Two mifepristone doses and two intervals of misoprostol administration for termination of early pregnancy: a randomised factorial controlled equivalence trial

OBJECTIVE

To compare the efficacy of 100 mg and 200 mg of mifepristone and 24- and 48-hour intervals to administration of 800 microg vaginal misoprostol for termination of early pregnancy.

DESIGN

Placebo-controlled, randomized, equivalence trial, stratified by centre.

SETTING

13 departments of obstetrics and gynecology in nine countries.

POPULATION

2,181 women with 63 days or less gestation requesting medical abortion.

METHODS

Two-sided 95% CI for the risk differences of failure to complete abortion were calculated and compared with 5% equivalence margin between two doses of mifepristone and two intervals to misoprostol administration. Proportions of women with adverse effects were compared between the regimens using standard testes for proportions.

OUTCOME MEASURES

Rates of complete abortion without surgical intervention and adverse effects associated with the regimens.

RESULTS

Efficacy outcome was analysed for 2,126 women (97.5%) excluding 55 lost to follow up. Both mifepristone doses were found to be similar in efficacy. The rate of complete abortion was 92.0% for women assigned 100 mg of mifepristone and 93.2% for women assigned 200 mg of mifepristone (difference 1.2%, 95% CI: -1.0 to 3.5). Equivalence was also evident for the two intervals of administration: the rate of complete abortion was 93.5% for 24-hour interval and 91.7% for the 48-hour interval (difference -1.8%, 95% CI: -4.0 to 0.5). Interaction between doses and interval to misoprostol administration was not significant (P = 0.92). Adverse effects related to treatments did not differ between the groups.

CONCLUSIONS

Both the 100 and 200 mg doses of mifepristone and the 24- and 48-hour intervals have a similar efficacy to achieve complete abortion in early pregnancy when mifepristone is followed by 800 micrograms of vaginally administered misoprostol.

DNA integrity and semen quality in men with low seminal antioxidant levels

Accurate transmission of information coded in the sperm genome is vital to the pre- and post-natal development of the offspring. Recent advances in reproductive biology have proposed evaluation of sperm DNA integrity as an important assessment tool to infer the presence of DNA strand breaks, numerical abnormalities in sperm chromosome complement, and alterations in the epigenetic regulation of the paternal genome. Oxidative stress (OS), characterized by increased free radicals, may lead to the production of apurine sites, apyrimidine sites, oxidation of nucleotides of sperm genome. This study was performed to assess the impact of OS on DNA integrity in sperms. 52 infertile men [oligozoospermic-13, asthenozoospermic-15, teratozoospermic-19, oligoasthenoteratozoospermic-5] and 20 fertile controls were investigated for products of lipidperoxides as malondialdehyde; antioxidants such as superoxide dismutase, catalase and glutathione in seminal plasma by biochemical methods. DNA integrity of the sperms was analyzed by visual scoring method in which the comets were graded into 4 categories (A-D) on the basis of their tail length indicative of increasing levels of DNA damage. Significant increase in DNA damage (higher number of sperms in group D) in cases (oligozoospermic (O)-20%, asthenozoospermic (A)-24%, teratozoospermic (T)-28%, OAT-43%) as compared to controls (8%) was found. Increased malondialdehyde levels, abnormal sperm morphology and higher DNA damage were observed in the cases. The antioxidants superoxide dismutase, catalase and glutathione had a positive association with sperm count and motility while a negative association with the percentage of dead sperms and abnormal morphology was observed. This study highlights the influence of low antioxidants on sperm genome integrity and indicates sperm DNA integrity as a better and more reliable prognostic tool for infertility evaluation than simple quantitative and morphologic evaluation of spermatozoa.

