Collaborative study for the establishment of replacement batches of Ph. Eur. Heparin Low-Molecular-Mass for Calibration CRS.

An international collaborative study was run within the framework of the Biological Standardisation Programme (BSP) of the Council of Europe and the Commission of the European Union to establish replacement batches for European Pharmacopoeia (Ph. Eur.) Heparin Low-Molecular-Mass (LMM) for calibration Chemical Reference Substance batch 3 (CRS3) used for the characterisation of LMM heparins by high performance size-exclusion chromatography. Two candidate batches (A, cCRS4 and B, cCRS5) were filled using the same material as the existing official calibrants, adopted with either an assigned number-average molecular mass (Mna) or a broad standard table (BST). Fifteen laboratories evaluated the suitability of these candidate batches for use as calibrants with the pharmacopoeial dual refractive index/ultraviolet (RI/UV) detector calibration method, as well as with a modified mobile phase and the BST calibration method. Seven preparations of LMM heparin were tested. The results confirmed that the proposed batches are suitable for use with the same characteristic Mna as CRS3 and with the BST established for the World Health Organization (WHO) 2nd International Standard (IS). The BST calibration method gave comparable results to the RI/UV method, while showing better reproducibility, being easier to perform and requiring no calibrant with UV absorbance. The modified mobile phase had no impact on the calculated values while improving separation between the calibrant and salt peaks. The two candidate batches were adopted as Ph. Eur. Heparin LMM for calibration CRS batches 4 and 5, respectively, with the assigned Mna value of 3800 and a BST. In anticipation of the depletion of the calibrant required for use with the RI/UV method, and taking into account the unlikely procurement of a new lot of suitable starting material, it was recommended to include the BST method in Ph. Eur. monograph 0828, Heparins, low-molecular-mass. In order to improve peak separation, it was also recommended to include the use of ammonium acetate solution as mobile phase in the monograph, both for the Ph. Eur. RI/UV and the proposed BST calibration methods. Further to this study, Ph. Eur. monograph 0828 was revised to replace the RI/UV method by the BST method. This contributed to the harmonisation of methods across regions, thereby facilitating a concerted global action for the development and establishment of the next batches of calibrants for the quality control of LMM heparins.

Canonical Wnt/ß-catenin activity and differential epigenetic marks direct sexually dimorphic regulation of Irx3 and Irx5 in developing mouse gonads.

Members of the Iroquois B (IrxB) homeodomain cluster genes, specifically Irx3 and Irx5, are crucial for heart, limb and bone development. Recently, we reported their importance for oocyte and follicle survival within the developing ovary. Irx3 and Irx5 expression begins after sex determination in the ovary but remains absent in the fetal testis. Mutually antagonistic molecular signals ensure ovary versus testis differentiation with canonical Wnt/ß-catenin signals paramount for promoting the ovary pathway. Notably, few direct downstream targets have been identified. We report that Wnt/ß-catenin signaling directly stimulates Irx3 and Irx5 transcription in the developing ovary. Using in silico analysis of ATAC- and ChIP-Seq databases in conjunction with mouse gonad explant transfection assays, we identified TCF/LEF-binding sequences within two distal enhancers of the IrxB locus that promote ß-catenin-responsive ovary expression. Meanwhile, Irx3 and Irx5 transcription is suppressed within the developing testis by the presence of H3K27me3 on these same sites. Thus, we resolved sexually dimorphic regulation of Irx3 and Irx5 via epigenetic and ß-catenin transcriptional control where their ovarian presence promotes oocyte and follicle survival vital for future ovarian health.

CBX2 is required to stabilize the testis pathway by repressing Wnt signaling.

