The cost-effectiveness of progesterone in preventing miscarriages in women with early pregnancy bleeding: an economic evaluation based on the PRISM trial.

OBJECTIVES: To assess the cost-effectiveness of progesterone compared with placebo in preventing pregnancy loss in women with early pregnancy vaginal bleeding. DESIGN: Economic evaluation alongside a large multi-centre randomised placebo-controlled trial. SETTING: Forty-eight UK NHS early pregnancy units. POPULATION: Four thousand one hundred and fifty-three women aged 16-39 years with bleeding in early pregnancy and ultrasound evidence of an intrauterine sac. METHODS: An incremental cost-effectiveness analysis was performed from National Health Service (NHS) and NHS and Personal Social Services perspectives. Subgroup analyses were carried out on women with one or more and three or more previous miscarriages. MAIN OUTCOME MEASURES: Cost per additional live birth at ≥34 weeks of gestation. RESULTS: Progesterone intervention led to an effect difference of 0.022 (95% CI -0.004 to 0.050) in the trial. The mean cost per woman in the progesterone group was £76 (95% CI -£559 to £711) more than the mean cost in the placebo group. The incremental cost-effectiveness ratio for progesterone compared with placebo was £3305 per additional live birth. For women with at least one previous miscarriage, progesterone was more effective than placebo with an effect difference of 0.055 (95% CI 0.014-0.096) and this was associated with a cost saving of £322 (95% CI -£1318 to £673). CONCLUSIONS: The results suggest that progesterone is associated with a small positive impact and a small additional cost. Both subgroup analyses were more favourable, especially for women who had one or more previous miscarriages. Given available evidence, progesterone is likely to be a cost-effective intervention, particularly for women with previous miscarriage(s). TWEETABLE ABSTRACT: Progesterone treatment is likely to be cost-effective in women with early pregnancy bleeding and a history of miscarriage.

The use of O-ring retractors at Caesarean section : A systematic review and meta analysis.

O-ring retractors (Alexis/Mobius) have been shown to reduce the risk of Surgical site infection (SSI) following general abdominal surgery. The benefit at caesarean section (CS) remains to be established given the relatively high cost. OBJECTIVES: To assess the efficacy of O-ring retractors when used at CS. STUDY DESIGN: Systematic review and meta-analysis. Electronic databases were searched from inception of each database until January 2018. No language restrictions were applied. All randomised controlled trials (RCTs) which compared the use of an O-ring retractor to routine care at CS were included. Primary outcome was SSI. Secondary outcomes were operating time, estimated blood loss, need for blood transfusion, need to exteriorise the uterus, requirement for additional postoperative analgesia and adequate operative field visualisation. Analysis was performed using Revman 5.3. RESULTS: 6 RCTs were included in the qualitative synthesis and the meta-analysis. This included 1669 women. The use of O-ring retractors did not reduce the risk of SSI when used at CS RR 0.76 (95% CI 0.34-1.70). Nor did the use of O-ring retractors reduce the operating time, estimated blood loss, the need for blood transfusion or the need for additional postoperative analgesia. The use O-ring retractors did reduce the need for exteriorisation of the uterus RR 0.48 (95% CI 0.33-0.69), and did increase the rate of adequate visualisation of the operative field RR 1.05 (95% CI 1.00-1.10). In a planned subgroup analysis there was a reduction in the rate of SSI with the use of O-ring retractors in women with a BMI < 35 RR 0.34(95% CI 0.12-0.98). CONCLUSION: This review has shown that O-ring retractors do not reduce the incidence of the common measurable complications of CS; SSI, blood loss, need for blood transfusion and need for additional postoperative analgesia. There may be a subgroup where these retractors are useful, but present evidence does not justify their routine use at CS.

Preparation of pH-adjusted local anesthetics.

Characteristics of alkalinized local anesthetics are poorly described with regard to stability and precipitation. Current fixed-volume methods of alkalinization often result in unstable, precipitated solutions of unpredictable pH. We determined a stable, nonprecipitating, anesthetic mixture and used it in a randomized double-blind crossover study of 21 patients to evaluate alkalinized anesthetic solutions in reducing pain on injection. Our solution significantly reduced pain associated with retrobulbar injection (analysis of variance, P = .0362) but not that associated with Nadbath injection. Fixed-volume alkalinization is not recommended because complications can result with the use of precipitated anesthetics.

Medical management of missed abortion and anembryonic pregnancy.

PIP: Mifepristone (an antiprogesterone) and misoprostol (a synthetic analogue of prostaglandin E1) were administered to 60 women diagnosed with missed abortion or anembryonic pregnancy (gestation sac present but no developing embryo) equivalent to 13 weeks' gestation or less who were recruited after counselling. The median age was 227 (range 15-44), and the median duration of amenorrhoea was 71 (42-110) days. 25 of the women had been referred for ultrasound scanning because of bleeding in early pregnancy, while the rest were diagnosed by routine scanning. 29 patients had anembryonic pregnancies, and 31 had a missed abortion. Each patient received a 600 mg single oral dose of mifepristone, and 36-48 hours later misoprostol 600 mcg was given orally (400 mcg and, 2 hours later, 200 mcg). If the products of conception were not expelled within 4 hours, vaginal ultrasonography was performed. 8 patients aborted with mifepristone alone, 43 aborted after taking 600 mcg of misoprostol, and 5 more aborted after receiving a 2nd divided dose of 600 mcg misoprostol. In 3 patients the treatment failed, and they underwent evacuation of the uterus under general anaesthesia. Exploratory curettage was performed in 2 other patients at 14 and 22 days after treatment with misoprostol, but no products of conception were obtained. The median time from administration of misoprostol to abortion was 4 (1-11) hours. The median duration of bleeding after abortion was 10 (2-22) days. Side effects included nausea, vomiting (5 patients received antiemetic drugs), and diarrhoea (7 patients) from misoprostol treatment. 39 women did not want any pain relief, 13 asked for oral analgesia, and 7 obtained parenteral analgesia.^ieng

Bilateral dacryocystitis after punctal occlusion with thermal cautery.

