Termination of pregnancy in the second trimester - the course of different therapy regimens.

OBJECTIVES: To compare two prostaglandin analogs and two application intervals between mifepristone and the prostaglandin analog administration on the time to abortion in second trimester termination of pregnancy. Other endpoints were live birth rate and fetal lifetime after expulsion. METHODS: Retrospective data of 373 abortions performed were evaluated. Four medical induction subgroups and two feticide subgroups were considered. The definition criteria of the subgroups were the choice of administered prostaglandin analog (misoprostol vs. sulprostone) and the time interval between mifepristone and prostaglandin analog administration (48 vs. 24 h). The outcome parameters were the time to complete uterine evacuation (TCUE), the live birth rate and duration of fetal life. RESULTS: In the misoprostol subgroups, the median TCUE was 1.6 h longer in the 24-h group than in the 48-h group (p=0.950). In the sulprostone subgroups, the median TCUE was 1.9 h shorter in the 24-h group than in the 48-h group (p=0.950). The median TCUE was shorter for sulprostone than for misoprostol in all six subgroups (p<0.001). The rate of fetal live births ranged between 13.6 and 15.9% within the medical induction subgroups (p=0.969). The median fetal lifetime was slightly shorter in the sulprostone groups than in the misoprostol groups (p=0.563). CONCLUSIONS: Both application intervals and prostaglandin analogs are similarly effective. The therapy regime should be adapted to the personal preferences of the woman, the situational and clinical conditions.

Evaluation of Cervical Elastography Strain Pattern to Predict Preterm Birth.

PURPOSE: To evaluate cervical elastography strain pattern as a predictive marker for spontaneous preterm delivery (SPTD). MATERIALS AND METHODS: In this case-control study cervical length (CL) and elastographic data (strain ratio, elastography index, strain pattern score) were acquired from 335 pregnant women (20th - 34th week of gestation) by transvaginal ultrasound. Data of 50 preterm deliveries were compared with 285 normal controls. Strain ratio and elastography index were calculated by placing two regions of interest (ROIs) in parallel on the anterior cervical lip. The strain ratio was determined by dividing the higher strain value by the lower one. The elastography index was defined as the maximum of the strain ratio curve. Elastographic images were assigned a new established strain pattern (SP) score between 0 and 2 according to the distribution of strain induced by compression. RESULTS: Elastography index, SP score and CL differed between preterm and normal pregnancies (1.61 vs. 1.27, p < 0.001; SP score value of "2": n = 31 (62 %) vs. n = 36 (12.6 %), p < 0.001; CL 30.7 vs. 41.0 mm, p < 0.001; respectively). The elastography index and SP score were associated with a higher predictive potential than CL measurement alone (AUC 0.8059 (area under the curve); AUC 0.7716; AUC 0.7631; respectively). A combination of all parameters proved more predictive than any single parameter (AUC 0.8987; respectively). CONCLUSION: Higher elastography index and SP scores were correlated with an elevated risk of SPTD and are superior to CL measurement as a predictive marker. A combination of these parameters could be used as a "Cervical Index" for the prediction of SPTD.

Disinfection of Transvaginal Ultrasound Probes by Ultraviolet C - A clinical Evaluation of Automated and Manual Reprocessing Methods.

