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Symon A, Lightly K, Howard R, Mundle S, Faragher B, Hanley M, Durocher J, Winikoff B, Weeks A. Introducing the participant-generated experience and satisfaction (PaGES) index: a novel, longitudinal mixed-methods evaluation tool. BMC Med Res Methodol 2023; 23:214. [PMID: 37759174 PMCID: PMC10537543 DOI: 10.1186/s12874-023-02016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/09/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Patient-Reported Outcomes or Experience Measures (PROMS / PREMS) are routinely used in clinical studies to assess participants' views and experiences of trial interventions and related quality of life. Purely quantitative approaches lack the necessary detail and flexibility to understand the real-world impact of study interventions on participants, according to their own priorities. Conversely, purely qualitative assessments are time consuming and usually restricted to a small, possibly unrepresentative, sub-sample. This paper, which reports a pilot study within a randomised controlled trial of induction of labour, reports the feasibility, and acceptability of the Participant-Generated Experience and Satisfaction (PaGES) Index, a new mixed qualitative / quantitative PREM tool. METHODS The single-sheet PaGES Index was completed by hypertensive pregnant women in two hospitals in Nagpur, India before and after taking part in the 'Misoprostol or Oxytocin for Labour Induction' (MOLI) randomised controlled trial. Participants recorded aspects of the impending birth they considered most important, and then ranked them. After the birth, participants completed the PaGES Index again, this time also scoring their satisfaction with each item. Forms were completed on paper in the local language or in English, supported by Research Assistants. Following translation (when needed), responses were uploaded to a REDCap database, coded in Excel and analysed thematically. A formal qualitative evaluation (qMOLI) was also conducted to obtain stakeholder perspectives of the PaGES Index and the wider trial. Semi-structured interviews were conducted with participants, and focus groups with researchers and clinicians. Data were managed using NVivo 12 software and analysed using the framework approach. RESULTS Participants and researchers found the PaGES Index easy to complete and administer; mothers valued the opportunity to speak about their experience. Qualitative analysis of the initial 68 PaGES Index responses identified areas of commonality and difference among participants and also when comparing antenatal and postnatal responses. Theme citations and associated comments scores were fairly stable before and after the birth. The qMOLI phase, comprising 53 one-to-one interviews with participants and eight focus groups involving 83 researchers and clinicians, provided support that the PaGES Index was an acceptable and even helpful means of capturing participant perspectives. CONCLUSIONS Subjective participant experiences are an important aspect of clinical trials. The PaGES Index was found to be a feasible and acceptable measure that unites qualitative research's explanatory power with the comparative power of quantitative designs. It also offers the opportunity to conduct a before-and-after evaluation, allowing researchers to examine the expectations and actual experiences of all clinical trial participants, not just a small sub-sample. This study also shows that, with appropriate research assistant input, the PaGES Index can be used in different languages by participants with varying literacy levels. TRIAL REGISTRATION Clinical Trials.gov (21/11/2018) (NCT03749902).
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Affiliation(s)
- Andrew Symon
- Mother and Infant Research Unit, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
| | - Kate Lightly
- Clinical Research Fellow, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | - Rachel Howard
- Medical Student, University of Liverpool, Liverpool, L69 3BX, UK
| | - Shuchita Mundle
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Nagpur, India
| | - Brian Faragher
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Molly Hanley
- Medical Student, University of Liverpool, Liverpool, L69 3BX, UK
| | - Jill Durocher
- Gynuity Health Projects (GHP), MOLI Trial Manager, 220 East 42nd Street, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects (GHP), MOLI Trial Manager, 220 East 42nd Street, New York, NY, 10017, USA
| | - Andrew Weeks
- Sanyu Research Department, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK
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John JE, Sakarde A, Misra SS, Mundle S, Jose J, Tripathi SC, Amle D. Evaluating Ischemia-Modified Albumin as an Early Biomarker for Hypertensive Disorders During Pregnancy: A Case-Control Study. Cureus 2022; 14:e30867. [PMID: 36457615 PMCID: PMC9706492 DOI: 10.7759/cureus.30867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 06/17/2023] Open
Abstract
Background Ischemia-modified albumin (IMA) is looked upon as a newer marker of myocardial ischemia. There is a paucity of literature however with regard to studies correlating levels of IMA in patients with hypertensive disorders of pregnancy. The present study therefore aimed at estimating the levels of IMA in patients with gestational hypertension and assessing its utility in predicting hypertensive disorders of pregnancy. Methods The present study was a hospital-based case-control study conducted in the Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Nagpur. IMA was estimated in 30 controls (Group I) and 20 cases of gestational hypertension (Group II) using a spectrophotometric assay detecting free unbound Cobalt left behind. The clinical data and lab results were presented as mean ± SD. Student's t-test was applied and Pearson's correlation coefficient was calculated. A value of p < 0.05 was taken as statistically significant. The ROC (Receiver Operator Characteristic) curve was used to establish the cut-off of serum IMA levels in pregnancy-induced hypertension (PIH). Results There was no significant difference in age and period of gestation (POG) at the time of sample collection between the groups. There was a significant difference in the systolic and diastolic blood pressures (BPs) of both groups. The mean level of serum IMA was significantly higher in cases of gestational hypertension (0.88 ± 0.14 absorbance units {ABSU}) as compared to controls (0.69 ± 0.08 ABSU) (p<0.001). On correlation analysis, the systolic and diastolic BPs were found to be highly positively correlated with serum IMA levels (p<0.001). ROC curve analysis suggested that at a cut-off of 0.73 ABSU, IMA has 85% sensitivity and 80% specificity for predicting gestational hypertension. Conclusion Statistically significant results of serum IMA levels obtained in gestational hypertension which falls on the lesser severe spectrum of the disease imply that serum IMA can be used for early diagnosis of gestational hypertension and impending Pre-eclampsia (PE) and Eclampsia.
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Affiliation(s)
- Jyoti E John
- Biochemistry, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | - Apurva Sakarde
- Biochemistry, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | | | - Shuchita Mundle
- Obstetrics and Gynaecology, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | - Jancy Jose
- Biochemistry, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | | | - Dnyanesh Amle
- Biochemistry, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
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Kamath A, Yadav A, Baghel J, Mundle S. Locked Down: Experiences of Domestic Violence in Central India. Glob Health Sci Pract 2022; 10:e2100630. [PMID: 36041829 PMCID: PMC9426993 DOI: 10.9745/ghsp-d-21-00630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 06/03/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The National Family Health Survey (NFHS-4) data show that 31.1% of women faced domestic violence in 2015-2016, with no reduction since 2005-2006. Emerging data show that since the outbreak of the coronavirus disease (COVID-19), reports of intimate partner violence have increased worldwide because of mandatory lockdowns to curb the spread of the virus. The nature of the current pandemic, which has forced women to spend time with their abusers and restricted their mobility, has made them more vulnerable to abuse. We aimed to determine the proportion of domestic violence among Indian women during the lockdown period. METHODS This is a cross-sectional study, conducted in June-August 2020 on married, Indian women of reproductive age who attended the obstetrics-gynecology outpatient department during the COVID-19 pandemic. The Abuse Assessment Screening questionnaire validated during NFHS-4 (2015-2016) was used as a data collection tool. Our primary objective was to determine the proportion of women presenting to the hospital who were exposed to domestic violence during the lockdown period. Analysis was done using SPSS Statistics V22.0. RESULTS A total of 412 women were recruited for the study. The mean age was 23 years (range 19-52 years). The prevalence of domestic violence in any form was found to be 32.5%, with the majority being verbal abuse in the form of insults, threats of physical violence, or public humiliation. CONCLUSION The results of this study indicated a high proportion of women with a history of domestic violence during the pandemic. Thus, health care policy makers and experts involved in women's care-particularly during crisis conditions such as the COVID-19 pandemic-should be aware of the extent of this problem and take measures to properly address it.
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Affiliation(s)
- Anusha Kamath
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Nagpur, India
| | - Anita Yadav
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Nagpur, India
| | - Jyoti Baghel
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Nagpur, India
| | - Shuchita Mundle
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Nagpur, India.
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Baghel J, Yadav A, Kamath A, Mundle S, Sharma C, Prakash A, Rawat R. The socioeconomic apprehensions of a pregnant woman around COVID-19 – Do we need to be worried? J Family Med Prim Care 2022; 11:963-968. [PMID: 35495843 PMCID: PMC9051699 DOI: 10.4103/jfmpc.jfmpc_979_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/03/2021] [Accepted: 10/08/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction: Coronavirus 2019 (COVID-19) pandemic has become the most severe intercontinental health challenge and pregnant women are deemed to be a special population group. The COVID-19-related restrictions on visiting the hospital for antenatal check-up and procedures may be distressing for them. The present study aims at assessing the level of anxiety and risk perception of pregnant women during the pandemic. Materials and Methods: This cross-sectional observational study included all pregnant women who were above 18 years of age, irrespective of their gestational age. They were administered the pre-designed, pre-tested questionnaire via face-to-face interview. The effect of the COVID-19 pandemic and its influence on women’s experience including her worries were collected. Data analysis was done using SPSS software version 22. Results: A total of 130 pregnant women with a mean maternal age of 26.1 ± 6.5 years were enrolled in the study. The mean gestational age of the women was 19 ± 4.7 weeks and most of them were in the second trimester (48.5%). Most of the pregnant women encountered the adverse socioeconomic influence of COVID-19 on their daily life (55.6% somewhat, 9.1% moderately so, 1.1% very much). Majority of them reported that they had limited their social activities (78.5%) and amorous relationship with their partner (30.8%). Also, around 59.2% of antenatal women experienced a moderate level and 40.7% had a mild level of anxiety. Conclusion: It is essential for obstetric providers to do prompt identification of mental health concerns in perinatal women and to liaise with mental health professionals to provide relevant interference.
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Bracken H, Lightly K, Mundle S, Kerr R, Faragher B, Easterling T, Leigh S, Turner M, Alfirevic Z, Winikoff B, Weeks A. Oral Misoprostol alone versus oral misoprostol followed by oxytocin for labour induction in women with hypertension in pregnancy (MOLI): protocol for a randomised controlled trial. BMC Pregnancy Childbirth 2021; 21:537. [PMID: 34325670 PMCID: PMC8320158 DOI: 10.1186/s12884-021-04009-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Every year approximately 30,000 women die from hypertensive disease in pregnancy. Magnesium sulphate and anti-hypertensives reduce morbidity, but delivery is the only cure. Low dose oral misoprostol, a prostaglandin E1 analogue, is a highly effective method for labour induction. Usually, once active labour has commenced, the misoprostol is replaced with an intravenous oxytocin infusion if ongoing stimulation is required. However, some studies have shown that oral misoprostol can be continued into active labour, a simpler and potentially more acceptable protocol for women. To date, these two protocols have never been directly compared. METHODS This pragmatic, open-label, randomised trial will compare a misoprostol alone labour induction protocol with the standard misoprostol plus oxytocin protocol in three Indian hospitals. The study will recruit 520 pregnant women being induced for hypertensive disease in pregnancy and requiring augmentation after membrane rupture. Participants will be randomised to receive either further oral misoprostol 25mcg every 2 h, or titrated intravenous oxytocin. The primary outcome will be caesarean birth. Secondary outcomes will assess the efficacy of the induction process, maternal and fetal/neonatal complications and patient acceptability. This protocol (version 1.04) adheres to the SPIRIT checklist. A cost-effectiveness analysis, situational analysis and formal qualitative assessment of women's experience are also planned. DISCUSSION Avoiding oxytocin and continuing low dose misoprostol into active labour may have a number of benefits for both women and the health care system. Misoprostol is heat stable, oral medication and thus easy to store, transport and administer; qualities particularly desirable in low resource settings. An oral medication protocol requires less equipment (e.g. electronic infusion pumps) and may free up health care providers to assist with other aspects of the woman's care. The simplicity of the protocol may also help to reduce human errors associated with the delivery of intravenous infusions. Finally, women may prefer to be mobile during labour and not restricted by an intravenous infusion. There is a need, therefore, to assess whether augmentation using oral misoprostol is superior clinically and economically to the standard protocol of intravenous oxytocin. TRIAL REGISTRATION Clinical Trials.gov, NCT03749902 , registered on 21st Nov 2018.
