ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial.

BACKGROUND: Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences. METHODS: This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers. DISCUSSION: TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Aberrant activation of the PI3K/mTOR pathway promotes resistance to sorafenib in AML.

Therapy directed against oncogenic FLT3 has been shown to induce response in patients with acute myeloid leukemia (AML), but these responses are almost always transient. To address the mechanism of FLT3 inhibitor resistance, we generated two resistant AML cell lines by sustained treatment with the FLT3 inhibitor sorafenib. Parental cell lines carry the FLT3-ITD (tandem duplication) mutation and are highly responsive to FLT3 inhibitors, whereas resistant cell lines display resistance to multiple FLT3 inhibitors. Sanger sequencing and protein mass-spectrometry did not identify any acquired mutations in FLT3 in the resistant cells. Moreover, sorafenib treatment effectively blocked FLT3 activation in resistant cells, whereas it was unable to block colony formation or cell survival, suggesting that the resistant cells are no longer FLT3 dependent. Gene expression analysis of sensitive and resistant cell lines, as well as of blasts from patients with sorafenib-resistant AML, suggested an enrichment of the PI3K/mTOR pathway in the resistant phenotype, which was further supported by next-generation sequencing and phospho-specific-antibody array analysis. Furthermore, a selective PI3K/mTOR inhibitor, gedatolisib, efficiently blocked proliferation, colony and tumor formation, and induced apoptosis in resistant cell lines. Gedatolisib significantly extended survival of mice in a sorafenib-resistant AML patient-derived xenograft model. Taken together, our data suggest that aberrant activation of the PI3K/mTOR pathway in FLT3-ITD-dependent AML results in resistance to drugs targeting FLT3.

Effects of propranolol and L-NAME on beta-adrenoceptor-mediated relaxation in rat carotid artery.

1. The properties of beta-adrenoceptors mediating vascular relaxation in rat isolated carotid artery were investigated. Ring segments of arteries were preconstricted with the thromboxane A2 receptor agonist U-46619 and relaxation to beta-adrenoceptor agonists determined. 2. Isoprenaline produced a concentration-dependent relaxation of U-44619-constricted arteries. The concentration-response curve (CRC) to isoprenaline was shifted to the right by propranolol (1 microM) although the shift was less (105 fold; pA2, 8.02) than would be expected for an effect of isoprenaline at classical beta-adrenoceptors (300-1000 fold; pA2, 8.5-9). L-NAME (100 microM) significantly reduced responses to isoprenaline, lowering the slope of the CRC and reducing the maximum response. 3. The selective beta3-adrenoceptor agonists, BRL 37344 and ZD2079, also produced concentration-dependent relaxation of the arteries. L-NAME (100 microM) shifted the BRL 37344 CRC to the right 15 fold with no reduction in the slope or maximum response. L-NAME (100 microM) had no significant effect on the ZD2079 CRC. 4. In conclusion, relaxation to isoprenaline in rat carotid artery is inhibited by propranolol in a manner suggesting a mixed population of classical (beta1-/beta2-) and atypical (beta3-) adrenoceptors. The presence of beta3-adrenoceptors was confirmed by the relaxant effects of the selective beta3-adrenoceptor agonists BRL 37344 and ZD2079. L-NAME attenuated responses to both isoprenaline and the beta3-adrenoceptor agonist BRL 37344, suggesting a role for endothelial release of nitric oxide in beta-adrenoceptor mediated relaxation. However, the relaxant effect of BRL 37344 was attenuated by L-NAME to a lesser extent than that of isoprenaline. In addition, L-NAME had no effect on relaxation induced by ZD2079. These results suggest that there may be a differential contribution of endothelium to classical beta-and beta3-adrenoceptor-mediated effects, with endothelium contributing less to beta3-adrenoceptor-mediated relaxation.

Unconventional conceptions and HIV.

The condom is widely recommended as the principal method for preventing HIV transmission, but such advice obviously does not apply to women who are seeking to become pregnant. In this sense, 'safer sex' is incompatible with reproduction. Existing research into HIV transmission has examined the choices made by those wishing to conceive within a sexual relationship; such research shows that HIV is not a highly significant factor in their decision-making processes. This study aims to extend the debate by exploring the decision-making processes of women seeking to become pregnant with donated sperm. In particular, we focus on women outside the fertility clinic system who do not have access to sperm screened for HIV to see whether HIV is a significant factor in these women's decisions. The study involved in-depth interviews with 20 women (14 lesbians, one bisexual and five heterosexuals) recruited through informal networking and snowball sampling. HIV was a salient concern for our sample, largely because of their contacts with gay men, but nonetheless most of these women took some risks. On the one hand, the conscious deliberations necessary to conceive through self-insemination facilitated risk reduction, as did factors such as 'stranger-danger'. On the other hand, factors such as the scarcity of suitable sperm donors and the women's own feelings of gratitude and loyalty to their donors mitigated against their requesting that their donor take an HIV test. This study highlights the need to provide information for women seeking self-insemination, and to remove restrictions on access to fertility clinics, in order to reduce their risk of HIV infection and subsequent vertical transmission.

