Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial)

OBJECTIVE

To ascertain whether a clinically important difference exists in the incidence of gynaecological infection between surgical management and expectant or medical management of miscarriage.

DESIGN

Randomised controlled trial comparing medical and expectant management with surgical management of first trimester miscarriage.

SETTING

Early pregnancy assessment units of seven hospitals in the United Kingdom.

PARTICIPANTS

Women of less than 13 weeks' gestation, with a diagnosis of early fetal demise or incomplete miscarriage.

INTERVENTIONS

Expectant management (no specific intervention); medical management (vaginal dose of misoprostol preceded, for women with early fetal demise, by oral mifepristone 24-48 hours earlier); surgical management (surgical evacuation).

MAIN OUTCOME MEASURES

Confirmed gynaecological infection at 14 days and eight weeks; need for unplanned admission or surgical intervention.

RESULTS

1200 women were recruited: 399 to expectant management, 398 to medical management, and 403 to surgical management. No differences were found in the incidence of confirmed infection within 14 days between the expectant group (3%) and the surgical group (3%) (risk difference 0.2%, 95% confidence interval - 2.2% to 2.7%) or between the medical group (2%) and the surgical group (0.7%, - 1.6% to 3.1%). Compared with the surgical group, the number of unplanned hospital admissions was significantly higher in both the expectant group (risk difference - 41%, - 47% to - 36%) and the medical group (- 10%, - 15% to - 6%). Similarly, when compared with the surgical group, the number of women who had an unplanned surgical curettage was significantly higher in the expectant group (risk difference - 39%, - 44% to - 34%) and the medical group (- 30%, - 35% to - 25%).

CONCLUSIONS

The incidence of gynaecological infection after surgical, expectant, and medical management of first trimester miscarriage is low (2-3%), and no evidence exists of a difference by the method of management. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management and medical management than after surgical management. TRIAL REGISTRATION NATIONAL RESEARCH REGISTER: N0467011677/N0467073587.

Anorexia and weight loss in male rats 24 h following single dose treatment with orexin-1 receptor antagonist SB-334867

Acute systemic treatment with the selective orexin-1 receptor antagonist SB-334867 (30 mg/kg, i.p.) has been reported not only to inhibit food intake and to accelerate behavioural satiety in rats, but also to produce a significant loss of bodyweight over the 24 h period post-dosing. The present studies were designed to test the hypothesis that the inhibition of weight gain following acute treatment with SB-334867 is due to a persistent anorectic action of the compound. In Experiment 1, the acute effects of SB-334867 (30 mg/kg, i.p.) on food intake and behaviour in a 1 h test with palatable mash were assessed as a function of injection-test interval. Results confirmed that, when administered 30 min prior to testing, SB-334867 significantly suppressed mash intake and accelerated behavioural satiety. More importantly, significant anorexia and behavioural change were also observed when animals were tested 24 h, but not 48 h, post-dosing. As previously reported, all animals treated with the orexin-1 receptor antagonist lost bodyweight over the 24 h period following acute treatment. The generality of these findings was confirmed in Experiment 2, where acute treatment with SB-334867 (30 mg/kg, i.p.) significantly suppressed home cage chow consumption over the 24 h period post-dosing, an effect also accompanied by a significant loss of bodyweight. The results of Experiment 3 showed that, following i.p. administration of 30 mg/kg, SB-334867 has good CNS penetration, reaches peak plasma and brain concentrations at 30 min, and maintains good exposure over 4 h post-dosing. Overall, current data support the hypothesis that a persistent anorectic action contributes to the significant loss of bodyweight observed 24 h following acute dosing with SB-334867. As the compound is virtually undetectable in plasma or brain beyond 8 h post-dosing, and since nothing is known about potentially active metabolites, we consider the possibility that single dose treatment with SB-334867 results in enduring alterations to the orexin-1 receptor and/or downstream signalling pathways.

