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Zhu A, Yao F, Shen M. Oxycodone alleviates mifepristone-stimulated human endometrial stromal cell injury by activating the Keap1/Nrf2/HO-1 signaling pathway. Immun Inflamm Dis 2023; 11:e1008. [PMID: 37773689 PMCID: PMC10510466 DOI: 10.1002/iid3.1008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 08/16/2023] [Accepted: 08/30/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Endometrial injury is a common disease in women caused by intrauterine inflammation, infections, and endocrine disorders. Human endometrial stromal cells (hEndoSCs) can maintain endometrial homeostasis and play an important role in repairing endometrial injury. Mifepristone, a steroidal anti-progesterone drug, is widely used in the field of reproductive medicine worldwide. Mifepristone-induced hEndoSC injury has been used to study endometrial injury in vitro. At present, the pathogenesis and potential regulatory mechanisms of oxycodone in endometrial injury remain unknown. AIMS We aimed to evaluate the functions of oxycodone in mifepristone-stimulated hEndoSC injury and analyze its potential molecular mechanism. MATERIALS & METHODS hEndoSC viability, cytotoxicity, and apoptosis were analyzed using the methyl thiazolyl tetrazolium assay, the lactate dehydrogenase assay, and flow cytometry, respectively. Furthermore, the levels of cleaved-Caspase3, Keap1, Nrf2, HO-1, and NQO1 were assessed using reverse transcription quantitative polymerase chain reaction and western blot analysis, and the release of inflammatory cytokines was determined using the enzyme-linked immunosorbent assay. RESULTS We observed that oxycodone had no adverse effects on hEndoSCs; rather, it protected hEndoSCs against mifepristone-induced endometrial damage, as confirmed by the enhanced cell viability, reduced number of apoptotic cells, decreased Caspase3 activity and inflammatory cytokine secretion, and increased Keap1/Nrf2/HO-1 pathway-related protein expression. In addition, we found that the protective effects of oxycodone on mifepristone-induced hEndoSC injury were inhibited by ML385 (a Keap1/Nrf2/HO-1 inhibitor). CONCLUSION In summary, we confirmed that oxycodone alleviates mifepristone-induced hEndoSC injury by activating the Keap1/Nrf2/HO-1 signaling pathway.
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Affiliation(s)
- Aibing Zhu
- Department of AnesthesiologyWuxi Maternity and Child Health Care HospitalWuxiChina
| | - Fei Yao
- Department of AnesthesiologyWuxi Maternity and Child Health Care HospitalWuxiChina
| | - Mingkun Shen
- Department of AnesthesiologyWuxi Maternity and Child Health Care HospitalWuxiChina
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Cirucci CA. Self-Managed Medication Abortion: Implications for Clinical Practice. LINACRE QUARTERLY 2023; 90:273-289. [PMID: 37841380 PMCID: PMC10566489 DOI: 10.1177/00243639221128389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women. Summary Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.
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Varela-Chavez C, Blondel A, Popoff MR. Bacterial intracellularly active toxins: Membrane localisation of the active domain. Cell Microbiol 2020; 22:e13213. [PMID: 32353188 DOI: 10.1111/cmi.13213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 12/31/2022]
Abstract
Numerous bacterial toxins exert their activity by inactivating or modulating a specific intracellular host target. For this purpose, these toxins have developed efficient strategies to overcome the different host cell defences including specific binding to cell surface, internalisation, passage through the endosome or plasma membrane, exploiting intracellular trafficking and addressing to intracellular targets. Several intracellularly active toxins deliver an active domain into the cytosol that interacts with a target localised to the inner face of the plasma membrane. Thus, the large clostridial glucosylating toxins (LCGTs) target Rho/Ras-GTPases, certain virulence factors of Gram negative bacteria, Rho-GTPases, while Pasteurella multocida toxin (PMT) targets trimeric G-proteins. Others such as botulinum neurotoxins and tetanus neurotoxin have their substrate on synaptic vesicle membrane. LCGTs, PMT, and certain virulence factors from Vibrio sp. show a particular structure constituted of a four-helix bundle membrane (4HBM) protruding from the catalytic site that specifically binds to the membrane phospholipids and then trap the catalytic domain at the proximity of the membrane anchored substrate. Structural and functional analysis indicate that the 4HBM tip of the Clostridium sordellii lethal toxin (TcsL) from the LCGT family contain two loops forming a cavity that mediates the binding to phospholipids and more specifically to phosphatidylserine.