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Affiliation(s)
- Hillary Bracken
- Gynuity Health Projects, 220 East 42nd Street, Suite 710, New York, NY, 10017, USA
| | - Kate Lightly
- Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS, UK
| | - Shuchita Mundle
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Plot no 2, Sector 20, Mihan, Nagpur, 441108, India
| | - Robbie Kerr
- Fetal Medicine, St Michael's Hospital, Marlborough Street, BS1 3NU, Bristol, UK
| | - Brian Faragher
- Medical Statistics, LSTM Clinical Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Thomas Easterling
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, 98195, USA
| | - Simon Leigh
- Nexus Clinical Analytics, Ltd, 15 Glencroft, Euxton, PR7 6BX, Lancashire, UK
| | - Mark Turner
- Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS, UK
| | - Zarko Alfirevic
- Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS, UK
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street, Suite 710, New York, NY, 10017, USA
| | - Andrew Weeks
- Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS, UK.
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Yadav A, Kamath A, Mundle S, Baghel J, Sharma C, Prakash A. Exploring the perspective of nursing staff or caregivers on birthing positions in Central India. J Family Med Prim Care 2021; 10:1149-1154. [PMID: 34041142 PMCID: PMC8140275 DOI: 10.4103/jfmpc.jfmpc_2066_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/02/2020] [Accepted: 12/08/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Maternal birthing positions refer to the various physical postures a pregnant mother may assume at the time of delivery. The World Health Organisation recommends that woman should be given an opportunity to make a choice on the type of position to use during labour. Alternative birth positions are associated with lower incidence rates of performing episiotomy, less perineal tears and less use of instrumental deliveries. Nurses' perspective on women's positions has rarely been explored in India. Present study aims at assessing the knowledge regarding alternative birth positions among nursing officers. Materials and Methods This cross-sectional observational study was conducted on 52 nursing officers who were posted in the labour room. A pretested questionnaire was administered to them. Data analysis was done using SPSS software version 22. Results Majority (82.7%) of nursing officers felt that there is a need of giving a choice to the woman regarding alternate birth position. 76.9% of them were aware of position other than lithotomy. Around 48.1% would recommend squatting position to a woman in labour. Ease and convenience in conducting the delivery was the foremost reason chosen in advocating a birth position. Whereas overcrowding in the labour room, ignorance about alternate positions and difficulty in converting to instrumental delivery were cited as reasons of not recommending these positions. Conclusion Educating nursing officers about emerging evidence regarding birthing positions will enable them to give accurate information to women.
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Affiliation(s)
- Anita Yadav
- Department of Obstetrics and Gynecology, AIIMS, Nagpur, Maharashtra, India
| | - Anusha Kamath
- Department of Obstetrics and Gynecology, AIIMS, Nagpur, Maharashtra, India
| | - Shuchita Mundle
- Department of Obstetrics and Gynecology, AIIMS, Nagpur, Maharashtra, India
| | - Jyoti Baghel
- Department of Obstetrics and Gynecology, AIIMS, Nagpur, Maharashtra, India
| | - Charu Sharma
- Department of Obstetrics and Gynecology, AIIMS, Jodhpur, Rajasthan, India
| | - Avinash Prakash
- Department of Anesthesiology, AIIMS, Nagpur, Maharashtra, India
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Kemper JI, Li W, Goni S, Flanagan M, Weeks A, Alfirevic Z, Bracken H, Mundle S, Goonewardene M, Ten Eikelder M, Bloemenkamp K, Rengerink KO, Kruit H, Mol BW, Palmer KR. Foley catheter vs oral misoprostol for induction of labor: individual participant data meta-analysis. Ultrasound Obstet Gynecol 2021; 57:215-223. [PMID: 33258514 DOI: 10.1002/uog.23563] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/15/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To compare the effectiveness and safety of Foley catheter and oral misoprostol for induction of labor (IOL). METHODS The Cochrane Review on Mechanical Methods for Induction of Labour and Ovid MEDLINE, EMBASE via Ovid, Ovid Emcare, CINAHL Plus, ClinicalTrials.gov and Scopus, from inception to April 2019, were searched for randomized controlled trials (RCTs) comparing Foley catheter to oral misoprostol for IOL in viable singleton gestations. Eligible trials for which raw data were obtained were included and individual participant data meta-analysis was performed. Primary outcomes were vaginal birth, a composite of adverse perinatal outcome (including stillbirth, neonatal death, neonatal seizures, admission to the neonatal intensive care unit, severe respiratory compromise or meconium aspiration syndrome) and a composite of adverse maternal outcome (including admission to the intensive care unit, maternal infection, severe postpartum hemorrhage, maternal death or uterine rupture). The quality of the included RCTs was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence was evaluated using the GRADE approach. A two-stage random-effects model was used for meta-analysis according to the intention-to-treat principle and interactions between treatment and baseline characteristics were assessed. RESULTS Of seven eligible trials, four provided individual participant data for a total of 2815 participants undergoing IOL, of whom 1399 were assigned to Foley catheter and 1416 to oral misoprostol. All four trials provided data for each of the primary outcomes in all 2815 women. Compared with those receiving oral misoprostol, Foley catheter recipients had a slightly decreased chance of vaginal birth (risk ratio (RR), 0.95 (95% CI, 0.91-0.99); I2 , 2.0%; moderate-certainty evidence). A trend towards a lower rate of composite adverse perinatal outcome was found in women undergoing IOL using a Foley catheter compared with oral misoprostol (RR, 0.71 (95% CI, 0.48-1.05); I2 , 14.9%; low-certainty evidence). Composite adverse maternal outcome did not differ between the groups (RR, 1.00 (95% CI, 0.97-1.03); I2 , 0%; moderate-certainty evidence). Meta-analyses of effect modifications did not show significant interactions between intervention and parity or gestational age for any of the primary outcomes. CONCLUSIONS For women undergoing IOL, Foley catheter is less effective than oral misoprostol, as it was associated with fewer vaginal births. However, while we found no significant difference in maternal safety, Foley catheter induction may reduce adverse perinatal outcomes. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J I Kemper
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - W Li
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - S Goni
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - M Flanagan
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - A Weeks
- Department of Women's & Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - Z Alfirevic
- Department of Women's & Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - H Bracken
- Gynuity Health Projects, New York, NY, USA
| | - S Mundle
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, Nagpur, India
| | - M Goonewardene
- Department of Obstetrics & Gynaecology, University of Ruhuna, Galle, Sri Lanka
| | - M Ten Eikelder
- Leiden University Medical Center, Leiden, The Netherlands
| | - K Bloemenkamp
- Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - K O Rengerink
- Julius Center for Health Science and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Kruit
- Department of Obstetrics & Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - B W Mol
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
- Monash Women's, Monash Health, Melbourne, Australia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - K R Palmer
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
- Monash Women's, Monash Health, Melbourne, Australia
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Kachikis A, Eckert LO, Walker C, Bardají A, Varricchio F, Lipkind HS, Diouf K, Huang WT, Mataya R, Bittaye M, Cutland C, Boghossian NS, Mallett Moore T, McCall R, King J, Mundle S, Munoz FM, Rouse C, Gravett M, Katikaneni L, Ault K, Klein NP, Roberts DJ, Kochhar S, Chescheir N. Chorioamnionitis: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2019; 37:7610-7622. [PMID: 31783982 PMCID: PMC6891229 DOI: 10.1016/j.vaccine.2019.05.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/09/2019] [Indexed: 12/26/2022]
Affiliation(s)
| | | | | | - Azucena Bardají
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | | | - Khady Diouf
- Brigham and Women's Hospital, Boston, MA, USA
| | | | - Ronald Mataya
- Loma Linda University, Loma Linda, CA, USA; University of Malawi College of Medicine, Malawi
| | - Mustapha Bittaye
- Edward Francis Small Teaching Hospital, Banjul, The Gambia; Medical Research Council - The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia; University of The Gambia School of Medicine & Allied Health Sciences, The Gambia
| | - Clare Cutland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Johannesburg, South Africa; Department of Science and Technology National Research Foundation, Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nansi S Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | | | | | | | | | | | - Caroline Rouse
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Kevin Ault
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Nicola P Klein
- Kaiser Permanente Vaccine Study Centre, Oakland, CA, USA
| | | | - Sonali Kochhar
- Global Healthcare Consulting, India; Erasmus University Medical Center, Rotterdam, the Netherlands; University of Washington, Seattle, WA, USA
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Easterling T, Mundle S, Bracken H, Parvekar S, Mool S, Magee LA, von Dadelszen P, Shochet T, Winikoff B. Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial. Lancet 2019; 394:1011-1021. [PMID: 31378394 PMCID: PMC6857437 DOI: 10.1016/s0140-6736(19)31282-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/15/2019] [Accepted: 05/24/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypertension is the most common medical disorder in pregnancy, complicating one in ten pregnancies. Treatment of severely increased blood pressure is widely recommended to reduce the risk for maternal complications. Regimens for the acute treatment of severe hypertension typically include intravenous medications. Although effective, these drugs require venous access and careful fetal monitoring and might not be feasible in busy or low-resource environments. We therefore aimed to compare the efficacy and safety of three oral drugs, labetalol, nifedipine retard, and methyldopa for the management of severe hypertension in pregnancy. METHODS In this multicentre, parallel-group, open-label, randomised controlled trial, we compared these oral antihypertensives in two public hospitals in Nagpur, India. Pregnant women were eligible for the trial if they were aged at least 18 years; they were pregnant with fetuses that had reached a gestational age of at least 28 weeks; they required pharmacological blood pressure control for severe hypertension (systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg); and were able to swallow oral medications. Women were randomly assigned to receive 10 mg oral nifedipine, 200 mg oral labetalol (hourly, in both of which the dose could be escalated if hypertension was maintained), or 1000 mg methyldopa (a single dose, without dose escalation). Masking of participants, study investigators, and care providers to group allocation was not possible because of different escalation protocols in the study groups. The primary outcome was blood pressure control (defined as 120-150 mm Hg systolic blood pressure and 70-100 mm Hg diastolic blood pressure) within 6 h with no adverse outcomes. This study is registered with ClinicalTrials.gov, number NCT01912677, and the Clinical Trial Registry, India, number ctri/2013/08/003866. FINDINGS Between April 1, 2015, and Aug 21, 2017, we screened 2307 women for their inclusion in the study. We excluded 1413 (61%) women who were ineligible, declined to participate, had impending eclampsia, were in active labour, or had a combination of these factors. 11 (4%) women in the nifedipine group, ten (3%) women in the labetalol group, and 11 (4%) women in the methyldopa group were ineligible for treatment (because they had only one qualifying blood pressure measurement) or had treatment stopped (because of delivery or transfer elsewhere). 894 (39%) women were randomly assigned to a treatment group and were included in the intention-to-treat analysis: 298 (33%) women were assigned to receive nifedipine, 295 (33%) women were assigned to receive labetalol, and 301 (33%) women were assigned to receive methyldopa. The primary outcome was significantly more common in women in the nifedipine group than in those in the methyldopa group (249 [84%] women vs 230 [76%] women; p=0·03). However, the primary outcome did not differ between the nifedipine and labetalol groups (249 [84%] women vs 228 [77%] women; p=0·05) or the labetalol and methyldopa groups (p=0·80). Seven serious adverse events (1% of births) were reported during the study: one (<1%) woman in the labetalol group had an intrapartum seizure and six (1%) neonates (one [<1%] neonate in the nifedipine group, two [1%] neonates in the labetalol group, and three [1%] neonates in the methyldopa group) were stillborn. No birth had more than one adverse event. INTERPRETATION All oral antihypertensives reduced blood pressure to the reference range in most women. As single drugs, nifedipine retard use resulted in a greater frequency of primary outcome attainment than labetalol or methyldopa use. All three oral drugs-methyldopa, nifedipine, and labetalol-are viable initial options for treating severe hypertension in low-resource settings. FUNDING PREEMPT (University of British Columbia, Vancouver, BC, Canada; grantee of Bill & Melinda Gates Foundation).
