Vaginal compared with intramuscular progestogen for preventing preterm birth in high-risk pregnant women (VICTORIA study): a multicentre, open-label randomised trial and meta-analysis

OBJECTIVE

To compare the efficacy of two types of progestogen therapy for preventing preterm birth (PTB) and to review the relevant literature.

DESIGN

A multicentre, randomised, open-label, equivalence trial and a meta-analysis.

SETTING

Tertiary referral hospitals in South Korea.

POPULATION

Pregnant women with a history of spontaneous PTB or short cervical length (<25 mm).

METHODS

Eligible women were screened and randomised at 16-22 weeks of gestation to receive either 200 mg of vaginal micronised progesterone daily (vaginal group) or an intramuscular injection of 250 mg 17α-hydroxyprogesterone caproate weekly (IM group). Stratified randomisation was carried out according to participating centres and indications for progestogen therapy. This trial was registered at ClinicalTrials.gov (NCT02304237).

MAIN OUTCOME MEASURE

Preterm birth (PTB) before 37 weeks of gestation.

RESULTS

A total of 266 women were randomly assigned and a total of 247 women (119 and 128 women in the vaginal and IM groups, respectively) were available for the intention-to-treat analysis. Risks of PTB before 37 weeks of gestation did not significantly differ between the two groups (22.7 versus 25.8%, P = 0.571). The difference in PTB risk between the two groups was 3.1% (95% CI -7.6 to 13.8%), which was within the equivalence margin of 15%. The meta-analysis results showed no significant differences in the risk of PTB between the vaginal and IM progestogen treatments.

CONCLUSION

Compared with vaginal progesterone, treatment with intramuscular progestin might increase the risk of PTB before 37 weeks of gestation by as much as 13.8%, or reduce the risk by as much as 7.6%, in women with a history of spontaneous PTB or with short cervical length.

TWEETABLE ABSTRACT

Vaginal and intramuscular progestogen showed equivalent efficacy for preventing preterm birth before 37 weeks of gestation.

High spatial and temporal resolution breast DCE-MRI: A feasibility study

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Background: The typical 1-2 min low temporal resolution (tRes) of conventional gradient-echo (GRE) breast dynamic contrast-enhanced (DCE) MRI precludes accurate quantitative pharmacokinetic (PK) analysis. The commercially available GRE-based TWIST (time-resolved angiography with stochastic trajectories) sequence employs an alternative k-space sampling scheme to provide high spatial and temporal resolution for dynamic imaging, originally intended for time-resolved MR angiography. Here we sought to evaluate the feasibility of breast DCE-MRI with the TWIST sequence, using both tumor morphology and quantitative PK analyses.

Methods: 22 patients with 25 mammography-detected suspicious lesions underwent TWIST DCE-MRI on a 3T Siemens system prior to biopsy. The axial bilateral images were acquired with 20 s tRes and 1.0x1.0x1.4 mm3 spatial resolution (sRes). Immediately after TWIST DCE-MRI, a single DCE image set was acquired in 68 s using a conventional GRE sequence with the same sRes. Blinded to pathology, 3 radiologists compared lesion morphology assessments from the last TWIST DCE and the conventional images, and gave MRI BIRADS scores based on morphology and qualitative kinetic curve analyses. The TWIST DCE lesion signal time-courses were also subjected to Shutter-Speed Model PK analysis.

Results: Normal parenchyma S/N ratios were not statistically different between TWIST and conventional GRE images. All readers indicated 88% [95% CI: (68%, 97%)] agreement in morphology evaluation between the TWIST and conventional DCE images. The degree of inter-reader agreement was substantial (κ = 0.75), as was the agreement in BIRADS scores (κ = 0.76). Pathology revealed 8 malignant and 17 benign lesions. Based on MRI BIRADS scores, all 3 readers attained 100% sensitivity and 82% specificity. With PK analysis, a Ktrans (contrast agent plasma/interstitium transfer rate constant) cut-off value of 0.1 min-1 further improved specificity to 94%.