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Affiliation(s)
| | - Arnaud Blondel
- Unité de Bio-Informatique Structurale, Institut Pasteur, Paris, France
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4
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Gary MM, Harrison DJ. Analysis of Severe Adverse Events Related to the Use of Mifepristone as an Abortifacient. Ann Pharmacother 2016; 40:191-7. [PMID: 16380436 DOI: 10.1345/aph.1g481] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: The systematic analysis of morbidity and mortality for the Food and Drug Administration (FDA)-approved medical abortion regimen using mifepristone is possible using data from the FDA's Adverse Event Reporting System. Objective: To assess mifepristone's mortality, morbidity, sentinel events, and quality of postmarketing surveillance using mifepristone adverse event reports (AERs). Methods: Six hundred seven unique mifepristone AERs submitted to the FDA over a 4 year span were coded using the National Cancer Institute's Common Terminology Criteria for Adverse Events. Coding was based only on data in AERs and may underestimate severity and treatment rendered. Two board-certified obstetrician/gynecologists, the authors, made individual evaluations, compared them, and agreed upon final coding. Results: The most frequent AERs were hemorrhage (n = 237) and infection (66). Hemorrhages included 1 fatal, 42 life threatening, and 168 serious cases; 68 required transfusions. Infections included 7 cases of septic shock (3 fatal, 4 life threatening) and 43 cases requiring parenteral antibiotics. Surgical interventions were required in 513 cases (235 emergent, 278 nonemergent). Emergent cases included 17 ectopic pregnancies (11 ruptured). Second trimester viability was documented in 22 cases (9 lost to follow-up, 13 documented fetal outcome). Of the 13 documented cases, 9 were terminated without comment on fetal morphology, 1 was enrolled in fetal registry, and 3 fetuses were diagnosed with serious malformations, suggesting a malformation rate of 23%. Conclusions: Hemorrhage and infection are the leading causes of mifepristone-related morbidity and mortality. AERs relied upon by the FDA to monitor mifepristone's postmarketing safety are grossly deficient due to extremely poor quality.
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Affiliation(s)
- Margaret M Gary
- American Association of Profile Obstetricians and Gynecologists, Eau Claire, MI 49111-0414, USA
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6
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Miech RP. Pathopharmacology of Excessive Hemorrhage in Mifepristone Abortions. Ann Pharmacother 2016; 41:2002-7. [DOI: 10.1345/aph.1k351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To explain a pathopharmacologic mechanism that initiates an increase in hemorrhage following medical abortions with mifepristone. Data Sources: MEDLINE, PubMed, and Google Scholar databases were searched (1990–July 2007). Key search terms were mifepristone, RU486, medical abortion hemorrhage, bleeding, inflammation, innate immune system, phagocytes, macrocytes, cytokines, interleukins, and nitric oxide. Study Selection and Data Extraction: All articles identified from the data sources were evaluated and all information deemed relevant was included for the information related to the development of the understanding of the pathopharmacology of mifepristone as the initiating cause of increased hemorrhage in medical abortions. Mifepristone's blockade of glucocorticoid receptors, prolonged generation of nitric oxide (NO), and postabortion vasodilatation of uterine vasculature by NO that favors excessive hemontiage were the criteria used to determine whether information was relevant for inclusion. Data Synthesis: Inescapable bacterial contamination of the decidua accompanies spontaneous, surgical, and mifepristone abortions and is routinely overcome by activation of the innate immune system. The combination of the induction of NO synthase (NOS) and local production of NO is one of the key features of the activation of the innate immune system's phagocytes. NO is a potent vasodilator and is associated with menstrual menorrhagia. Glucocorticoids prevent the overproduction of NOS and NO and thereby contribute to the control of hemorrhage in the postabortion phase. Conclusions: Blockade of the glucocorticoid receptors by mifepristone can result in an excess of NO that is theorized to be the cause of excessive hemorrhage seen in mifepristone abortions.
