND: Fragile X syndrome is caused by CGG repeat expansion mutation in the FMR1 gene. Normal alleles have 5-44 CGG repeats with AGG interruptions. The expanded gray zone (GZ) (45-54 repeats) and premutation (PM) (55-200 repeats) alleles are often uninterrupted and are unstably inherited in subsequent generations. The prevalence of PM and GZ carriers is high in the female population, at 1/66 and 1/113, respectively, and PM is associated with fertility problems in 20% of cases. OBJECTIVE: Our objective was to molecularly characterize CGG repeats and AGG interruption sequences in the FMR1 gene in women of reproductive age and in women with premature ovarian insufficiency (POI). MATERIALS AND METHODS: We conducted molecular analysis of the FMR1 gene from 300 women of reproductive age and 140 women with POI using triplet primed-polymerase chain reaction. This enabled us to identify carriers and to document CGG repeat size and the AGG interruption pattern. RESULTS: In women of reproductive age, 1.7% were GZ carriers and 0.3% were PM carriers; in women with POI, 3.6% were GZ carriers and 2.14% were PM carriers. The frequency of GZ and PM carriers did not significantly differ between the cohorts (Fisher's exact test: p < 2.23 for GZ vs. control and p < 0.101 for PM vs. control). Carriers received genetic counselling; family screening identified an additional seven carriers. CONCLUSION: We documented preliminary data on the prevalence of GZ and PM carriers among the studied cohorts. The identification of PM carriers among women with POI serves a dual purpose of recognizing a cause for ovarian dysfunction and enabling genetic counselling, which will help carriers when making reproductive decisions.

Simultaneous Transabdominal Hysterectomy and Cystolithotomy in an Augmented Urinary Bladder: Challenges and Outcome.

Augmentation cystoplasty is a procedure to increase the anatomical as well as functional capacity of the urinary bladder using a segment of bowel or ureter. Upto half of these patients develop complications but most of them are minor and managed easily. Urolithiasis, especially bladder calculi are seen in upto half of the cases and are removed endoscopically or by open approach. Hysterectomy is an uncommon procedure in patients with augmentation cystoplasty and is complicated by the altered anatomy of the pelvis. We describe a rare case of simultaneous abdominal hysterectomy and cystolithotomy in a patient with augmentation cystoplasty and discuss the relevant surgical anatomy.

Trans-vaginal anterior vaginal wall prolapse repair using a customized tension-free bell-shaped prolene mesh: A single-center experience with long-term functional analysis.

INTRODUCTION: The existing literature shows that mesh reinforcement improves the anatomical success rate of cystocele repair. We report the long-term results of a custom bell-shaped mesh with simultaneous urethral support for the repair of cystocele. MATERIALS AND METHODS: The present study was a single-center, single-surgeon case series of 36 patients. Only patients with Pelvic Organ Prolapse Quantification system (POP-Q) stage 2 and above were included in the study. Patients having rectocele or uterine/vault prolapse were excluded. Body of the mesh was used for reinforcement of the cystocele repair and two limbs were left tension free in the retropubic space. Patients were followed 3 monthly for the first year and yearly thereafter. Recurrence was defined as cystocele ≥stage 2 (Aa or Ba 0) any time after the first follow-up. RESULTS: Mean patient age was 58.5 ± 6.2 years. The mean parity was 3.2 ± 1.6. Of 36 patients, 11 (30.5%) of the patients were POPQ stage 2, 15 (41.7%) were stage 3 and 10 (27.7%) were stage 4 cystocele. The mean follow-up period was 53.4 months, with 32 patients reporting for follow-up till date (88.9%). There was no bladder injury, no mesh erosion or infection. No patient required CIC (clean intermittent catheterization) or had stress urinary incontinence post-operatively at 5 years of follow-up. CONCLUSION: The bell-shaped mesh is a simple, effective and safe procedure in the surgical management of cystocele with excellent long-term outcome.

Newborn screening for congenital hypothyroidism, galactosemia and biotinidase deficiency in Uttar Pradesh, India.

