Is there an interest in repeating the vaginal administration of dinoprostone (Propess®), to promote induction of labor of pregnant women at term? (RE-DINO): study protocol for a randomized controlled trial

BACKGROUND

Labor is induced in over 20% of women in France. Prostaglandins, especially intravaginal dinoprostone (Propess®), are widely used to initiate cervical ripening. If labor does not start within 24 h, there is uncertainty about whether to administer a second dinoprostone pessary or to use oxytocin to induce labor in order to achieve a vaginal delivery.

METHODS

RE-DINO is a prospective, open-label, multicenter, randomized superiority trial with two parallel arms running in six French hospitals. A total of 360 patients ≥ 18 years of age at > 37 weeks of gestation who exhibit unfavorable cervical conditions (Bishop score < 6) 24 h after placement of the first Propess®, with fetuses in cephalic presentation, will be included. Patients with premature membrane rupture, uterine scars, or multiple pregnancies will be excluded. Our principal objective is to determine whether placement of a second Propess® (followed by oxytocin [Syntocinon®], if necessary) in women for whom the first Propess® failed to induce cervical ripening increases the vaginal delivery rate compared to direct oxytocin injection. The vaginal delivery rate is therefore the primary outcome. The secondary outcomes are the induction failure rates and maternofetal morbidity and mortality.

DISCUSSION

This study may help in determining the optimal way to induce labor after failure of a first Propess®, an unresolved problem to date. This trial explores the effectiveness and safety of placing a second Propess® and may contribute to development of an obstetric consensus.

TRIAL REGISTRATION

Registered on 2 September 2016 at clinicaltrials.gov (identification number NCT02888041).

Measurement of α-Amylase Activity in White Wheat Flour, Milled Malt, and Microbial Enzyme Preparations, Using the Ceralpha Assay: Collaborative Study

This study was conducted to evaluate the method performance of a rapid procedure for the measurement of α-amylase activity in flours and microbial enzyme preparations. Samples were milled (if necessary) to pass a 0.5 mm sieve and then extracted with a buffer/salt solution, and the extracts were clarified and diluted. Aliquots of diluted extract (containing α-amylase) were incubated with substrate mixture under defined conditions of pH, temperature, and time. The substrate used was nonreducing end-blocked p-nitrophenyl maltoheptaoside (BPNPG7) in the presence of excess quantities of thermostable α-glucosidase. The blocking group in BPNPG7 prevents hydrolysis of this substrate by exo-acting enzymes such as amyloglucosidase, α-glucosidase, and β-amylase. When the substrate is cleaved by endo-acting α-amylase, the nitrophenyl oligosaccharide is immediately and completely hydrolyzed to p-nitrophenol and free glucose by the excess quantities of α-glucosidase present in the substrate mixture. The reaction is terminated, and the phenolate color developed by the addition of an alkaline solution is measured at 400 nm. Amylase activity is expressed in terms of Ceralpha units; 1 unit is defined as the amount of enzyme required to release 1 μmol p-nitrophenyl (in the presence of excess quantities of α-glucosidase) in 1 min at 40°C. In the present study, 15 laboratories analyzed 16 samples as blind duplicates. The analyzed samples were white wheat flour, white wheat flour to which fungal α-amylase had been added, milled malt, and fungal and bacterial enzyme preparations. Repeatability relative standard deviations ranged from 1.4 to 14.4%, and reproducibility relative standard deviations ranged from 5.0 to 16.7%.

A two-level large-volume epidural blood patch protocol for spontaneous intracranial hypotension: retrospective analysis of risk and benefit

BACKGROUND

We report a retrospective analysis of a two-level, variable-volume epidural blood patch (EBP) technique for the treatment of spontaneous intracranial hypotension (SIH).

METHODS

Ninety-four patients with SIH underwent EBPs. Injectate volume was variable and guided by the onset of back pain, radiculopathy or symptoms referable to the EBP. Patients were a responder if no invasive treatment was necessary for SIH symptoms after the first EBP. Baseline patient characteristics, including presenting symptoms and imaging findings, were compared between responders and non-responders. Adverse events were recorded.

