Pathogenesis of Adrenal Aldosterone-Producing Adenomas Carrying Mutations of the Na(+)/K(+)-ATPase.

Aldosterone-producing adenoma (APA) is a major cause of primary aldosteronism, leading to secondary hypertension. Somatic mutations in the gene for the α1 subunit of the Na(+)/K(+)-ATPase were found in about 6% of APAs. APA-related α1 subunit of the Na(+)/K(+)-ATPase mutations lead to a loss of the pump function of the Na(+)/K(+)-ATPase, which is believed to result in membrane depolarization and Ca(2+)-dependent stimulation of aldosterone synthesis in adrenal cells. In addition, H(+) and Na(+) leak currents via the mutant Na(+)/K(+)-ATPase were suggested to contribute to the phenotype. The aim of this study was to investigate the cellular pathophysiology of adenoma-associated Na(+)/K(+)-ATPase mutants (L104R, V332G, G99R) in adrenocortical NCI-H295R cells. The expression of these Na(+)/K(+)-ATPase mutants depolarized adrenal cells and stimulated aldosterone secretion. However, an increase of basal cytosolic Ca(2+) levels in Na(+)/K(+)-ATPase mutant cells was not detectable, and stimulation with high extracellular K(+) hardly increased Ca(2+) levels in cells expressing L104R and V332G mutant Na(+)/K(+)-ATPase. Cytosolic pH measurements revealed an acidification of L104R and V332G mutant cells, despite an increased activity of the Na(+)/H(+) exchanger. The possible contribution of cellular acidification to the hypersecretion of aldosterone was supported by the observation that aldosterone secretion of normal adrenocortical cells was stimulated by acetate-induced acidification. Taken together, mutations of the Na(+)/K(+)-ATPase depolarize adrenocortical cells, disturb the K(+) sensitivity, and lower intracellular pH but, surprisingly, do not induce an overt increase of intracellular Ca(2+). Probably, the autonomous aldosterone secretion is caused by the concerted action of several pathological signaling pathways and incomplete cellular compensation.

Pharmacology and pathophysiology of mutated KCNJ5 found in adrenal aldosterone-producing adenomas.

Somatic mutations of the potassium channel KCNJ5 are found in 40% of aldosterone producing adenomas (APAs). APA-related mutations of KCNJ5 lead to a pathological Na(+) permeability and a rise in cytosolic Ca(2+), the latter presumably by depolarizing the membrane and activating voltage-gated Ca(2+) channels. The aim of this study was to further investigate the effects of mutated KCNJ5 channels on intracellular Na(+) and Ca(2+) homeostasis in human adrenocortical NCI-H295R cells. Expression of mutant KCNJ5 led to a 2-fold increase in intracellular Na(+) and, in parallel, to a substantial rise in intracellular Ca(2+). The increase in Ca(2+) appeared to be caused by activation of voltage-gated Ca(2+) channels and by an impairment of Ca(2+) extrusion by Na(+)/Ca(2+) exchangers. The mutated KCNJ5 exhibited a pharmacological profile that differed from the one of wild-type channels. Mutated KCNJ5 was less Ba(2+) and tertiapin-Q sensitive but was inhibited by blockers of Na(+) and Ca(2+)-transporting proteins, such as verapamil and amiloride. The clinical use of these drugs might influence aldosterone levels in APA patients with KCNJ5 mutations. This might implicate diagnostic testing of APAs and could offer new therapeutic strategies.

Effect of the intrauterine contraceptive device on protein components of human uterine fluid.

The albumin, immunoglobulin G (IgG), immunoglobulin A (IgA), lysozyme, lactoferrin, alpha 1-antitrypsin, alpha 1x-antichymotrypsin, and neutral proteinase levels of uterine fluid and serum of IUD-bearing women were studied in relationship to the phase of the menstrual cycle, the length of IUD implantation and the presence of reported side effects. Selection of these proteins was based on their potential importance in IUD-induced contraceptive action and/or side effects. Generally, only small differences were found in the serum levels of these proteins during the cycle, with different length of implantation or between patients with and without side effects. However, transudation of proteins (albumin, IgG, alpha 1-antitrypsin, alpha 1x-antichymotrypsin) from blood into the uterine cavity was enhanced by the IUD, especially during the postmenstrual and premenstrual periods. The IUD enhanced the local secretory response even more, i.e., the increased release of proteins from the endometrium (lysozyme, neutral proteinase, IgA) and from leukocytes (lysozyme, lactoferrin). Protein changes occurred as the period of insertion increased. These changes in the uterine milieu may account in part for the contraceptive action of the IUD. The secretory proteins rather than the transudation products differed between patients who showed IUD-associated side effects vs. those who did not, implying that IUD-related pathology is primarily associated with changes in local secretory response. The possible role of each protein in the mechanism of IUD action is presented in view of the present findings.