Reductive activation of Cr(Vi) by nitric oxide synthase

Chromium(VI) is a recognized toxicant whose effects have been linked to its reduction to lower oxidation states. Although Cr(VI) is reduced by several systems, it is anticipated that its reduction by nitric oxide synthase (NOS) could have significant effects in endothelial and brain cells that express high constitutive levels of the enzyme. This possibility was examined by electron paramagnetic resonance that showed the formation of a stable Cr(V) species from NOS/Cr(VI). The formation of Cr(V) was calcium/calmodulin-independent indicating that Cr(VI) to Cr(V) reduction occurs at the flavin-containing domain of NOS. Accordingly, Cr(VI) reduction by the reductase domain of NOS and the chimera protein cytochrome-P450-reductase+tail-nNOS also generated Cr(V). Activation of tetrahydrobiopterin (BH(4))-free NOS with calcium/calmodulin diminished Cr(V) steady-state levels while increasing superoxide formation. Since SOD restored Cr(V) to control levels, this result was taken as evidence for a reaction between Cr(V) and superoxide. Supplementation of NOS with BH(4) cofactor not only failed to increase Cr(V) yields but generated superoxide and hydroxyl radical. Since the holoenzyme does not generate superoxide, this reaction indicated that Cr(V) mediates the oxidation of BH(4)-bound to the enzyme. In the presence of L-arginine, however, Cr(VI) neither enhances superoxide release nor inhibits NO formation from fully active NOS. This suggests that L-arginine protects BH(4) from Cr(V)-mediated oxidation. While Cr(V) was inactive toward NO, spin trapping experiments with 5-tert-butoxycarbonyl 5-methyl-1-pyrroline N-oxide and oxygen consumption measurements showed that Cr(V) reacts with superoxide by a one-electron-transfer mechanism to generate oxygen and Cr(IV). Thus, reduction of Cr(VI) to Cr(V) by NOS occurs in resting and fully active states. It is likely that the reaction between Cr(V) and superoxide influences the cytotoxic mechanisms of Cr(VI) in cells.

Satiety enhancement by selective orexin-1 receptor antagonist SB-334867: influence of test context and profile comparison with CCK-8S

Acute systemic treatment with the selective orexin-1 (OX1R) antagonist SB-334867 reduces food intake in rats, an effect associated with an acceleration in behavioural satiety and unrelated to gross behavioural disruption, alterations in palatability, or toxicity. However, as enhanced satiety is behaviourally indexed by an earlier-than-normal transition from eating to resting, and since orexin-A has been implicated in mechanisms of arousal, it remains possible that sedation contributes to the anorectic effect of acute OX1R blockade. Previous work has shown that, when treated with SB-334867 (30 mg/kg, i.p.) 30 min before a 1h test with palatable food, rats begin to show appreciable levels of resting 10-15 min earlier than under control conditions (i.e. around 20 min versus 30-35 min into the session). The present results demonstrate that a 20 min increase in the injection-test interval (i.e. 50 min) had no significant impact on the anorectic, behavioural or weight gain effects of SB-334867 in non-deprived male rats. Most importantly, this altered treatment regimen led to a temporal profile of resting virtually identical to that previously observed with the more conventional 30 min injection-test interval. Although parallel studies indicated that the OX1R antagonist accelerated the onset of resting (and suppressed most active behaviours) even in the absence of food, an equianorectic dose of the natural satiety-related signal cholescystokinin octapeptide (CCK-8S; 5 microg/kg, i.p.) also produced very similar behavioural effects regardless of the presence of food. Together with evidence that SB-334867 preserves the structural integrity of natural feeding behaviour, does not induce nausea/illness or alter taste/palatability and fails to influence EEG measures of arousal/sleep, the present findings are consistent with the view that acute OX1R antagonism selectively enhances satiety. However, unlike the immediate short-circuiting of the satiety sequence induced by CCK-8S, the slower response to SB-334867 implies a more indirect mechanism of action.

Differential effects of the selective orexin-1 receptor antagonist SB-334867 and lithium chloride on the behavioural satiety sequence in rats

Recent studies have shown that acute systemic administration of the selective orexin-1 receptor antagonist SB-334867 significantly reduces food intake in rats. Although this anorectic action of orexin-1 receptor blockade is associated with an acceleration in the transition from eating to resting, it is widely recognised that the behavioural indices of satiety are not dissimilar to those of illness. In this context, Experiment 1 confirmed a significant anorectic effect of 90 (but not 60) mg/kg lithium chloride (LiCl) in male rats presented with palatable mash in the home-cage environment. Experiment 2 employed a continuous monitoring technique to contrast the effects of LiCl (90 mg/kg) and SB-334867 (10 and 30 mg/kg) on food intake and behaviour during a 1-h test with palatable mash. SB-334867 dose-dependently inhibited food intake, with the higher dose producing a comparable degree of appetite suppression (approximately 40%) to that seen with LiCl. Despite equivalent anorectic action, the two compounds produced very different effects on behaviour. LiCl reduced active behaviours (locomotion, rearing, grooming and sniffing), slowed the rate of eating and disrupted the behavioural satiety sequence (BSS). In contrast, SB-334867 (30 mg/kg) decreased the duration of feeding and grooming, and modestly accelerated the transition between eating and resting. Furthermore, whereas LiCl failed to alter posttreatment bodyweight gain, SB-334867 (30 mg/kg) produced a significant weight loss in the 24-h period immediately following injection. Overall, the divergent profiles obtained with equianorectic doses of LiCl and SB-334867 provide convincing evidence for the behavioural selectivity of SB-334867-induced anorexia.