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Affiliation(s)
- Ralph P Miech
- Department of Molecular Pharmacology (Box GB3), Warren Alpert Medical School, Brown University, Providence, RI 02912
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7
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Varela Chavez C, Hoos S, Haustant GM, Chenal A, England P, Blondel A, Pauillac S, Lacy DB, Popoff MR. The catalytic domains of Clostridium sordellii lethal toxin and related large clostridial glucosylating toxins specifically recognize the negatively charged phospholipids phosphatidylserine and phosphatidic acid. Cell Microbiol 2015; 17:1477-93. [PMID: 25882477 DOI: 10.1111/cmi.12449] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 04/15/2015] [Indexed: 12/23/2022]
Abstract
Clostridium sordellii lethal toxin (TcsL) is a potent virulence factor belonging to the large clostridial glucosylating toxin family. TcsL enters target cells via receptor-mediated endocytosis and delivers the N-terminal catalytic domain (TcsL-cat) into the cytosol upon an autoproteolytic process. TcsL-cat inactivates small GTPases including Rac and Ras by glucosylation with uridine-diphosphate (UDP)-glucose as cofactor leading to drastic changes in cytoskeleton and cell viability. TcsL-cat was found to preferentially bind to phosphatidylserine (PS)-containing membranes and to increase the glucosylation of Rac anchored to lipid membrane. We here report binding affinity measurements of TcsL-cat for brain PS-containing membranes by surface plasmon resonance and enzyme-linked immunosorbent assay (ELISA). In addition, TcsL-cat bound to phosphatidic acid (PA) and, to a lesser extent, to other anionic lipids, but not to neutral lipids, sphingolipids or sterol. We further show that the lipid unsaturation status influenced TcsL-cat binding to phospholipids, PS with unsaturated acyl chains and PA with saturated acyl chains being the preferred bindingsubstrates. Phospholipid binding site is localized at the N-terminal four helical bundle structure (1-93 domain). However, TcsL-1-93 bound to a broad range of substrates, whereas TcsL-cat, which is the active domain physiologically delivered into the cytosol, selectively bound to PS and PA. Similar findings were observed with the other large clostridial glucosylating toxins from C. difficile, C. novyi and C. perfringens.
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Affiliation(s)
| | - Sylviane Hoos
- Plateforme de Biophysique Moléculaire, Institut Pasteur, Paris, France
| | | | - Alexandre Chenal
- Unité de Biochimie des Interactions Macromoléculaires, Institut Pasteur, Paris, France
| | - Patrick England
- Plateforme de Biophysique Moléculaire, Institut Pasteur, Paris, France
| | - Arnaud Blondel
- Unité de Bioinformatique Structurale, Institut Pasteur, Paris, France
| | - Serge Pauillac
- Unité des Bactéries anaérobies et Toxines, Institut Pasteur, Paris, France
| | - D Borden Lacy
- Unité de Bioinformatique Structurale, Institut Pasteur, Paris, France.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA
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Foot infection by Clostridium sordellii: case report and review of 15 cases in France. J Clin Microbiol 2015; 53:1423-7. [PMID: 25609723 DOI: 10.1128/jcm.03414-14] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We report a case of foot infection by Clostridium sordellii and review 15 human infections registered at a Reference Center in France during the period 1998 to 2011. All strains were found nontoxigenic, lacking the lethal toxin gene coding for TcsL. Like Clostridium septicum, several C. sordellii infections were associated with intestinal neoplasms.