PURPOSE: Since pathogens can be transmitted to patients via transvaginal ultrasound probes, it is of particular importance that cleaning and disinfection are performed adequately. This study was designed to do a qualitative comparison of a low-level disinfection technique with disinfectant-impregnated wipes and an automated disinfection technique using ultraviolet C radiation in a clinical setting. MATERIALS AND METHODS: The transvaginal ultrasound probes used in two groups of 160 patients were compared in a prospective controlled study regarding the effectiveness of manual low-level disinfection (Mikrozid sensitive wipes) and automated disinfection using ultraviolet C radiation (Antigermix AS1). Microbiological samples were taken from the whole surface of the probe before and after the disinfection process. RESULTS: Before disinfection, 98.75 % (316/320) of the samples showed bacterial contamination. After automated and manual disinfection, the contamination rates were 34.2 % (54/158, automated) and 40.5 % (64/158, disinfectant wipes) (p > 0.05). Pathogens with the potential to cause healthcare-associated infections, such as Enterococcus faecalis and Klebsiella pneumoniae, were removed completely by both techniques. Manual disinfection showed a lower contamination rate after disinfection of bacteria that usually belong to the vaginal, pharyngeal and skin flora (disinfectant wipes 10.6 %, 11/104, automated 32.5 %, 38/117) (p < 0.001). CONCLUSION: For the clinical routine, automated disinfection with ultraviolet C is a promising technique for transvaginal ultrasound probes because of the simple handling and time efficiency. In our study, this method was completely effective against nosocomial pathogens. However, the study didn't show any significant difference in terms of effectiveness compared to low-level wipe disinfection.

Synthetic sideromycins (skepticism and optimism): selective generation of either broad or narrow spectrum Gram-negative antibiotics.

New or repurposed antibiotics are desperately needed since bacterial resistance has risen to essentially all of our current antibiotics, and few new antibiotics have been developed over the last several decades. A primary cause of drug resistance is the overuse of antibiotics that can result in alteration of microbial permeability, alteration of drug target binding sites, induction of enzymes that destroy antibiotics (i.e., ß-lactamases) and even induction of efflux mechanisms. Research efforts are described that are designed to determine if the known critical dependence of iron assimilation by microbes for growth and virulence can be exploited for the development of new approaches to antibiotic therapy. Iron recognition and active transport relies on the biosyntheses and use of microbe-selective iron chelating compounds called siderophores. Several natural siderophore-antibiotic conjugates (sideromycins) have been discovered and studied. The natural sideromycins consist of an iron binding siderophore linked to a warhead that exerts antibiotic activity once assimilated by targeted bacteria. Inspired these natural conjugates, a combination of chemical syntheses, microbiological and biochemical studies have been used to generate semi-synthetic and totally synthetic sideromycin analogs. The results demonstrate that siderophores and analogs can be used for iron transport-mediated drug delivery ("Trojan Horse" antibiotics or sideromycins) and induction of iron limitation/starvation (development of new agents to block iron assimilation). While several examples illustrate that this approach can generate microbe selective antibiotics that are active in vitro, the scope and limitations of this approach, especially related to development of resistance, siderophore based molecular recognition requirements, appropriate linker and drug choices, will be described.

Novel insight into the reaction of nitro, nitroso and hydroxylamino benzothiazinones and of benzoxacinones with Mycobacterium tuberculosis DprE1.

Nitro-substituted 1,3-benzothiazinones (nitro-BTZs) are mechanism-based covalent inhibitors of Mycobacterium tuberculosis decaprenylphosphoryl-ß-D-ribose-2'-oxidase (DprE1) with strong antimycobacterial properties. We prepared a number of oxidized and reduced forms of nitro-BTZs to probe the mechanism of inactivation of the enzyme and to identify opportunities for further chemistry. The kinetics of inactivation of DprE1 was examined using an enzymatic assay that monitored reaction progress up to 100 min, permitting compound ranking according to kinact/Ki values. The side-chain at the 2-position and heteroatom identity at the 1-position of the BTZs were found to be important for inhibitory activity. We obtained crystal structures with several compounds covalently bound. The data suggest that steps upstream from the covalent end-points are likely the key determinants of potency and reactivity. The results of protein mass spectrometry using a 7-chloro-nitro-BTZ suggest that nucleophilic reactions at the 7-position do not operate and support a previously proposed mechanism in which BTZ activation by a reduced flavin intermediate is required. Unexpectedly, a hydroxylamino-BTZ showed time-dependent inhibition and mass spectrometry corroborated that this hydroxylamino-BTZ is a mechanism-based suicide inhibitor of DprE1. With this BTZ derivative, we propose a new covalent mechanism of inhibition of DprE1 that takes advantage of the oxidation cycle of the enzyme.

