Responsive neurostimulation as a treatment for super-refractory focal status epilepticus: a systematic review and case series

OBJECTIVE

Super-refractory status epilepticus (SRSE) has high rates of morbidity and mortality. Few published studies have investigated neurostimulation treatment options in the setting of SRSE. This systematic literature review and series of 10 cases investigated the safety and efficacy of implanting and activating the responsive neurostimulation (RNS) system acutely during SRSE and discusses the rationale for lead placement and selection of stimulation parameters.

METHODS

Through a literature search (of databases and American Epilepsy Society abstracts that were last searched on March 1, 2023) and direct contact with the manufacturer of the RNS system, 10 total cases were identified that utilized RNS acutely during SE (9 SRSE cases and 1 case of refractory SE [RSE]). Nine centers obtained IRB approval for retrospective chart review and completed data collection forms. A tenth case had published data from a case report that were referenced in this study. Data from the collection forms and the published case report were compiled in Excel.

RESULTS

All 10 cases presented with focal SE: 9 with SRSE and 1 with RSE. Etiology varied from known lesion (focal cortical dysplasia in 7 cases and recurrent meningioma in 1) to unknown (2 cases, with 1 presenting with new-onset refractory focal SE [NORSE]). Seven of 10 cases exited SRSE after RNS placement and activation, with a time frame ranging from 1 to 27 days. Two patients died of complications due to ongoing SRSE. Another patient's SE never resolved but was subclinical. One of 10 cases had a device-related significant adverse event (trace hemorrhage), which did not require intervention. There was 1 reported recurrence of SE after discharge among the cases in which SRSE resolved up to the defined endpoint.

CONCLUSIONS

This case series offers preliminary evidence that RNS is a safe and potentially effective treatment option for SRSE in patients with 1-2 well-defined seizure-onset zone(s) who meet the eligibility criteria for RNS. The unique features of RNS offer multiple benefits in the SRSE setting, including real-time electrocorticography to supplement scalp EEG for monitoring SRSE progress and response to treatment, as well as numerous stimulation options. Further research is indicated to investigate the optimal stimulation settings in this unique clinical scenario.

Intersectionality and COVID-19: Academic Medicine Faculty's Lived Experiences of Well-Being, Workload, and Productivity During the Pandemic

Purpose: The aim of this study was to utilize an intersectional framework to examine academic faculty's lived experiences during COVID-19. Specifically, we set out to: (1) describe the multiple intersectional identities (e.g., gender, race/ethnicity, rank, caregiver status, disability status) represented by the faculty, (2) examine potential disparities in well-being, workload, and productivity linked to these intersectional factors, and (3) identify qualitative themes endorsed by faculty as they relate to lived experiences during COVID-19. Methods: This was a cross-sectional mixed-methods research study. The Center for Women in Medicine and Science (CWIMS) at the University of Minnesota developed and implemented a survey between February-June of 2021 in response to national reports of disparities in the impacts of COVID-19 on faculty with lived experiences from multiple intersections. Results: There were 291 full-time faculty who participated in the study. Quantitative findings indicated that faculty with multiple intersectional identities (e.g., woman+assistant professor+caregiver+underrepresented in medicine) reported greater depression symptoms, work/family conflict, and stress in contrast to faculty with fewer intersectional identities. Furthermore, faculty with more intersectional identities reported higher clinical workloads and service responsibilities and lower productivity with regard to research article submissions, publications, and grant submissions in contrast to faculty with fewer intersectional identities. Qualitative findings supported quantitative findings and broadened understanding of potential underlying reasons. Conclusions: Findings confirm anecdotal evidence that faculty with lived experiences from multiple intersections may be disproportionately experiencing negative outcomes from the pandemic. These findings can inform decisions about how to address these disparities moving into the next several years with regard to promotion and tenure, burnout and well-being, and faculty retention in academic medical settings. Given these findings, it is also important to intentionally plan responses for future public health crises to prevent continued disparities for faculty with multiple intersectional identities.