Identification of renal cathepsin B as a human prorenin-processing enzyme.

Prorenin, the inactive biosynthetic precursor of renin, is proteolytically cleaved in the renal juxtaglomerular cells to renin. The activity of renin is rate-limiting for generation of angiotensin II in the circulation. We identified a renal thiol protease which activates and accurately cleaves the 43-amino acid prosegment of human recombinant prorenin. In the current studies, 6.5 mg of this protease was purified from human renal cortex using a three-step procedure dependent upon Leu-Leu-arginyl affinity chromatography. This represented an overall 766-fold purification and resulted in three protein bands on sodium dodecyl sulfate-polyacrylamide gel electrophoresis of molecular weights 30,000, 25,000, and 24,000. All three bands cross-reacted with an anti-human liver cathepsin B antibody upon immunoblot analysis; electrolution of each band and amino-terminal sequence analysis confirmed that the Mr 30,000 protein was mature cathepsin B and the Mr 25,000 and 24,000 bands were cathepsin B subunits. The pH optimum for the hydrolysis of pure human recombinant prorenin by pure renal cathepsin B was 6, and the Michaelis-Menten constant, Km, of the reaction was 1.4 x 10(-9) M. Immunostaining of human kidney using a sheep anti-human cathepsin B antibody demonstrated the presence of cathepsin B in the juxtaglomerular areas of the kidney, as well as in the renal proximal tubules. Electron microscopic immunohistochemistry using the same antibody demonstrated cathepsin B in dense secretory granules of the juxtaglomerular cells. Renin was also shown to be present in these granules. This study provides both biochemical and morphological evidence that renal cathepsin B is a human prorenin-processing enzyme.

Auer rod-like inclusions in circulating lymphoma cells.

Circulating malignant lymphocytes from a 55-year-old woman with small cleaved follicular center cell lymphoma contained azurophilic splinter-shaped cytoplasmic inclusions. By light microscopic and ultrastructural criteria, these structures closely resembled Auer rods found in acute myeloid leukemia; however, the authors could not find cytochemical evidence of lysosomal origin (results were negative for myeloperoxidase, Sudan black B, acid phosphatase, and periodic acid-Schiff). Immunostaining and flow cytometric analysis confirmed a monoclonal IgM-kappa immunophenotype of the circulating malignant lymphoid cells. The inclusions did not show specific immunoglobulin staining by light microscopic or electron microscopic immunostaining techniques. The authors conclude that these membrane-bound inclusions probably represent aberrant lysosomes in the malignant cells.

Extrarenal renin-secreting tumors: insights into hypertension and ovarian renin production.

Although renin-secreting tumors are rare, they must be considered in the differential diagnosis of hypertension associated with hypokalemia, which occurs commonly in the hypertensive population. The finding of an ovarian renin-secreting tumor emphasizes the potential importance of the ovary as an extrarenal source of renin; the local ovarian renin-angiotensin system may play a key role in reproductive function by regulating vascular reactivity, local blood flow, steroidogenesis and other physiologic effects. In the illustrative case presented, a renin-secreting ovarian leiomyosarcoma was obtained from a women who presented with hypertension and hypokalemia. Plasma prorenin levels were markedly elevated. Tumor excision was quickly followed by a fall in prorenin levels and tumor recurrence was accompanied by an increase in prorenin levels. Active renin concentration in the tumor homogenates was similar to that found in kidney homogenates while the tissue prorenin concentration was approximately 20 times that found in kidney tissue. When cultured for up to 4 weeks, ovarian tumor cells secreted greater than 95% prorenin. Immunoblot analysis demonstrated that tumor renin had a molecular weight of 47,000, similar to that of human recombinant prorenin. Immunohistochemical staining of tumor tissue with antibodies against human renal renin at the electron microscopic level demonstrated the presence of renin primarily in membrane-bound vesicles and rarely in dense-core secretory granules. These findings suggest that prorenin in this ovarian tumor was secreted by the constitutive pathway, which is mediated by these amorphous vesicles.