Siderophore Conjugates of Daptomycin are Potent Inhibitors of Carbapenem Resistant Strains of Acinetobacter baumannii.

Development of resistance to antibiotics is a major medical problem. One approach to extending the utility of our limited antibiotic arsenal is to repurpose antibiotics by altering their bacterial selectivity. Many antibiotics that are used to treat infections caused by Gram-positive bacteria might be made effective against Gram-negative bacterial infections, if they could circumvent permeability barriers and antibiotic deactivation processes associated with Gram-negative bacteria. Herein, we report that covalent attachment of the normally Gram-positive-only antibiotic, daptomycin, with iron sequestering siderophore mimetics that are recognized by Gram-negative bacteria, provides conjugates that are active against virulent strains of Acinetobacter baumannii, including carbapenemase and cephalosporinase producers. The result is the generation of a new set of antibiotics designed to target bacterial infections that have been designated as being of dire concern.

Targeted Antibiotic Delivery: Selective Siderophore Conjugation with Daptomycin Confers Potent Activity against Multidrug Resistant Acinetobacter baumannii Both in Vitro and in Vivo.

In order to address the dire need for new antibiotics to treat specific strains of drug resistant Gram-negative bacterial infections, a mixed ligand analog of the natural Acinetobacter baumannii selective siderophore, fimsbactin, was coupled to daptomycin, a Gram-positive only antibiotic. The resulting conjugate 11 has potent activity against multidrug resistant strains of A. baumannii both in vitro and in vivo. The study also indicates that conjugation of siderophores to "drugs" that are much larger than the siderophore (iron transport agent) itself facilitates active uptake that circumvents the normal permeability problems in Gram-negative bacteria. The results demonstrate the ability to extend activity of a normally Gram-positive only antibiotic to create a potent and targeted Gram-negative antibiotic using a bacterial iron transport based sideromycin Trojan horse strategy.

Assessment of cervical elastography strain pattern and its association with preterm birth.

OBJECTIVE: The aim of the study was to assess the cervical strain pattern by an ultrasound elastography cervix examination and to determine its association with preterm delivery. METHODS: In this study, 30 cases resulting in preterm birth and 30 gestational age-matched controls were included. A vaginal ultrasound examination with cervical length and elastography measurement was performed. We calculated four strain ratios (SR1-SR4) of the regions of interest (ROIs) arranged in pairs in four different positions on the anterior cervical lip. The strain ratios were correlated to the outcome of spontaneous preterm delivery. The inter-observer and intra-observer variability of the strain measurement was evaluated. RESULTS: We observed an association between the value of the strain ratio that was calculated from the ROIs placed side by side in the middle of the anterior lip (SR4), and preterm delivery (P<0.001). The predictive values of cervical length and SR4 were comparable (AUC 0.7394; AUC 0.8322, respectively). The combination of cervical length and SR4 was superior in predicting preterm delivery compared to both parameters alone (AUC 0.8789). The inter-observer and intra-observer variability of data acquisition and measurement was excellent. CONCLUSIONS: Our study assesses the cervical elastography strain pattern and shows a correlation to a spontaneous preterm birth.

Fetal thymus size in pregnant women with diabetic diseases.

AIM: The aim of our study was to assess fetal thymus size in diabetic pregnancies compared with normal pregnancies. METHODS: Sonographic fetal thymus size was retrospectively assessed in 161 pregnancies with maternal diabetes and in 161 uncomplicated pregnancies matched by gestational age. The anteroposterior thymic and the intrathoracic mediastinal diameter were measured and the quotient was calculated [thymic-thoracic ratio (TT-ratio)]. In addition, we defined the quotient of the anteroposterior thymic diameter and the head circumference as thymus-head ratio (TH-ratio). The maternal diabetes cases were subdivided into three groups: (1) diet-controlled gestational diabetes, (2) insulin-dependent gestational diabetes and (3) preexisting maternal diabetes. RESULTS: TT-ratio and TH-ratio were smaller in pregnancies with maternal diabetes (P<0.001 and P<0.001, respectively). In all three maternal diabetes subgroups, the TT-ratio and the TH-ratio were lower compared with the control group (P<0.001 for each group). CONCLUSIONS: Reduced fetal thymus size seems to be associated with diabetic pregnancy. We introduce fetal thymus size as a new potential prognostic parameter for maternal diabetes.