Immune Checkpoint Inhibition and Single Fraction Stereotactic Radiosurgery in Non-Small Cell Lung Cancer Brain Metastases: An International Multicenter Study of 395 Patients

PURPOSE/OBJECTIVE(S)

Brain metastases most commonly arise from non-small cell lung cancer (NSCLC). In recent years, immune checkpoint inhibitors (ICI) have demonstrated improvements in overall survival (OS) in NSCLC. However, concerns remain about the risk of radiation necrosis (RN) when ICI are administered with stereotactic radiosurgery (SRS).

MATERIALS/METHODS

Logistic regression was used to evaluate prognostic factors associated with the development of any grade RN and symptomatic RN. Cumulative incidence of RN was evaluated using competing risks analysis and the Fine and Gray model, where the null hypothesis was rejected for p < 0.05.

RESULTS

There were 395 patients with 2,513 brain metastases treated across 11 international institutions included in the analysis. The median follow-up was 14.2 months. Median patient age was 67 years (Interquartile Range [IQR]: 61-73), 53.4% were male, the median Karnofsky Performance Status was 80 (IQR: 80-90), and 88.6% has active extracranial disease at the time of SRS. The median margin dose was 19 Gy (IQR: 18-20), 97.5% of patients were treated on the Gamma Knife ®, 3.8% underwent prior whole brain radiation therapy (WBRT). The median V12 Gy was 5.2 cm3 and 36.5% of patients had a V12 Gy ≥ 10 cm3, anti-PD-1 agents were administered in 91.6% of patients. A V12 Gy ³ 10 cm3 was associated with an increased risk of developing any grade RN; odds ratio (OR): 2.12, p = 0.04 and OR: 2.18; p = 0.03 on univariable and multivariable analysis, respectively. Similarly, a V12 Gy ≥ 10 cm3 was associated with an increased risk of developing symptomatic RN; OR: 3.80, p = 0.003 and OR: 3.95; p = 0.003 on univariable and multivariable analysis, respectively. Receipt of concurrent ICI and prior WBRT were not statistically significant. At 1-year, the cumulative incidence of any grade and symptomatic RN was 4.8% and 3.8%, respectively. The cumulative incidence of any grade RN was 3.8% vs. 5.3% for the concurrent and non-concurrent groups at 1-year, respectively (p = 0.35). The cumulative incidence of symptomatic RN was 3.8% vs. 3.6% for the concurrent and non-concurrent groups at 1-year, respectively (p = 0.95).

CONCLUSION

The risk of any grade and symptomatic RN following SRS and ICI administration for NSCLC brain metastases increases as the V12 Gy exceeds 10 cm3. Concurrent ICI and SRS does not appear to increase this risk. Radiosurgical planning techniques should aim to minimize the V12 Gy.

Validation of a Genomic Classifier in the NRG Oncology/RTOG 0521 Phase III Trial of Docetaxel with Androgen Suppression and Radiotherapy for Localized High-Risk Prostate Cancer

PURPOSE/OBJECTIVE(S)

Decipher is a prognostic genomic classifier (GC) validated in several prospective NRG Oncology Phase III trials. Herein, we validate the GC in pre-treatment biopsy samples for risk stratification in a cohort of high-risk men treated with definitive radiotherapy and androgen suppression with or without docetaxel chemotherapy.

MATERIALS/METHODS

As per a pre-specified and approved NCI analysis plan (Navigator #1061), we obtained available formalin-fixed paraffin-embedded tissue from biopsy specimens from the NRG biobank from patients enrolled on the NRG/RTOG 0521 randomized phase III trial. After central review, the highest-grade tumors were profiled on clinical-grade whole-transcriptome arrays (Veracyte, San Diego, CA) and GC scores were obtained. Pre-specified categorical GC scores, adjusted for archival tissue analysis, were used to define higher (>0.46) and lower (≤0.46) risk groups. The primary objective was to validate the independent prognostic ability of GC for metastasis-free survival (MFS) with Cox multivariable analyses (MVA).