Conclusions: TWIST breast DCE-MRI provides both high tRes and sRes for accurate quantitative PK analysis and morphology evaluation, respectively. Utilizing TWIST for clinical breast DCE-MRI with quantitative PK analysis is feasible and may improve MRI interpretation.

Limited abdominal MRI in the evaluation of acute right upper quadrant pain

BACKGROUND

We investigated whether limited abdominal magnetic resonance imaging (MRI) is as effective as transabdominal ultrasound (US) in evaluating patients presenting with acute right upper quadrant pain.

METHODS

Twenty-four patients underwent evaluation with a limited abdominal MRI using single-shot fast spin-echo sequences and a right upper quadrant US within 24 h. Two MRI and two US readers independently evaluated the images for gallstones, gallbladder wall thickness, pericholecystic fluid, acute cholecystitis, visualization of the common bile duct, and requests for further imaging. US and MRI findings were compared. Surgical pathology was the gold standard.

RESULTS

MRI and US demonstrated no statistically significant difference in the diagnosis of gallbladder wall thickening, the presence of gallstones or pericholecystic fluid, or the diagnosis of acute cholecystitis (p > 0.05). The sensitivity of both for acute cholecystitis was 50%, with specificities of 89% and 86% for US and MRI, respectively. US readers more frequently requested additional tests and displayed more variability in whether they could adequately see the common bile duct.

CONCLUSION

Limited MRI is equivalent to US in diagnosing gallstones, gallbladder wall thickening, pericholecystic fluid, and acute cholecystitis in patients presenting with symptoms of acute right upper quadrant pain. Especially in sonographically challenging patients, limited MRI may provide a faster, easier method of diagnosis.

Single-particle analysis of aerosols at Cheju Island, Korea, using low-Z electron probe X-ray microanalysis: a direct proof of nitrate formation from sea salts

A recently developed electron probe X-ray microanalysis (EPMA), called low-Z EPMA, employing an ultrathin window energy-dispersive X-ray detector, was applied to characterize aerosol particles collected at two sampling sites, namely, Kosan and 1100 Hill of Cheju Island, Korea, on a summer day in 1999. Since low-Z EPMA can provide quantitative information on the chemical composition of aerosol particles, the collected aerosol particles were classified and analyzed based on their chemical species. Many different particle types were identified, such as marine-originated, carbonaceous, soil-derived, and anthropogenic particles. Marine-originated particles, such as NaNO3- and Na2SO4-containing particles, are very frequently encountered in the two samples. In this study, it was directly proven that the observed nitrate particles were from sea salts. In addition, two types of nitrate particles from sea salts were observed, with and without Mg. The sodium nitrate particles without Mg were believed to be collected as crystalline form, either with the sodium nitrate particles being fractionally recrystallized within evaporating seawater drops or with recrystallized sodium chloride particles having reacted with gaseous nitrogen species in the air to form the crystalline sodium nitrate particles. The other seemed to be collected as seawater drops, where the atmospheric reaction had occurred in the droplets, and thus sodium as well as magnesium nitrates were observed. Carbonaceous particles are the most abundant in the samples at both sites. From this study, it was found that about three-quarters of the carbonaceous particles in the samples were biogenic, which partially explains a previously reported observation of a large concentration of organic carbon particles as compared to elemental carbon. Various soil-derived particles were also observed. In addition to aluminosilicate- and iron oxide-containing particles, which are ubiquitous components in soil-derived particles, CaCO3-, Al2O3- and Cr-containing particles were also frequently encountered.

