Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial.

OBJECTIVES: Women with a sonographic short cervix in the mid-trimester are at increased risk for preterm delivery. This study was undertaken to determine the efficacy and safety of using micronized vaginal progesterone gel to reduce the risk of preterm birth and associated neonatal complications in women with a sonographic short cervix. METHODS: This was a multicenter, randomized, double-blind, placebo-controlled trial that enrolled asymptomatic women with a singleton pregnancy and a sonographic short cervix (10-20 mm) at 19 + 0 to 23 + 6 weeks of gestation. Women were allocated randomly to receive vaginal progesterone gel or placebo daily starting from 20 to 23 + 6 weeks until 36 + 6 weeks, rupture of membranes or delivery, whichever occurred first. Randomization sequence was stratified by center and history of a previous preterm birth. The primary endpoint was preterm birth before 33 weeks of gestation. Analysis was by intention to treat. RESULTS: Of 465 women randomized, seven were lost to follow-up and 458 (vaginal progesterone gel, n=235; placebo, n=223) were included in the analysis. Women allocated to receive vaginal progesterone had a lower rate of preterm birth before 33 weeks than did those allocated to placebo (8.9% (n=21) vs 16.1% (n=36); relative risk (RR), 0.55; 95% CI, 0.33-0.92; P=0.02). The effect remained significant after adjustment for covariables (adjusted RR, 0.52; 95% CI, 0.31-0.91; P=0.02). Vaginal progesterone was also associated with a significant reduction in the rate of preterm birth before 28 weeks (5.1% vs 10.3%; RR, 0.50; 95% CI, 0.25-0.97; P=0.04) and 35 weeks (14.5% vs 23.3%; RR, 0.62; 95% CI, 0.42-0.92; P=0.02), respiratory distress syndrome (3.0% vs 7.6%; RR, 0.39; 95% CI, 0.17-0.92; P=0.03), any neonatal morbidity or mortality event (7.7% vs 13.5%; RR, 0.57; 95% CI, 0.33-0.99; P=0.04) and birth weight < 1500 g (6.4% (15/234) vs 13.6% (30/220); RR, 0.47; 95% CI, 0.26-0.85; P=0.01). There were no differences in the incidence of treatment-related adverse events between the groups. CONCLUSIONS: The administration of vaginal progesterone gel to women with a sonographic short cervix in the mid-trimester is associated with a 45% reduction in the rate of preterm birth before 33 weeks of gestation and with improved neonatal outcome.

An assessment of fluoride in the coastal aquifer of the Bara tract in Bharuch district, Gujarat (India).

The fluoride (F) concentration in the coastal aquifers of Bara tract in Bharuch district, Gujarat was determined by potentiometric method using an ion-selective electrode. The fluoride concentration in these aquifers varies between 0.060 to 3.51 mg/L. It was also found that F has a positive correlation with pH and HCO(3)(-) whereas negatively correlated with Ca(2+), indicating that high fluoride in ground water is associated with low calcium content. This suggests that the higher pH of water promotes the leaching of fluoride and thus affects the concentration of fluoride in the ground water. It was also found that there exists no relationship between F, EC, and ground water table from surface in the ground water.

Patient and technique survival of diabetics on peritoneal dialysis: one-center's experience and review of the literature.