Immature teratomas of different origin carried by a pregnant mother and her fetus.

We describe the case of a pregnant mother and her fetus who both carried teratomas during the pregnancy. The fetus was diagnosed at 38 weeks' gestation to have an intracranial mass, which was later determined to be an immature teratoma. During a cesarean section delivery, an ovarian tumor was found in the 27-year-old mother that was also diagnosed to be an immature teratoma. Because of the similar histology of the tumors carried by both mother and child, a single clonal origin was suspected. Using polymerase chain reaction (PCR) and electrophoresis of highly polymorphic DNA satellite sequences, we determined that the origin of the intracranial teratoma carried by the child was independent of the mother's tumor. We also examined the p53 tumor suppressor gene in constitutional cells from both mother and child for the possible presence of a cancer-predisposing inherited mutation, but none was found. To our knowledge, this is the first report of the simultaneous occurrence of independent malignant immature teratomas in a mother and child during pregnancy.

Severe pain at interval IUD insertion: a case-control analysis of patient risk factors.

This investigation, using a case-control analysis approach on an IUD data set from a less-developed country center, delineated four risk factors in patient characteristics that are associated with severe pain at interval IUD insertion. They are: higher education (greater than or equal to seven years), low-parity (1-2 live births), longer open interval (greater than or equal to 13 months) between the end of the last pregnancy and insertion, and non-breastfeeding at the time of insertion. Adjusted relative risks estimated by odds ratios are 2.1, 2.7, 2.7 and 5.0, respectively. For women with a combination of the above risk factors, they have a further increased (additive in nature) risk of suffering severe insertion pain. Similar analysis was also performed on a developed country center data set for which only the effect of education and parity could be studied; an odds ratio of 5.0 for nulliparity was obtained. The plausibility of these findings as well as their clinical and programmatic implications are discussed.

PIP: This investigation, using a case-control analysis approach on an intrauterine device (IUD) data set from a less-developed country center, delineated 4 risk factors in patient characteristics that are associated with severe pain at interval IUD insertion. They are: higher education ( or = 7 years) low parity (1-2 live births), longer open interval ( or = 13 months) between the end of the last pregnancy and insertion, and non-breast feeding at the time of insertion. Adjusted relative risks estimated by odds ratios are 2.1, 2.7, 2.7, and 5.0 respectively. For women with a combination of the above risk factors, they have a further increased (additive in nature) risk of suffering severe insertion pain. Similar analysis was also performed on a developed country center data set for which only the effect of education and parity could be studied; an odds ratio of 5.0 for nulliparity was obtained. Better educated women are probably less inhibited to complain of pain than less-educated women. A tighter uterine cervix and a smaller uterine cavity in women of low parity may account for IUD insertion pain. Postpartum involution of the uterus could explain pain upon insertion for women with a long open interval. These findings support the hypothesis that cervical stretching and direct endometrial pressure are probably the most important factors for IUD insertion pain.

Diffusable proteins of the mucosa of the human cervix, uterus, and fallopian tubes: distribution and variations during the menstrual cycle.