XX and XY fetal gonads are initially bipotential, poised between the ovary and testis fate. Multiple lines of evidence suggest that commitment to testis fate requires the repression of genes associated with ovary fate. It was previously shown that loss of CBX2, the subunit of the Polycomb Repressive Complex 1 (PRC1) that binds H3K27me3 and mediates silencing, leads to ovary development in XY mice and humans. While it had been proposed that CBX2 is an activator of the testis-determining gene Sry, we investigated the alternative possibility that CBX2 has a direct role as a repressor of the antagonistic ovary-promoting pathway. To investigate this possibility, we developed a quantitative genome-wide profile of the repressive histone mark H3K27me3 and its active counterpart H3K4me3 in isolated XY and XX gonadal supporting cells before and after sex determination. We show that testis and ovary sex-determining (SD) genes are bivalent before sex determination, providing insight into how the bipotential state of the gonad is established at the epigenetic level. After sex determination, many SD genes of the alternate pathway remain bivalent, possibly contributing to the ability of these cells to transdifferentiate even in adults. The finding that many genes in the Wnt signaling pathway were targeted for H3K27me3-mediated repression in Sertoli cells led us to test whether deletion of Wnt4 could rescue testis development in Cbx2 mutants. We show that Sry expression and testis development were rescued in XY Cbx2-/-;Wnt4-/- mice. Furthermore, we show that CBX2 directly binds the downstream Wnt signaler Lef1, an ovary-promoting gene that remains bivalent in Sertoli cells. Our results suggest that stabilization of the testis fate requires CBX2-mediated repression of bivalent ovary-determining genes, which would otherwise block testis development.

Gonadal supporting cells acquire sex-specific chromatin landscapes during mammalian sex determination.

Cis-regulatory elements are critical for the precise spatiotemporal regulation of genes during development. However, identifying functional regulatory sites that drive cell differentiation in vivo has been complicated by the high numbers of cells required for whole-genome epigenetic assays. Here, we identified putative regulatory elements during sex determination by performing ATAC-seq and ChIP-seq for H3K27ac in purified XX and XY gonadal supporting cells before and after sex determination in mice. We show that XX and XY supporting cells initiate sex determination with similar chromatin landscapes and acquire sex-specific regulatory elements as they commit to the male or female fate. To validate our approach, we identified a functional gonad-specific enhancer downstream of Bmp2, an ovary-promoting gene. This work increases our understanding of the complex regulatory network underlying mammalian sex determination and provides a powerful resource for identifying non-coding regulatory elements that could harbor mutations that lead to Disorders of Sexual Development.

Sex reversal following deletion of a single distal enhancer of Sox9.

Cell fate decisions require appropriate regulation of key genes. Sox9, a direct target of SRY, is pivotal in mammalian sex determination. In vivo high-throughput chromatin accessibility techniques, transgenic assays, and genome editing revealed several novel gonadal regulatory elements in the 2-megabase gene desert upstream of Sox9 Although others are redundant, enhancer 13 (Enh13), a 557-base pair element located 565 kilobases 5' from the transcriptional start site, is essential to initiate mouse testis development; its deletion results in XY females with Sox9 transcript levels equivalent to those in XX gonads. Our data are consistent with the time-sensitive activity of SRY and indicate a strict order of enhancer usage. Enh13 is conserved and embedded within a 32.5-kilobase region whose deletion in humans is associated with XY sex reversal, suggesting that it is also critical in humans.

Implant stability using piezoelectric bone surgery compared with conventional drilling: a systematic review and meta-analysis.

The aim of this systematic review was to assess the primary and secondary stability of dental implants placed at sites prepared with piezoelectric bone surgery (PBS) and conventional drilling (CD). The PubMed/MEDLINE and Cochrane Library databases were searched without date or language restriction up to June 2017. Controlled clinical trials in which each patient received implants placed at sites prepared with both PBS and CD were selected. Implant stability had to be measured on day 0 and during the osseointegration period. Methodological quality was assessed using the Cochrane Collaboration tool. A meta-analysis was performed to compare primary stability (on day 0) and secondary stability (after 2 and 3months) between the two groups. The studies included were determined to have a high risk of bias. There was no significant difference between the two groups for primary stability (on day 0) (P=0.51). After 2 and 3months, secondary stability was statistically higher in implants placed with PBS preparation (P=0.04 and P=0.01, respectively). The implant survival rate was 97.5% in the CD group and 100% in the PBS group. PBS preparation improves secondary stability after 2 and 3months in comparison to CD, with similar implant survival rates. Further studies are needed to determine whether implant osseointegration periods could be shortened with PBS preparation.