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Vidor C, Awad M, Lyras D. Antibiotic resistance, virulence factors and genetics of Clostridium sordellii. Res Microbiol 2014; 166:368-74. [PMID: 25290059 DOI: 10.1016/j.resmic.2014.09.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 08/25/2014] [Accepted: 09/09/2014] [Indexed: 02/04/2023]
Abstract
Clostridium sordellii is gram positive bacterial pathogen of humans and animals. While the incidence of human-related C. sordellii infection is low, the mortality rate associated with infection is high. Of particular concern are C. sordellii infections after child-birth or medical abortion, which have an almost 100% mortality rate. Recent genetic and epidemiological work has increased our understanding of how this pathogen has evolved and how it causes disease. This review will summarise studies involving the genetics of C. sordellii, including an antibiotic resistance profile, the genetic determinants of virulence and mutagenesis of C. sordellii.
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Affiliation(s)
- Callum Vidor
- Department of Microbiology, Monash University, Victoria 3800, Australia.
| | - Milena Awad
- Department of Microbiology, Monash University, Victoria 3800, Australia.
| | - Dena Lyras
- Department of Microbiology, Monash University, Victoria 3800, Australia.
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10
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Spitz IM. Progesterone receptor antagonists and selective progesterone receptor modulators: proven and potential clinical applications. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.2.227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Sirigi Reddy AR, Girinathan BP, Zapotocny R, Govind R. Identification and characterization of Clostridium sordellii toxin gene regulator. J Bacteriol 2013; 195:4246-54. [PMID: 23873908 PMCID: PMC3754755 DOI: 10.1128/jb.00711-13] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 07/12/2013] [Indexed: 02/05/2023] Open
Abstract
Toxigenic Clostridium sordellii causes uncommon but highly lethal infections in humans and animals. Recently, an increased incidence of C. sordellii infections has been reported in women undergoing obstetric interventions. Pathogenic strains of C. sordellii produce numerous virulence factors, including sordellilysin, phospholipase, neuraminidase, and two large clostridial glucosylating toxins, TcsL and TcsH. Recent studies have demonstrated that TcsL toxin is an essential virulence factor for the pathogenicity of C. sordellii. In this study, we identified and characterized TcsR as the toxin gene (tcsL) regulator in C. sordellii. High-throughput sequencing of two C. sordellii strains revealed that tcsR lies within a genomic region that encodes TcsL, TcsH, and TcsE, a putative holin. By using ClosTron technology, we inactivated the tcsR gene in strain ATCC 9714. Toxin production and tcsL transcription were decreased in the tcsR mutant strain. However, the complemented tcsR mutant produced large amounts of toxins, similar to the parental strain. Expression of the Clostridium difficile toxin gene regulator tcdR also restored toxin production to the C. sordellii tcsR mutant, showing that these sigma factors are functionally interchangeable.
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12
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Abstract
Though serious infection after induced abortion is rare, infections account for one third of abortion-related deaths in the United States. Most fatal cases of infection after induced medical abortion have involved clostridial species. These reported cases share important clinical features that may guide clinicians to earlier recognition and institution of therapy. This article reviews our current knowledge regarding serious clostridial infections postabortion including the typical clinical presentation, pathophysiology, modes of diagnosis, and available treatment.
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13
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Progesterone analogs influence germination of Clostridium sordellii and Clostridium difficile spores in vitro. J Bacteriol 2011; 193:2776-83. [PMID: 21478359 DOI: 10.1128/jb.00058-11] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium sordellii and Clostridium difficile are closely related anaerobic Gram-positive, spore-forming human pathogens. C. sordellii and C. difficile form spores that are believed to be the infectious form of these bacteria. These spores return to toxin-producing vegetative cells upon binding to small molecule germinants. The endogenous compounds that regulate clostridial spore germination are not fully understood. While C. sordellii spores require three structurally distinct amino acids to germinate, the occurrence of postpregnancy C. sordellii infections suggests that steroidal sex hormones might regulate its capacity to germinate. On the other hand, C. difficile spores require taurocholate (a bile salt) and glycine (an amino acid) to germinate. Bile salts and steroid hormones are biosynthesized from cholesterol, suggesting that the common sterane structure can affect the germination of both C. sordellii and C. difficile spores. Therefore, we tested the effect of sterane compounds on C. sordellii and C. difficile spore germination. Our results show that both steroid hormones and bile salts are able to increase C. sordellii spore germination rates. In contrast, a subset of steroid hormones acted as competitive inhibitors of C. difficile spore germination. Thus, even though C. sordellii and C. difficile are phylogenetically related, the two species' spores respond differently to steroidal compounds.