RESULTS

Samples were obtained from 283 consented, evaluable patients with tissue (50% of trial) yielding 183 (65%) GC scores that passed quality metrics, 91 from control and 92 from the interventional arm. Median age was 66 years, median PSA was 19.3 ng/uL (IQR: 8.1-41.4), 81% had clinical stage ≥T2 and 80% had Gleason score ≥8 (47% ≥9). Median GC score was 0.55 (IQR: 0.38-0.78) and overall the arms were balanced for key covariates. With a median follow-up of 9.9 years (IQR: 9.3, 10.7), 67 MFS events including 34 distant metastases (DM) were observed. On MVA, only the GC (per 0.1 unit) was independently associated with MFS (HR 1.12, 95% CI 1.01-1.25) as well as DM (sHR 1.22, 95% CI 1.06-1.41), whereas the 4 pre-defined trial risk groups used for stratification (based on Gleason score, T-stage and PSA), randomization and patient age were not. For categorical GC, on MVA, higher-risk GC patients (65%) had worse DM (sHR 2.82, 95% CI 1.1-7.3) compared to those with lower GC. Cumulative incidence of DM at 10-years was 27% for higher GC vs 9% (95% CI 7-18%) for lower GC. No biomarker-by-treatment interaction with GC and the addition of docetaxel was detected.

CONCLUSION

In pre-treatment biopsy samples from a randomized Phase 3 trial cohort, GC demonstrated its ability to further risk stratify clinically high-risk men demonstrating an independent association of GC score with DM and MFS. High-risk prostate cancer is a heterogeneous disease state and GC can improve risk stratification to help personalize shared decision-making. NRG-GU009/PREDICT-RT (NCT04513717) aims to determine the optimal therapy based on GC score for high-risk prostate cancer.

0701 Positive Airway Pressure Therapy To Treat Sleep Disordered Breathing Impacts Number Of Hospitalizations In Patients With Heart Failure

Introduction

Some studies have shown a benefit while others have shown possible harm in patient outcomes when using positive airway pressure therapy (PAP) for treating sleep disordered breathing (SDB) in patients with heart failure (HF). The goal of this study was to evaluate the number of HF-related and all-cause related hospitalizations in patients with HF and SDB on various forms of PAP therapy versus those on no PAP therapy.

Methods

Administrative claims data from the Truven Health MarketScan Database from 1/1/2005- 10/31/2015 were analyzed. Those included were at least 21 years old, were continuously enrolled for 12 months before and 6 months after their index date (date of PAP prescription), had at least two distinct HF-related claims and were prescribed PAP therapy (n=1,324,414). To model the relationship between each device and hospitalization risk, and to account for the longitudinal and correlated nature of these binary outcome data, generalized estimating equations with binomial family, logit link, and unstructured correlation structure were used.

Results

There were a total of 12,538 patients on Bilevel-PAP, 2,700 patients on bilevel-PAP with backup rate, and 57,405 patients on CPAP, and 73,353 patients with HF and comorbid sleep apnea who were not on any treatment. The reduction in HF-related hospitalization for patients with HF and comorbid SDB treated with bilevel-PAP therapy (0.28; 95% CI 0.26, 0.31) was greater than that in patients receiving CPAP (OR 0.46 95% CI 0.43, 0.49), bilevel PAP with back-up rate (0.39; 95% CI 0.32, 0.49), or no PAP treatment (OR 0.54; 95%CI 0.50, 0.57)(P&lt;0.01). Similar trend was observed for all-cause related hospitalizations. All results were adjusted for propensity score and other relevant confounders.

Conclusion

In claims-based analysis of patients with HF and comorbid SDB, bilevel PAP treatment was associated with reduced hospitalizations when compared to CPAP therapy or no PAP treatment.

Support

Phillips Respironics

0571 Repolarization Variability Predicts Cardiovascular Death in Obstructive Sleep Apnea

Introduction

Patients with untreated obstructive sleep apnea (OSA) have a 2-3—fold increased risk of cardiovascular mortality (CVD) compared with individuals without OSA. QTc prolongation and increased QT variability among OSA patients may contribute to this association.