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Affiliation(s)
- Thomas Easterling
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Shuchita Mundle
- Department of Obstetrics and Gynecology, Government Medical College, Nagpur, India
| | | | - Seema Parvekar
- Department of Obstetrics and Gynaecology, Daga Memorial Women's Government Hospital, Nagpur, India
| | - Sulabha Mool
- Department of Obstetrics and Gynaecology, Daga Memorial Women's Government Hospital, Nagpur, India
| | - Laura A Magee
- Department of Women and Children's Health, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, London, UK
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Leigh S, Granby P, Haycox A, Mundle S, Bracken H, Khedikar V, Mulik J, Faragher B, Easterling T, Turner MA, Alfirevic Z, Winikoff B, Weeks AD. Foley catheter vs. oral misoprostol to induce labour among hypertensive women in India: a cost-consequence analysis alongside a clinical trial. BJOG 2018; 125:1734-1742. [PMID: 29782065 PMCID: PMC6282740 DOI: 10.1111/1471-0528.15285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low-resource settings. DESIGN Cost-consequence analysis of a previously reported multicentre, parallel, open-label randomised trial. SETTING & POPULATION A total of 602 women with a live fetus, aged ≥18 years requiring delivery for pre-eclampsia or hypertension, in two public hospitals in Nagpur, India. METHODS We performed a formal economic evaluation alongside the INFORM clinical trial. Women were randomised to receive transcervical Foley catheterisation or oral misoprostol 25 mcg. Healthcare expenditure was calculated using a provider-side microcosting approach. MAIN OUTCOME MEASURES Rates of vaginal this delivery within 24 hours of induction, healthcare expenditure per completed treatment episode. RESULTS Induction with oral misoprostol resulted in a (mean difference) $20.6USD reduction in healthcare expenditure [95% CI (-) $123.59 (-) $72.49], and improved achievement of vaginal delivery within 24 hours of induction, mean difference 10% [95% CI (-2 to 17.9%), P = 0.016]. Oxytocin administration time was reduced by 135.3 minutes [95% CI (84.4-186.2 minutes), P < 0.01] and caesarean sections by 9.1% [95% CI (1.1-17%), P = 0.025] for those receiving oral misoprostol. Following probabilistic sensitivity analysis, oral misoprostol was cost-saving in 63% of 5,000 bootstrap replications and achieved superior rates of vaginal delivery, delivery within 24 hours of induction and vaginal delivery within 24 hours of induction in 98.7%, 90.7%, and 99.4% of bootstrap simulations. Based on univariate threshold analysis, the unit price of oral misoprostol 25 mcg could feasibly increase 31-fold from $0.24 to $7.50 per 25 mcg tablet and remain cost-saving. CONCLUSION Compared to Foley catheterisation for the induction of high-risk hypertensive women, oral misoprostol improves rates of vaginal delivery within 24 hours of induction and may also reduce costs. Additional research performed in other low-resource settings is required to determine their relative cost-effectiveness. TWEETABLE ABSTRACT Oral misoprostol less costly and more effective than Foley catheter for labour induction in hypertension.
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Affiliation(s)
- S Leigh
- University of Liverpool Management SchoolLiverpoolUK
| | - P Granby
- University of Liverpool Management SchoolLiverpoolUK
| | - A Haycox
- University of Liverpool Management SchoolLiverpoolUK
| | - S Mundle
- Department of Obstetrics & GynaecologyGovernment Medical CollegeNagpurIndia
| | - H Bracken
- Gynuity Health ProjectsNew YorkNYUSA
| | - V Khedikar
- Daga Memorial Women's Government HospitalNagpurIndia
| | - J Mulik
- Department of Obstetrics & GynaecologyGovernment Medical CollegeNagpurIndia
| | - B Faragher
- Medical Statistics UnitDepartment of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUK
| | - T Easterling
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWAUSA
| | - MA Turner
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
| | - Z Alfirevic
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
| | | | - AD Weeks
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
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Easterling T, Mundle S, Bracken H, Magee L, Dadelszen PV, Winikoff B. 199. Oral antihypertensive treatment of severe hypertension in pregnancy – A randomized trial of 3 regimens. Pregnancy Hypertens 2018. [DOI: 10.1016/j.preghy.2018.08.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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12
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Mundle S, Bracken H, Khedikar V, Mulik J, Faragher B, Easterling T, Leigh S, Granby P, Haycox A, Turner MA, Alfirevic Z, Winikoff B, Weeks AD. Foley catheterisation versus oral misoprostol for induction of labour in hypertensive women in India (INFORM): a multicentre, open-label, randomised controlled trial. Lancet 2017; 390:669-680. [PMID: 28668289 DOI: 10.1016/s0140-6736(17)31367-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/19/2017] [Accepted: 02/01/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Between 62 000 and 77 000 women die annually from pre-eclampsia and eclampsia. Prompt delivery, preferably by the vaginal route, is vital for good maternal and neonatal outcomes. Two low-cost interventions-low-dose oral misoprostol tablets and transcervical Foley catheterisation-are already used in low-resource settings. We aimed to compare the relative risks and benefits of these interventions. METHODS We undertook this multicentre, open-label, randomised controlled trial in two public hospitals in Nagpur, India. Women (aged ≥18 years) who were at 20 weeks' gestation or later with a live fetus and required delivery as a result of pre-eclampsia or hypertension were randomly assigned (1:1), via computer-generated block randomisation (block sizes of four, six, and eight) with concealment by use of opaque, sequentially numbered, sealed envelopes, to receive labour induction with either oral misoprostol 25 μg every 2 h (maximum of 12 doses) or a transcervical Foley catheter (silicone, size 18 F with 30 mL balloon). Randomisation was stratified by study centre. The catheter remained in place until active labour started, the catheter fell out, or 12 h had elapsed. If the catheter did not fall out within 12 h, induction continued with artificial membrane rupture and oxytocin, administered through a micro-drip gravity infusion set. Fetal monitoring was by intermittent auscultation. The primary outcome was vaginal birth within 24 h. Due to the nature of the interventions, masking of participants, study investigators, and care providers to group allocation was not possible. We analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01801410. FINDINGS Between Dec 20, 2013, and June 29, 2015, we randomly assigned 602 women to induction with misoprostol (n=302) or the Foley catheter (n=300; intention-to-treat population). Vaginal birth within 24 h was more common in women in the misoprostol group than in the Foley catheter group (172 [57·0%] vs 141 [47·0%] women; absolute risk difference 10·0%, 95% CI 2·0-17·9; p=0·0136). Rates of uterine hyperstimulation were low in both the misoprostol and Foley catheter groups (two [0·7%] vs one [0·3%] cases; absolute risk difference 0·3%, 95% CI -0·8 to 1·5; p=0·566) and neonatal deaths did not differ significantly between groups (six [2·0%] vs three [1·0%] neonatal deaths; 1·0, -1·04 to 2·97; p=0·322). 17 serious adverse events (3%) were reported during the study: one case of intrapartum convulsion and one case of disseminated intravascular coagulation (both in the Foley group); ten perinatal deaths, including two stillbirths (both in the Foley catheter group) and eight neonatal deaths (n=5 in the misoprostol group and n=3 in the Foley catheter group); and five of neonatal morbidity, comprising birth asphyxia (n=3), septicaemia (n=1), and neonatal convulsion (n=1). INTERPRETATION Oral misoprostol was more effective than transcervical Foley catheterisation for induction of labour in women with pre-eclampsia or hypertension. Future studies are required to assess whether oxytocin augmentation following misoprostol can be replaced by regular doses of oral misoprostol tablets. FUNDING Medical Research Council, Department for International Development, and Wellcome Trust Joint Global Health Trials Scheme.
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Affiliation(s)
- Shuchita Mundle
- Department of Obstetrics and Gynecology, Government Medical College, Nagpur, India
| | | | | | - Jayashree Mulik
- Department of Obstetrics and Gynecology, Government Medical College, Nagpur, India
| | - Brian Faragher
- Medical Statistics Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas Easterling
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Simon Leigh
- University of Liverpool Management School, Liverpool, UK
| | - Paul Granby
- University of Liverpool Management School, Liverpool, UK
| | - Alan Haycox
- University of Liverpool Management School, Liverpool, UK
| | - Mark A Turner
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - Zarko Alfirevic
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | | | - Andrew D Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK.