In†Vivo Dearomatization of the Potent Antituberculosis Agent BTZ043 via Meisenheimer Complex Formation.

Nitrobenzothiazinones are among the most potent antituberculosis agents. Herein, we disclose an unprecedented in vivo reduction process that affords Meisenheimer complexes of the clinical candidates BTZ043 and PBTZ169. The reduction is reversible, occurs in all mammalian species investigated, has a profound influence on the in vivo ADME characteristics, and has considerable implications for the design and implementation of clinical studies. The reduction was confirmed by chemical studies that enabled the complete characterization of the Meisenheimer complex and its subsequent chemistry. Combination of the in vivo and chemical studies with LC-MS characterization and assay development also provides a basis for rational lead optimization of this very promising class of antituberculosis agents.

Quantification of mechanical dyssynchrony in growth restricted fetuses and normal controls using speckle tracking echocardiography (STE).

PURPOSE: To evaluate longitudinal mechanical dyssynchrony in normally grown fetuses by speckle tracking echocardiography (STE) and to compare longitudinal mechanical dyssynchrony in fetal growth restriction (FGR) with normal controls. MATERIALS AND METHODS: A prospective study was performed on 30 FGR and 62 normally grown fetuses, including 30 controls matched by gestational age, using STE and a transversal four-chamber view. Data analysis was carried out with a high frame rate of about 175 frames/s. Dyssynchrony was analyzed offline with QLab 9 (Philips Medical Systems, Andover, MA, USA) as time differences between peaks in strain of both ventricles and the septum. Inter- and intraventricular and intraseptal dyssynchrony were obtained and inter- and intraobserver reliability was analyzed. RESULTS: Longitudinal mechanical dyssynchrony was feasible in all cases, with high inter- and intraobserver reliability. Levels of inter- and intraventricular dyssynchrony were higher in the FGR than in the control group. CONCLUSION: Speckle tracking echocardiography (STE) is a reliable technique for cardiac function assessment in the fetal heart. Interventricular dyssynchrony could be a potential parameter for early detection of subclinical myocardial dysfunction before other parameters demand intervention. The future clinical role of longitudinal mechanical dyssynchrony needs to be verified in larger studies and with a technique customized for prenatal echocardiography.

Design and Syntheses of Anti-Tuberculosis Agents Inspired by BTZ043 Using a Scaffold Simplification Strategy.

Tuberculosis (TB), a disease caused by Mycobacterium tuberculosis (Mtb), is a global public health concern because of the emergence of various resistant strains. Benzothiazin-4-ones (BTZs), represented by BTZ043, are a promising new class of agents for the treatment of tuberculosis and have been shown to kill Mtb in vitro, ex vivo, and in mouse models of TB. Herein we report the design and syntheses of nitroaromatic sulfonamide, reverse-amide, and ester classes of anti-TB agents using a scaffold simplification strategy based on BTZ043. The presented work explores the effect of functional groups such as sulfonamides, reverse-amides, and esters that are attached to the nitroaromatic rings on their anti-TB activity. The in vitro activity of the compounds evaluated against the H37Rv strain of Mtb show that nitroaromatic sulfonamides and nitrobenzoic acid esters with two nitro substituents were most active and highlights the importance of the electronic character (electron deficient aromatic ring) of the nitroaromatic ring as a central theme in these types of nitroaromatic anti-TB agents.

Imaging of fetal thymus in pregnant women with rheumatic diseases.