Methods

Patients with OSA from the Sleep Heart Health study were identified based on polysomnography criteria and their continuous electrocardiograms (ECG) analyzed for QTc duration and QT variability. Both Fridericia’s and Bazett’s heart rate corrections were used to calculate QTc. QT variability was measured as standard deviation of QT intervals (SDQT) and normalized QT interval variance (QTVN) at 1- and 5-minute intervals and short-term interval beat-to-beat QT variability (STVQT) was measured at 5-minute intervals. Lasso with elastic-net regularization was used as the variable/covariate selection method. Cox proportional hazards regression models were used to determine predictors of CVD.

Results

Data from 365 patients with OSA were screened. Ninety-seven patients were excluded from analysis due to low quality ECG data (n=50) or extremely high (&gt; ln (10)) variability in QT/QTc and/or QT variability (n=12). Fifty two percent of the sample was male with mean age 65 years (±10). Fifty-six of these patients died of CVD. The mean (SD) QTc in the group that died was 411 (30) ms and 416 (34) ms compared to 406 (24) ms and 411 (25) ms using Fridericia (Cox LR p-value 0.055) and Bazett (p=0.090), respectively. Gender, age, race, diabetes, SDQT and STVQT were significant predictors for CVD. We fit models with the covariates and SDQT (at both 1 and 5 min) and STVQT as three models and demonstrate that both SDQT and STVQT are significantly associated with CVD death (p-values of 0.0048, 0.0089, and 0.0113, respectively) and all models had high area under the curve (0.8095, 0.8085, and 0.8125, respectively).

Conclusion

In patients with OSA, QT variability was associated with CVD.

Support

American Academy of Sleep Medicine Foundation

0717 Peer-intervention Can Reduce Health Disparities In Patients With Obstructive Sleep Apnea

Introduction

In patients with obstructive sleep apnea (OSA), adherence to continuous positive airway pressure (CPAP) therapy is a major problem. Moreover, up to 20% of patients with suspected OSA who are referred to sleep study testing do not adhere to such diagnostic work-up. Although, peer-driven intervention with an interactive voice response system (PDI-IVR) can improve CPAP adherence, whether such an intervention can improve adherence to sleep study testing is unknown. Also, there remain health disparities with greater levels of CPAP nonadherence disproportionately affecting individuals of lower socioeconomic status. We aimed to determine whether PDI-IVR can improve adherence to sleep study testing and CPAP adherence in a lower income population.

Methods

We performed a prospective, randomized, parallel group, controlled trial wherein patients with suspected OSA were randomly assigned to receive PDI-IVR or provided with educational information regarding OSA and CPAP therapy (attention-control group) while both groups received usual care. The PDI-IVR interactions aimed at promoting adherence to sleep study testing and in patients diagnosed with OSA the peer-intervention was focused on improving CPAP adherence. In the PDI-IVR group, trained peers (peer-buddies) with OSA were paired with randomized patients over a 6-month period combined with an ability to meet in-person, email, text message, or phone an inter-disciplinary team of providers.

Results

In this pilot study, there were 63 patients (48.4 ± 12.5 years; 30 men) who were randomized to intervention (n=31) and attention-control (n=32) arms. There were 36 peer-buddies who mentored the patients in the intervention group. Intention to treat analysis revealed that failure to undergo sleep study testing was 15.6% of patients in the attention-control arm and 9.7% in the PDI-IVR arm (P=0.7). Per protocol analysis revealed that failure to undergo sleep study testing was 18.4% of patients in the attention-control arm and 4% in the PDI-IVR arm (P=0.13). At 6 months, CPAP adherence was greater in PDI-IVR arm (290 ± 45 min [SE]) than attention-control arm (181 ± 43 min; P=0.01).

Conclusion

In a lower income population, PDI-IVR improved CPAP adherence with a tendency for better adherence to sleep-study testing. Peer-intervention can reduce sleep health disparities.