Surface ultrastructure of gill arches and gill rakers in relation to feeding of an Indian major carp, Cirrhinus mrigala

The surface ultrastructure of the gill arches and the gill rakers of an herbivorous fish, Cirrhinus mrigala was investigated by scanning electron microscopy. These structures show significant adaptive modifications associated with the food and feeding ecology of the fish. Closely lying short gill rakers and narrow inter-raker channels on the gill arches are associated to filter and retain food particles. Prominent epithelial protuberances on the gill rakers and the gill arches enable the taste buds, located at their summit, to project well above the surface of the epithelium. This could increase the efficiency of the taste buds in selective sorting of palatable food. Surface specializations of the postlingual organ are recognized adaptive modifications for selecting, trapping or holding food particles. Prominent molariform teeth born on the lower pharyngeal jaw, and the chewing pad opposite it, are associated to work together as an efficient pharyngeal mill. Mucous goblet cells are considered to elaborate mucus secretions to trap, glue and lubricate food particles for their smooth transport for swallowing.

Silent ischemic interval on exercise test is a predictor of response to drug therapy: a randomized crossover trial of metoprolol versus diltiazem in stable angina

BACKGROUND AND HYPOTHESIS

There is no method available to predict the relative antianginal efficacy of beta blockers and calcium-channel antagonists. The present study was undertaken to assess the role of silent ischemic interval (SII) on exercise treadmill test (ETT) as a predictor of response to therapy with metoprolol and diltiazem in patients with stable angina.

METHODS

Thirty-four patients with stable angina were divided into two groups depending upon the presence or absence of an SII gap of at least 1 min between onset of ST depression and appearance of angina on ETT. Metoprolol (50-100 mg twice daily) and diltiazem (60-120 mg three times daily) were randomly assigned for 6 weeks to patients in each group, and then patients were crossed over for further 6 weeks after a washout period of 2 weeks. Antianginal efficacy was assessed by clinical and exercise parameters.

RESULTS

In patients with SII, the clinical responder rate was better with metoprolol than with diltiazem (90 vs. 60%, respectively), and on ETT, metoprolol produced significant improvement in the total exercise time (p< 0.01), time to 1 mm ST depression (p <0.01), time to angina (p <0.01), and a significant decrease in peak rate-pressure product (p<0.001), whereas diltiazem had no significant effect on exercise parameters. However, in patients without SII, metoprolol and diltiazem had a similar clinical responder rate (57%), and both produced a significant increase in total exercise time (p < 0.01), time to 1 mm ST depression (p < 0.01), and time to angina (p < 0.01). In addition, metoprolol had a significant effect on peak rate-pressure product (p < 0.001).

CONCLUSION

Silent ischemic interval on ETT can be a predictor of response to antianginal therapy in stable angina, as patients with SII respond better to metoprolol and those without SII respond equally to both metoprolol and diltiazem.

Susceptibility-weighted imaging: technical aspects and clinical applications, part 2

SUMMARY

Susceptibility-weighted imaging (SWI) has continued to develop into a powerful clinical tool to visualize venous structures and iron in the brain and to study diverse pathologic conditions. SWI offers a unique contrast, different from spin attenuation, T1, T2, and T2* (see Susceptibility-Weighted Imaging: Technical Aspects and Clinical Applications, Part 1). In this clinical review (Part 2), we present a variety of neurovascular and neurodegenerative disease applications for SWI, covering trauma, stroke, cerebral amyloid angiopathy, venous anomalies, multiple sclerosis, and tumors. We conclude that SWI often offers complementary information valuable in the diagnosis and potential treatment of patients with neurologic disorders.

Susceptibility-weighted imaging: technical aspects and clinical applications, part 1

Susceptibility-weighted imaging (SWI) is a new neuroimaging technique, which uses tissue magnetic susceptibility differences to generate a unique contrast, different from that of spin density, T1, T2, and T2*. In this review (the first of 2 parts), we present the technical background for SWI. We discuss the concept of gradient-echo images and how we can measure local changes in susceptibility. Armed with this material, we introduce the steps required to transform the original magnitude and phase images into SWI data. The use of SWI filtered phase as a means to visualize and potentially quantify iron in the brain is presented. Advice for the correct interpretation of SWI data is discussed, and a set of recommended sequence parameters for different field strengths is given.