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Popoff MR, Geny B. Rho/Ras-GTPase-dependent and -independent activity of clostridial glucosylating toxins. J Med Microbiol 2011; 60:1057-1069. [PMID: 21349986 DOI: 10.1099/jmm.0.029314-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Clostridial glucosylating toxins are the main virulence factors of clostridia responsible for gangrene and/or colitis. These toxins have been well characterized to inactivate Rho/Ras-GTPases through glucosylation. However, the signalling pathways downstream of Rho/Ras-GTPases leading to the intracellular effects of these toxins are only partially known. Rac-dependent modification of focal adhesion complexes and phosphoinositide metabolism seem to be key processes involved in actin filament depolymerization and disorganization of intercellular junctions. In addition, clostridial glucosylating toxins induce Rho/Ras-independent intracellular effects such as activation of mitogen-activated protein kinase pathways, which are used by some of these toxins to trigger an inflammatory response.
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Affiliation(s)
- Michel R Popoff
- Institut Pasteur, Unité des Bactéries Anaérobies et Toxines, 25 rue du Dr Roux, 75724 Paris cedex 15, France
| | - Bladine Geny
- Institut Pasteur, Unité des Bactéries Anaérobies et Toxines, 25 rue du Dr Roux, 75724 Paris cedex 15, France
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Harrison DJ, Mitroka JG. Defining reality: the potential role of pharmacists in assessing the impact of progesterone receptor modulators and misoprostol in reproductive health. Ann Pharmacother 2010; 45:115-9. [PMID: 21177418 DOI: 10.1345/aph.1p608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Medical abortion is increasingly heralded as an ideal method for decreasing maternal mortality in health-care resource-deprived areas and as an answer to the shrinking pool of physicians willing to perform abortions. The advent of progesterone receptor modulators (PRMs) and the recent approval by the Food and Drug Administration of ella (ulipristal) as an emergency contraceptive put pharmacists in the center of abortion controversy. Pharmacists, worldwide, need to be aware of the controversy surrounding the introduction of PRMs, particularly with regard to the effect on health policy, their mechanism of action, associated adverse events, and common off-label uses. Once understood, genuine opportunity exists for pharmacists to serve a fundamental role in positively shaping public health policy.
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Affiliation(s)
- Donna J Harrison
- American Association of Pro-Life Obstetricians and Gynecologists, Holland, MI, USA.
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Spitz IM. Mifepristone: where do we come from and where are we going? Contraception 2010; 82:442-52. [DOI: 10.1016/j.contraception.2009.12.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Accepted: 12/15/2009] [Indexed: 01/08/2023]
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Rodríguez-Galán MC, Porporatto C, Sotomayor CE, Cano R, Cejas H, Correa SG. Immune-metabolic balance in stressed rats during Candida albicans infection. Stress 2010; 13:373-83. [PMID: 20666649 DOI: 10.3109/10253891003667870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We evaluated the host metabolic response to chronic varied stress during infection with the fungus Candida albicans. We used four groups of female Wistar rats: normal uninfected and unstressed, stressed, C. albicans infected and infected, and stressed. Infected rats reacted with rapid metabolic adjustments, evident as anorexia and body weight loss, partly mediated by glucocorticoids and TNF-alpha. Higher circulating levels of IL-6 and glucose (p < 0.05) revealed the progress and catabolic effect of the inflammatory response. Infected and stressed rats instead showed anorexia associated with infection and weight loss as the result of reduced food intake. This group exhibited a prompt reduction in circulating leptin on day 3 (p < 0.05), reduction in glucose levels and depletion of hepatic glycogen depots. We also evaluated the contribution of TNF-alpha, glucocorticoids, and food deprivation to liver damage. Lipid peroxidation in liver detected in the infected and infected-stressed groups was exacerbated by the glucocorticoid receptor antagonist RU 486, suggesting the modulatory activity of glucocorticoids, while hepatic fat accumulation and glycogen depletion decreased with anti-TNF-alpha treatment. Food deprivation exacerbated liver injury while the response to stress contributed to greater fungal colonization. Our findings emphasize the impact of metabolic alterations on tissue damage when the host immune activity is modulated by stress mediators.