Support

HL138377

1188 Test Characteristics of a Machine Learned Electronic Medical Record Extractable Tool for OSA Case Identification in a Community-Based Population

Introduction

Obstructive sleep apnea (OSA) is a significantly underdiagnosed medical condition. A machine learning method known as SLIM (Supersparse Linear Integer Models) that can be extracted from the Electronic Health Record (EHR) has found to be superior to patient-reported sleep-related symptoms to diagnose OSA. Such an evaluation, however, was previously validated in a laboratory-based population. Our aim was to determine the test characteristics for the EHR-extractable SLIM tool in a community-based population.

Methods

Subjects who participated in the Sleep Heart Health Study (SHHS) were included in this analysis. Variable definitions of OSA were determined using an Apnea Hypopnea Index (AHI) threshold of 5 per hour, 15 per hour, or the presence of any comorbidity (hypertension, ischemic heart disease, stroke, mood disorders, impairment of cognition, or sleepiness) when the AHI was between 5 to 15 per hour. Variable hypopnea definitions based upon degree of oxygen desaturation and associated arousals were considered.

Results

In the SHHS dataset, the Receiver Operating Characteristics (ROC) for a SLIM score threshold of 9 for men and 5 for women was good when OSA was defined by AHI &gt; 5 per hour (hypopneas with either &gt; 3% oxygen desaturation or arousals). Specifically, the ROC was 0.72 (95% Confidence Intervals [CI] 0.70; 0.74) with a Positive Predictive Value [PPV] of 0.98 and Likelihood Ratio of a positive test (LR+) of 11.3. The LR+ (6.0) and PPV (0.92) were also good when an AHI of 5 per hour threshold was adopted with hypopneas scored using the minimum 3% oxygen desaturation alone. Similarly, the ROC was good 0.74 (95%CI 0.73; 0.76) with a Positive Predictive Value [PPV] of 0.98 and Likelihood Ratio of a positive test (LR+) of 11.3. The LR+ (8.9) and PPV (0.81) were also good in the presence of comorbidities when AHI was 5 to 15 per hour using &gt; 4% oxygen desaturation alone.

Conclusion

The EHR-extractable tool can be an actionable tool for case-identification of patients needing a referral for sleep study in a community-based population. Such an approach could facilitate an automated, rather than manual, OSA screening approach aimed at managing population health.

Support

HL138377

1209 Effect Of Wearables On Sleep In Healthy Individuals: A Randomized Cross-over Trial And Validation Study

Introduction

To determine whether a wearable sleep-tracker improves perceived sleep quality in healthy subjects. To test whether wearables reliably measure sleep quantity and quality compared to polysomnography.

Methods

A single-center randomized cross-over trial of community-based participants without medical conditions or sleep disorders. Wearable device (WHOOP, Inc.) that provided feedback regarding sleep information to the participant for 1-week and maintaining sleep logs versus 1-week of maintaining sleep logs alone. Self-reported daily sleep behaviors were documented in sleep logs. Polysomnography was performed on one night when wearing the wearable. PROMIS Sleep disturbance sleep scale was measured at baseline, 7, and 14 days of study participation.

Results

In 32 participants (21 women; 23.8 + 5 years), wearables improved nighttime sleep quality (PROMIS sleep disturbance; B= -1.69; 95% Confidence Interval -3.11, -0.27; P=0.021) after adjusting for age, sex, baseline, and order effect. There was a small increase in self-reported daytime naps when wearing the device (B = 3.2; SE 1.4; P=0.023) but total daily sleep remained unchanged (P=0.43). The wearable had low bias (2.5 minutes) and low precision (5.6 minutes) errors for measuring sleep duration and measured dream sleep and slow wave sleep accurately (Intra-class coefficient 0.74 + 0.28 and 0.85 + 0.15, respectively). Bias and precision error for heart rate (bias -0.17%; precision 1.5%) and respiratory rate (bias 1.8%’ precision 6.7%) were very low when compared to that measured by electrocardiogram and inductance plethysmography during polysomnography.

Conclusion

In healthy people, wearables can improve sleep quality and accurately measure sleep and cardiorespiratory variables.

Support

WHOOP Inc.