BACKGROUND: Diabetes is the leading cause of end-stage renal disease (ESRD). This retrospective study investigated the long-term patient and technique survival and sought to identify the predictors of mortality in diabetic patients receiving PD. METHODS: Patients, aged 17 years or more who commenced home PD between January 31, 1994, and December 31, 2001 were included. Clinical data were available for 358 patients out of 418 total patients who started PD during this period. They were followed until cessation of PD, death, or to January 31, 2003. Survival probabilities were generated according to the Kaplan-Meier method, and multivariate Cox proportional hazards models were used to assess predictors of survival. RESULTS: A total of 358 patients were enrolled in the study. Among them, 139 patients (38.8%) were diabetics. The 1-, 2-, 3- and 5-year patient survival rates were 91%, 76%, 66% and 47% in diabetics and 94%, 89%, 84% and 69% in non-diabetics, respectively. Median actuarial patient survival for diabetic patients (51.8 months; 95% CI 36.0 â 67.5 months) was significantly shorter than that of non-diabetic patients (log rank 14.117, p < 0.001). Death-censored technique survival rates at 1-, 2-, 3- and 5-year were 90%, 83%, 67% and 58% in diabetic, and 94%, 87%, 77% and 70% in non-diabetic patients, respectively. Similar to patient survival, the median technique survival time was significantly shorter for diabetic patients (63.9 months; 95% CI 35.7 - 92.2 months) than that of non-diabetic patients (log rank 4.884, p = 0.027). Multivariate Cox regression analysis showed that advancing age was the only independent predictor of death in the diabetic patients, whereas higher age and wider pulse pressure were associated with mortality in non-diabetic patients. CONCLUSION: Long-term patient and technique survival for diabetic patients on PD seem to be improved compared to our previous report and other studies. The mortality of diabetic patients was predicted predominantly by advancing age. PD remains a viable form of long-term renal replacement therapy for diabetic patients with ESRD.

In vivo effects of nonionic and ionic contrast media on beta-thromboglobulin and fibrinopeptide levels.

Nonionic contrast media are suggested to cause increased thromboembolism (in vivo), platelet aggregation and procoagulant effect (in vitro) as compared with ionic contrast media. To study these effects in vivo, 30 consecutive patients undergoing routine angiography were prospectively randomized to three groups of 10 patients each. Group A received diatrizoate (ionic, high osmolality), Group B ioxaglate (ionic, low osmolality) and Group C iohexol (nonionic, low osmolality). In vivo platelet alpha-granule release and fibrin-1 formation were measured by radioimmunoassay of beta-thromboglobulin and fibrinopeptide A in peripheral venous samples. Levels were estimated at three stages during the procedure: before and after left ventriculography and after coronary angiography. No differences were noted (p = NS) when the ratios of beta-thromboglobulin and fibrinopeptide A were compared among the three groups. These data suggest that the newer nonionic contrast media do not demonstrate enhanced systemic platelet activation or fibrin formation as compared with standard ionic contrast media. However, larger randomized clinical studies are necessary to conclusively establish the suggested thromboembolic potential of nonionic contrast media.

RMS Pictorial Scale (RMS-PS): an innovative scale for the assessment of child's dental anxiety.

BACKGROUND: Dental anxiety assessment for young children is as important as performing their treatment. Appropriate knowledge of patient's anxiety boosts confidence and will help us to review potential management options specific to every child. AIM: This study aimed to validate (RMS) Pictorial Scale (RMS-PS) and to compare it with Venham Picture Test (VPT) and Facial image scale (FIS) in measuring dental anxiety for young children during their first dental visit. MATERIALS AND METHODS: A total of 102 healthy children aged between 4 and 14 years during their first dental visit were randomly selected for the study. Childs anxiety level was measured using three different scales namely (i) RMS-PS (ii) VPT, and (iii) FIS. STATISTICAL ANALYSIS: Student t test was used to compare the scores obtained from all the three scales. Pearson correlation test was used to obtain correlation among the scales used in the study. RESULTS: A strong correlation (0·76) was found between the VPT and RMS-PS, and a moderate correlation (0.5) was found between RMS-PS and FIS, indicating good validity for the RMS-PS. CONCLUSIONS: The findings of this study suggest that the RMS-PS can be a newer and easiest means for the assessment of dental anxiety for young children in a clinical context.

Apoptosis associated with esophageal adenocarcinoma: influence of photodynamic therapy.