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Affiliation(s)
- María C Rodríguez-Galán
- Immunology, Department of Clinical Biochemistry, Faculty of Chemical Sciences, CIBICI (CONICET), National University of Cordoba, Cordoba, Argentina
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Abstract
Large bacterial protein toxins autotranslocate functional effector domains to the eukaryotic cell cytosol, resulting in alterations to cellular functions that ultimately benefit the infecting pathogen. Among these toxins, the clostridial glucosylating toxins (CGTs) produced by Gram-positive bacteria and the multifunctional-autoprocessing RTX (MARTX) toxins of Gram-negative bacteria have distinct mechanisms for effector translocation, but a shared mechanism of post-translocation autoprocessing that releases these functional domains from the large holotoxins. These toxins carry an embedded cysteine protease domain (CPD) that is activated for autoprocessing by binding inositol hexakisphosphate (InsP6), a molecule found exclusively in eukaryotic cells. Thus, InsP6-induced autoprocessing represents a unique mechanism for toxin effector delivery specifically within the target cell. This review summarizes recent studies of the structural and molecular events for activation of autoprocessing for both CGT and MARTX toxins, demonstrating both similar and potentially distinct aspects of autoprocessing among the toxins that utilize this method of activation and effector delivery.
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Marketon JIW, Sternberg EM. The glucocorticoid receptor: a revisited target for toxins. Toxins (Basel) 2010; 2:1357-80. [PMID: 22069642 PMCID: PMC3153245 DOI: 10.3390/toxins2061357] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Revised: 05/28/2010] [Accepted: 06/07/2010] [Indexed: 12/15/2022] Open
Abstract
The hypothalamic-pituitary-adrenal (HPA) axis activation and glucocorticoid responses are critical for survival from a number of bacterial, viral and toxic insults, demonstrated by the fact that removal of the HPA axis or GR blockade enhances mortality rates. Replacement with synthetic glucocorticoids reverses these effects by providing protection against lethal effects. Glucocorticoid resistance/insensitivity is a common problem in the treatment of many diseases. Much research has focused on the molecular mechanism behind this resistance, but an area that has been neglected is the role of infectious agents and toxins. We have recently shown that the anthrax lethal toxin is able to repress glucocorticoid receptor function. Data suggesting that the glucocorticoid receptor may be a target for a variety of toxins is reviewed here. These studies have important implications for glucocorticoid therapy.
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Affiliation(s)
- Jeanette I. Webster Marketon
- Department of Internal Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, 201 DHLRI, 473 W. 12th Avenue, Columbus, OH 43210, USA
- Institute for Behavioral Medicine Research, The Ohio State University Medical Center, 460 Medical Center Drive, Columbus, OH 43210, USA
- Author to whom correspondence should be addressed; ; Tel.: +1-614-293-3496; Fax: +1-614-366-2074
| | - Esther M. Sternberg
- Department of Health and Human Services, Section on Neuroendocrine Immunology and Behavior, National Institute of Mental Health, National Institutes of Health, 5625 Fishers Lane, Rm. 4N13 (MSC 9401), Bethesda, MD 20892-9401, USA;
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Kaponis A, Papatheodorou S, Makrydimas G. Septic shock due to Klebsiella pneumoniae after medical abortion with misoprostol-only regimen. Fertil Steril 2010; 94:1529.e3-1529.e5. [PMID: 20303487 DOI: 10.1016/j.fertnstert.2010.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Revised: 02/08/2010] [Accepted: 02/08/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report a case of a healthy woman who was admitted to the hospital with septic shock caused by a common uropathogen after self-administration of misoprostol for pregnancy termination. DESIGN Case report. SETTING Tertiary hospital. PATIENT(S) A 38-year-old woman, gravida 5, para 3, who developed septic shock after medical termination of pregnancy. INTERVENTION(S) Suction curettage, antibiotic treatment, plasma and platelet transfusions. MAIN OUTCOME MEASURE(S) Klebsiella pneumoniae was isolated from blood samples. RESULT Ten days after her admission she was discharged home in good condition on oral antibiotics. CONCLUSION(S) Severe infections leading to septic shock from common pathogen bacteria can occur after medical termination of pregnancy, independently of the regimen used.