Heterogeneity assessment in individual CaCO3-CaSO4 particles using ultrathin window electron probe X-ray microanalysis

In our previous studies, it has been demonstrated that both the excitation interactions between electrons and the atoms of the matrix and the matrix and geometric effects of electron-induced X-ray signals can be described by Monte Carlo simulation for low-Z elements, such as carbon, nitrogen, and oxygen, in individual atmospheric microparticles. In addition, by the application of a quantification method, which employs Monte Carlo simulation combined with successive approximations, at least semi-quantitative specification of the chemical compositions could be done. This has enlarged the scope of electron probe X-ray microanalysis (EPMA) for the single particle analysis of atmospheric environmental aerosol particles. In this work, we demonstrate that the heterogeneity of individual particles, even of micrometer size, can be characterized by the application of EPMA. X-ray photons obtained with different primary electron beam energies carry information on the chemical compositions for different regions in the particles. Artificially generated heterogeneous CaCO3-CaSO4 individual particles were measured at different accelerating voltages, and it was found that the Monte Carlo calculation is a powerful technique to extract the information on the heterogeneity of the particles that is contained in the measured X-ray data. Our approach can even estimate the thickness of the surface CaSO4 species by the application of the Monte Carlo calculation. A preliminary result for carbon-coated glass particles is also presented. The complexity involved in the analysis of real world particles is briefly mentioned with a result for heterogeneous SiO2 particle.

Surgical pathology of the parietal pericardium: a study of 344 cases (1993-1999)

Among 344 cases with surgically resected parietal pericardium, ages ranged from 1 to 87 years (mean, 55), and 64% were male. Causes of pericardial disease included neoplastic (33%), idiopathic (30%), iatrogenic (23%), and others (14%). Pericardial constriction (Group 1) represented the largest group (143 cases, 76% male). Maximal pericardial thickness was 1-17 mm (mean, 4). Fibrotic thickening occurred in 96%. Chronic lymphoplasmacytic inflammation affected 73% (mild or moderate in 97%). Calcification was uncommon (gross in 28%, microscopic in 8%), and granulomas were rare (4%, none tubercular). Constriction was idiopathic in 49% and iatrogenic (postpericardiotomy or postirradiation) in 41%. Neoplasms and cysts (Group 2) represented the second largest group (96 cases). Among 43 cases with secondary pericardial involvement, carcinomas accounted for 53% and lymphomas 21%. Forty cases (Group 3) had pericardial effusions (75% chronic), which were idiopathic in 28% and postpericardiotomy in 23%. Thirty-three cases (Group 4) had acute or recurrent pericarditis clinically, which was idiopathic in 70%. Lastly, 32 cases (Group 5) had pericardial resection for conditions unrelated to primary pericardial disease. In conclusion, pericardial constriction tended to be nontubercular (100%), nongranulomatous (96%), idiopathic or iatrogenic (90%), and noncalcific (64%), and it could occur with normal pericardial thickness (4%). Because considerable overlap in the gross and microscopic features existed among cases with noncalcific pericardial constriction (Group 1), pericardial effusions (Group 3), and pericarditis (Group 4), clinical information was necessary to provide an accurate clinicopathologic interpretation.

Effects of dehydroepiandrosterone on collagen and collagenase gene expression by skin fibroblasts in culture

Dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S) are the most abundant steroids in humans whose low levels are related to aging, greater incidence of various cancers, immune dysfunction, atherosclerosis, and osteoporosis. It has been shown that collagen and collagenase gene expression decreases in fibroblasts taken from more aged donors. In this paper, to investigate the relationship between DHEA and skin aging, we examined the effects of DHEA on the regulation of collagen, collegians and stromelysin-1 genes in cultured human skin fibroblasts. In collagen assay, DHEA slightly increased collagen production in a dose-related fashion, its maximal effect occurred at 10(-5) M DHEA (P>0.05). In the presence of DHEA, steady-state levels of alpha1 (I) procollagen mRNA increased to 1. 6-fold of the non-treated group, while those of fibronectin were not. Interestingly, DHEA differently regulated collagenase and stromelysin-1 gene expression. The steady-state levels of collagenase mRNA decreased in response to DHEA by 40%, whereas those of stromelysin-1 mRNA increased up to 2.4-fold, compared to controls. Similar results were obtained for chloramphenicol acetyltransferase assay (CAT); maximal promoter activation of stromelysin-1 gene occurred at 10(-6) M DHEA, 4.5-fold higher than control. CAT assay revealed that treatment with 10(-5) M DHEA resulted in a strong ( approximately 70%) inhibition of the collagenase promoter activity. In our experiments, the effects of DHEA on these gene expressions were higher at pharmacologic concentration (>/=10(-5) M) than those at physiologic concentration (10(-8)-10(-6) M). This study suggests that the level of DHEA may be related to the process of skin aging through the regulation of production and degradation in extracellular matrix.

