Human-relevant near-organ neuromodulation of the immune system via the splenic nerve.

Neuromodulation of immune function by stimulating the autonomic connections to the spleen has been demonstrated in rodent models. Consequently, neuroimmune modulation has been proposed as a new therapeutic strategy for the treatment of inflammatory conditions. However, demonstration of the translation of these immunomodulatory mechanisms in anatomically and physiologically relevant models is still lacking. Additionally, translational models are required to identify stimulation parameters that can be transferred to clinical applications of bioelectronic medicines. Here, we performed neuroanatomical and functional comparison of the mouse, rat, pig, and human splenic nerve using in vivo and ex vivo preparations. The pig was identified as a more suitable model of the human splenic innervation. Using functional electrophysiology, we developed a clinically relevant marker of splenic nerve engagement through stimulation-dependent reversible reduction in local blood flow. Translation of immunomodulatory mechanisms were then assessed using pig splenocytes and two models of acute inflammation in anesthetized pigs. The pig splenic nerve was shown to locally release noradrenaline upon stimulation, which was able to modulate cytokine production by pig splenocytes. Splenic nerve stimulation was found to promote cardiovascular protection as well as cytokine modulation in a high- and a low-dose lipopolysaccharide model, respectively. Importantly, splenic nerve-induced cytokine modulation was reproduced by stimulating the efferent trunk of the cervical vagus nerve. This work demonstrates that immune responses can be modulated by stimulation of spleen-targeted autonomic nerves in translational species and identifies splenic nerve stimulation parameters and biomarkers that are directly applicable to humans due to anatomical and electrophysiological similarities.

Splenic Nerve Neuromodulation Reduces Inflammation and Promotes Resolution in Chronically Implanted Pigs.

Neuromodulation of the immune system has been proposed as a novel therapeutic strategy for the treatment of inflammatory conditions. We recently demonstrated that stimulation of near-organ autonomic nerves to the spleen can be harnessed to modulate the inflammatory response in an anesthetized pig model. The development of neuromodulation therapy for the clinic requires chronic efficacy and safety testing in a large animal model. This manuscript describes the effects of longitudinal conscious splenic nerve neuromodulation in chronically-implanted pigs. Firstly, clinically-relevant stimulation parameters were refined to efficiently activate the splenic nerve while reducing changes in cardiovascular parameters. Subsequently, pigs were implanted with a circumferential cuff electrode around the splenic neurovascular bundle connected to an implantable pulse generator, using a minimally-invasive laparoscopic procedure. Tolerability of stimulation was demonstrated in freely-behaving pigs using the refined stimulation parameters. Longitudinal stimulation significantly reduced circulating tumor necrosis factor alpha levels induced by systemic endotoxemia. This effect was accompanied by reduced peripheral monocytopenia as well as a lower systemic accumulation of CD16+CD14high pro-inflammatory monocytes. Further, lipid mediator profiling analysis demonstrated an increased concentration of specialized pro-resolving mediators in peripheral plasma of stimulated animals, with a concomitant reduction of pro-inflammatory eicosanoids including prostaglandins. Terminal electrophysiological and physiological measurements and histopathological assessment demonstrated integrity of the splenic nerves up to 70 days post implantation. These chronic translational experiments demonstrate that daily splenic nerve neuromodulation, via implanted electronics and clinically-relevant stimulation parameters, is well tolerated and is able to prime the immune system toward a less inflammatory, pro-resolving phenotype.

Field study of adult male circumcision using the ShangRing in routine clinical settings in Kenya and Zambia.