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Affiliation(s)
- Apostolos Kaponis
- Department of Obstetrics and Gynecology, Ioannina University School of Medicine, Ioannina, Greece.
| | - Stefania Papatheodorou
- Department of Obstetrics and Gynecology, Ioannina University School of Medicine, Ioannina, Greece
| | - George Makrydimas
- Department of Obstetrics and Gynecology, Ioannina University School of Medicine, Ioannina, Greece
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Abstract
Clostridia produce the highest number of toxins of any type of bacteria and are involved in severe diseases in humans and other animals. Most of the clostridial toxins are pore-forming toxins responsible for gangrenes and gastrointestinal diseases. Among them, perfringolysin has been extensively studied and it is the paradigm of the cholesterol-dependent cytolysins, whereas Clostridium perfringens epsilon-toxin and Clostridium septicum alpha-toxin, which are related to aerolysin, are the prototypes of clostridial toxins that form small pores. Other toxins active on the cell surface possess an enzymatic activity, such as phospholipase C and collagenase, and are involved in the degradation of specific cell-membrane or extracellular-matrix components. Three groups of clostridial toxins have the ability to enter cells: large clostridial glucosylating toxins, binary toxins and neurotoxins. The binary and large clostridial glucosylating toxins alter the actin cytoskeleton by enzymatically modifying the actin monomers and the regulatory proteins from the Rho family, respectively. Clostridial neurotoxins proteolyse key components of neuroexocytosis. Botulinum neurotoxins inhibit neurotransmission at neuromuscular junctions, whereas tetanus toxin targets the inhibitory interneurons of the CNS. The high potency of clostridial toxins results from their specific targets, which have an essential cellular function, and from the type of modification that they induce. In addition, clostridial toxins are useful pharmacological and biological tools.
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Affiliation(s)
- Michel R Popoff
- Institut Pasteur, Bactéries Anaérobies et Toxines, 75724 Paris cedex 15, France.
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Nyirjesy P, Dallabetta G. Infections of the female pelvis including septic abortion. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
Clostridium sordellii is a spore-forming, obligately anaerobic, Gram-positive bacterium that can cause toxic shock syndrome after gynecological procedures. Although the incidence of C. sordellii infection is low, it is fatal in most cases. Since spore germination is believed to be the first step in the establishment of Bacilli and Clostridia infections, we analyzed the requirements for C. sordellii spore germination in vitro. Our data showed that C. sordellii spores require three structurally different amino acids and bicarbonate for maximum germination. Unlike the case for Bacilli species, d-alanine had no effect on C. sordellii spore germination. C. sordellii spores germinated only in a narrow pH range between 5.7 and 6.5. In contrast, C. sordellii spore germination was significantly less sensitive to temperature changes than that of the Bacilli. The analysis of the kinetics of C. sordellii spore germination showed strong allosteric behavior in the binding of l-phenylalanine and l-alanine but not in that of bicarbonate or l-arginine. By comparing germinant apparent binding affinities to their known in vivo concentrations, we postulated a mechanism for differential C. sordellii spore activation in the female reproductive tract.