Acute myeloid leukemia, FAB M-1 microgranular variant: a multiparameter study.

Acute leukemia was diagnosed in 62 adults and children over a recent 13-month period. Using light microscopy, cytochemical profiles, surface markers, and cytogenetics, 25 cases were classified as acute myeloid leukemia (AML) and 32 as acute lymphoblastic leukemia (ALL). The remaining 5 cases of de novo acute leukemia were unclassifiable. The routine cytochemical battery used on these 62 cases included: myeloperoxidase, sudan black B, nonspecific esterase, and periodic acid-Schiff (PAS). Flow markers utilized were: T3, T4, T5, T8, T10, T11, B1, B4, kappa, lambda, Ia, CALLA, Mo1, Mo2, My4, My7, My8, and My9. TdT was performed by immunoperoxidase and ELISA methods. The five unclassified cases were cytochemically negative and expressed no B- or T-cell-specific antigens, or TdT positivity. The morphologic differential diagnosis was between FAB L-2 and M-1. Karyotypic abnormalities involving chromosomes 3 and 7 were suggestive of myeloid origin in 2 of 4 patients studied. Flow cytometry demonstrated My7 on greater than 50% of blasts from two cases. Myeloperoxidase ultracytochemistry showed reaction product in small primary granules of blasts from all 5 cases. Positive cells contained only 1-2 granules/cell profile. The number of positive cells per case was in the range 10-20%. We conclude from this study that ultracytochemistry is very useful in providing definitive diagnosis and accurate subclassification of some AML FAB M-1 cases, particularly when light microscopic cytochemistry, cytogenetics, and flow cytometric markers are noncontributory. We propose to designate these acute "unclassified" leukemias as AML FAB M-1 "microgranular" type.

Changes of plasminogen activator in human uterine tissue induced by intrauterine contraceptive devices.

Potassium thiocyanate-extractable uterine plasminogen activator activity was determined to be highest in the endometrium surrounding intrauterine devices (IUDs). Such activity was significantly higher than that encountered in control endometrium or in the endometrium remote to IUDs. As in control cases, extracted endometrial activity fluctuated during the intermenstrual ovarian cycle. It was highest in the pre- or periovulation part of the cycle, and it rose again prior to menstruation. These peaks of activity seem to correspond to times in the cycle when metrorrhagia and abnormal menstruation are usually encountered. Possible implications of the myometrial and endometrial patterns of plasminogen activator in control and IUD-exposed uterine tissue are discussed.

PIP: This research study was designed to determine the relative activator concentration in uterine tissue depressed by, adjacent to, and remote from the IUD and to compare these concentrations to control uterine tissues. Uterine tissue used in the study was obtained following hysterectomy in 22 women wearing IUDs. All analyzed tissues were acquired from uteri containing either Lippes loop D or large Saf-T-Coils. These IUDs had been in place for a minimum of 1 year and a maximum of 8 years. Hysterectomies were performed primarily for indications related to symptomatic pelvic relaxation secondary to multiparity. No patient was taking hormonal medication or contraceptives for 12 months prior to hysterectomy. No cases included specimens with significant uterine pathology other than that related to the IUD. Ovarian cycle phase was determined for all specimens analyzed by histologic criteria on adjacent slices of the excised samples. Cases included the following phases: menstrual; early proliferative; mid to late proliferative; early to mid secretory; and late secretory. The myometrium contained considerably more extractable activator than the endometrium in terms of activity per milligram of tissue protein. Variation of endometrial plasminogen activator (PA) showed the same pattern as did previously analyzed control specimens at different stages of the intermenstrual ovarian cycle. Values reached the highest levels in mid to late proliferative endometrium with a fall during the early to mid secretroy phase to the lowest levels, followed by a rise in late secretory endometrium. Myometrium did not parallel endometrium as closely as reported for control cases. In IUD cases, the highest myometrial levels were encountered in the late follicular phase and a fall occurred in the secretory phase, as was the case with endometrium, but no myometrial rise occurred prior to menses. Comparison of mean activator results of depressed, adjacent, and remote endometrial sites from IUD cases and mean endometrial activator levels from control cases revealed the highest values in IUD depressed endometrial tissues. The next highest were in IUD adjacent endometrium. Significantly lower results occurred in IUD remote endometrial samples. These comparisons were not considered to be biased by interphase differences in activator since equal proportions of all 4 menstrual phases existed among the 3 IUD sampling sites and the total control material studied. In sum, uterine PA activity plays an important role in IUD associated menorrhagia, and the results indicate that it is also important in IUD associated metrorrhagia. The causes of cyclic physiologic fluctuation and of IUD stimulated increases in uterine PA activity are poorly understood at this time.