RESULTS

The mean first EBP volume was 45.3±23.2 (range 4-124 mL). The responder rate was 28.7% after the first EBP, improving to 41.5% and 46.8% after a second and third EBP, respectively. Baseline characteristics were similar between groups, except for the greater prevalence of subdural fluid collections in the responder group (48% vs 18%, p=0.003). Two severe complications occurred: transient bilateral paraplegia and cauda equina syndrome from arachnoiditis.

CONCLUSIONS

Our protocol can be used to treat SIH but carries risks that require meticulous attention. EBP volumes were variable across patients, demonstrating the variability in the elastance of the epidural space. Rigorous monitoring for neurological symptoms is necessary throughout the procedure to limit complications and determine the endpoint of the EBP. We advocate for rigorous confirmation of epidural placement of the EBP with contrast-imaging studies to limit intrathecal placement of blood, which can lead to arachnoiditis. Randomized controlled trials are needed to determine the safety and efficacy of large-volume EBPs.

Satellite conjunction analysis and the false confidence theorem

Satellite conjunction analysis is the assessment of collision risk during a close encounter between a satellite and another object in orbit. A counterintuitive phenomenon has emerged in the conjunction analysis literature, namely, probability dilution, in which lower quality data paradoxically appear to reduce the risk of collision. We show that probability dilution is a symptom of a fundamental deficiency in probabilistic representations of statistical inference, in which there are propositions that will consistently be assigned a high degree of belief, regardless of whether or not they are true. We call this deficiency false confidence. In satellite conjunction analysis, it results in a severe and persistent underestimate of collision risk exposure. We introduce the Martin–Liu validity criterion as a benchmark by which to identify statistical methods that are free from false confidence. Such inferences will necessarily be non-probabilistic. In satellite conjunction analysis, we show that uncertainty ellipsoids satisfy the validity criterion. Performing collision avoidance manoeuvres based on ellipsoid overlap will ensure that collision risk is capped at the user-specified level. Furthermore, this investigation into satellite conjunction analysis provides a template for recognizing and resolving false confidence issues as they occur in other problems of statistical inference.

Spinal radiographic progression over 2 years in ankylosing spondylitis patients treated with secukinumab: a historical cohort comparison

OBJECTIVE

The aim of this study was to compare radiographic progression in patients with ankylosing spondylitis (AS) treated for up to 2 years with secukinumab (MEASURE 1) with a historical cohort of biologic-naïve patients treated with NSAIDs (ENRADAS).

METHODS

Baseline and 2-year lateral cervical and lumbar spine radiographs were independently evaluated using mSASSS by two readers, who were blinded to the chronology and cohort of the radiographs. The primary endpoint was the proportion of patients with no radiographic progression (mSASSS change ≤ 0 from baseline to year 2). The Primary Analysis Set included patients with baseline (≤ day 30) and post-baseline day 31-743 radiographs. Sensitivity analyses were performed to assess the robustness of the comparison between the two cohorts, as follows: Sensitivity Analysis Set 1 included all patients with baseline (≤ day 30) and year 2 (days 640-819) radiographs; Sensitivity Analysis Set 2 included all patients with baseline and post-baseline (> day 30) radiographs.

RESULTS

A total of 168 patients (84%) from the MEASURE 1 cohort and 69 (57%) from the ENRADAS cohort qualified for the Primary Analysis Set. Over 2 years, the LS (SE) mean change from baseline in mSASSS for the primary analysis was 0.55 (0.139) for MEASURE 1 vs 0.89 (0.216) for ENRADAS (p = 0.1852). Mean changes from baseline in mSASSS were lower in MEASURE 1 vs ENRADAS for the primary and sensitivity analyses. The proportion of patients with no radiographic progression was consistently higher in the MEASURE 1 vs ENRADAS cohort across all cutoffs for no radiographic progression (change in mSASSS from baseline to year 2 of ≤ 0, ≤ 0.5, ≤ 1, and ≤ 2), but the differences were not statistically significant.

CONCLUSION

Secukinumab-treated patients demonstrated a numerical, but statistically non-significant, higher proportion of non-progressors and lower change in mSASSS over 2 years versus a cohort of biologic-naïve patients treated with NSAIDs.