OBJECTIVE: To assess feasibility and recall rates for newborn screening for congenital hypothyroidism, galactosemia and biotinidase deficiency in a predominantly rural and inner city population in and around the City of Lucknow in Uttar Pradesh, India. DESIGN: Prospective observational study. SETTING: Two tertiary-care and 5 district hospitals in and around Lucknow. PARTICIPANTS: All babies born in above hospitals during the study period. METHODS: Heel prick samples were collected after 24 hours of life. Dried blood spot TSH, total galactose and biotinidase were assayed by immunofluorometry. Age related cut-offs were applied for recall for TSH. For galactosemia and biotinidase deficiency, manufacturer-suggested recall cut-offs used initially were modified after analysis of initial data. MAIN OUTCOME MEASURE: Recall rate for hypothyroidism, galactosemia and biotinidase deficiency. RESULTS: Screening was carried out for 13426 newborns, 73% of all deliveries. Eighty-five percent of those recalled for confirmatory sampling responded. Using fixed TSH cut off of 20 mIU/L yielded high recall rate of 1.39%, which decreased to 0.84% with use of age-related cut-offs. Mean TSH was higher in males, and in low birth weight and vaginally delivered babies. Eleven babies had congenital hypothyroidism. Recall rates with modified cut-offs for galactosemia and biotinidase deficiency were 0.32% and 0.16%, respectively. CONCLUSIONS: An outreach program for newborn screening can be successfully carried out in similar socio-cultural settings in India. For hypothyroidism, the high recall rate due to early discharge was addressed by age-related cut-offs.

Delivery after augmentation cystoplasty: Implications and precautions.

A young female with history of genitourinary tuberculosis with solitary functioning kidney became pregnant 1 year after augmentation cystoplasty (AC) with ureteric reimplantation. Throughout pregnancy she had two episode of febrile urinary tract infection. Her renal function remained normal. She was planned for cesarian section due to obstetric indications. Despite altered pelvic anatomy, we successfully did the lower segment cesarian section. We reviewed the literature regarding pregnancy in patients with AC to find that what the treating Urologist and Gynecologist should know about these rare cases. Various complications which should be anticipated and measures to prevent them are also discussed.

Dorsal onlay vaginal graft urethroplasty for female urethral stricture.

INTRODUCTION: Female urethral stricture is an underdiagnosed and overlooked cause of female bladder outlet obstruction. The possible etiologies may be infection, prior dilation, difficult catheterization with subsequent fibrosis, urethral surgery, trauma, or idiopathic. We present our technique and results of dorsal onlay full thickness vaginal graft urethroplasty for female urethral stricture. MATERIALS AND METHODS: A retrospective review was performed on 16 female patients with mid-urethral stricture who underwent dorsal onlay vaginal graft urethroplasty from January 2007 to June 2011. Of these, 13 patients had previously undergone multiple Hegar dilatations, three had previous internal urethrotomies. The preoperative work up included detailed voiding history, local examination, uroflowmetry, calibration, and micturating cystourethrogram. RESULTS: All patients had mid-urethral stricture. Mean age was 47.5 years. Mean Qmax improved from 6.2 to 27.6 ml/s. Mean residual volume decreased from 160 to 20 ml. Mean duration of follow-up was 24.5 months (6 months to 3 years). Only one patient required self-calibration for 6 months after which her stricture stabilized. None of the patient was incontinent. CONCLUSION: Dorsal vaginal onlay graft urethroplasty could be considered as an effective way to treat female urethral stricture.

Trans-vaginal total pelvic floor repair using customized prolene mesh: A safe and cost-effective approach for high-grade pelvic organ prolapse.