Biological activities of an extract from Cleome viscosa L. (Capparaceae)

Electron micrograph examination of the leaf and stem surfaces of Cleome viscosa L (Family Capparaceae) revealed the presence of secretory glandular trichomes with club-cylinder and cylinder morphologies. In the present study, the leaves and stems of C. viscosa were extracted with hexane and the extract was evaluated for the following biological activities: anti-bacterial, anti-fungal, contact insecticidal and nematicidal. The extract was found to be a potent anti-bacterial agent according to the thin layer chromatography autobiographic assay. Activity-directed isolation studies of the anti-bacterially active compounds led to a 14-member ring cembranoid diterpene being identified as one of the effective agents. Minimum inhibitory concentration (MIC) values (microg/spot) of 5.0 microg/spot and 1.0 microg/spot were found for the diterpene on Bacillus subtilis (Gram-positive) and Pseudomonas fluorescens (Gram-negative), respectively. The diterpene did not inhibit the growth of the fungus Cladosporium cucumerinum. The extract demonstrated a pyrethroid type of contact insecticidal activity on adult Cylas formicarius elegantulus Summer (Coleoptera: Curculionidae). The extract also had high nematicidal activity with a percentage Abbott's value of 72.69 on the plant parasitic nematode Meloidogyne incognita Chitwood; however, the extract lost its potency upon subfractionation.

Comparative genetics at the gene and chromosome levels between rice ( Oryza sativa) and wildrice ( Zizania palustris)

Using comparative genetics, genes, repetitive DNA sequences and chromosomes were studied in the Oryzeae in order to more fully exploit the rice genome sequence data. Of particular focus was Zizania palustris L., n = 15, commonly known as American wildrice. Previous work has shown that rice chromosomes 1, 4 and 9 are duplicated in wildrice. The Adh1 and Adh2 genes were sequenced and, based on phylogenetic analyses, found to be duplicated in wildrice. The majority of the sequence diversity in the Adh sequences was in intron 3, in which were found several MITE insertions. Cytological and molecular approaches were used to analyze the evolution of rDNA and centromeric repetitive sequences in the Oryzeae. In wildrice, copies of the 5S rDNA monomer were found at two loci on two different chromosomes near the centromeres, as in rice. One nucleolar organizer region (NOR) locus was found adjacent to the telomere, as in rice. RCS1, a middle repetitive sequence in rice, was present in all of the centromeres of wildrice. RCS2/CentO, the highly repetitive component of Oryza sativa L. centromeres, was conserved in eight of the Oryza species examined, but was not found in wildrice. Three other middle repetitive centromeric sequences (RCH1, RCH2/CentO and RCH3) were also examined and found to have variable evolutionary patterns between species of Oryza and Zizania.

Conference report

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Pathological effects of Pseudodiplorchis americanus (Monogenea: Polystomatidae) on the lung epithelium of its host, Scaphiopus couchii

Infection of the desert toad, Scaphiopus couchii, by the monogenean Pseudodiplorchis americanus involves 2 principal sites: post-invasion juveniles reside in the respiratory tract for 1 month before migrating to the urinary bladder where they reach sexual maturity and may live up to 4 years. While previous work has demonstrated the long-term impact on host condition of the blood-feeding adults, this study assesses pathological effects of the short-term pulmonary infection. Lung ultrastructure was compared in toads (i) maintained in captivity for 1 year without invasion, and (ii) experimentally infected with 50-300 juveniles/host, equivalent to burdens in the wild, and examined 23-44 days p.i. Typically, the alveolar lining of S. couchii is composed of a single cell type with characteristics of both Type I and Type II pneumocytes. However, infected lung tissue exhibited an inflammatory reaction with epithelial cell vacuolation, interstitial oedema, and an increase of alveolar exudate, leucocytes and fibrous tissue. Accompanying a post-infection increase in host immune cells in the lungs, there was evidence of reciprocal tegumental damage to the parasites. Lung epithelium of toads free of infection for 1 year exhibited scar tissue representing a residual effect of past infection. The pathological consequences of P. americanus infection therefore have 2 components. Acute lung infection coincides with the host's brief activity season: impaired respiratory function could compromise feeding and accumulation of reserves and hence ability to survive following a 10 month period of hibernation. Additionally, adult toads are normally exposed annually to re-infection and may accumulate chronic lung damage with extended effects on host survival.