Epigenetic regulation of male fate commitment from an initially bipotential system.

A fundamental goal in biology is to understand how distinct cell types containing the same genetic information arise from a single stem cell throughout development. Sex determination is a key developmental process that requires a unidirectional commitment of an initially bipotential gonad towards either the male or female fate. This makes sex determination a unique model to study cell fate commitment and differentiation in vivo. We have focused this review on the accumulating evidence that epigenetic mechanisms contribute to the bipotential state of the fetal gonad and to the regulation of chromatin accessibility during and immediately downstream of the primary sex-determining switch that establishes the male fate.

[Patients with end-stage chronic renal insufficiency on programmed withdrawal from dialysis]. / Pacientes con insuficiencia renal crónica terminal retirados de diálisis bajo protocolización.

UNLABELLED: The voluntary discontinuation of dialysis by patients is a common mode of death in dialysis programmes. Unfortunately the Spanish experience has not been related in the nephrological literature. Initiation of, and withdrawal from, dialysis pose ethical questions for medicine in the 21st century. The dialysis population is aging and they have multiple medical problems. The choice may be between prolongation of quantity or quality of life. We evaluated a protocol for initiation of dialysis in patients with end stage renal failure and their subsequent withdrawal. We determined the factors predicting withdrawal of dialysis and revised the protocol to take account of these. We carried out an opinion poll of doctors and nurses about the effectiveness of the protocol. We studied prospectively the reasons for death of patients in the last seven years. RESULTS: Thirty patients were withdrawn from dialysis out of 116 who died during treatment by hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) in the last seven years. Vascular nephropathy is the principal disease predicting withdrawal from dialysis; the main precipitating cause is mental incapacity. The availability of a protocol for withdrawal of dialysis is well received by doctors and nurses and it engenders moral and legal calm when facing difficult decisions. Twenty-six per cent of deaths on regular dialysis are the result of withdrawal of treatment.

Pacientes con insuficiencia renal crónica terminal retirados de diálisis bajo protocolización / Voluntary discontinuation of dialysis

La retirada de diálisis no es motivo de investigación ni de tratamiento habitual en la literatura nefrológica española. Es un tema de debate que conlleva disyuntivas de tipo ético. Su presentación es frecuente actualmente en la clínica diaria. Con la prolongación de expectativas de vida de los pacientes, aumentan los dilemas acerca de la prolongación de esa vida en las mínimas condiciones de calidad.Se comprueba la utilidad de un protocolo de entrada/retirada de pacientes con insuficiencia renal crónica terminal, diseñando los parámetros pronósticos de retirada de diálisis, y revisando los parámetros que inciden en la toma de decisión de esa retirada. Se realiza una encuesta a los profesionales sobre la efectividad del protocolo. Se revisan prospectivamente las causas de muerte acaecidas en los últimos siete años.Los resultados muestran 30 pacientes retirados del total de 116 enfermos fallecidos durante ese tiempo. La nefropatía vascular es la enfermedad que plantea con mayor frecuencia la retirada de diálisis, siendo la causa inmediata la incapacidad mental.La disponibilidad de un protocolo de retirada de diálisis confiere un aceptable grado de satisfacción entre los profesionales y les da tranquilidad moral y tal vez legal, a pesar del vacío existente en ese sentido, ante unas tomas de decisiones eventualmente conflictivas, dado que un 26 por ciento de los fallecimientos son debidos a esa retirada. (AU)