Management of epilepsy during pregnancy: an update

The clinical management of women with epilepsy on antiepileptic drugs (AEDs) during pregnancy presents unique challenges. The goal of treatment is optimal seizure control with minimal in utero fetal exposure to AEDs in an effort to reduce the risk of structural and neurodevelopmental teratogenic effects. This paper reviews the following key issues pertaining to women with epilepsy during pregnancy: AED pharmacokinetics; clinical management of AEDs; seizure frequency; major congenital malformation; neurodevelopmental outcomes; perinatal complications; and breast feeding.

Comparison of molecular and microscopic technique for detection of Theileria annulata from the field cases of cattle

AIM

Tropical theileriosis is fatal hemoprotozoal disease of dairy animals caused by Theileria annulata. The aim of the present study was to detect the T. annulata and comparison of results of molecular and microscopic techniques.

MATERIALS AND METHODS

A total of 52 blood samples were collected from the cattle suspected for theileriosis across the Banaskantha district. All the samples were screened for theileriosis using Giemsa's staining technique and polymerase chain reaction (PCR).

RESULTS

Total of 17 (32.69%) and 24 (46.15%) samples were found positive for theileriosis by microscopic examination and PCR test, respectively. It revealed that the study area is endemic for theileriosis, and the microscopic technique has 70.83% sensitivity and 100% specificity with respect to PCR technique.

CONCLUSION

It may be concluded from the present study that the PCR is comparatively sensitive technique than microscopic examination and may be recommended to use in the field for screening of theileriosis in the study area, where a high prevalence of diseases have been reported due to intensive dairy farming.

Intramuscular and rectal therapies of acute seizures

The intramuscular (IM) and rectal routes are alternative routes of delivery for antiepileptic drugs (AEDs) when the intravenous route is not practical or possible. For treatment of acute seizures, the AED used should have a short time to maximum concentration (Tmax). Some AEDs have preparations that may be given intramuscularly. These include the benzodiazepines (diazepam, lorazepam, and midazolam) and others (fosphenytoin, levetiracetam). Although phenytoin and valproate have parenteral preparations, these should not be given intramuscularly. A recent study of prehospital treatment of status epilepticus evaluated a midazolam (MDZ) autoinjector delivering IM drug compared to IV lorazepam (LZP). Seizures were absent on arrival to the emergency department in 73.4% of the IM MDZ compared to a 63.4% response in LZP-treated subjects (p < 0.001 for superiority). Almost all AEDs have been evaluated for rectal administration as solutions, gels, and suppositories. In a placebo-controlled study, diazepam (DZP) was administered at home by caregivers in doses that ranged from 0.2 to 0.5 mg/kg. Diazepam was superior to placebo in reduced seizure frequency in children (p < 0.001) and in adults (p = 0.02) and time to recurrent seizures after an initial treatment (p < 0.001). Thus, at this time, only MZD given intramuscularly and DZP given rectally appear to have the properties required for rapid enough absorption to be useful when intravenous routes are not possible. Some drugs cannot be administered rectally owing to factors such as poor absorption or poor solubility in aqueous solutions. The relative rectal bioavailability of gabapentin, oxcarbazepine, and phenytoin is so low that the current formulations are not considered to be suitable for administration by this route. When administered as a solution, diazepam is rapidly absorbed rectally, reaching the Tmax within 5-20 min in children. By contrast, rectal administration of lorazepam is relatively slow, with a Tmax of 1-2h. The dependence of gabapentin on an active transport system, and the much-reduced surface area of the rectum compared with the small intestine, may be responsible for its lack of absorption from the rectum. This article is part of a Special Issue entitled "Status Epilepticus".

Validation of the Patient Health Questionnaire-9 (PHQ-9) for depression screening in adults with epilepsy

OBJECTIVE

This study aimed to assess the accuracy and operating characteristics of the Patient Health Questionnaire-9 (PHQ-9) for depression screening in adults with epilepsy.