OBJECTIVE: To determine whether certain rheumatic diseases will affect the fetal thymus diameter when compared to uncomplicated singleton pregnancies. Additionally, we created a reference chart for fetal thymus size in healthy singleton pregnancies from 19 to 37 weeks of gestation. METHODS: Sonographic fetal thymus size was retrospectively evaluated in 190 healthy pregnant women, and 84 pregnancies of mothers suffering from systemic lupus erythematosus, antiphospholipid syndrome (APS), or Sjögren's syndrome between 19 and 37 weeks of gestation. These fetuses were matched one-to-one for gestational age with control fetuses. The thymic-thoracic ratio (TT-ratio) was defined as the quotient of the anteroposterior thymic and the intrathoracic mediastinal diameter. RESULTS: Rheumatic diseases often affect pregnancy outcome, especially in case of primary APS. The TT ratio of fetuses of mothers suffering from rheumatic disease was equal to controls (P=0.807). CONCLUSIONS: Ours is the first study to assess the correlation of fetal thymus size in high-risk pregnancies with rheumatic diseases in comparison to controls. Women with rheumatic diseases deal with pregnancy complications more frequently than controls. Our data suggest that maternal rheumatic diseases do not affect the fetal thymus size.

Trihydroxamate siderophore-fluoroquinolone conjugates are selective sideromycin antibiotics that target Staphylococcus aureus.

Siderophores are multidentate iron(III) chelators used by bacteria for iron assimilation. Sideromycins, also called siderophore-antibiotic conjugates, are a unique subset of siderophores that enter bacterial cells via siderophore uptake pathways and deliver the toxic antibiotic in a "Trojan horse" fashion. Sideromycins represent a novel antibiotic delivery technology with untapped potential for developing sophisticated microbe-selective antibacterial agents that limit the emergence of bacterial resistance. The chemical synthesis of a series of mono-, bis-, and trihydroxamate sideromycins are described here along with their biological evaluation in antibacterial susceptibility assays. The linear hydroxamate siderophores used for the sideromycins in this study were derived from the ferrioxamine family and inspired by the naturally occurring salmycin sideromycins. The antibacterial agents used were a ß-lactam carbacepholosporin, Lorabid, and a fluoroquinolone, ciprofloxacin, chosen for the different locations of their biological targets, the periplasm (extracellular) and the cytoplasm (intracellular). The linear hydroxamate-based sideromycins were selectively toxic toward Gram-positive bacteria, especially Staphylococcus aureus SG511 (MIC = 1.0 µM for the trihydroxamate-fluoroquinolone sideromycin). Siderophore-sideromycin competition assays demonstrated that only the fluoroquinolone sideromycins required membrane transport to reach their cytoplasmic biological target and that a trihydroxamate siderophore backbone was required for protein-mediated active transport of the sideromycins into S. aureus cells via siderophore uptake pathways. This work represents a comprehensive study of linear hydroxamate sideromycins and teaches how to build effective hydroxamate-based sideromycins as Gram-positive selective antibiotic agents.

Identification of antitubercular benzothiazinone compounds by ligand-based design.

1,3-Benzothiazin-4-ones (BTZs) are a novel class of TB drug candidates with potent activity against M. tuberculosis. An in silico ligand-based model based on structure-activity data from 170 BTZ compounds was used to design a new series. Compounds were tested against a panel of mycobacterial strains and were profiled for cytotoxicity, stability, and antiproliferative effects. Several of the compounds showed improved activity against MDR-TB while retaining low toxicity with higher microsomal, metabolic, and plasma stability.

Syntheses and biological studies of novel spiropiperazinyl oxazolidinone antibacterial agents using a spirocyclic diene derived acylnitroso Diels-Alder reaction.

Several novel oxazolidinone antibiotics with a spiropiperazinyl substituent at the 4'-position of the phenyl ring were synthesized through nitroso Diels-Alder chemistry and the in vitro antibacterial activities were evaluated against various Gram-positive bacteria (Bacillus subtilis, Staphylococcus aureus, Enterococcus faecalis), Gram-negative bacteria (Escherichia coli, Pseudomonas aeruginosa) and mycobacteria (Mycobacterium vaccae, Mycobacterium tuberculosis). Analogs (8a and 12) were active against selected drug resistant microbes, like methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) and had no mammalian toxicity in a Hep-2 cellular assay (CC(50) >100 µM).