BACKGROUND: Circumcision devices can facilitate adult voluntary medical male circumcision programs for HIV prevention. The World Health Organization recommends field studies to confirm the safety of devices in local settings. METHODS: We evaluated the safety of the ShangRing device in routine service delivery by measuring adverse event (AE) rates overall and by HIV status. We enrolled men aged 18-54 years and scheduled them for 2 post-circumcision follow-up visits at day 7 for device removal and days 35-42. Men were examined to document AEs and healing and to ascertain client acceptability. Provider preferences were also assessed. RESULTS: We enrolled 1163 men (557 in Kenya and 606 in Zambia); the as-treated analysis population comprised 1149 men, including 84 HIV-positive men. There were no serious AEs and 2 severe AEs: 1 severe wound dehiscence and 1 severe pain, both of which resolved with treatment. There were 18 moderate/severe AEs among 16 men (1.4% of men; 95% confidence interval: 0.8% to 2.3%). The most common AE was wound dehiscence (9 men, 0.8%). Healing was similar between HIV-infected and uninfected men, with 85.7% and 87.3% completely healed at days 35-42. Most men (94.8%) were very satisfied with post-circumcision appearance of the penis, and almost all would recommend a ShangRing procedure. Nineteen of 21 providers preferred the ShangRing over conventional surgery. CONCLUSIONS: The ShangRing has an excellent safety profile with few hemorrhagic and infectious complications. The ShangRing is well accepted by clients and preferred by providers, making it a potential boon to the scale-up of adult voluntary medical male circumcision in African countries.

Randomized controlled trial of the shang ring versus conventional surgical techniques for adult male circumcision: safety and acceptability.

OBJECTIVE: To compare clinical profiles of Shang Ring versus conventional circumcisions. DESIGN: Parallel group open-label randomized controlled trial with one-to-one allocations in 2 sites. METHODS: We enrolled HIV-negative men aged 18-54 years in Homa Bay, Kenya, and Lusaka, Zambia and followed them at 2, 7, 14, 21, 28, 42, and 60 days after Shang Ring versus conventional circumcision. We compared the duration of surgery, postoperative pain using a visual analog scale, adverse events rates, time to complete wound healing by clinical assessment, participant acceptability, and provider preferences between circumcision groups. RESULTS: We randomized 200 men to each group; 197 and 201 contributed to the Shang Ring and conventional surgery analyses, respectively. Adverse event rates were similar between groups. Pain scores at most time points were similar, however, the Shang Ring group reported higher scores for worst pain during erections (3.5 ± 1.9 vs. 2.3 ± 1.7; P < 0.001). Significantly more men were satisfied with the cosmetic appearance following Shang Ring male circumcision (MC), 95.7% versus 85.9% (P = 0.02) in Kenya, and 96.8% versus 71.3% (P < 0.01) in Zambia. Although median time to complete wound healing was 43 days in both groups, conventional circumcisions healed on average 5.2 days sooner (P < 0.001). Shang Ring procedures took one-third the time of conventional MC, 7 versus 20 minutes. All circumcision providers preferred the Shang Ring. CONCLUSIONS: Safety profiles of the 2 techniques were similar, all MC providers preferred the Shang Ring technique, and study participants preferred the Shang Ring's cosmetic results. The Shang Ring should be considered for adult MC as programs scale-up.

Reproductive factors in relation to ovarian cancer: a case-control study in Northern Vietnam.

BACKGROUND: Ovarian cancer, one of the most common cancers in women and the most serious gynecologic cancer, is known to be influenced by reproductive factors, but these factors have not previously been examined in Vietnamese women. STUDY DESIGN: We analyzed 262 ovarian cancer patients recruited from 27 hospitals in 12 provinces and Ha Noi City from April 2001 to May 2006, plus 755 controls matched by age and residential address. RESULTS: The risk of ovarian cancer was significantly lower in parous women than nulliparous women. Use of an intrauterine contraceptive device was also associated with a reduced risk. In contrast, induced abortion, late menopause and years of ovulation were significantly associated with an increased risk of cancer. CONCLUSIONS: Parity and intrauterine device use were associated with a reduced risk of ovarian cancer in Vietnamese women, whereas induced abortion, late menopause and years of ovulation were associated with an increased risk.

Pelvic surgery and hospitalization among Chilean women after nonsurgical sterilization with quinacrine pellets between 1977 and 1989.