The modulating actions of sulfonylurea on atrial natriuretic peptide release in experimental acute heart failure

OBJECTIVES

This study defined the modulating actions of sulfonylurea on acute release of atrial natriuretic peptide (ANP) in experimental acute heart failure.

BACKGROUND

Sulfonylurea drugs, blockers of cardioprotective ATP-sensitive K(+) (K(ATP)) channels, may increase the risk of early cardiovascular mortality. In cardiovascular diseases such as acute heart failure, early release of ANP is essential for cardiorenal homeostasis. Although K(ATP) channels regulate secretion of hormones, such as insulin, it is unknown whether sulfonylureas interfere with ANP release in acute heart failure.

METHODS

The effects of acute administration of glyburide (0.3 mg/kg), a prototype sulfonylurea, on ANP release and sodium excretion were measured in vivo in a canine model of pacing-induced acute heart failure characterized by acute atrial stretch. Immunoreactivity, in atrial tissue, for ANP and the K(ATP) channel subunit, Kir6.2, was determined using specific antibodies.

RESULTS

With increased left atrial pressure in heart failure, plasma levels of ANP increased rapidly and peaked within 25+/-3 min. Glyburide delayed the time required for peak plasma ANP secretion to 48+/-5 min. This resulted in reduced natriuresis from 84+/-17 microEq/min in the absence of glyburide, to 34+/-9 microEq/min in the presence of glyburide. However, glyburide did not alter the renal natriuretic responsiveness to exogenously administered ANP in normal dogs. In atrial tissue, both ANP and the K(ATP) channel subunit, Kir6.2, displayed strong immunoreactivity and co-localization.

CONCLUSIONS

Glyburide delays release of ANP in acute heart failure resulting in impaired natriuresis. This cannot be ascribed to an antinatriuretic effect on the kidney, but rather may be due to interference with K(ATP) channel-dependent ANP secretion from the atrium. Such adverse outcome of sulfonylurea drug use could reduce the compensatory capacity to preserve cardiorenal homeostasis in acute heart failure.

Oligogalacturonic acid and chitosan reduce stomatal aperture by inducing the evolution of reactive oxygen species from guard cells of tomato and Commelina communis

Stomatal opening provides access to inner leaf tissues for many plant pathogens, so narrowing stomatal apertures may be advantageous for plant defense. We investigated how guard cells respond to elicitors that can be generated from cell walls of plants or pathogens during pathogen infection. The effect of oligogalacturonic acid (OGA), a degradation product of the plant cell wall, and chitosan (beta-1,4-linked glucosamine), a component of the fungal cell wall, on stomatal movements were examined in leaf epidermis of tomato (Lycopersicon esculentum L.) and Commelina communis L. These elicitors reduced the size of the stomatal aperture. OGA not only inhibited light-induced stomatal opening, but also accelerated stomatal closing in both species; chitosan inhibited light-induced stomatal opening in tomato epidermis. The effects of OGA and chitosan were suppressed when EGTA, catalase, or ascorbic acid was present in the medium, suggesting that Ca(2+) and H(2)O(2) mediate the elicitor-induced decrease of stomatal apertures. We show that the H(2)O(2) that is involved in this process is produced by guard cells in response to elicitors. Our results suggest that guard cells infected by pathogens may close their stomata via a pathway involving H(2)O(2) production, thus interfering with the continuous invasion of pathogens through the stomatal pores.