P2X receptor-mediated visceral hyperalgesia in a rat model of chronic visceral hypersensitivity

BACKGROUND

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterised by abdominal pain and bloating in association with altered bowel movements. Its pathogenesis and the underlying molecular mechanisms of visceral hyperalgesia remain elusive. Recent studies of somatic and other visceral pain models suggest a role for purinergic signalling mediated by the P2X receptor (P2XR) family.

AIMS

To examine the role of P2XR signalling in the pathogenesis in a rat model of IBS-like visceral hyperalgesia.

METHODS

Visceral hypersensitivity was induced by colonic injection of 0.5% acetic acid (AA) in 10-day-old rats and experiments were conducted at 8 weeks of age. Dorsal root ganglion (DRG) neurons innervating the colon were labelled by injection of DiI (1,1'-dioleyl-3,3,3',3-tetramethylindocarbocyanine methanesulfonate) fluorescence into the colon wall.

RESULTS

Visceral hypersensitivity was reversed by TNP-ATP (2'-(or-3')-O-(trinitrophenyl) ATP), a potent P2X1, P2X3 and P2X2/3 receptor antagonist. Rapid application of ATP (20 microM) induced a fast inactivating current in colon-specific DRG neurons from both control and AA-treated rats. There was a twofold increase in the peak ATP responses in neurons from AA-treated rats. These currents were sensitive to TNP-ATP (100 nM). Under current-clamped conditions, ATP evoked a larger membrane depolarisation in neurons from neonatal AA-treated rats than in controls. P2X3R protein expression was significantly enhanced in colon-specific DRGs 8 weeks after neonatal AA treatment.

CONCLUSIONS

These data suggest that the large enhancement of P2XR expression and function may contribute to the maintenance of visceral hypersensitivity, thus identifying a specific neurobiological target for the treatment of chronic visceral hyperalgesia.

Postoperative flare-up of genital tuberculosis: a clinical reality

We report three cases of flare-up of tuberculosis (TB) following genital surgery. In two cases, both patients developed abdominal distension postoperatively with vomiting and fever following total laparoscopic hysterectomy. Polymerase chain reaction (PCR) analysis of fluid detected and aspirated from the abdomen under ultrasound guidance was positive for Mycobacterium tuberculosis. In another instance, the patient developed abdominal distension with discharge per vaginum following a vaginal hysterectomy. X-ray of the abdomen showed dilated bowel loops and also a pseudo acetabular right hip joint suggestive of TB. PCR analysis of ascitic fluid was positive for TB. All patients responded to anti-tuberculosis treatment.

Intraoperative magnetic resonance imaging in neurosurgery: the Brigham concept

The resection of brain tumors is limited by the surgeon's ability to precisely define margins. To overcome this problem, various neuronavigational tools have been used. The development of image-guided navigation systems represents a substantial improvement in the microsurgical treatment of various intracranial lesions. However, a major drawback of this technology is that they use images acquired preoperatively, on which the surgical planning and intraoperative performance is based. As the intracranial anatomy dynamically changes during a neurosurgical procedure, only intraoperatively acquired images can provide the neurosurgeon with the information needed to perform real-time, image-guided surgery. Because magnetic resonance imaging best delineates the soft-tissue extent of most tumors, it currently remains the superior method for intraoperative image guidance. In this review, we outline the development as well as current and possible future applications of the intraoperative MRI (iMRI) unit at the Brigham and Women's Hospital, Boston, MA.

Immunomodulation against leukemias and lymphomas: a realistic future treatment?

Immunotherapy offers the potential for cure of malignancy without the side effects too commonly seen with conventional chemotherapy. The efficacy of allogenic transplantation and monoclonal antibodies in hematological malignancies illustrate this principle and are now part of routine care. Newer cell based and molecular approaches aimed at stimulating cytotoxic activity against host derived tumor associated antigens are able to 'boost' anti-tumor immunity as judged by immunological assays in vitro. Although clinically meaningful responses were originally less evident, more promising results are now being reported. Our growing understanding of tumor immunology provide rationales for further improvements in the field.