A 61-year-old woman developed acute bilateral dacryocystitis secondary to Staphylococcus aureus 3 weeks after undergoing punctal occlusion with thermal cautery for keratoconjunctivitis sicca. The dacryocystitis resolved with intravenous antibiotics, aspiration of the lacrimal sacs, injection of sulfacetamide into the lacrimal sacs, and bilateral dacryocystorhinostomy. Preexisting bilateral nasolacrimal duct obstruction was postulated as the underlying cause. In these cases, irrigation of the lacrimal system is recommended before proceeding with punctal occlusion.

Urethral dilatation compared with cystoscopy alone in the treatment of women with recurrent frequency and dysuria.

The relative merits of cystoscopy alone and cystoscopy plus urethral dilatation were compared in a randomised study of women with recurrent frequency and dysuria. One hundred women were studied before and at least 6 months after operation. A detailed questionnaire was completed, the severity of the symptoms was scored and patients underwent urodynamic investigation. Forty-eight patients underwent cystoscopy alone and 52 underwent urethral dilatation. The two groups were well matched with regard to age, parity, menopausal status, previous gynaecological surgery and severity of symptoms. A significant improvement in symptoms was observed in both groups after treatment: 30% had no residual symptoms, 50% were improved and 20% were no better. However, no difference in final outcome was observed between those who had undergone cystoscopy alone and those who had undergone urethral dilatation. Furthermore, 7 patients who underwent urethral dilatation experienced transient stress incontinence of urine, a complication not observed in women who underwent cystoscopy alone. No benefit was observed from the addition of urethral dilatation to cystoscopy alone in women with recurrent frequency and dysuria.

Ovarian function in the elephant: luteinizing hormone and progesterone cycles in African and Asian elephants.

Serum samples were collected weekly for 3 yr from two female African elephants, for 18 mo from two other female African elephants, and for 2 yr from two female Asian elephants. Animals were not sedated at the time of blood collection. Ovarian cycles, characterized by changes in progesterone and immunoreactive luteinizing hormone (ILH) concentrations, averaged 15.9 +/- 0.6 wk (N = 25) for African females and 14.7 +/- 0.5 wk for Asian females (N = 10). The length of the active luteal phase averaged 10.0 +/- 0.3 wk for African elephants (range 8-14 wk) and 10.6 +/- 0.6 wk for Asian females (range 9-13 wk). Interluteal phases were 5.9 +/- 0.6 wk for African females and 4.2 +/- 0.5 wk for Asian females. One African female (Maliaca) had two extended interluteal phases, both occurring between the months of February and May. Excluding these two periods, there were no differences in the length of the ovarian cycle or the length of the luteal phase between species of elephant. Serum progesterone in both species ranged from less than 50 pg/ml to 933 pg/ml. Average progesterone concentrations during the luteal phase were significantly lower in African elephants compared with Asian elephants (328 +/- 13, N = 30 cycles vs. 456 +/- 23, N = 14 cycles; p less than 0.001). ILH ranged from nondetectable to 11.6 ng/ml. These data suggest that the length of the ovarian cycle in the African elephant is about 16 wk and confirm that the length of the ovarian cycle in the Asian elephant is about 15 wk.

Upper gastrointestinal endoscopy for diagnosis of complications of regional hepatic chemotherapy.

Seven of 26 patients undergoing insertion of "Infusaid" perfusion pumps with hepatic artery catheters for regional hepatic perfusion with 5 fluorodeoxyuridine were diagnosed to have gastritis (n = 5) or penetrating duodenal ulcers with catheter exposure (n = 2). Diagnosis is best achieved by esophagogastroduodenoscopy. The ulcers required removal of the pumps and gastric resections. The gastritis responded only to cessation of drug infusion. These complications represent a significant risk to regional hepatic chemotherapy. Physicians caring for this group of patients will be unable to predict which individuals will suffer these complications when using preoperative or postoperative parameters such as age, sex, tumor type, arterial anatomy or flow patterns on nuclear isotope scanning. A high index of suspicion must be maintained during the critical third and fourth cycles of chemotherapy in all patients undergoing regional hepatic chemotherapy.

Islet autotransplantation after pancreatectomy for chronic pancreatitis with a new method of islet preparation.

Near-total (95 percent) pancreatectomy with intraportal islet autotransplantation was performed in five patients with chronic pancreatitis. Two patients are completely insulin-independent 7 and 14 months after autotransplantation; the other three patients obtained partial independence. A new method of islet cell preparation is described. Islet cell autotransplantation after total or near-total pancreatectomy should at present be viewed with cautious optimism. Additional cases need to be studied and followed up before its role in the surgery of chronic pancreatitis will be clear.