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Kerr R, Eckert LO, Winikoff B, Durocher J, Meher S, Fawcus S, Mundle S, Mol B, Arulkumaran S, Khan K, Wandwabwa J, Kochhar S, Weeks A. Postpartum haemorrhage: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2016; 34:6102-6109. [PMID: 27431424 PMCID: PMC5139805 DOI: 10.1016/j.vaccine.2016.03.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 12/02/2022]
Affiliation(s)
| | | | | | | | | | - Sue Fawcus
- Mowbray Maternity Hospital, South Africa
| | | | - Ben Mol
- University of Adelaide, Australia
| | | | - Khalid Khan
- Barts and The London School of Medicine and Dentistry, UK
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Bracken H, Mundle S, Faragher B, Easterling T, Haycox A, Turner M, Alfirevic Z, Winikoff B, Weeks A. Induction of labour in pre-eclamptic women: a randomised trial comparing the Foley balloon catheter with oral misoprostol. BMC Pregnancy Childbirth 2014; 14:308. [PMID: 25193157 PMCID: PMC4261642 DOI: 10.1186/1471-2393-14-308] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 07/09/2014] [Indexed: 12/18/2022] Open
Abstract
Background Between 40,000 and 80,000 pregnant women die annually from pre-eclampsia and eclampsia. Although magnesium sulphate and anti-hypertensive therapies can reduce the morbidity and mortality associated with pre-eclampsia, the only cure comes with delivery. Prompt delivery of the baby, preferably by vaginal route, is vital in order to achieve good maternal and neonatal outcomes. Induction of labour is therefore a critical intervention in order to prevent morbidity to both mother and baby. Two low cost interventions – oral misoprostol tablets and transcervical Foley catheterization – are already used by some in low resource settings, but their relative risks and benefits are not known. The trial will compare the risks, benefits, and trade-offs in efficacy, safety, acceptability and cost of misoprostol and Foley catheter for induction in women with preeclampsia or uncontrolled hypertension. Methods/Design A total of 602 women with an ongoing pregnancy with a live fetus requiring delivery because of pre-eclampsia or uncontrolled hypertension will be randomly assigned to labor induction with a transcervical Foley catheter or oral misoprostol 25 micrograms. Women will be recruited at two hospitals in Nagpur, India. The misoprostol group will receive oral misoprostol 25 microgram every 2 hours for a maximum of 12 doses or until active labor commences. The Foley group will undergo induction using a Foley catheter (silicone, size 18 F with 30 ml balloon) which will remain until active labor starts, the Foley catheter falls out, or 12 hours have elapsed. The primary outcome will be the attainment of vaginal delivery within 24 hours. Providers administering the treatment and those assessing the outcomes will not be blinded to group assignment. Trial registration NCT01801410 (ClinicalTrials.gov).
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Affiliation(s)
- Hillary Bracken
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY 10010, USA.
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Bracken H, Dabash R, Tsertsvadze G, Posohova S, Shah M, Hajri S, Mundle S, Chelli H, Zeramdini D, Tsereteli T, Platais I, Winikoff B. A two-pill sublingual misoprostol outpatient regimen following mifepristone for medical abortion through 70 days' LMP: a prospective comparative open-label trial. Contraception 2014; 89:181-6. [DOI: 10.1016/j.contraception.2013.10.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
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Salinger DH, Mundle S, Regi A, Bracken H, Winikoff B, Vicini P, Easterling T. Magnesium sulphate for prevention of eclampsia: are intramuscular and intravenous regimens equivalent? A population pharmacokinetic study. BJOG 2013; 120:894-900. [PMID: 23530757 DOI: 10.1111/1471-0528.12222] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare magnesium sulphate concentrations achieved by intramuscular and intravenous regimens used for the prevention of eclampsia. SETTING Low-resource obstetric hospitals in Nagpur and Vellore, India. POPULATION Pregnant women at risk for eclampsia due to hypertensive disease. METHODS A pharmacokinetic study was performed as part of a randomised trial that enrolled 300 women comparing intramuscular and intravenous maintenance regimens of magnesium dosing. Data from 258 enrolled women were analysed in the pharmacokinetic study. A single sample was drawn per woman with the expectation of using samples in a pooled data analysis. MAIN OUTCOME MEASURES Pharmacokinetic parameters of magnesium distribution and clearance. RESULTS Magnesium clearance was estimated to be 48.1 dl/hour, volume of distribution to be 156 dl and intramuscular bioavailability to be 86.2%. The intramuscular regimen produced higher initial serum concentrations, consistent with a substantially larger loading dose. At steady state, magnesium concentrations in the intramuscular and intravenous groups were comparable. With either regimen, a substantial number of women would be expected to have serum concentrations lower than those generally held to be therapeutic. CONCLUSIONS Clinical implications were that a larger loading dose for the intravenous regimen should be considered; where feasible, individualised dosing of magnesium sulphate would reduce the variability in serum concentrations and might result in more women with clinically effective magnesium concentrations; and lower dose magnesium sulphate regimens should be considered with caution.
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Affiliation(s)
- D H Salinger
- Department of Bioengineering, University of Washington, Seattle, WA, USA
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Jejeebhoy SJ, Kalyanwala S, Mundle S, Tank J, Zavier AJF, Kumar R, Acharya R, Jha N. Feasibility of expanding the medication abortion provider base in India to include ayurvedic physicians and nurses. Int Perspect Sex Reprod Health 2013; 38:133-42. [PMID: 23018135 DOI: 10.1363/3813312] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
CONTEXT The availability of trained abortion providers is limited in India. Allowing ayurvedic physicians and nurses to perform medication abortions may improve women's access to the procedure, but it is unclear whether these clinicians can provide these services safely and effectively. METHODS Allopathic physicians, ayurvedic physicians and nurses (10 of each), none of whom had experience in abortion provision, were trained to perform medication abortions. In 2008-2010, these providers performed medication abortions in five clinics in Bihar and Jharkhand for 1,225 women with a pregnancy of up to eight weeks' gestation. A two-sided equivalence design was used to test whether providers' assessments of client eligibility and completeness of abortion matched those of an experienced physician "verifier," and whether medication abortions performed by nurses and ayurvedic physicians were as safe and effective as those done by allopathic physicians. RESULTS Failure rates were low (5-6%), and those for nurses and ayurvedic physicians were statistically equivalent to those for allopathic physicians. Provider assessments of client eligibility and completeness of abortion differed from those of the verifier in only a small proportion of cases (3-4% for eligibility and 4-5% for completeness); these proportions, and rates of loss to follow-up, were statistically equivalent among provider types. No serious complications were observed, and services by all three groups of providers were acceptable to women. CONCLUSION Findings support amending existing laws to improve women's access to medication abortion by expanding the provider base to include ayurvedic physicians and nurses.
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Jejeebhoy SJ, Kalyanwala S, Zavier AF, Kumar R, Mundle S, Tank J, Acharya R, Jha N. Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India. Contraception 2011; 84:615-21. [DOI: 10.1016/j.contraception.2011.08.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/10/2011] [Accepted: 08/17/2011] [Indexed: 11/30/2022]
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Mundle S, Regi A, Biswas B, Bracken H, Easterling T, Winikoff B. O645 Preeclampsia in low-resource settings: A randomized trial of IV MgSO4 via flow controlled pump. Int J Gynaecol Obstet 2011. [DOI: 10.1016/s0020-7292(09)61018-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Barua A, Mundle S, Bracken H, Easterling T, Winikoff B. Facility and personnel factors influencing magnesium sulfate use for eclampsia and pre-eclampsia in 3 Indian hospitals. Int J Gynaecol Obstet 2011; 115:231-4. [PMID: 21930268 DOI: 10.1016/j.ijgo.2011.07.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 07/06/2011] [Accepted: 08/17/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify factors at the health facility and health professional levels that might hinder or facilitate the appropriate use of magnesium sulfate for the treatment of pre-eclampsia and eclampsia. METHODS Seven focus group discussions were conducted with a purposively sampled group of obstetricians/gynecologists, medical residents, and nurses at 3 hospitals in Nagpur, India. Data were collected on facility and drug availability, criteria for diagnosis and management of pre-eclampsia and eclampsia, attitudes about magnesium sulfate use, and perceived barriers to the treatment of pre-eclampsia and eclampsia. RESULTS Senior gynecologists seemed to encourage the use of magnesium sulfate, especially management prior to transfer to a higher facility. However, clinicians noted a lack of specific institutional guidelines on dose, timing, and indications, particularly in cases in which delivery was not imminent. In all facilities, service providers noted that their clinical care decisions were sometimes influenced by political and social factors, making management of eclampsia and pre-eclampsia cases difficult. Care was further challenged by limited drug availability, particularly at the tertiary-care center. CONCLUSION Limited drug supply and lack of specific institutional guidelines, equipment, and trained staff hinder the translation of evidence-based policy on magnesium sulfate into practice.
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Moyo VM, Lefebvre P, Vekeman F, Duh MS, Yektashenas B, Mundle S. Comparison of erythroid response (ER) rates to epoetin alfa (EPO) alone or in combination versus non-erythropoiesis-stimulating agents (non-ESAs) in treatment-naïve anemic MDS patients: A meta-analysis approach. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.7094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Moyo VM, Lefebvre P, Duh M, Yektashenas B, Mundle S. Treating the anemia of MDS with erythropoietin: Impact of higher dose compared to combination with G/GM-CSF. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.7082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7082 Background: Recombinant human erythropoietin (EPO) is extensively used to improve erythropoiesis and reduce transfusions in anemic MDS pts. The addition of G/GM-CSF to EPO alfa or beta has been associated with higher erythroid response (ER) rates vs. EPO alone. Studies suggest higher ER rates could be achieved with EPO monotherapy if higher initiation doses were used. To study this question a meta-analysis was performed on studies of MDS pts treated with EPO alfa or beta + G/GM-CSF. Methods: Data extraction was performed on studies from PubMed, ASCO and ASH proceedings from 1990–2006 in MDS pts treated with EPO (alfa or beta) ± G/GM-CSF. To allow for cross comparisons, only studies including IWG or IWG-like ER criteria were selected for analysis. Pooled estimates of ER rates were calculated using fixed-effect (F-E) meta-analysis methods. Results were stratified by: (i) EPO-alfa at standard doses, (ii) EPO- alfa at high doses, (iii) EPO-alfa + G/GM-CSF, and (iv) EPO-beta + G/GM-CSF. Results: From 39 studies identified, 19 met inclusion criteria. Most pts (>55%) had RA/RARS. Studies using EPO-alfa at standard doses showed comparable ER rates to studies using EPO- alfa + G/GM-CSF (49.0% vs. 50.6%; p=0.731) ( Table ). Among EPO-alfa studies, those using higher EPO doses had higher ER rates vs. studies using standard EPO doses (p<0.001) or EPO + G/GM-CSF combination (p=0.007). Overall ER rates were not available for studies using EPO- beta + G/GM-CSF, however, 52 pts (37.7%) had major ER, similar to that observed in all EPO-alfa monotherapy studies (195/589=33.1%). Conclusions: These findings suggest increasing EPO-alfa dose may have a greater impact on ER than addition of G/GM-CSF. Further validation is warranted. [Table: see text] [Table: see text]
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Affiliation(s)
- V. M. Moyo
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
| | - P. Lefebvre
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
| | - M. Duh
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
| | - B. Yektashenas
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
| | - S. Mundle
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
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Mundle S, Elul B, Anand A, Kalyanwala S, Ughade S. Increasing access to safe abortion services in rural India: experiences with medical abortion in a primary health center. Contraception 2007; 76:66-70. [PMID: 17586140 DOI: 10.1016/j.contraception.2007.03.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Revised: 02/14/2007] [Accepted: 03/21/2007] [Indexed: 11/30/2022]
Abstract
INTRODUCTION To increase access to safe abortion in rural India, the feasibility and acceptability of mifepristone-misoprostol abortion was assessed in a typical government run primary health center (PHC) in Nagpur district, Maharashtra State, that does not offer surgical abortion services and must refer off-site for emergency and backup services. MATERIALS AND METHODS Consenting pregnant women (n=149) with <or=56 days amenorrhea seeking terminations received 200 mg mifepristone, and returned 48 h later for 400-microg sublingual misoprostol and 12 days later for abortion confirmation. Surgical backup was conducted at a nearby community health center (CHC). RESULTS Nearly all women (98.6%) with known outcomes had successful medical abortions, and those who did not (1.4%) were successfully referred to the CHC for surgical backup. Women reported the method's ease and simplicity as the best features. CONCLUSION Medical abortion provision is feasible and acceptable in an Indian rural PHC that does not offer surgical abortion services. This study suggests that introduction of medical abortion at lower levels of the health-care system could increase access to safe abortion in rural India.