Tumor cell death in vitro by photodynamic therapy (PDT) has been related to the induction of apoptosis. We measured and compared changes in apoptosis and caspase 3 activity, an effector of apoptosis, in normal and neoplastic esophageal tissues during PDT. Apoptosis index, caspase 3 cleavage activity, pro-caspase 3, p53, and bcl-2 levels were measured in normal and neoplastic tissues of patients with esophageal adenocarcinoma before, during, and after PDT with Photofrin. The apoptotic index was greater in carcinoma tissue compared to adjacent normal tissues. In concert, pro-caspase 3 immunoreactivity was absent and caspase 3-like cleavage activity was over 30-fold greater in carcinoma tissue compared to normal esophageal tissues. These parameters were unaffected by PDT. Variable changes in bcl-2 and p53 immunoreactivity were noted in normal and carcinoma tissues during PDT. Greater levels of apoptosis and caspase 3 activity are hallmarks of esophageal adenocarcinoma compared to normal esophageal tissue. These differences were unaffected by PDT. This may be due to the fact that tissues were obtained 72 h post-PDT therapy. Changes in these parameters may have occurred early after PDT therapy. An assessment of apoptosis and caspase 3 activity prior to 72 h post-PDT may provide further insight into the mechanism involved, although no sustained effects on these parameters by PDT were noted.

The clinical usefulness of routine stacked multiplanar reconstruction in helical abdominal computed tomography.

RATIONALE AND OBJECTIVES: The authors evaluate the usefulness of stacked multiplanar reconstructions in routine, thick-section abdominal computed tomography. MATERIALS AND METHODS: Twenty-five routine, thick-section contrast abdominal CTs performed with equivalent technique were reformatted by multiplanar reconstructions in sagittal and coronal planes sequentially from side-to-side and front-to-back. The image sets were submitted, first axial images only followed by axial plus multiplanar reconstructions (MPRs), to 5 separate physician readers including 2 radiologists and 3 nonradiologists. These readers graded the visualization of a variety of normal and up to 5 pathologic lesions per patient on a scale of 1 to 5 (5 = best). RESULTS: The addition of sagittal and coronal multiplanar reconstructions significantly improved the visualization of all normal anatomic structures (mean axial only, 3.8; mean axial plus MPR, 4.1; P < 0.0001). In addition, most pathologic lesions were statistically better visualized with the addition of multiplanar reconstructions (mean axial images only, 3.9; mean axial plus MPR, 4.1; P < 0.0001). All five readers found improved visualization in nearly every category with the addition of the multiplanar reconstructions. However, in only 7% of cases, did a reviewer find new diagnostic information with the addition of MPR images. CONCLUSIONS: Stacked multiplanar reconstructions of routine, thick-section abdominal CT has clinical value in both the display of normal anatomic and pathologic lesions. Further studies, however, are required to confirm these findings before it is commonly used.

Evaluation of fetal and uterine hemodynamics during maternal cardiopulmonary bypass.

BACKGROUND: About 4% of pregnant women have concomitant cardiac disease and a few of these do not respond to medical therapy and require surgical correction during pregnancy. We report a unique case describing fetal hemodynamics and uterine blood flow before, during, and after maternal cardiopulmonary bypass, and compare them to normal reference values in the second trimester. CASE: A woman with severe aortic regurgitation underwent aortic valve replacement at 19 weeks' gestation. A nonpulsatile cardiac pump was used for cardiopulmonary bypass, maintaining the mean arterial pressure at 77-90 mmHg, with a peak flow rate of 3.5-4.0 L/minute/m2 and core temperature of 34-35C throughout surgery. Blood velocity waveforms were recorded by Doppler ultrasound at the level of maternal main uterine artery and fetal vessels. Pulsatility index (PI) values were calculated. Preoperatively, fetal hemodynamic characteristics were within normal limits. Preoperatively, uterine artery PI was 3.9 (normal 0.5-1.5 at 20 weeks). Intraoperatively, fetal bradycardia ensued after aortic clamping (120 to 75 beats per minute), with a rise in umbilical artery PI (1.7 to 7.1) and disappearance of diastolic flow. The middle cerebral artery PI decreased (2.0 to 0.92) and the PI increased in the descending aorta (2.22 to 3.55), inferior vena cava (2.7 to 9.3), and ductus venosus (0.6 to 1.7). During bypass, after aortic clamping, nonpulsatile uterine artery flow was noted. Postoperatively, the uterine artery PI improved, to 1.0. Two days later, hydrocephalus and hydrops were observed. CONCLUSION: Despite high peak flow rates, normal mean arterial pressure, and normothermia, fetal outcome was dismal. Nonpulsatile cardiopulmonary bypass under normothermia may not be able to meet the demands of the fetoplacental circulation.