METHODS

Tertiary epilepsy center patients served as the study population, with 237 agreeing to structured interview using the Mini-International Neuropsychiatric Interview (MINI), a "gold standard" instrument developed for rapid diagnosis of neuropsychiatric disorders, including major depressive disorder (MDD); 172 also completed the PHQ-9, and 127 completed both the PHQ-9 and the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) within two days of the MINI. Sensitivity, specificity, positive and negative predictive values, and areas under the ROC curves for each instrument were determined. Cut-points of 10 for the PHQ-9 and 15 for the NDDI-E were used, and ratings at or above the cut-points were considered screen-positive. The PHQ-9 was divided into cognitive/affective (PHQ-9/CA) and somatic (PHQ-9/S) subscales to determine comparative depression screening accuracy.

RESULTS

The calculated areas under the ROC curves for the PHQ-9 (n=172) and the PHQ-9/CA and PHQ-9/S subscales were 0.914, 0.924, and 0.846, respectively, with the PHQ-9 more accurate than the PHQ-9/S (p=0.002) but not different from the PHQ-9/CA (p=0.378). At cut-points of 10 and 15, respectively, the PHQ-9 had higher sensitivity (0.92 vs 0.87) but lower specificity (0.74 vs 0.89) compared with the NDDI-E. The areas under the ROC curves of the PHQ-9 and the NDDI-E showed similar accuracy (n=127; 0.930 vs 0.934; p=0.864).

SIGNIFICANCE

The PHQ-9 is an efficient and nonproprietary depression screening instrument with excellent accuracy validated for use in adult patients with epilepsy as well as multiple other medical populations.

Use of Crinone vaginal progesterone gel for luteal support in in vitro fertilization cycles

OBJECTIVE

To investigate the efficacy and safety of intravaginal Crinone 8% (Columbia Research Laboratories, Miami. FL) versus IM progesterone for luteal phase support after IVF-ET.

DESIGN

Prospective open trial with comparison to historical controls.

SETTING

University hospital.

PATIENT(S)

Two hundred six women undergoing IVF-ET.

INTERVENTION(S)

One hundred patients received Crinone vaginal progesterone gel (90 mg once daily) and 106 patients received IM progesterone (50 mg once daily) beginning on the evening of oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Pregnancy and miscarriage rates, and midluteal serum progesterone levels.

RESULT(S)

Positive beta-hCG pregnancy rates, clinical pregnancy rates per transfer, and ongoing pregnancy rates were similar for the Crinone and IM progesterone groups. Women who received Crinone had higher rates of biochemical pregnancy loss but lower rates of clinical pregnancy loss (i.e., spontaneous abortion) than women who received IM progesterone. Midluteal serum progesterone concentrations were significantly higher in the IM progesterone group (94.3+/-8.8 ng/mL versus 57.7+/-7.4 ng/mL). Several women who received Crinone had vaginal bleeding 11-13 days after oocyte retrieval.

CONCLUSION(S)

For all age categories, positive beta-hCG and ongoing pregnancy rates were similar when Crinone or IM progesterone was given for luteal phase support in IVF-ET cycles, despite lower serum progesterone concentrations and higher rates of biochemical pregnancy loss with Crinone. Although the results of this study support the use of Crinone as an acceptable alternative for luteal support after IVF-ET, differences in bleeding patterns and rates of biochemical pregnancy loss demonstrate the need for a prospective randomized study.

Anaesthetic considerations in a patient with wolff-Parkinson-white syndrome

Wolff-Parkinson-White syndrome is an important variant of pre-excitation syndromes caused by congenital atrioventricular accessory pathway. It can lead to various types of serious cardiac arrhythmias. We describe general anaesthesia management using fentanyl-vecuronium-halothane technique to achieve haemodynamic stability.

Effects of purified insulins on insulin requirement and metabolic control

Seventeen diabetics requiring high insulin doses were transferred from conventional insulin to purified chromatographed porcine insulins (Actrapid and Lentard-Novo, Denmark). At the end of 8 to 12 weeks, there was a 46% reduction in insulin dosage while metabolic control improved. Some of these patients when transferred again to conventional insulins demonstrated poor metabolic control and an increase in insulin requirements. Use of purified insulin is beneficial as insulin requirement is reduced with improved metabolic control.