The secretory proteins of the mucosa of the cervix, uterus, and fallopian tubes were investigated by measuring the proteins that were released by isolated mucosal areas. Initial screening disclosed that the immunoglobulins IgG and IgA were released in measurable quantities, but that IgM and the secretory (T) piece of IgA were either absent or present only in trace amounts. Relatively low levels of diffusable total complement activity and the C3 component of complement were present, whereas the C1q, C1r, and C4 components were either absent or present only in trace quantities. No neutral proteinase activity was present, but lysozyme, plasminogen activator, alpha 1-antitrypsin, and alpha 1x-antichymotrypsin could be found in reasonable amounts. The site of secretion, concentration, and cyclic variation of the proteins that diffused from the mucosal sites in measurable quantities were studied. The types and amounts of protein secreted by a particular site in the cervix, uterus, or fallopian tube varied from those of protein from other sites, even within the same organ. During the menstrual cycle, variations occurred in the amount of protein secreted by each mucosal site. However, whether an increase or a decrease in the release of a particular protein took place varied with each protein, even at the same site. The mucosal sites also differed from each other in their response to the phase of the menstrual cycle, that is, whether more or less protein was released, even sites within the same organ. The conclusion is that each organ and even different sites within an organ can respond independently from each other to changes in hormone levels, producing different types and amounts of secretory proteins. The amount of diffusable protein produced by an individual site during the menstrual cycle depends on the type of protein as well as the mucosal site.

[Short-term prevention with cefoxitin in cesarean section]. / Kurzzeitprophylaxe mit Cefoxitin beim Kaiser-schnitt.

In a preliminary prospective study, the febrile morbidity of 60 patients after Caesarean section was determined to investigate the prophylactic effect of a single-dose cefoxitin-application (2 g) intravenously at the time of induction of anaesthesia. Patients were randomly assigned to either the cefoxitin group or a control group without the antibiotic. Each group consisted of 30 patients. Although the numbers of patients were small, a statistically significant reduction (p less than 0.05) of febrile days was found for the cefoxitin group. As compared to previous studies with a three-dose regimen of cefoxitin, the per cent reduction rate of febrile morbidity was similar. In cases with certain risk profiles, such as premature rupture of the membranes or prolonged delivery, a single-dose appears to suffice and is therefore indicated.

[Intrauterine contraception]. / Die intrauterine Kontrazeption.

PIP: Approximately 60 million women worldwide use IUDs. Despite worldwide distribution, the total number of IUD carriers has barely increased since 1970. Due to its risks and side effects there is a retrograding tendency both in West Germany and the US. To generate positive development, 3 basic trends have emerged: 1) Restrictive usage of the pharmacologically inactive, 1st generation IUDs such as the Lippes Loop or the Saf-T-Coil, 2) the increasing usage of small plastic IUDs with bioactive alloys to decrease failure rates such as the copper (2nd generation) or hormone-releasing IUDs, and 3) improvements made by changing its design to reduce side effects without loss of contraceptive effectiveness. Almost all IUDs increase monthly blood loss by 50-100%. The risk of illness for women with IUDs is 2-3 times higher than for a woman without or with other contraceptive methods. About 20% of all expulsions occur unnoticed. There are 2 kinds of perforations: primary (iatrogenic), at time of insertion, and secondary, some time after insertion. The IUD failure rate is about 1-3 pregnancies/100 woman years. In case of pregnancy, the IUD must be removed immediately. IUD insertion requires consent of the woman and can be made to women from 16 years on, presupposing moral maturity. IUD insertion after a miscarriage or abortion does not lead to risks or complications. Due to its corrosive quality, the copper IUD can only remain inside the uterus for a limited time. IUDs could become an excellent contraceptive method if it were possible to decrease bleeding, design easily-removeable IUDs, and prolong their potential for duration in the body.^ieng

[Intrauterine contraception. Risks, indications, trends]. / Intrauterine Kontrazeption. Risiken--Indikationen--Trends.

Intrauterine contraception is used by approximately 1 million fertile women in Germany. IUDs work through various factors, i.e. impaired activity of spermatozoa, defects in the lining surface epithelium of the endometrium, and inhibitory effects towards the blastocyst itself. The main risks of intrauterine contraception are perforation of the uterus at the time of insertion, irregular bleedings, ascending infections and ectopic pregnancies. If intrauterine pregnancy occurs despite the presence of an IUD (2-4%), the rate of abortion is considerably high. In few those cases septic sequelae may complicate the spontaneous abortion. After the removal of the IUD of any type fertility immediately returns to normal with the exception of cases suffering from inflammatory complications in association with an IUD in situ. The indication for the application of an IUD should be seriously considered, the use of a formal sheet for informed consent is advisable.