Glucose monitoring and insulin therapy during pregnancy.

Excellent blood glucose control is necessary to reduce the excess fetal morbidity and mortality associated with the diabetic pregnancy. This article outlines the roles of glucose monitoring and insulin therapy in intensive treatment regimens during gestation. The discussion includes recommended monitoring frequency, glycemic standards, types of insulin and mechanism of action, goals and timing of insulin therapy, as well as the complications of insulin therapy.

Role of diltiazem in pregnant women with chronic renal disease.

OBJECTIVE: To determine whether diltiazem therapy decreases proteinuria during pregnancy in women with chronic renal disease, resulting in decreased risk of pre-eclampsia, preterm delivery and intrauterine fetal growth restriction. METHODS: We undertook retrospective data collection by chart review of pregnant women with chronic renal disease. Women treated with and without diltiazem were compared by independent t test analysis. RESULTS: Seven women were eligible for inclusion in the study. Individual patient trends revealed decreased or attenuated increase in proteinuria across gestation with diltiazem therapy. Mean arterial pressure was also decreased in the therapy group compared to increased pressure in the third trimester in the group with no therapy. The incidence of fetal growth restriction and need for labor induction were lower in the diltiazem-treated group. CONCLUSIONS: Diltiazem, a non-dihydropyridine calcium channel antagonist, decreases proteinuria and preserves renal structure and function and should be considered an alternative to angiotensin converting enzyme inhibitors in pregnancy in women with chronic renal disease.

Structural changes in silicon rubber peritoneal dialysis catheters in patients using mupirocin at the exit site.

Structural damage to polyurethane PD (peritoneal dialysis) catheters in patients using mupirocin ointment is widely appreciated, but damage to silicon rubber PD catheters is less well described. Ten catheters (6.6%) out of 152 were found to have structural alterations such as opacification, ballooning, thinning, and rupture. The duration of PD in these 10 patients ranged from 23 months to 80 months (mean duration 51.1 months). The frequency of mupirocin application varied from daily (2 cases) to 2-3 times per week (7 cases). In eight catheters opacification occurred at the exit site whereas one catheter showed opacification midway between the exit site and the titanium adaptor. One catheter showed opacification, ballooning, and thinning at the exit site ruptured in the form of two slit-like openings. In conclusion, various structural changes such as opacification, ballooning or thinning were seen in 6.6% of silicon rubber PD catheters in patients using mupirocin at the exit site. Although the mechanism remains elusive, mupirocin or the antiseptic solution alone or in combination may be contributory. We believe that this is an under-reported complication and encourage other health care givers to incorporate a search for such changes during clinic visits.

Palliative therapy for carcinoma of the esophagus.