Immunohistochemical identification of mast cells in paraffin- and epon-embedded tissues using platelet factor 41.

An immunoperoxidase method has been developed for staining heparin in the granules of mast cells. The method employs human platelet factor 4 (or anti-heparin) and a rabbit antiserum to this polypeptide. Platelet factor 4 binds to mast cell heparin and provides the basis for immunoperoxidase staining using the rabbit antiserum. Preliminary studies of mast cells in various tissues indicate that the stain is quite specific for the content of mast cell granules, presumably heparin and possibly other glycosaminoglycans.

Effects of a progesterone-releasing intrauterine contraceptive device on endometrial blood vessels: a morphometric study.

The concentration of microscopically detectable blood vessels was significantly lower in endometrium exposed to progesterone-releasing intrauterine contraceptive devices (IUDs) than in control endometrium (mean vessel density 2.39 and 3.92, respectively). The percentage of vessels with defects was significantly higher in IUD samples (35.0%) than in control samples (13.4%). There was no significant difference in hemostatic response to vessel injury between the IUD and control samples. Although they were more defective than in controls, the blood vessels of progesterone IUD-exposed endometrium were far fewer in number, which may account for significantly less uterine blood loss in the users of these devices. In addition, the progesterone IUDs do not appear to inhibit hemostasis in the endometrium so that blood loss from injured vessels may be minimized.

PIP: It has been previously demonstrated that increased vascularity, vessel defect formation, and poor hemostasis are prime factors in the increased endometrial bleeding associated with plastic IUDs. This paper presents the results of a morphologic sutdy on progestogen IUD-exposed endometrium to determine the reasons for long-term decreased menstrual blood loss and short-term increased intermenstrual blood loss following insertion of such an IUD. Endometrial biopsies were collected from 8 women wearing a Progestasert at various times in the cycle, and from 9 control women during the middle to late luteal phase of the menstrual cycle. All morphometric and electron microscopic studies were done at the Women's Hospital, Los Angeles County/USC Medical Center. Biopsies from the Progestasert users were taken 54 months after initial insertion. Each progesterone-IUD was replaced approximately every 24 months. Electron microscopy was used to examine the tissue samples. Chi-square test and the Mann-Whitney U Test according to Siegel were used in statistical analysis. Average blood vessel density for the 8 progesterone users was 2.39 (range, 13.0 to 3.71) compared to 3.92 for the controls (range, 3.33 to 4.68); the difference was significant at p0.01, Mann-Whitney test. Vessel concentration ratio of experimental to control endometrium was 3.5. Defective vessels for control cases expressed as a percentage of total vessels ranged from 0% to 24%. For progesterone IUD-endometrium, values per case varied from 7.1% to 64%. Average percentage of defective vessels for controls was 13.4 and for Progestasert users, 35.0%; the difference was significant at p0.001, Chi-square test. Majority of defects in the Progestasert users were associated with degenerative changes in endothelium. The increased concentration of vascular defects in the progesterone IUD-exposed endometria compared to control tissue in this series confirm earlier studies with plastic IUDs and defective vessels. Several factors contribute to decreased endometrial bleeding in women who have worn a progestrone-releasing IUD for at least 6 months. 2 critical factors include: 1) decreasing concentration of blood vessels in the endometrial functionalis (possibly the cause for progressive endometrial atrophy); and 2) no apparent inhibition of platelet hemostasis.

Quantitative menstrual and intermenstrual blood loss in women using Lippes Loop and Copper T intrauterine devices.

PIP: 127 women were studied during 3 consecutive menstrual cycles preceding, and 6 non-consecutive menstrual cycles during the 1st year following insertion of either Lippes Loop C or Copper T. Both (MBL) menstrual blood loss and (IMBL) intermenstrual blood loss were quantified during these cycles. When postinsertion MBL was averaged and compared to mean preinsertion MBL, the Lippes Loop and Copper T devices increased the volume of menstrual bleeding by 99 and 42% respectively. In spite of this, mean hemoglobin levels did not change significantly during the period of study. Quantifiable MBL was experienced primarily during the 1st cycle postinsertion. The incidence was 90% in women inserted with the Lippes Loop C and 48% in those women inserted with the Copper T during this cycle. The volume of IMBL was extremely variable among the women studied (0.7 - 398 ml). In several cases the volume nearly equalled or even exceeded the MBL of the 1st cycle. Incidence of IMBL fell to 6.5% and 5.0% in the 2nd postinsertion cycle for women with loops and copper devices, respectively. Thereafter the incidence was neglibible. This marked decrease in incidence was not due to closures for bleeding. Less than 10% of the total blood loss experienced during the 1st year postinsertion was the result of IMBL and following the 1st postinsertion cycle, it contributed less than 2% of the total blood loss. The conclusion is that IMBL, while contributory to IUD discontinuation rates, does not contribute significantly to total blood loss and thus to iron loss following IUD insertion.^ieng