Structure-activity relationships of 2-benzylsulfanylbenzothiazoles: synthesis and selective antimycobacterial properties.

A set of 2-benzylsulfanyl derivatives of benzothiazole was synthesized and evaluated for antimicrobial and cytotoxic activities. The biological screening on antimicrobial activity against a panel of Gram-positive and Gram-negative bacteria, yeasts and fungi identified benzylsulfanyl derivatives of benzothiazole as selective inhibitors of mycobacteria. The lead compounds in the set, dinitro derivatives exhibited significant activity against sensitive and multidrug-resistant strains of M. tuberculosis and low cytotoxicity. The QSAR study indicated that the antituberculotic activity is connected with LUMO and HOMO energies. The lower lipophilicity and the increased size of the molecule contribute to antituberculotic activity. Thus, dinitrobenzylsulfanyl derivatives of benzothiazole represent promising smallmolecule synthetic antimycobacterials.

Design, synthesis, and study of a mycobactin-artemisinin conjugate that has selective and potent activity against tuberculosis and malaria.

Although the antimalarial agent artemisinin itself is not active against tuberculosis, conjugation to a mycobacterial-specific siderophore (microbial iron chelator) analogue induces significant and selective antituberculosis activity, including activity against multi- and extensively drug-resistant strains of Mycobacterium tuberculosis. The conjugate also retains potent antimalarial activity. Physicochemical and whole-cell studies indicated that ferric-to-ferrous reduction of the iron complex of the conjugate initiates the expected bactericidal Fenton-type radical chemistry on the artemisinin component. Thus, this "Trojan horse" approach demonstrates that new pathogen-selective therapeutic agents in which the iron component of the delivery vehicle also participates in triggering the antibiotic activity can be generated. The result is that one appropriate conjugate has potent and selective activity against two of the most deadly diseases in the world.

A note to the biological activity of benzoxazine derivatives containing the thioxo group.

New 3-benzyl-4-thioxo-2H-1,3-benzoxazine-2(3H)-ones and 3-benzyl-2H-1,3-benzoxazine-2,4(3H)-dithiones were synthesized. The compounds were tested for in vitro antimycobacterial activity against Mycobacterium tuberculosis, Mycobacterium kansasii and Mycobacterium avium. The replacement of the carbonyl group by the thiocarbonyl group increased the antimycobacterial activity. The most active derivatives were more active than isonicotinhydrazide (INH). The cytotoxicity and the antiproliferative activity were studied as well.

Structure-activity relationship of new anti-tuberculosis agents derived from oxazoline and oxazole benzyl esters.

During the syntheses and studies of natural iron chelators (mycobactins), we serendipitously discovered that a simple, small molecule, oxazoline-containing intermediate 3 displayed surprising anti-tuberculosis activity (MIC of 7.7 microM, average). Herein we report elaboration of SAR around this hit as well as the syntheses and evaluation of a hundred oxazoline- and oxazole-containing compounds derived from an efficient three step process: 1) formation of beta-hydroxy amides with serine or threonine; 2) cyclization to afford oxazolines; and 3) dehydration to give the corresponding oxazoles. A number of compounds prepared by this method were shown to possess impressive activity against Mycobacterium tuberculosis, extremely low toxicity and therefore high therapeutic indexes, as well as activity against even the more recalcitrant non-replicating form of M. tuberculosis. The uniqueness of their structures and their simplicity should allow them to be further optimized to meet ADME (absorption, distribution, metabolism, excretion) requirements. The syntheses of eight of the most potent in vitro compounds were scaled up and the compounds were tested in an in vivo mouse infection model to evaluate their efficacy before engaging upon more elaborate compound design and optimization.