SAT-037 Functional Interplay between Distinct P-TEFb Complexes Following Endothelin or α1-Adrenergic Receptor Activation in Rat Cardiomyocytes

Heart disease is characterized by the remodelling of cardiac tissue following prolonged stress on the heart, such as myocardial infarction and chronic hypertension. The heart initially undergoes hypertrophy of the individual contractile unit, the cardiomyocyte, in order to preserve cardiac function. However, prolonged stress can lead to fibrosis, cardiomyocyte death, and subsequent heart failure. Cardiac remodelling is mediated predominantly through neurohormonal activation of G protein-coupled receptors (GPCRs) expressed by cardiomyocytes and other cell types in the heart. Current therapeutic approaches target implicated GPCRs to slow disease progression by inhibiting signalling pathways leading to remodelling. While this approach benefits a portion of patients, other therapeutic approaches are required to improve disease prognosis (1). A potential target downstream of GPCR activation is the transcription regulator positive transcription elongation factor b (P-TEFb). Hormonal activation of multiple GPCRs, such as the α₁-adrenergic receptor (α₁AR) by epinephrine or the endothelin receptor (ETR) by endothelin-1, leads to P-TEFb-dependent cardiomyocyte hypertrophy, a hallmark of cardiac remodelling (2). Active P-TEFb is recruited to chromatin to regulate gene expression as a constituent of two complexes, either through interactions with the Super Elongation Complex (SEC) or the bromodomain and extra-terminal protein Brd4. Small molecule inhibition of Brd4 prevents hypertrophy and activation of inflammatory and profibrotic genes in cardiomyocytes (3). On the other hand, the role of the SEC in regulating cardiomyocyte gene expression has not been examined. Furthermore, the signalling mechanisms leading to activation of either complex and subsequent gene expression changes are not known. We hypothesized that activation and interplay between distinct P-TEFb complexes differs following activation of different GPCRs implicated in heart failure. We assessed the role of Brd4 and the SEC downstream of the endogenous ETR and α₁AR stimulated with endothelin-1 or phenylephrine, respectively, in primary neonatal rat cardiomyocytes. Although P-TEFb activity is required downstream of both receptors to drive gene expression changes and cardiomyocyte hypertrophy, we find evidence for receptor-specific differences in the functions of the SEC and the Brd4 complex. We are currently investigating signalling mechanisms regulating each complex downstream of the ETR and α₁AR. Understanding how mechanisms downstream of various hormones differentially regulate transcription has clinical implications as therapies targeting transcriptional machinery are being explored for heart failure. (1) Wang et al., Circ Res. 2018; 123:716-35 (2) Sano et al., Nat Med. 2002; 8:1310-7 (3) Duan et al., Sci Transl Med; 9(390)

Specific aspects of immunotherapy for multiple sclerosis in Switzerland: A structured commentary

More than a dozen substances are meanwhile available for the disease-modifying immunotherapy of multiple sclerosis (MS). However, for some substances, there is a clear difference between approval in Switzerland (Swissmedic) and neighboring countries (European Medicines Agency (EMA)). In addition, limitations imposed by the Swiss Federal Office of Public Health in the specialties list (SL) have significant effects on use in daily clinical practice. In the following, we present consensus recommendations, which were reviewed and agreed upon by the Scientific Advisory Board of the Swiss Multiple Sclerosis Society and the Swiss Neurological Society. We explicitly focus on practice-relevant differences in the approval of MS immunotherapies in Switzerland compared with the EMA area and discuss further limitations (SL) and their impact on the use in clinical practice. Immunotherapies with the same approval in Switzerland and the EMA area and symptomatic therapies are not discussed here.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Calibrating general posterior credible regions

Calibration of credible regions derived from under- or misspecified models is an important and challenging problem. In this paper, we introduce a scalar tuning parameter that controls the posterior distribution spread, and develop a Monte Carlo algorithm that sets this parameter so that the corresponding credible region achieves the nominal frequentist coverage probability.