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Affiliation(s)
- Shuchita Mundle
- Department of Obstetrics and Gynaecology, Government Medical College, Nagpur 440003, India
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Moyo V, Lefebvre P, Duh MS, Bourezak A, Yektashenas B, Woodman RC, Mundle S. Erythroid response (ER) rates in myelodysplastic syndromes (MDS) patients treated with epoetin alfa (EPO): A meta-analysis using the International Working Group criteria (IWGc) for MDS response. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.6572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6572 Background: Refractory anemia is a clinical hallmark of MDS. The most consistently used therapy for this anemia is EPO. Prior to the introduction of IWGc in 1997, ER rates varied substantially between studies. The present meta-analysis was undertaken to compare ER rates in studies of EPO-treated patients in MDS when defined by either IWGc or non-IWGc. Methods: A systematic review and data extraction of studies published from 1990–2005 in MDS patients treated with EPO was performed and yielded 21 studies evaluating a total of 895 patients. Pooled estimates of ER rates, stratified by IWGc, were calculated using random-effects meta-analysis methods, which incorporated both between- and within-study variations. Univariate meta-regression analyses were conducted to identify study characteristics that were significant determinants of ER rate. Results: Ten studies (604 patients) used the IWGc to define ER (overall, major, minor), while 11 studies (291 patients) used other definitions. Mean age for all patients was 70.6 years; 45% women. Mean baseline (BL) serum erythropoietin level and proportion of patients with refractory anemia or refractory anemia with ringed sideroblasts were comparable between studies; however, the proportion of transfusion-dependent patients at BL was lower in the IWG studies vs the non-IWG studies (36% vs. 84%, respectively, p<.001). The pooled estimate of ER rate was significantly higher for the IWG studies compared to the non-IWG studies (50.5%, 95% CI: 38.6%-62.3% vs. 27.8%, 95% CI: 22.7%-32.8% respectively, p=.002). Among patients in the IWG studies who achieved an ER, 62% (188/305) achieved a major ER. Studies reporting mean BL serum erythropoietin level <400mU/mL, <65% of patients transfusion-dependent at BL and use of subcutaneous EPO were found to be associated with higher ER rates. Conclusions: This meta-analysis of MDS patients treated with EPO demonstrates significantly higher ER rates in studies utilizing IWGc. These findings may be due to more refined definitions of ER and MDS diagnostic criteria as well as improvement in the management of anemia. [Table: see text]
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Affiliation(s)
- V. Moyo
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - P. Lefebvre
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - M. S. Duh
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - A. Bourezak
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - B. Yektashenas
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - R. C. Woodman
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - S. Mundle
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
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Alvi S, Shaher A, Shetty V, Henderson B, Dangerfield B, Zorat F, Joshi L, Anthwal S, Lisak L, Little L, Gezer S, Mundle S, Reddy PL, Allampallam K, Huang X, Galili N, Borok RZ, Raza A. Successful establishment of long-term bone marrow cultures in 103 patients with myelodysplastic syndromes. Leuk Res 2001; 25:941-54. [PMID: 11597729 DOI: 10.1016/s0145-2126(01)00061-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We used bone marrow biopsies instead of mononuclear cells to maintain long-term cultures from 103 patients belonging to all five sub-categories of myelodysplastic syndromes (MDS), as well as 12 normal controls. By week 4, 30-50% confluency was reached and could be maintained for up to 12 weeks with 100% confluency. The four prominent cells were fibroblasts, macrophages, endothelial cells and adipocytes. Immunohistochemical and electron microscopic studies provided lineage confirmation. Normal hematopoiesis was well supported by MDS stroma. Neither the FAB nor cytogenetics was co-related with the potency of growth. MDS stroma appears to be both morphologically and functionally normal.
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Affiliation(s)
- S Alvi
- MDS Center, Section of Myeloid Diseases, Rush Cancer Institute, Rush University, Suite 108, 2242 West Harrison Street, Chicago, IL 60612-3515, USA
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26
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Mundle S, Allampallam K, Aftab Rashid K, Dangerfield B, Cartlidge J, Zeitler D, Afenya E, Alvi S, Shetty V, Venugopal P, Raza A. Presence of activation-related m-RNA for EBV and CMV in the bone marrow of patients with myelodysplastic syndromes. Cancer Lett 2001; 164:197-205. [PMID: 11179835 DOI: 10.1016/s0304-3835(01)00385-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The bone marrow (BM) in myelodysplastic syndromes (MDS) undergoes pathobiological changes that mimic an inflammatory process, and hence, an infectious etiology was suspected in these disorders. In the present report, we examined the bone marrow mononuclear cells (BMMNC) of 19 MDS patients and seven normal donors for the expression of one latency-related (Latency membrane protein 1 (LMP-1) and immediate early protein (IEP)) and one activation-related (BZLF and DNA-Pol) m-RNA each for two herpes viruses, Epstein-Barr virus (EBV) and cytomegalovirus (CMV), respectively. Reverse transcriptase polymerase chain reaction was used for this purpose. The latency-related transcripts (EBV-LMP-1 and CMV-IEP) were present in all the MDS and normal specimens. Intriguingly, 10/19 MDS specimens ( approximately 53%) and 2/7 normal donors ( approximately 28%) were positive for active EBV-BZLF (P=0.0067), while 2/19 MDS specimens ( approximately 11%) with 1/7 normal ( approximately 14%) showed active CMV-DNA-Pol (P=0.1588). Later, from another set of MDS patients (n=7) and normal donors (n=4), BM stromal cultures were established, which, at a 75% confluency, were overlaid with cord blood mononuclear cells (CBMNC). IEP was detectable in the CBMNC before and after co-incubation with MDS, as well as normal stroma. So, it was also present both in MDS and normal stromal cells. The other three were absent both in MDS and normal stromal layers. In CBMNC though, active EBV-BZLF and CMV-DNA-Pol m-RNA were detectable in one of seven MDS co-cultures each, albeit from different patients. None of the normal co-cultures showed active virus, either in stroma or CBMNC. Thus, the present report demonstrates, for the first time, the presence of active herpes viruses in the BMMNC of MDS patients and reveals the ability of the MDS stroma to support the viral activation.
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Affiliation(s)
- S Mundle
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, 2242 West Harrison Street, Suite 108, Chicago, IL 60612-3515, USA.
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Shetty V, Hussaini S, Broady-Robinson L, Allampallam K, Mundle S, Borok R, Broderick E, Mazzoran L, Zorat F, Raza A. Intramedullary apoptosis of hematopoietic cells in myelodysplastic syndrome patients can be massive: apoptotic cells recovered from high-density fraction of bone marrow aspirates. Blood 2000; 96:1388-92. [PMID: 10942382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
A higher percentage of apoptotic cells (apoptotic index or AI) is consistently found in bone marrow (BM) biopsies compared to BM aspirates of patients with myelodysplastic syndrome (MDS). Most studies have only investigated the low-density fraction (LDF) mononuclear cells from BM aspirates following density separation for AI determination. In the present study, both LDF and high-density fraction (HDF) cells for AI were examined by electron microscopy (EM) in 10 MDS patients and 4 healthy donors. Matched BM biopsies were subjected to AI detection by in situ end labeling (ISEL) of fragmented DNA. The results indicate that in LDF and HDF cells, AI is consistently higher in MDS patients (8.5% vs 1.5%, respectively; P =.039) compared to healthy donors (27% vs 4%, respectively; P =. 004). The BM biopsy AI was also higher in MDS patients than in healthy donors (3+ vs 0+, respectively; P =.036). In addition, in MDS patients, more apoptotic cells were found in HDF cells than in LDF cells (27% vs 8.5%, respectively;P =.0001). All stages of maturation, ranging from blasts to terminally mature cells belonging to all 3 lineages, were represented in the dying cells in both compartments. Using EM, typical Pelger-Huett-type cells appeared to be apoptotic granulocytes. Both LDF and HDF cells should be examined for an accurate estimation of apoptotic cells because AI would be underestimated if only the LDF cells were studied. Ultrastructural studies consistently show a higher AI in BM biopsies compared to BM aspirates despite the correction factor of HDF cells provided by AI. This may represent the actual extant state, which could conceivably be due to a higher concentration of proapoptotic signals in the biopsies. (Blood. 2000;96:1388-1392)
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Affiliation(s)
- V Shetty
- Rush Cancer Institute, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL 60612-3515, USA.
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Abstract
Apoptosis has been documented in chondrocytes both in the growth plates of young, healthy cartilages and in osteoarthritic cartilages; little, however, is known about apoptosis in chondrocytes of normal adult articular cartilage. For the current study, apoptosis in adult chondrocytes was evaluated by labeling DNA fragments using the ISEL in situ end labeling of 3'-recessed strand breaks) or TUNEL (5'-recessed or blunt-ended strand breaks with terminal deoxynucleotidyl transferase-mediated nick end labeling) techniques in primary cultures of chondrocytes in monolayer. Apoptosis was induced in the chondrocytes by either Tumor Necrosis Factor alpha (TNF alpha), Interleukin 1-beta (IL-1 beta), or anti-Fas antibody but only after 48 hours in culture. At 4 and 24 hours, there was no detectable DNA fragmentation. With TNF alpha, IL1 beta, and anti-Fas antibody, chondrocytes show evidence of at least two types of DNA strand breaks within the same cell (as assessed by simultaneous labeling with ISEL and TUNEL). Therefore, some pathways leading to apoptosis in chondrocytes appear to involve more than one type of endonuclease activity. When the chondrocytes were cultured as explants with the articular matrix intact (ex vivo), neither IL-1 beta, TNF alpha, the anti-Fas antibody, nor fibronectin fragments were able to induce apoptosis in the chondrocytes. In normal human adult cartilage that was untreated and uncultured (in situ), DNA fragmentation was undetectable; however, a significant number of chondrocytes in osteoarthritic cartilage did contain strand breaks. These data suggest that apoptosis occurs in chondrocytes in which the matrix has been disrupted experimentally or destroyed by the osteoarthritic disease process. The results of these studies suggest that the ECM may be an essential survival factor for chondrocytes.