AIMS: To assess safety, efficacy, and cost-effectiveness of trans-vaginal total pelvic floor repair with customized prolene mesh in patients with high-grade pelvic organ prolapse. MATERIALS AND METHODS: A total of 32 patients, who underwent trans-vaginal total pelvic floor repair using a customized prolene mesh from January 2007 to June 2010 for grade III and IV pelvic organ prolapse, were analyzed retrospectively. Prolapse was graded using Pelvic Organ Prolapse Quantification system of International Continence Society. Patients were evaluated for symptoms associated with prolapse pre- and postoperatively. RESULTS: Of the 32 patients, 18 were grade IV uterine prolapse, 10 were grade III uterine prolapse, and 4 were grade IV vault prolapse. Twenty-eight patients underwent vaginal hysterectomy at the time of repair. All the patients had associated anterior and posterior prolapse of varying degree. Follow-up ranged from 6 to 42 months. All patients had symptomatic relief after surgery. There were no intraoperative rectal or bladder injuries. Early complications were perineal pain (30), de novo urgency (4), vaginal discharge (3), vaginal wall hematoma (2), and failure to void (2). Two patients had vaginal erosion of mesh. CONCLUSIONS: Trans-vaginal total pelvic floor repair using a customized prolene mesh is safe and effective treatment for comprehensive repair of high-grade pelvic organ prolapse. The use of this custom-made prolene mesh makes the procedure very cost-effective and affordable. The reduction in cost is about 25-30 times with the use of this mesh when compared with commercially available variety.

Ruptured ovarian endometrioma with an extreme rise in serum CA 125 level - A case report: Ovarian endometrioma with very high CA-125 level.

► CA 125 is the most useful tumor marker for epithelial ovarian carcinoma. ► Very high serum CA 125 level does not necessarily indicate ovarian malignancy. ► Rapidly rising and persistent levels of CA 125 may be consistent with benign disease.

Anaesthetic management of Wolff-Parkinson-White syndrome for hysterectomy.

Wolff-Parkinson-White syndrome (WPW) is an uncommon cardiac disorder having an aberrant pathway between atria and ventricles. We are reporting a known case of WPW syndrome for hysterectomy under combined spinal epidural anaesthesia. Management of the present case is an important pearl to revisit management of WPW syndrome. The perioperative management should be tailored according to the nature of surgery and the clinical presentation of the patient.

Is modified Raz technique of midurethral sling a reliable and cost-effective method of treating stress urinary incontinence?

OBJECTIVES: We report our experience of pure stress urinary incontinence (SUI) treated by midurethral synthetic sling placement by modified Raz technique. MATERIALS AND METHODS: Fifty-three patients with pure SUI operated at our institute between June 2003 and December 2008 were included in this study. Midurethral sling tape, fashioned from commercially available large pore synthetic mesh, was placed using the modified Raz technique. The technique consisted of placing the tape within retropubic space using double-pronged needle, which is passed under finger control through the fascia and retropubic space. Outcomes were assessed on the basis of patient's interview in follow-up OPD. RESULTS: Mean age was 57.68 (28-69) years. Forty-five (85%) patients were totally dry and eight (15%) socially dry at the end of the follow-up. Mean operative time was 46.5 + 11.3 minutes (35-80 minutes). None of the patients required blood transfusion or had bladder/bowel injury. Mean duration of hospital stay was 2.17 days (2-4 days). Mean duration of follow-up was 46.1 months (12-78 months). CONCLUSIONS: Modified Raz technique is safe and cost-effective for placing midurethral sling for genuine stress incontinence.

Gossypiboma, a rare cause of acute abdomen: A case report and review of literature.

Gossypiboma or textiloma is used to describe a retained surgical swab in the body after an operation. Inadvertent retention of a foreign body in the abdomen often requires another surgery. This increases morbidity and mortality of the patient, cost of treatment, and medicolegal problems. We are reporting case of a 45-year-old woman who was referred from periphery with acute pain in abdomen. She had a surgical history of abdominal hysterectomy 3 years back, performed at another hospital. On clinical examination and investigation, twisted ovarian cyst was suspected. That is a cystic mass further confirmed by abdominal computerized tomography (CT). During laparotomy, the cyst wall was opened incidentally which lead to the drainage of a large amount of dense pus. In between pus, there was found retained surgical gauze that confirmed the diagnosis of gossypiboma.