Despite improvements in medical and surgical care, the prognosis of patients with cancer of the esophagus has remained poor. The majority of patients are candidates for palliative rather than curative therapy. Surgery probably provides the most effective palliation of dysphagia, but it is associated with a high morbidity, and many patients are not candidates for surgery because of underlying medical problems. There are several endoscopic modalities for palliation. The choice of therapy depends on the location of the tumor, the presence or absence of a tracheo-esophageal fistula, and the projected prognosis for the patient. Expandable stents will probably become the treatment of choice for the inoperable patient because of ease of insertion and relative safety. Nevertheless, other endoscopic techniques will be a useful complement prior to stent insertion in order to debulk the tumor. With adequate palliation, attention can be given to treatment that may serve to prolong survival. Future trials on radiation therapy and chemotherapy are necessary so that we can improve survival without sacrificing the patient's quality of life. On the horizon is the administration of chemotherapy through such vehicles as tumor-specific photosensitizing agents, or intratumoral injection of cytotoxic agents.

Methionine down-regulates TLR4/MyD88/NF-κB signalling in osteoclast precursors to reduce bone loss during osteoporosis.

BACKGROUND AND PURPOSE: Studies have demonstrated that a moderate intake of amino acids is associated with development of bone health. Methionine, a sulphur-containing essential amino acid, has been largely implicated for improving cartilage formation, however its physiological significance on bone integrity and functionality have not been elucidated. We investigated whether methionine can prevent osteoporotic bone loss. EXPERIMENTAL APPROACH: The anti-resorptive effect of methionine, (250 mg kg(-1) body wt administered in drinking water for 10 weeks), was evaluated in ovariectomized (OVX) rats by monitoring changes in bone turnover, formation of osteoclasts from blood-derived mononuclear cells and changes in the synthesis of pro-osteoclastogenic cytokines. KEY RESULTS: Methionine improved bone density and significantly decreased the degree of osteoclast development from blood mononuclear cells in OVX rats, as indicated by decreased production of osteoclast markers tartarate resistant acid phosphatase b (TRAP5b) and MIP-1α. siRNA-mediated knockdown of myeloid differentiation primary response 88 [MyD88], a signalling molecule in the toll-like receptor (TLR) signalling cascade, abolished the synthesis of both TRAP5b and MIP-1α in developing osteoclasts. Methionine supplementation disrupted osteoclast development by inhibiting TLR-4/MyD88/NF-κB pathway. CONCLUSIONS AND IMPLICATIONS: TLR-4/MyD88/NF-κB signalling pathway is integral for osteoclast development and this is down-regulated in osteoporotic system on methionine treatment. Methionine treatment could be beneficial for the treatment of postmenopausal osteoporosis.

The effect of transdermal nitroglycerine on intrathecal fentanyl with bupivacaine for postoperative analgesia following gynaecological surgery.

Fentanyl is a short-acting synthetic opioid with spinal analgesic properties and dose-dependent side-effects. The analgesic effect of opioids is mediated in part through activation of inhibitory descending pain pathways involving nitric oxide (as a central neurotransmitter) through the NO-cGMP system. This NO-cGMP pathway plays an important role in spinal nociception. The aim of the study was to evaluate the effect of transdermal nitroglycerine on the analgesic action of intrathecal fentanyl in patients undergoing abdominal hysterectomy. Patients (n=120) were randomised into one of four groups. All received 3 ml bupivacaine 0.5% plus 0.5 ml of an intrathecal test drug. Twenty minutes after lumbar puncture, a transdermal patch of either nitroglycerine or placebo was applied. Group B received spinal bupivacaine plus saline 0.5 ml and a placebo patch. Group B-N received bupivacaine plus saline 0.5 ml and a nitroglycerine patch. Group F received bupivacaine plus fentanyl 25 microg and a placebo patch. Group F-N received bupivacaine plus fentanyl 25 microg and a nitroglycerine patch. The duration of effective analgesia was longer in group FN (363.53 +/- 34.09 min) compared from the other groups (P < 0.001). The times to two-segment regression in group F-N and group F were 132.87 +/- 31.2 min and 126.40 +/- 26.81 min respectively. The visual analog scale pain score at the time of the first rescue analgesic was similar in all groups. We conclude that nitroglycerine does not result in postoperative analgesia but enhances the analgesic effect of intrathecal fentanyl.