BACKGROUND: Concern about quinacrine lingers because of its carcinogenic effects in rats. We describe results of long-term follow-up of women who underwent quinacrine pellet sterilization in Chile between 1977 and 1989 (N=1492). METHODS: We interviewed the women or relatives in five rounds of data collection between 1991-1993 and 2006-2007, and reviewed hospital records. Median follow-up was 18.5 years; total person-time was 23,894 woman-years. This analysis focuses on pelvic and abdominal surgeries and conditions. We used survival analysis to estimate the 15-year cumulative probability of hysterectomy, other pelvic surgical procedures and relevant adverse events. RESULTS: Uterine fibroids were by far the most common gynecologic condition, reported by 11% of the cohort. Surgical procedures were recorded for 15% of the cohort; hysterectomy was the most frequent procedure (10%), followed by salpingectomy (2%). The 15-year probability of any pelvic or abdominal procedure was 14.7 per 100 women (95% confidence interval 12.4-16.9). The probability of hysterectomy was 9.3 per 100 women (95% confidence interval 7.4-11.1). Number of quinacrine insertions had little impact on the probabilities. CONCLUSION: During long-term follow-up of women who received quinacrine pellets for nonsurgical sterilization, the incidence of noncancer adverse outcomes was not unusually high, and no alarming patterns emerged.

Increased phasic activity of VTA dopamine neurons in mice 3 weeks after repeated social defeat.

Social defeat is an ethologically relevant stress inducing neuroadaptive changes in the mesocorticolimbic dopaminergic system. Three weeks after 10 days of daily defeat salient behaviors and in vivo dopamine (DA) neuron firing were evaluated in mice. Prior defeat induced social avoidance and hyperphagia and increased ventral tegmental area (VTA) DA neuron bursting activity. These data extend previous studies and suggest that increased phasic DA neuron firing in the VTA could be considered amongst the features defining the lasting imprint of social defeat stress.

Quinacrine sterilization and gynecologic cancers: a case-control study in northern Vietnam.

BACKGROUND: Over 100,000 women worldwide have been sterilized by insertion of quinacrine into the uterus to induce tubal scarring. Concern has been expressed about possible carcinogenicity, and specifically the risk of uterine cancer. METHODS: From 2001 through 2006, we conducted a population-based, case-control study of gynecologic cancers in 12 provinces in northern Vietnam, where relatively large numbers of women had received quinacrine. Cases of incident cervical, ovarian, and uterine cancer were identified at provincial hospitals or at referral hospitals in Hanoi. For each case, 3 age- and residence-matched controls were randomly selected from the population registries of the case's home community. RESULTS: The prevalence of quinacrine exposure was 1.2% among cases and 1.1% among controls. For cervical cancer, analysis of 606 cases (9 exposed) and their 1774 matched controls (18 exposed) produced an odds ratio of 1.44 (95% confidence interval = 0.59-3.48) (adjusted for several covariates including human papillomavirus risk score). For ovarian cancer, based on 262 cases (3 exposed) and 755 controls (8 exposed) and adjusted for age and number of years of ovulation, the odds ratio was 1.26 (0.21-5.45). For uterine cancer, none of the cases-including 23 cases of leiomyosarcoma-was exposed to quinacrine. The 95% confidence interval, based on 161 cases (none exposed) and 470 controls (7 exposed) and adjusted only for age, was 0-1.85. CONCLUSION: We found no evidence of a relationship between quinacrine sterilization and gynecologic cancer.

A lifetime cancer bioassay of quinacrine administered into the uterine horns of female rats.

This study investigated if quinacrine can induce a tumorigenic response in rats when administered in a manner similar to the intended human use for female non-surgical sterilization. Young sexually mature female rats received two doses of quinacrine (or 1% methylcellulose control) into each uterine horn approximately 21 days apart, and were observed for 23 months after the second dose administration. Dose levels were 0/0, 0/0, 10/10, 70/70, and 70/250-350 mg/kg (first dose/second dose), which represent local doses in the uterus at approximate multiples of 1x, 8x and 40x the human dose (mg quinacrine/g uterine weight) used for female non-surgical sterilization. Rats were observed for viability, clinical signs of toxicity, and changes in body weight and food consumption. At necropsy, selected organs were weighed, macroscopic observations were recorded, and tissues were collected, fixed, processed, and examined for microscopic pathologic findings. Acute quinacrine toxicity was evident during the dosing period but did not affect long-term survival. Non-neoplastic findings were more common in treated animals than controls, providing evidence of the appropriateness of the bioassay. The incidence of uncommon tumors of the reproductive tract was similar to controls at doses of 10/10mg/kg but increased with dose level and was significantly greater than controls at >or=70/70 mg/kg. We conclude that two doses of quinacrine administered approximately 21 days apart into the uterus of young sexually mature rats at a local dose approximately 8 times the human dose used for non-surgical female sterilization increased the lifetime risk of tumor development in the reproductive tract.