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Affiliation(s)
- B A Fischer
- Department of Biochemistry, Rush Medical College at Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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Allampallam K, Dutt D, Nair C, Shetty V, Mundle S, Lisak L, Andrews C, Ahmed B, Mazzone L, Zorat F, Borok R, Muzammil M, Gundroo A, Ansaarie I, Raza A. The clinical and biologic significance of abnormal lipid profiles in patients with myelodysplastic syndromes. J Hematother Stem Cell Res 2000; 9:247-55. [PMID: 10813538 DOI: 10.1089/152581600319469] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Serum lipid profiles were obtained in 108 patients with myelodysplastic syndrome (MDS) and compared to 28 healthy volunteers. Serum cholesterol and low-density and high-density lipoproteins (LDL and HDL) were found to be significantly lower in MDS patients than in normals (p = 0.0001, 0.0038 and 0.037, respectively). This difference was significant for all MDS categories. Serum cholesterol and HDL were negatively related to biopsy cellularity (p = 0.001 and 0.0001, respectively), and serum triglycerides were negatively related to labeling index (p = 0.0003). No differences were noted in the lipid profiles of MDS patients with normal versus abnormal karyotypes. However, low-risk MDS patients with abnormal karyotypes had significantly lower triglyceride levels compared with the high-risk patients (p = 0.027), as did low-risk patients with normal cytogenetics (p = 0.015). Serum HDL levels were significantly higher for the low-risk group with normal cytogenetics as well (p = 0.003). We conclude that serum cholesterol, LDL, and HDL are significantly reduced in MDS patients, probably indicating excessive intracellular lipid biosynthesis in the expanding clone. These relatively simple measurements could serve as important prognostic markers and reliable indicators of disease activity in individual patients. Prospective studies to determine their utility as independent variables that guide the need for active therapeutic intervention are warranted.
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Affiliation(s)
- K Allampallam
- Rush Cancer Institute, Rush-Presbyterian St. Luke's Medical Center, Chicago, IL 60612-3515, USA
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Mundle S, Venugopal P, Shetty V, Ali A, Chopra H, Handa H, Rose S, Mativi BY, Gregory SA, Preisler HD, Raza A. The relative extent and propensity of CD34+ vs. CD34- cells to undergo apoptosis in myelodysplastic marrows. Int J Hematol 1999; 69:152-9. [PMID: 10222652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The paradox of peripheral cytopenias despite cellular bone marrow (BM) observed in myelodysplastic syndromes (MDS) has been associated with excessive intramedullary apoptosis of hematopoietic cells. Since MDS is regarded as a stem cell disorder, the present studies were undertaken to examine the relative susceptibility and propensity of early progenitor CD34+ cells to undergo apoptosis as compared to more maturing/matured CD34- cells. Five serial studies were performed on 4 independent groups of 36 newly diagnosed MDS patients. First, in 2 separate groups of 16 and 8 patients each, measurement of the extent of apoptosis in CD34+ and CD34- fractions of the BM aspirate mononuclear cells was carried out using independent biparametric flow cytometry methods, CD34 labeling/terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) (n = 16), and CD34 labeling/reduced uptake of nucleic acid staining dye LDS751 (n = 8). The difference in the median degrees of apoptosis in CD34+ vs. CD34- cells was not statistically significant by either technique (P = 0.583 and P = 0.674 for TUNEL and LDS751, respectively). In the next group of 4 MDS patients, a double-labeling was performed on plastic embedded marrow biopsy sections, to detect CD34 antigen with specific monoclonal antibody and apoptosis by in situ end labeling (ISEL) of fragmented DNA. Despite high overall apoptosis (56.2% +/- 18.4%), only an occasional CD34+ cell was found to be simultaneously labeled with ISEL. Finally, in the last group of 8 MDS patients, CD34+ cells were separated from CD34- cells on affinity column and cultured in serum containing medium for 4 hours. At 0- and 4-hour time points, ISEL was carried out to label apoptotic cells. In addition, a fluorometric assay was employed to estimate the activity of a proapoptotic enzyme, Caspase 3. Both the net increase in % ISEL labeled cells (apoptotic index or AI) and Caspase-3 activity were significantly lower in CD34+ cells as compared to CD34- cells (AI, 0.87% +/- 0.5% vs. 3.97% +/- 1.4%, n = 6, P = 0.028 and Caspase-3 Units/mg protein, 46.9 +/- 25.0 vs. 71.7 +/- 23.03, n = 5, P = 0.042, respectively). We conclude that when estimated in a total population of mononuclear cells, CD34+ cells and CD34- cells show comparable degrees of apoptosis. However, once separated the CD34+ fraction demonstrates lower propensity to undergo apoptosis, thereby suggesting the CD34- fraction as being a possible source for proapoptotic signaling.
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Affiliation(s)
- S Mundle
- Rush Cancer Institute, Rush Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA.
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Goyal R, Qawi H, Ali I, Dar S, Mundle S, Shetty V, Mativi Y, Allampallam K, Lisak L, Loew J, Venugopal P, Gezer S, Robin E, Rifkin S, Raza A. Biologic characteristics of patients with hypocellular myelodysplastic syndromes. Leuk Res 1999; 23:357-64. [PMID: 10229321 DOI: 10.1016/s0145-2126(98)00187-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Rates of proliferation and apoptosis as well as expression of tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta (TGF-beta) and the number of macrophages were measured in bone marrow (BM) biopsies of 33 patients who presented with hypocellular (cellularity < 30%) myelodysplastic syndromes (MDS). Results showed that 2/3 of the patients had high apoptosis, high cytokine levels and large number of macrophages in their biopsies while 1/3 did not. Apoptosis and TNF-alpha levels were directly related (r = 0.583, P = 0.003, n = 24) as was apoptosis and the degree of anemia (P = 0.033, n = 18). A subgroup of patients with abnormalities of chromosomes 5 or 7 had higher platelets (P = 0.026) and higher apoptosis (P = 0.038) when compared with the rest of the group. Eight patients had no evidence of apoptosis and almost no detectable TNF-alpha in their biopsies. We conclude that within the hypocellular variant of MDS, there may be two distinct sub-groups of patients, one who present with high cytokine-mediated intramedullary apoptosis and the other who may be better characterized as having a stem-cell failure defect since they showed no evidence of apoptosis.
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Affiliation(s)
- R Goyal
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL, USA
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Reza S, Dar S, Andric T, Qawi H, Mundle S, Shetty V, Venugopal P, Ali I, Lisak L, Raza A. Biologic characteristics of 164 patients with myelodysplastic syndromes. Leuk Lymphoma 1999; 33:281-7. [PMID: 10221507 DOI: 10.3109/10428199909058427] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Rates of proliferation, apoptosis and cytokine expression were measured in bone marrow (BM) biopsies of 164 myelodysplastic syndrome (MDS) patients. There were 107 males and 57 females. Median age was 69 years and 101 had refractory anemia (RA), 17 RA with ringed sideroblasts (RARS), 38 with RA and excess blasts (RAEB) and 8 with RAEB in transformation (RAEB-t). Apoptosis measured by in-situ end labeling (ISEL) was directly related to the number of macrophages (p = 0.028, n = 83). Mean tumor necrosis factor alpha (TNF-alpha) and ISEL positivity were higher in RAEB + RAEB-t patients (p = 0.0554 and p = 0.06 respectively) while hemoglobin was higher for RA + RARS group (p = 0.0472). Patients with high apoptosis had lower white blood cell counts (p = 0.0009), lower percentage of blasts (p = 0.0009) and higher number of macrophages (p = 0.0086). We conclude that measurements of apoptosis, proliferation and cytokine expression provide important biological information which helps to distinguish RA + RARS patients from RAEB + RAEB-t patients, and may be of additive prognostic significance.
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Affiliation(s)
- S Reza
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612-3515, USA
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Dar S, Mundle S, Andric T, Qawi H, Shetty V, Reza S, Mativi BY, Allampallam K, Ali A, Venugopal P, Gezer S, Broady-Robinson L, Cartlidge J, Showel M, Hussaini S, Ragasa D, Ali I, Chaudhry A, Waggoner S, Lisak L, Huang RW, Raza A. Biological characteristics of myelodysplastic syndrome patients who demonstrated high versus no intramedullary apoptosis. Eur J Haematol Suppl 1999; 62:90-4. [PMID: 10052711 DOI: 10.1111/j.1600-0609.1999.tb01727.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Spontaneous intramedullary apoptosis was measured in bone marrow (BM) biopsies of 175 patients with myelodysplastic syndromes (MDS) using in situ end-labeling (ISEL) of fragmented DNA. Two groups of high (n=71) versus low (n =43) levels of apoptosis were identified while 61 patients were ISEL-negative. Semiquantitative assessment of 3 cytokines, the number of macrophages and in vivo labeling indices (LI) were also determined from consecutive sections of the biopsy. Patients with high apoptosis levels tended to have a high LI (p=0.013), more macrophages in their BM biopsies (p=0.006) and higher tumor necrosis factor alpha (TNF-alpha) levels (not significant) compared to patients with no apoptosis. In addition, low risk MDS patients had significantly lower rates of apoptosis (p = 0.047) and lower levels of TNF-alpha (p = 0.055) compared to high-risk MDS patients. We conclude that the genesis of cytopenias in MDS is of multifactorial origin and that cytokine-associated apoptosis clearly identifies a distinct biological subgroup of patients who may benefit selectively by use of anti-cytokine therapies.
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Affiliation(s)
- S Dar
- Rush Cancer Institute, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL 60612-3515, USA
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Span L, Dar S, Shetty V, Mundle S, Broady-Robinson L, Alvi S, de Witte T, Raza A. 76 The absolute number of CD34+ cells and CD34+ cells in S-phase increase during the evolution of myelodysplastic syndromes (MDS). Leuk Res 1997. [DOI: 10.1016/s0145-2126(97)81290-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kotelnikov VM, Coon JS, Mundle S, Kelanic S, LaFollette S, Taylor S IV, Hutchinson J, Panje W, Caldarelli DD, Preisler HD. Cyclin D1 expression in squamous cell carcinomas of the head and neck and in oral mucosa in relation to proliferation and apoptosis. Clin Cancer Res 1997; 3:95-101. [PMID: 9815543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Deregulation of expression of the cell cycle regulator cyclin D1 (cD1) may be responsible for rapid proliferation of squamous cell carcinoma of the head and neck (SCCHN). We have studied the expression of cD1 in 46 SCCHNs using immunohistochemistry. Before biopsy, the patients received an in vivo infusion of iododeoxyuridine (IdUrd) for cell proliferation assessment. Additionally, the level of apoptosis was estimated using in situ end labeling (ISEL). Among 33 tumors, the proportion of cD1(+) cells varied from 0.5 to 51.3% (19.9 +/- 2.2%). Thirteen tumors did not express cD1. The fraction of S-phase (IdUrd-positive) cells was 26.3 +/- 1.8% in cD1(+) versus 20.0 +/- 2.4% in cD1(-) tumors (P = 0.06). The percentages of cD1(+) cells and of S-phase cells were not correlated (P = 0.37). Apoptosis was detected by ISEL in 15 of 33 tumors studied. ISEL-positive tumors contained a significantly higher proportion of cD1(+) cells (14.9 +/- 2.6%) than cD1(-) ones (7.9 +/- 2.8%; P = 0.03). There was a positive correlation between the percentage of cD1(+) cells and the degree of ISEL (r = 0.54; P < 0.001). In noninvolved oral mucosa, cD1(+) cells were located primarily in the suprabasal layers (29.3 +/- 3.8% versus 1.2 +/- 0. 2% in the basal layer). Only 23 of 44 mucosal specimens contained cD1(+) cells. All cD1(-) samples were proliferatively active and contained IdUrd-labeled cells. The percentage of cD1(+) cells in the oral epithelium from nontumor controls (uvula samples) was significantly higher than in the SCCHN group in both basal (2.4 +/- 0.4%; P = 0.008) and suprabasal (42.7 +/- 3.3%; P = 0.005) layers. Additionally, whereas in uvuli, cD1(+) cells were distributed evenly along the epithelial lining, in SCCHN samples the regions showing cD1 expression alternated with areas in which cD1 expression was undetectable. These data indicate that cD1 expression in SCCHN varies among tumors and is not correlated with cell proliferation. In noninvolved oral mucosa, cD1 expression differs from that in truly normal epithelium obtained from nontumor patients. A correlation between cD1 expression and the extent of ISEL positivity suggests a possible involvement of cD1 expression in the apoptotic pathways.