Qualitätskriterien forensischer Ambulanzen des Strafvollzugs

Mit dem Gesetz zur Reform der Führungsaufsicht 2007 wurde forensische Nachsorge sowohl für ehemalige Patienten aus dem Maßregelvollzug als auch für Straffällige aus dem Justizvollzug verbindlich etabliert. Im Lauf der vergangenen zehn Jahre entstanden somit bundesweit forensische Ambulanzen des Strafvollzugs, welche den gesetzlichen Auftrag zu Behandlung und Betreuung entlassener Straffälliger länderspezifisch umsetzen. Hierbei handelt es sich teils um neu gegründete Ambulanzen, teils um bereits lange in der Behandlung von straffälligen Menschen tätige Einrichtungen, die ihr bisheriges Angebot um die Betreuung von Menschen unter Führungsaufsicht erweiterten. Diese heterogenen Ambulanzen haben sich seit einigen Jahren in einem jährlich stattfindenden fachlichen Austausch bundesweit vernetzt und Gemeinsamkeiten, Unterschiede und Besonderheiten in der Umsetzung des gesetzlichen Auftrags diskutiert. Angestoßen von der Diskussion um Mindeststandards in forensisch-psychiatrischen Nachsorgeambulanzen des Maßregelvollzugs 2014 entwickelte diese Bundesarbeitsgemeinschaft der forensischen Ambulanzen des Strafvollzug Qualitätskriterien, die trotz verschiedener Länder- und Trägerspezifika gemeinsame inhaltliche und formale Parameter erfolgreicher ambulanter Behandlung zur Deliktprävention fokussieren. Der Artikel stellt das Ergebnis dieses Diskussionsprozesses mit den verabschiedeten Qualitätskriterien in den Kategorien Struktur‑, Prozess- und Ergebnisqualität vor.

A numerical simulation of neural fields on curved geometries

Despite the highly convoluted nature of the human brain, neural field models typically treat the cortex as a planar two-dimensional sheet of ne;urons. Here, we present an approach for solving neural field equations on surfaces more akin to the cortical geometries typically obtained from neuroimaging data. Our approach involves solving the integral form of the partial integro-differential equation directly using collocation techniques alongside efficient numerical procedures for determining geodesic distances between neural units. To illustrate our methods, we study localised activity patterns in a two-dimensional neural field equation posed on a periodic square domain, the curved surface of a torus, and the cortical surface of a rat brain, the latter of which is constructed using neuroimaging data. Our results are twofold: Firstly, we find that collocation techniques are able to replicate solutions obtained using more standard Fourier based methods on a flat, periodic domain, independent of the underlying mesh. This result is particularly significant given the highly irregular nature of the type of meshes derived from modern neuroimaging data. And secondly, by deploying efficient numerical schemes to compute geodesics, our approach is not only capable of modelling macroscopic pattern formation on realistic cortical geometries, but can also be extended to include cortical architectures of more physiological relevance. Importantly, such an approach provides a means by which to investigate the influence of cortical geometry upon the nucleation and propagation of spatially localised neural activity and beyond. It thus promises to provide model-based insights into disorders like epilepsy, or spreading depression, as well as healthy cognitive processes like working memory or attention.

A rotary and reciprocating scintillator based fast-ion loss detector for the MAST-U tokamak

The design and unique feature of the first fast-ion loss detector (FILD) for the Mega Amp Spherical Tokamak - Upgrade (MAST-U) is presented here. The MAST-U FILD head is mounted on an axially and angularly actuated mechanism that makes it possible to independently adapt the orientation [0°, 90°] and radial position [1.40 m, 1.60 m] of the FILD head, i.e., its collimator, thus maximizing the detector velocity-space coverage in a broad range of plasma scenarios with different q₉₅. The 3D geometry of the detector has been optimized to detect fast-ion losses from the neutral beam injectors. Orbit simulations are used to calculate the strike map and predict the expected signals. The results show a velocity-space range of [4 cm, 13 cm] in gyroradius and [30°, 85°] in pitch angle, covering the entire neutral beam ion energy range. The optical system will provide direct sight of the scintillator and simultaneous detection with two cameras, giving high spatial and temporal resolution. The MAST-U FILD will shed light on the dominant fast-ion transport mechanisms in one of the world's two largest spherical tokamaks through absolute measurements of fast-ion losses.