Cancer risk after sterilization with transcervical quinacrine: updated findings from a Chilean cohort.

BACKGROUND: Dating back to the 1970s, thousands of women worldwide have voluntarily been sterilized with transcervical insertion of quinacrine pellets. The safety and efficacy of the technology are still being assessed today; in particular, better estimates on the incidence of human cancers are now feasible. METHODS: We conducted a cohort study of 1492 women in Santiago and Valdivia, Chile, who received transcervical quinacrine pellets for contraceptive sterilization between 1977 and 1989. We periodically interviewed women with the last interviews in 2006-2007 and reviewed their medical records. We calculated age and site-specific incidence of invasive cancers and compared the observed cases to the number of expected cases based on data from the Cali, Colombia, cancer registry, gathered by the International Agency for Research on Cancer. RESULTS: During 23,894 person-years of follow-up, 41 invasive cancers were identified, including 16 new cases that had occurred since the previous analysis. Ten cases of cervical cancer were observed, compared with 12.1 expected. Since the initial study's confirmation of a single case of leiomyosarcoma, no other uterine cancers have been diagnosed. We would expect 2.0 uterine cancers during this number of observed women-years. One case of ovarian cancer was diagnosed, compared with 3.1 expected. CONCLUSION: Rates of cancer among women exposed to intrauterine quinacrine are similar to population-based rates.

Effectiveness of vasectomy techniques.

The effectiveness of various vasectomy techniques is reviewed, with a focus on methods used for vas occlusion. Spontaneous recanalization of the vas is more common than generally recognized and is often transient. Simple ligation and excision has an unacceptably high risk for failure. Techniques that include cautery seem to have a lower risk for failure than techniques that do not include cautery. There is insufficient evidence to recommend a particular standardized cautery technique, but adding fascial interposition to cautery seems to be associated with the lowest risk for failure.

[A recommendable standard protocol of adult male circumcision with the Chinese Shang Ring: outcomes of 328 cases in China].

OBJECTIVE: Standardization of and training in adult male circumcision can significantly reduce its complication rate. Currently no such program exists for its standardization and training, making it difficult to guarantee the quality of male circumcision services. We therefore established a standardized surgical protocol for adult male circumcision in China using the Shang Ring, and applied it to a clinical study examining the performance of the Shang Ring in adult male circumcision. METHODS: A total of 328 adult men aged 18-58 (mean 27.8) years, 25 with phimosis and 303 with redundant prepuce, underwent circumcision with the Shang Ring, and evaluation of the operation time, pain scores (using the visual analog scale), postoperative complications, time for wound healing, and their satisfaction with the postoperative appearance. RESULTS: The operation time was 4.7 +/- 1.3 minutes. The pain scores were 0. 2 +/- 0.6 during the surgery, 1.6 +/- 1.0 twenty hours postoperatively, 1.7 +/- 1.1 twenty hours prior to the ring removal, and 2.7 +/- 1.4 during the ring removal. Complications included infection in 2 (0.6%), bleeding in 2 (0.6%), and wound dehiscence in 2 (0.6%) of the patients. None of the patients with wound dehiscence required postoperative suturing and all were managed conservatively instead. Sixteen of the patients (4.9%) experienced penile edema. The time for complete wound healing after circumcision was 20.3 +/- 6.7 days. The rate of the patients'satisfaction was 99.7% (327/328). CONCLUSION: The standard protocol of adult male circumcision with the Shang Ring has the advantages of short operation time, slight pain, low rate of complications, and high satisfaction and acceptance of the patients. Strict standardization of the surgical protocol can maximize its clinical advantages for adult male circumcision.

[The need for high-quality training and surgical standards for adult male circumcision in China].

Although HIV is a significant problem in Africa, HIV infection rates are rising rapidly in other regions such as Asia and South America. International health organizations have recognized the need to develop effective strategies to check the worldwide transmission of HIV. Studies have demonstrated the significant reduction of HIV, HPV, HSV-2 and other STD infection rates with male circumcision (MC). Although numerous MC techniques are available, there are no standardized protocols and surgical training programs. Studies have shown that the standardization of MC techniques coupled with training programs can significantly reduce complication rates. High complication rates have been a primary obstacle to the implementation of MC services. We recommend the establishment of surgical standards and training protocols prior to the promotion of MC services in China.