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Affiliation(s)
- V M Kotelnikov
- Rush Cancer Institute, Department of Pathology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612-3833, USA
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Shetty V, Mundle S, Alvi S, Showel M, Broady-Robinson L, Dar S, Borok R, Showel J, Gregory S, Rifkin S, Gezer S, Parcharidou A, Venugopal P, Shah R, Hernandez B, Klein M, Alston D, Robin E, Dominquez C, Raza A. Measurement of apoptosis, proliferation and three cytokines in 46 patients with myelodysplastic syndromes. Leuk Res 1996; 20:891-900. [PMID: 9009245 DOI: 10.1016/s0145-2126(96)00008-2] [Citation(s) in RCA: 151] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Extensive apoptosis or programmed cell death (PCD) of both hematopoietic (erythroid, myeloid, megakaryocytic) and stromal cells in myelodysplastic syndromes (MDS) cancels the high birth-rate resulting in ineffective hematopoiesis and has been demonstrated as the probable basis for peripheral cytopenias in MDS by our group. It is proposed that factors present in the microenvironment are inducing apoptosis in all the cells whether stromal or parenchymal. To investigate this hypothesis further, bone marrow biopsies from 46 MDS patients and eight normal individuals were examined for the presence of three cytokines, tumor necrosis factor-alpha (TNF-alpha), transforming growth factor-beta (TGF-beta) and granulocyte macrophage-colony stimulating factor (GM-CSF) and one cellular component, macrophages, by the use of monoclonal antibodies immunohistochemically. Results showed the presence of TNF-alpha and TGF-beta in 41/46 and 40/46 cases of MDS respectively, while only 15 cases showed the presence of GM-CSF. Further a significant direct relationship was found between the degree of TNF-alpha and the incidence of PCD (p= 0.0015). Patients who showed high PCD also had an elevated TNF-alpha level. Thus, the expression of high amounts of TNF-alpha and TGF-beta and low amounts of the viability factor GM-CSF may be responsible for the high incidence of PCD leading to ineffective hematopoiesis in MDS. Future studies will be directed at attempting to reverse the lesion in MDS by using anti-TNF-alpha drugs such as pentoxifylline.
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Affiliation(s)
- V Shetty
- Rush Cancer Institute and the Department of Pathology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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37
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Raza A, Mundle S, Shetty V, Alvi S, Chopra H, Span L, Parcharidou A, Dar S, Venugopal P, Borok R, Gezer S, Showel J, Loew J, Robin E, Rifkin S, Alston D, Hernandez B, Shah R, Kaizer H, Gregory S, Preisler H. A paradigm shift in myelodysplastic syndromes. Leukemia 1996; 10:1648-52. [PMID: 8847900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A poorly defined transforming event(s) affects the pluripotential bone marrow (BM) stem cell in myelodysplastic syndromes (MDS), conferring a growth advantage upon it which leads eventually to monoclonal hematopoiesis. The progeny of this transformed ancestor undergo recognizable albeit dysplastic maturation. We propose that this picture is further complicated by a variety of cytokines, tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta (TGF-beta) and interleukin 1beta (IL-1beta) which exert a dual effect on the diseased cells. The immature CD34+ cells are stimulated to proliferate, while their later differentiated daughters are induced to undergo apoptosis accounting for the clinical syndrome of pancytopenia despite hypercellular BMs. Studies directed at measuring the rates of proliferation and apoptosis as well as the levels of TNF-alpha, TGF-beta and IL-1beta confirm this hypothesis and are presented in greater detail. A novel approach towards MDS therapy emerges as a result of this paradigm shift based upon the premise that anti-cytokine therapy would prevent excessive intramedullary apoptosis and result in improved cytopenias as well as cause a slowing down of the diseased precursor cell proliferation resulting in resumption of polyclonal hematopoiesis. Because a number of cytokines function through common lipid second messengers, interruption of this pathway should theoretically cause disruption in the signalling of a cascade of cytokines.
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Affiliation(s)
- A Raza
- Rush Cancer Institute, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL 60612, USA
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38
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Preisler HD, Kotelnikov VM, LaFollette S, Taylor S, Mundle S, Wood N, Coon JS, Hutchinson J, Panje W, Caldarelli DD, Griem K. Continued malignant cell proliferation in head and neck tumors during cytotoxic therapy. Clin Cancer Res 1996; 2:1453-60. [PMID: 9816320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The effect of cytotoxic therapy on the proliferation of squamous cell carcinoma of the head and neck in vivo in patients was evaluated before and 15-35 days after the start of therapy. To accomplish this, iododeoxyuridine was administered at t = 0, and bromodeoxyuridine was administered 15-35 days later during treatment with a tumor biopsy obtained for study immediately after each pyrimidine infusion. Monoclonal antibodies specific for the halogenated pyrimidines were used to identify cells that were in the S-phase at the time of the infusions. Eleven patients were studied prior to treatment. Of those, the intratreatment biopsy of eight patients contained tumor tissue. In the other three patients, tumor tissue was not present in the second biopsy. Continued precursor incorporation into DNA-synthesizing cells during treatment was detected in six of eight tumor specimens. In two tumor specimens, an increase in the percentage of S-phase cells was noted, in two specimens tumor cells synthesizing DNA were not detected, and in four specimens the percentage of S-phase tumor cells was lower than that in the pretherapy specimen. Patients in whom there were no S-phase cells detected during treatment or in whom no tumor was detected in the second biopsy had a favorable treatment outcome in comparison to those patients in whom continued tumor proliferation during treatment was detected. The number of cells in S-phase prior to the initiation of treatment was not predictive of whether or not proliferation would continue during cytotoxic therapy. Evidence for reentry of kinetically quiescent cells into the cycle during treatment was noted. Additionally, cytotoxic therapy altered the proliferation pattern of normal-appearing mucosa as well. The results of this study demonstrate that tumor cell proliferation does continue in some squamous cell carcinoma of the head and neck during intensive cytotoxic therapy.
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Affiliation(s)
- H D Preisler
- Rush Cancer Institute, Department of Pathology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612-3833, USA
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39
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Raza A, Mundle S, Shetty V, Alvi S, Chopra H, Span L, Parcharidou A, Dar S, Venugopal P, Borok R, Gezer S, Showel J, Loew J, Robin E, Rifkin S, Alston D, Hernandez B, Shah R, Kaizer H, Gregory S. Novel insights into the biology of myelodysplastic syndromes: excessive apoptosis and the role of cytokines. Int J Hematol 1996; 63:265-78. [PMID: 8762810 DOI: 10.1016/0925-5710(96)00455-0] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The paradox of myelodysplastic syndromes (MDS) which present with pancytopenias despite cellular bone marrows (BM) was investigated by conducting detailed studies of proliferation and apoptosis in 89 MDS patients. Our results demonstrated a rapid rate of both proliferation as well as apoptosis. Levels of three cytokines, tumor necrosis factor-alpha (TNF-alpha), transforming growth factor-beta (TGF-beta) and interleukin-1 beta (IL-1 beta) were measured in the same patients. High levels of TNF-alpha were found to correlate with high levels of apoptosis in 83 MDS patients (P = 0.0045). We propose a dual role for TNF-alpha (or other cytokines) in the pathogenesis of MDS. On the one hand, TNF-alpha induces apoptosis in the maturing cells causing pancytopenia while on the other, it stimulates the proliferation of the primitive progenitors accounting for the hypercellular BM frequently seen in MDS. A new model for MDS is presented. The initial abnormality probably affects a primitive hemopoietic progenitor which acquires a growth advantage leading to monoclonal hemopoiesis, which in turn makes these cells susceptible towards acquiring additional mutations and appearance of cytogenetically marked (or unmarked) clones. Cytokines such as TNF-alpha whose source is presently unknown, then contribute towards the clinical syndrome of pancytopenia and hypercellularity.
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Affiliation(s)
- A Raza
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA
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40
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Mundle S, Kotelnikov V, Wood N, Coon J, Horvath E, Taylor S, Lafollette S, Caldarelli D, Hutchinson J, Panje W, Preisler H, Raza A. Assessment of apoptosis in relation to proliferation and mutational status of p53 gene in head and neck cancers. Int J Oncol 1996; 8:1257-64. [PMID: 21544492 DOI: 10.3892/ijo.8.6.1257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The present studies were undertaken to determine the incidence of apoptosis in plastic embedded head and neck (HN) tumor biopsies (n=31) using in situ end labeling (ISEL) of fragmented DNA. The extent of spontaneous apoptosis in untreated tumors was correlated with histological grade, percent S-phase cells (Labeling Index, LI) and with the mutational status of p53 gene in these tumors. Additionally, the in vivo effects of chemo- and/or radiotherapy on apoptosis were evaluated in seven patients. In the majority of tumors studied (25/31) spontaneous apoptosis was virtually undetectable or was very low (1-15% positively labeled cells). Only 6 tumors showed intermediate to high apoptosis (>15% positively labeled cells). High apoptosis was more frequent in poorly differentiated tumors (similar to 50%), as compared to well and moderately differentiated tumors. The median LI for 31 tumors studied was 20.2%. The mean LI for moderately differentiated tumors (23.7+/-1.7%) was significantly higher than that in well differentiated (15.1+/-2.1%, p=0.005) and was comparable in poorly differentiated tumors (24.5%). Cytotoxic therapy significantly increased the degree of apoptosis in 5/7 specimens studied (p=0.03). Double labeling of 5 of these tumors before and after the therapy, combining ISEL with detection of IUdR/BrdU, showed compartmentalized apoptosis and proliferation with virtually no double labeled cells in any specimen. Interestingly, tumors with a mutated p53 gene (n=6) showed intermediate to high degree of pretherapy, baseline apoptosis in contrast to low or undetectable levels of apoptosis in tumors bearing wild-type p53 (n=13, p=0.034). It appears that low levels of apoptosis and high proliferation may be characteristic of HN tumors. The spontaneous apoptosis in HN tumors seems unrelated to mutations in the p53 gene. Moreover, our data also show that despite overall increase in apoptosis induced by cytotoxic therapy, some proliferating tumor cells escaped the effects of therapy, which may contribute to the tumor relapse.