PIP: Intrauterine contraception is used by approximately 1 million fertile women in Germany. IUDs work through a variety of factors; i.e., impaired activity of spermatozoa, defects in the surface lining of the endometrial epithelium, and inhibitory effects towards the blastocyst itself. The main risks of intrauterine contraception are perforation of the uterus at the time of insertion, irregular bleeding, ascending infection, and ectopic pregnancy. If intrauterine pregnancy occurs despite the presence of an IUD (2-4%), the rate of abortion is considerably high. In those few cases, septic sequelae may complicate the spontaneous abortion. After any type of IUD removal, fertility immediately returns to normal with the exception of those cases where there is inflammatory complication along with the IUD in situ. Indications for IUD application should be seriously considered and the use of a formal sheet for informed consent is advisable. (author's)

Clinical experience with a new endometrial cell sampling kit (Isaacs curity endometrium cell sampler) in the early detection of endometrial cancer.

The Isaacs Curity Endometrium Cell Sampler (ICECS) is a new device for the detection of precancerous lesions of the endometrium and asymptomatic endometrial carcinoma. Our clinical experience with the ICECS in a group of 136 women 45 years of age and older with an increased risk for endometrial cancer showed that it was easily used, caused minimal discomfort to the patients and gave good results. The cytologic smears were acceptable for screening in 130 of the 136 cases (95.6%). Normal premenopausal or postmenopausal endometrial cells were found in 100 cases. Hyperplastic changes were found in 18 cases. Carcinoma were diagnosed in 12 cases; all were proven by histologic examination of tissue obtained by curettage. Our results indicate that the new device is valuable for mass cytologic screening for endometrial cancer.

[IUD under the aspects of sexual medicine (author's transl)]. / IUD unter sexualmedizinischen Aspekten (Studie an 198 Frauen mit IUD und 514 Frauen unter hormonaler Kontrazeption zum Vergleich).

PIP: The question is whether there is any difference between women who prefer hormonal contraception and those using an IUD. In this study, 198 women using IUDs were compared with 514 women utilizing hormonal contraception. There was little difference between the 2 groups as far as simple social data was concerned. However, while the tendency displayed was the same, the more detailed questions regarding sexual medicine were answered differently. For those women using hormonal contraception, low or absent libido was noted twice as often (24%) than by women using an IUD (11%). Likewise, the group that reported low or absent capacity for orgasm more often (21%) than by those using the IUD (13%). Pain during intercourse was reported twice as often by women with hormonal contraception (18%) than by those with an IUD (9%). These and other results point to a possible involvement of psychosocial factors and, in particular, factors of a sexual medicine which can prompt women to prefer hormonal contraception to the IUD or vice versa. This is indirectly confirmed by the personality dimension recorded by psychometric means. Additional steroid influences must be clarified by means of prospective comparative studies between hormonal contraception and IUD. (author's)^ieng

Reduced menstrual blood loss by release of an antifibrinolytic agent from intrauterine contraceptive devices.

Lippes Loop and Multiload intrauterine contraceptive devices (IUDs) were fitted with silicone rubber sleeves which either did not contain any compound (blank) or contained the antifibrinolytic agent, epsilon-aminocaproic acid (EACA. In vitro measurements showed that the antifibrinolytic agent was released from the sleeves for a period of 20 days. After insertion into women, the blank Lippes Loop IUDs and Multiload IUDs as well as copper-containing Multiload IUDs caused a significant increase in blood loss beginning with the first menstrual cycle after insertion. The enhanced blood loss was generally retained during subsequent menstrual cycles. By contrast, the menstrual blood loss induced by IUDs containing EACA sleeves was not significantly greater during the first menstrual cycle after insertion that the preinsertion levels. When no more EACA was released, menstrual blood loss increased to approximately the same level as that observed with the blank and copper IUDs. Thus, release of EACA from an IUD retains menstrual blood loss at approximately physiologic levels. These results encourage the development of IUDs that are capable of releasing antifirbrinolytic agents over a long period so that the antimenorrhagic effect is maintained.