An electro-active system of immuno-assay (EASI assay) utilising self assembled monolayer modified electrodes

Most immunoassays currently rely on optical methods for signal generation e.g. in ELISA and rapid assay formats. It has become apparent as in the Glucose sensor market that there is a need for simple direct electrical immuno-sensors. We have investigated the novel use of organic conducting monolayers used as a direct electrochemical detection support for an immuno-reaction. It was found that antibodies raised to a carbazole dimer monolayer could increase the charge movement across that monolayer surface. Antibody fragments were taken from a specific anti-carbazole antibody fragment library and combined with an antibody fragment directed to the hormone estrone 3 glucuronide (E3G), the target antigen to form a bispecific antibody fragment. The device utilised these specific antibody fragments and incorporated them on the top plate of a capillary fill format as the immuno-assay components. The immuno-reaction utilised a competition assay. Free E3G analyte in the sample displaced the bispecific antibody fragment from the immuno-surface leaving it free to bind the carbazole monolayer surface. There the binding was detected using amperometric or coulometric methods. By combining all there element it was possible to develop a sensitive immuno-assay that could detect E3G in a reproducible calibrated fashion down to 10 ng/ml.

The historiography of medicine in the U.K

The practice of the history of medicine in Britain is characterized by a health pluralism and diversity. Thirty years ago, history of medicine in Britain was generally considered a space of no particular relevance to history at large; today, public attitudes towards scientific medicine and the medical profession have grown critical, and the history of medicine has itself been problematized, commanding widespread scholarly attention. This article deals with some of the historiographical fields thanks to which the discipline has been energized over the last thirty years: the history of health, analyzing the healthiness of populations, the length of their lives and the causes of death; the history of the body, which has been considered as a biological and as a sociological entity; the history of sexuality and sexual behaviour; the demographic and epidemiological history, both ocnnected with the environmental history; the history of death and corpses; the history of mental disorders; the historical role of the hospital in the reformation of popular health care.

Charles Garrett Phillips: 13 October 1916 - 9 September 1994

Charles Garrett Phillips was born in London on 13 October 1916, the eldest of four children, having one brother and twin sisters. His own comment on his categorically medical ancestry and distinguished family traditions reads: ‘My grandfather, George Arthur Phillips, J.P (1850-1921), was a Surgeon of Walsall, Staffordshire, and my great-grandfather, George Marshall Phillips (1819-1904), was Surgeon of Whitwell, Hertfordshire.’ Charles’s father, George Ramsay Phillips, F.F.A., R.C.S. (1880-1953), was Senior Anaesthetist to St Mary’s Hospital, Paddington, London W2, a position from which he retired in 1948. His mother, Flora Phillips, née Green (1886-1956), had been a nurse at St George’s Hospital, then at Hyde Park Corner. At the age of 29, she married George Ramsay Phillips who had been Resident Anaesthetist at that hospital. Flora was the youngest of six children who were brought up on a farm in Kent. Her mother died when she was 18 and her father soon afterwards. She was helped by family friends in London, trained as a nurse at St George’s and became a ward sister at that hospital. After her marriage she worked at the Victoria Hospital for Children in Chelsea and, in 1939, became a matron at Bradfield College. Charles Phillips was proud of his medical family tree. His great-grandfather and his grandfather had both qualified at St Bartholomew’s Hospital, as had his father’s brother, Alfred Percy Phillips (1881-1961). His grandfather’s brother, Percy Cranston Phillips (1869-1946), had graduated from St Thomas’s Hospital and practised in Putney, London, as a general practitioner, while George Ramsay Phillips, his father, had qualified at Guy’s Hospital and served in the R.A.M.C. in World War I.