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Affiliation(s)
- S Mundle
- RUSH PRESBYTERIAN ST LUKES MED CTR,DEPT PATHOL,CHICAGO,IL 60612
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41
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Uhal BD, Joshi I, True AL, Mundle S, Raza A, Pardo A, Selman M. Fibroblasts isolated after fibrotic lung injury induce apoptosis of alveolar epithelial cells in vitro. Am J Physiol 1995; 269:L819-28. [PMID: 8572243 DOI: 10.1152/ajplung.1995.269.6.l819] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Primary lung fibroblasts were isolated from patients with idiopathic pulmonary fibrosis (HIPF), from normal human lung tissue (NH), from rats treated with 75% oxygen and paraquat (PA), and from normal adult rats (NR). Serum-free media conditioned by each fibroblast strain were tested on the human A549 cell line (HIPF and NH media) or on primary alveolar epithelial cells (AEC) isolated from normal adult rats (PA or NR media). Over 20-h incubation, HIPF- or PA-conditioned media induced DNA fragmentation and significant decreases in total recoverable DNA and cell number of A549 or AEC, respectively; NH or NR media had no significant effect relative to serum-free unconditioned media. Apoptosis of A549 and AEC was detected by altered nuclear morphology and was confirmed by terminal deoxynucleotidyl transferase-mediated bio-dUTP nick end labeling. The endonuclease inhibitors 10 microM aurintricarboxylic acid and 50 microM zinc inhibited HIPF-induced apoptosis of A549 cells by 68 and 71%, respectively. Both apoptosis and necrosis were induced by HIPF and PA media in a concentration-dependent manner. These results suggest that altered fibroblasts emerging during fibrotic lung injury release a soluble factor(s) capable of inducing cell death and net loss of AEC.
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Affiliation(s)
- B D Uhal
- Department of Pharmacology, Rush-Presbyterian St. Luke's Medical Center, Chicago, Illinois 60612, USA
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42
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Shetty V, Mundle S, Sanoy A, Sanghvi R, Loew J, Marcus B, Showel J, Gregory S, Raza A. A multivariate study of non Hodgkin's lymphoma involving proliferation, apoptosis, bcl-2 and the microenvironment. Leuk Lymphoma 1995; 18:273-9. [PMID: 8535193 DOI: 10.3109/10428199509059618] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The study was carried out on 22 patients with non-Hodgkin's lymphoma (NHL) who had received sequential infusions of two thymidine analogues iododeoxyuridine (IUdR) and bromodeoxyuridine (BrdU). Cell cycle kinetic studies seemed to differentiate distinctly between low grade lymphoma (n = 8, LI = 2.6%) compared to that of intermediate grade (n = 9, LI = 13%, p = 0.0001) and high grade NHL (n = 5, LI = 16.3%, p = 0.0062). While the majority of 14 intermediate and high grade lymphomas had a high labeling index there were 3/14 patients with a LI of 5.5%, 5.5% and 4.1% respectively. A decrease in the rate of programmed cell death (PCD) or apoptosis due to the overexpression of bcl-2 has been implicated as the possible pathogenesis for follicular lymphoma. We determined the presence of bcl-2 protein immunohistochemically and apoptosis by in situ end labeling of DNA which detects cells in early stages of PCD not recognized morphologically. Nine NHL patients demonstrated PCD ranging from 1%-40%, while it was undetectable in 13/22 patients. Of these 13 cases, 6 showed the presence of bcl-2 expression. To understand the relationship of the microenvironment to the lymphoma cells, the presence of transforming growth factor beta (TGF-beta) was determined immunohistochemically. TGF-beta was present in all the cases where bcl-2 was present, except one. This study highlights some of the key biological features of NHL cells and their microenvironment.
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Affiliation(s)
- V Shetty
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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43
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Raza A, Gezer S, Mundle S, Gao XZ, Alvi S, Borok R, Rifkin S, Iftikhar A, Shetty V, Parcharidou A. Apoptosis in bone marrow biopsy samples involving stromal and hematopoietic cells in 50 patients with myelodysplastic syndromes. Blood 1995; 86:268-76. [PMID: 7795232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Cell-cycle kinetics were measured in situ after infusions of iododeoxyuridine and/or bormodeoxyuridine in 50 patients with myelodysplastic syndromes (MDS) and the median labeling index in bone marrow (BM) biopsy samples was 28.6%. Unfortunately, 26 of 50 patients showed that > or = 75% of hematopoietic cells of all three lineages were undergoing programmed cell death (PCD) in their biopsy samples as shown by the in situ end labeling (ISEL) technique. Ten patients had 1/3 and eight had 2/3 ISEL+ cells. Stromal cells were frequently ISEL+ and often S-phase cells were also found to be simultaneously ISEL+. Nucleosomal DNA fragments as a ladder in agarose gel were present in BM aspirates of four patients who showed high ISEL and were absent in two who had no ISEL staining in biopsy samples, but only when DNA was extracted after a 4-hour in vitro incubation in complete medium. Therefore, laddering data confirmed the ISEL findings that the majority of hematopoietic cells in MDS are in early stages of PCD. We conclude that extensive intramedullary cell death may explain the paradox of pancytopenia despite hypercellular marrows in MDS patients. Investigating approaches that protect against PCD in some MDS subsets would be of interest.
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Affiliation(s)
- A Raza
- Division of Hematology, Rush Cancer Institute, Chicago, IL, USA
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Raza A, Mundle S, Iftikhar A, Gregory S, Marcus B, Khan Z, Alvi S, Shetty V, Dameron S, Wright V. Simultaneous assessment of cell kinetics and programmed cell death in bone marrow biopsies of myelodysplastics reveals extensive apoptosis as the probable basis for ineffective hematopoiesis. Am J Hematol 1995; 48:143-54. [PMID: 7864021 DOI: 10.1002/ajh.2830480302] [Citation(s) in RCA: 107] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Despite hypercellular bone marrows (BM), peripheral cytopenias are the rule in patients with myelodysplastic syndromes (MDS). This study examined the roles played by cell birth and cell death rates in generating this paradox. Cell kinetics from BM biopsies of 35 MDS patients were measured using intravenous infusions of either iododeoxyuridine or bromodeoxyuridine, or both. Degree of apoptosis or programmed cell death (PCD) was estimated using in situ end-labeling of DNA directly from BM biopsies, which were simultaneously double-labeled from proliferation/PCD. MDS were found to be highly proliferative disorders with large numbers of myeloid, erythroid, and megakaryocytic cells synthesizing DNA. Median cycling time (Tc) of myeloblasts was more rapid than that of patients with acute myeloid leukemia (44.1 hr vs. 56.0 hr). Interestingly, most marrow cells of all three lineages in 32 of 34 evaluable cases were undergoing PCD. In 19 of 32 patients, greater than 75% cells were apoptotic. Surprisingly, large numbers of S-phase cells were found to be simultaneously undergoing PCD, as were stromal cells of the BM microenvironment. We conclude that the extensive apoptosis in hematopoietic cells effectively cancels the high birth rate resulting in ineffective hematopoiesis and accounting for deficient bone marrow function.
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Affiliation(s)
- A Raza
- Division of Hematology, Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinos 60612
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Mundle S, Iftikhar A, Shetty V, Dameron S, Wright-Quinones V, Marcus B, Loew J, Gregory S, Raza A. Novel in situ double labeling for simultaneous detection of proliferation and apoptosis. J Histochem Cytochem 1994; 42:1533-7. [PMID: 7983354 DOI: 10.1177/42.12.7983354] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
We describe a novel double-labeling method to simultaneously investigate proliferation and apoptosis from plastic-embedded biopsy specimens (PEBs). Infusions of bromo- and/or iododeoxyuridine (BrdU/IudR) were given to 10 patients, five with acute myeloid leukemia (AML) and five with myelodysplastic syndromes (MDS), and S-phase cells were measured in PEBs using a monoclonal anti-IudR/BrdU antibody. Apoptosis was measured by in situ end-labeling (ISEL) of DNA. The results demonstrate that both AML and MDS are highly proliferative disorders but that there is almost no apoptosis in the former, whereas extensive apoptosis was observed in the latter. Double labeling revealed that large numbers of S-phase cells in MDS were simultaneously undergoing apoptosis. We conclude that the high cell death in MDS cancels the high cell birth, resulting in a functionally aplastic marrow and thus accounting for the observed ineffective hematopoiesis. On the other hand, AML is rapidly fatal, probably owing to high cell birth with no or minimal cell death. Therapeutic strategies to prevent intramedullary programmed cell death of hematopoietic precursors should be evaluated in MDS, and efficacy of chemotherapy in AML can be assessed by measuring the induction of apoptosis in post-treatment biopsy specimens.
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Affiliation(s)
- S Mundle
- Rush Cancer Institute, Chicago, Illinois
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46
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Mundle S, Iftikhar A, Shetty V, Alvi S, Dameron S, Gregory S, Marcus B, Khan S, Raza A. In situ end labelling of DNA to detect apoptotic cell death in a variety of human tumours. Cell Death Differ 1994; 1:117-22. [PMID: 17334328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/1994] [Revised: 05/24/1994] [Accepted: 05/25/1994] [Indexed: 05/14/2023] Open
Abstract
The present studies illustrate clinical applications of in situ end labelling (ISEL) of DNA to detect apoptosis in a variety of human malignancies including myelodysplastic syndromes (MDS, n=10), non-Hodgkin's lymphoma (NHL, n=10), head and neck cancer (n = 3), breast cancer (n = 1) and cervical cancer (n = 1). These studies also describe a new in situ double labelling technique to detect apoptosis and proliferation (S-phase cells) simultaneously in the same section of plastic embedded tissue. In vivo intravenous infusions of thymidine analogues (i.e. bromodeoxyuridine (BrdU) and/or iododeoxyuridine (IUdR)) followed by their detection with a specific monoclonal antibody in a plastic embedded biopsy, combined with ISEL in the same section, facilitated simultaneous estimations of apoptosis and proliferation. The most salient finding of these studies was excessive apoptosis in MDS including the cells in S-phase as indicated by uniquely double labelled cells in their bone marrow biopsies. On the other hand, a very low degree of apoptosis was observed in NHL and other solid tumours. Moreover, the solid tumours exhibited definite compartments of apoptosis and proliferation. Further experiments are underway to confirm these findings in a larger study in order to design appropriate therapeutic modalities for these disorders.
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Affiliation(s)
- S Mundle
- Rush Cancer Institute and the Department of Pathology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL, USA
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47
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Mundle S, Sheth A, Sheth N. Increased concentration of prostatic inhibin following orchidectomy in rat. Indian J Exp Biol 1990; 28:911-4. [PMID: 2279763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Inhibin, a predominant secretory protein of prostate has been shown earlier to increase in proliferative prostatic diseases. Since the prostate gland is under the profound influence of androgens, it's withdrawal by orchidectomy is many a time included in the therapy to prostate cancer. Hence it was interesting to study the reflection of long term orchidectomy on prostatic inhibin. With this aim two groups of bilaterally orchidectomised male Sprague-Dawley rats were sacrificed 15 days and 30 days after castration respectively. Another group of rats was administered with testosterone enanthate after 30 days of castration. As protein concentration and weight showed a significant decrease after orchidectomy, inhibin concentrations (estimated by RIA) were expressed per gland. The inhibin concentration was increased to a 5-6 fold higher value after 15 days of castration. While a remarkable 10-15 fold elevation of inhibin concentration was observed in 30 day castrated prostates. Concurrently the circulating inhibin levels were also found to be heightened. All these effects of orchidectomy were almost reversed on androgen administration. Thus in contrast to the decrease in the weight and concentration of other prostatic proteins after orchidectomy, the increase in inhibin appears to be striking.
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Affiliation(s)
- S Mundle
- Endocrinology Unit, Cancer Research Institute, Bombay, India
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