Diagnostic accuracy of an initial azoospermic reading compared with results of post-centrifugation semen analysis after vasectomy.

PURPOSE: Semen analysis is a common laboratory procedure but few data are available to support recommendations as to whether centrifugation is necessary in the post-vasectomy context. We evaluated the accuracy of a pre-centrifugation determination of azoospermia compared with post-centrifugation results. MATERIALS AND METHODS: We conducted a secondary analysis of data from 3,205 semen analyses performed during a randomized clinical trial of 2 vasectomy techniques--ligation and excision with fascial interposition vs ligation and excision without fascial interposition. We performed brief, initial microscopic examinations to categorize sperm numbers per high power field to decide whether centrifugation or dilution was needed before estimation of sperm concentration. For specimens initially categorized as azoospermic, we reviewed the post-centrifugation semen analysis results to estimate the accuracy of the initial finding. RESULTS: Of 2,104 samples categorized as azoospermic before centrifugation, post-centrifugation analysis demonstrated that all but 4 (99.8%) were azoospermic or had a sperm concentration of less than 100,000 sperm per ml. Four samples from 1 study site had counts between 104,000 and 315,000 sperm per ml. Of 1,610 apparently azoospermic samples obtained at 10 weeks or later after vasectomy there were 12 (0.7%) that had some motile sperm identified after centrifugation but the numbers of motile sperm were low (mean 1,124 motile sperm per ml, range 238 to 3,710). CONCLUSIONS: Microscopic examination of uncentrifuged specimens is a reliable method for identifying semen samples after vasectomy with more than 100,000 sperm per ml.

Safety of quinacrine contraceptive pellets: results from 10-year follow-up in Vietnam.

BACKGROUND: This study was conducted to evaluate long-term safety of quinacrine pellets for nonsurgical sterilization among women in Vietnam. STUDY DESIGN: Observational cohort study of 2735 women who had quinacrine insertions between 1989 and 1993 compared to 1623 women who received an intrauterine device (IUD). RESULTS: Cumulative follow-up times for the quinacrine and IUD cohorts were 28,697 and 17,382 person-years, respectively, and losses to follow-up were 6% and 7%, respectively. Quinacrine users had a higher incidence of ectopic pregnancy compared to IUD users (risk ratio, 2.2; 95% confidence interval, 1.06-4.54); the risks of cancer, hysterectomy, pelvic/gynecologic surgery and death were similar in the two groups. Two quinacrine insertions appeared to lower the risk of ectopic pregnancy to that of surgical tubal occlusion. CONCLUSIONS: Use of quinacrine in this cohort appeared to have minimal health risks. Other research, including preclinical studies, needs to be considered in an overall evaluation of whether the combination of safety and efficacy provide a basis for quinacrine's approval by appropriate regulatory agencies.

A one-year neonatal mouse carcinogenesis study of quinacrine dihydrochloride.

Quinacrine is an acridine derivative under investigation for its use in nonsurgical female sterilization. Safety issues regarding the carcinogenic potential of quinacrine have been raised because it is mutagenic and clastogenic in vitro. The objective of the study was to evaluate the carcinogenic potential of quinacrine dihydrochloride (quinacrine) in neonatal mice treated with single intraperitoneal doses on postpartum days 8 and 15 and observed for 52 weeks. Neonatal Crl: CD-1 mice of each sex were randomly allocated into four treatment groups (0, 10, 50, and 150 mg/kg), dosed twice with quinacrine suspended in carboxymethylcellulose, observed for 52 weeks post dose, and then euthanized, necropsied, and subjected to a full histopathological examination. In male mice, tumor incidence was not significantly increased at any site at any dose level. In female mice, the incidence of benign uterine endometrial stromal polyps was slightly greater at the mid and high dose (> or = 50 mg/kg), as was the incidence of endometrial hyperplasia. The incidence of polyps in these groups was not significantly greater than in controls by pair-wise comparison but was significantly greater (p = .042) by the linear trend test. The authors conclude that quinacrine administered twice to neonatal mice may have enhanced or accelerated the development of endometrial hyperplasia and uterine stromal polyps at higher doses. Because uterine stromal polyps are a commonly observed benign tumor in older mice, the significance of this finding is unclear and will require a weight of evidence evaluation for a conclusion on the carcinogenic potential of quinacrine.