Vessel density in endometrium of women with and without intrauterine contraceptive devices: a morphometric evaluation.

Increased vascularity was found in the endometrial functionalis in uteri of women wearing intrauterine contraceptive devices (IUDs) as compared to uteri of women without IUDs (control subjects). Vessel concentration was highest in endometrial tissue adjacent to that tissue which was depressed by the IUD. In control tissues there was a significant variation in vascularity according to geographic location in the following order of magnitude: fundus greater than corpus greater than cornua greater than isthmus. No significant variation was found, however, among different phases of the ovarian cycle in either control or IUD cases. Increased endometrial vascularity could be a reaction to vessel damage caused by the IUD and for several reasons may contribute to IUD-induced endometrial bleeding.

Morphologic studies on IUD-induced metrorrhagia. I. Endometrial changes and clinical correlations.

Morphologic studies on human hysterectomy specimens indicate the IUD elicits a vascular reaction which is most pronounced in the endometrium adjacent to the device. This reaction includes increased vascularity, congestion and increased permeability, and degeneration with defect formation. In addition, there is poor hemostatic responsiveness to vascular permeability and damage. The reaction leads to interstitial hemorrhage which undoubtedly causes metrorrhagia. A likely cause for initial vascular damage is mechanical stress transmitted by the IUD through the endometrium to its vascular network. Vascular reaction and poor hemostatic responsiveness may be perpetuated during each cycle by the products released from endothelial cell degeneration and necrosis. Bleeding is one of the most frequent complications leading to discontinuation of an otherwise effective form of long-term contraception and family spacing. Therefore, its solution could be of crucial importance to world-wide population control. Our findings suggest that better understanding of the mechanism of IUD-induced metrorrhagia should result from closer study of the endometrium adjacent to that which is compressed by the IUD.

Morphologic studies on IUD-induced metrorrhagia. II. Surface changes of the endometrium and microscopic localization of bleeding sites.

Surface changes were extensively studied by light and electron microscopy in human endometrium exposed to IUD's. A wide variety of alterations in the covering epithelium and its basal lamina (basement membrane) was observed. These ranged from essentially no alteration to a covering basement membrane completely denuded of its epithelium. Erosions or discontinuities of the surface basement membrane were uncommon, and when they occurred were most often associated with extrusion of fluid and cellular elements from the stroma into the uterine lumen. Metrorrhagia associated with IUDs probably results from two basic types of hemorrhage through the endometrial surface. Tissue adjacent to the IUD with interstitial hemorrhage bleed into the uterine cavity by (1) red cell transmigration through surface membranes (surface epithelium and its basal lamina), and (2) high interstitial pressure breaks in these same membranes.

Ultrastructural hemostasis in response to vascular injury induced by intrauterine devices in human endometrium.

PIP: 8 micrographs are presented to help elucidate the mechanism of endometrial bleeding caused by IUDs. A previous study, which reported endometrial vessels with defects or gaps in the superficial portion of IUD-exposed endometrium, is expanded. Since the endothelial cells forming these gaps were in stages of degeneration to complete necrosis, perhaps IUD/endometrial interactions injured some of the superficial vessels which then degenerated, formed gaps, and allowed blood to escape. However, the same endothelial degeneration should initiate platelet adhesion, aggregation, and thrombosis. Yet the micrographs showed degenerated endothelial cells at the vessel gaps, gaps which represent disintegrated endothelial cells, and collagen which appeared to be directly exposed to luminal blood through the gaps. All of these hemostasis-initiating conditions resulted in a surprizing low level of activity. Rarity of platelet and/or fibrin thrombi plugging vessel gaps in IUD-exposed endometrium supported the feasibility of bleeding through small gaps. The interstitial hemorrhage is apparent by electron micrograph. When the concentration of red cells within the superficial endometrium became sufficiently high, apparently the erythrocytes either exuded through the spaces between surface epithelial cells or ruptured into the uterine caivty and resulted in clinical bleeding.^ieng