PIP: Lippes Loop and Multiload IUDs were fitted with silicone rubber sleeves which either did not contain any compound (blank) or contained the antifibrinolytic agent (EACA), epsilon aminocaproic acid. In vitro measurements showed that the antifibrinolytic agent was released from the sleeves for a period of 20 days. After insertion into women, the blank Lippes loop IUDs and Multiload IUDs as well as copper-containing Multiload IUDs caused a significant increase in blood loss beginning with the 1st menstrual cycle after insertion. The enhanced blood loss was generally retained during subsequent menstrual cycles. By contrast, the menstrual blood loss induced by IUDs containing EACA sleeves was not significantly greater during the 1st menstrual cycle after insertion than the preinsertion levels. When no more EACA was released, menstrual blood loss increased to approximately the same level as that observed with the blank and copper IUDs. Thus, release of EACA from an IUD retains menstrual blood loss at approximately physiologic levels. These results encourage the development of IUDs that are capable of releasing antifibrinolytic agents over a long period so that the antimenorrhagic effect is maintained.

Further evaluation of the split ejaculate for artificial insemination.

The role of artificial insemination with husband semen (AIH) in solving fertility problems has been studied by many investigators. Different conclusions have been made due to the variety of indications for AIH. This communication attempts to evaluate the use of the best split ejaculate fraction for AIH in 55 couples in which the only pathological condition was oligozoospermia or oligoasthenozoospermia. Couples in which the women had a known history of anatomical abnormalities were excluded. Although the seminal parameters of spermatozoal density and/or motility in the best split fractions were frequently found to be in the fertile range, the pregnancy rate achieved was only 18% (n = 10). This was comparable to the results obtained by others using whole ejaculates for AIH. The spontaneous pregnancy rate in the present study after termination of treatment was 13% (n = 6). The observations suggest that men with a long-standing history of seminal deficiency produce spermatozoa with a pathology that cannot be microscopically recognized.

[Menstrual cycle changes during consecutive artificial insemination therapy and their treatment]. / Zyklusstörungen während konsekutiver artefizieller Inseminationstherapie und ihre Behandlung.

Emotional stress-induced problems generated by the application of artificial insemination therapy by donor (AID) are considerable. After 6 months of frustrane insemination treatment, 54% of the women exhibited irregular or anovulatory cycles. Especially the persistent late ovulation often leads to a failure of the mechanisms of conception. An early ovulation timing with high dosages of synthetic LH-releasing hormone or a stimulating LH-RH-analogue (HOE 766) lead to an increasing pregnancy rate after application in the third insemination cycle from 34,0% untreated to 51,1% treated. The early application of ovulation inducing or timing substances is underlined in a program of artificial insemination therapy to eliminate possible stress-induced failures at an early point of treatment. As the spontaneous pregnancy rate is high in the first treatment cycles, LH-RH or its analogue should be administered after two frustrane insemination cycles.

[Flow properties of blood in women on oral contraceptives (author's transl)]. / Die Fliessfähigkeit des Blutes unter Einnahme von Ovulationshemmern.

Erythrocyte deformability, whole-blood viscosity, haematocrit as well as fibrinogen and plasminogen concentrations were checked in 39 clinically intact women of whom 22 had been on oral contraceptives for upto five years. Also determined were several serum proteins, such as transferrin, coeruloplasmin, alpha-2 macroglobulin, alpha-1-trypsin, beta-lipoprotein, and inactivated complement component C3. -Seventeen women with intra-uterine devices were chosen to form a control group. Proteins with sensitivity to oestrogen as well as whole-blood viscosity were found to be increased whereas erythrocyte deformability was decreased. Yet, no haemodynamic manifestation took place ot those rheological parameters, since haematocrit declined or remained constant, and no change occurred to fibrinogen and plasminogen concentrations.

PIP: Erythrocyte deformability, whole blood viscosity, hematocrit, as well as fibrinogen and plasminogen concentrations were checked in 39 clinically intact women of whom 22 had been on (OCs) oral contraceptives for up to 5 years. Also determined were several serum proteins, such as transferrin, coeruloplasmin, alpha-2 macroglobulin, alpha-1 trypsin, beta-lipoprotein, and inactivated complement C3. 17 women with IUDs were chosen to form a control group. Proteins with sensitivity to estrogen as well as whole blood viscosity were found to be increased, whereas erythrocyte deformability was decreased. Yet, no hemodynamic manifestation took place of those rheological parameters, since hematocrit declined or remained constant, and no change occurred to fibrinogen and plasminogen concentrations. (author's)