Recent research on vasectomy techniques.

Vasectomy is a commonly used, highly effective method for the control of fertility in the human male. It is almost always performed as an outpatient procedure, is safer than tubal occlusion and has few side effects. The number of people relying on vasectomy as a method of contraception varies widely from country to country. Though vasectomy is highly effective, failures may occur due to re-canalization of the vas, surgical error, anatomical variants or failure of contraception during the post-operative waiting period. One of the disadvantages of this technique is that sperm are present in the posterior end of the vas following surgery and hence patients have to use alternative methods of contraception for a waiting period of 12 weeks to 15 weeks before relying on a vasectomy for contraception. This review summarizes recent research on vasectomy conducted by Family Health International, USA.

Effects of spinal administration of muscimol on C- and A-fibre evoked neuronal responses of spinal dorsal horn neurones in control and nerve injured rats.

Neuropathic pain is a common clinical problem with complex aetiology, mechanisms and symptoms. Alterations in spinal gamma-aminobutyric acid (GABA) receptors may contribute to persistent pain states. The aim of the present study is to investigate potential changes of spinal GABA(A)-receptor function following peripheral nerve injury. Effects of spinal administration of the GABA(A)-receptor agonist muscimol (0.1-30 microg/50 microl) on electrically-evoked responses of spinal neurones in control, spinal nerve ligated and sham operated halothane-anaesthetised rats were studied. Spinal muscimol significantly (10 microg/50 microl) reduced evoked Abeta-, Adelta- and C-fibre responses of spinal neurones in control rats (58+/-22% of control, P<0.05; 3+/-2% of control, P<0.001; and 8+/-7% of control, P<0.001; respectively). Muscimol produced significantly greater inhibition of Adelta- and C-fibre evoked neuronal responses compared to Abeta-fibre evoked neuronal responses in control rats (P<0.001). C-fibre mediated post-discharge responses and the non-potentiated C-fibre evoked responses were significantly inhibited by muscimol in control rats. Inhibitory effects of muscimol (10 microg/50 microl) were blocked by pre-application of spinal bicuculline (10 microg/50 microl). Following either sham surgery, or spinal nerve ligation, spinal muscimol inhibited Abeta-, Adelta- and C-fibre evoked responses of spinal neurones to a similar extent, however significant inhibitory effects on the post-discharge response were not observed in nerve injured rats. Our data demonstrate that GABA(A)-receptor control of Abeta- and Adelta-fibre evoked responses are not altered in nerve injured or sham operated rats, compared to control. However, following nerve injury we report a reduction in GABA(A)-receptor control of C-fibre responses, in particular in relation to post-discharge responses.

Tasas estandarizadas de incidencia y prevalencia de patología cervical preclínica en 1061 mujeres esterilizadas con quinacrina intrauterina / Standards index of incidence and prevalence of preclinic cervical pathology in sterilized women with intrauterine quinacrine

A un grupo de 1061 mujeres en edad fértil que solicitaron esterilización quirúrgica con pellets de quinacrina insertos en la cavidad uterina por 2 ó 3 veces con un intervalo de 30 a 40 días y en las cuales se había efectuado uno o varios exámenes de Papanicolaou, antes o después de la esterilización, obtuvimos algún grado de positividad en 75 mujeres 7,1 por ciento. En 36 de ellas esta positividad fue anterior a la inserción, tasa de prevalencia= 34,05 por ciento. En 39 mujeres aparecieron lesiones después de la inserción, tasa de incidencia= 2,62 por ciento en un total de 3285 años/mujer entre el primero y el último PAP efectuado. Los resúmenes de los análisis estadísticos se adjuntan en varias tablas. La conclusión de este estudio indica que la utilización de quinacrina intrauterina no aumenta las tasas de incidencia de cáncer cérvico uterino en la población esterilizada con respecto a las cifras que espontáneamente se presentan en la población de Santiago