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Miech RP. Disruption of the innate immune system by mifepristone and lethal toxin of Clostridium sordellii. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/17471060701200402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Popoff MR, Geny B. Multifaceted role of Rho, Rac, Cdc42 and Ras in intercellular junctions, lessons from toxins. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2009; 1788:797-812. [PMID: 19366594 DOI: 10.1016/j.bbamem.2009.01.011] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 01/20/2009] [Accepted: 01/22/2009] [Indexed: 12/20/2022]
Abstract
Tight junctions (TJs) and adherens junctions (AJs) are dynamic structures linked to the actin cytoskeleton, which control the paracellular permeability of epithelial and endothelial barriers. TJs and AJs are strictly regulated in a spatio-temporal manner by a complex signaling network, including Rho/Ras-GTPases, which have a pivotal role. Rho preferentially regulates TJs by controlling the contraction of apical acto-myosin filaments, whereas Rac/Cdc42 mainly coordinate the assembly-disassembly of AJ components. However, a subtle balance of Rho/Ras-GTPase activity and interplay between these molecules is required to maintain an optimal organization and function of TJs and AJs. Conversely, integrity of intercellular junctions generates signals through Rho-GTPases, which are involved in the regulation of multiple cellular processes. Rho/Ras-GTPases and the control of intercellular junctions are the target of various bacterial toxins responsible for severe diseases in man and animals, and are part of their mechanism of action. This review focuses on the regulation of TJs and AJs by Rho/Ras-GTPases through molecular approaches and bacterial toxins.
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Affiliation(s)
- Michel R Popoff
- Institut Pasteur, Unité des Bactéries anaérobies et Toxines, 75724 Paris cedex151, France.
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Group A Streptococcus Causing Necrotizing Fasciitis and Toxic Shock Syndrome After Medical Termination of Pregnancy. Obstet Gynecol 2009; 113:504-506. [DOI: 10.1097/aog.0b013e3181834626] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Corticosteroid Biology in Critical Illness: Modulatory Mechanisms and Clinical Implications. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Reboredo M, Kramer MG, Smerdou C, Prieto J, Rivas JDL. Transcriptomic Effects of Tet-On and Mifepristone-Inducible Systems in Mouse Liver. Hum Gene Ther 2008; 19:1233-47. [DOI: 10.1089/hum.2008.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mercedes Reboredo
- Division of Gene Therapy, Center for Applied Medical Research (CIMA) and University Clinic-University of Navarra, 31008 Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Clinic, 31008 Pamplona, Spain
| | - Maria Gabriela Kramer
- Division of Gene Therapy, Center for Applied Medical Research (CIMA) and University Clinic-University of Navarra, 31008 Pamplona, Spain
- Peter MacCallum Cancer Research Institute, Cancer Immunology Program, East Melbourne 3001, Australia
| | - Cristian Smerdou
- Division of Gene Therapy, Center for Applied Medical Research (CIMA) and University Clinic-University of Navarra, 31008 Pamplona, Spain
| | - Jesús Prieto
- Division of Gene Therapy, Center for Applied Medical Research (CIMA) and University Clinic-University of Navarra, 31008 Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Clinic, 31008 Pamplona, Spain
| | - Javier De Las Rivas
- Bioinformatics and Functional Genomics Research Group, Cancer Research Center (IBMCC-CIC), CSIC and University of Salamanca (CSIC/USAL), E37007 Salamanca, Spain
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Aronoff DM, Hao Y, Chung J, Coleman N, Lewis C, Peres CM, Serezani CH, Chen GH, Flamand N, Brock TG, Peters-Golden M. Misoprostol impairs female reproductive tract innate immunity against Clostridium sordellii. THE JOURNAL OF IMMUNOLOGY 2008; 180:8222-30. [PMID: 18523288 DOI: 10.4049/jimmunol.180.12.8222] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Fatal cases of acute shock complicating Clostridium sordellii endometritis following medical abortion with mifepristone (also known as RU-486) used with misoprostol were reported. The pathogenesis of this unexpected complication remains enigmatic. Misoprostol is a pharmacomimetic of PGE(2), an endogenous suppressor of innate immunity. Clinical C. sordellii infections were associated with intravaginal misoprostol administration, suggesting that high misoprostol concentrations within the uterus impair immune responses against C. sordellii. We modeled C. sordellii endometritis in rats to test this hypothesis. The intrauterine but not the intragastric delivery of misoprostol significantly worsened mortality from C. sordellii uterine infection, and impaired bacterial clearance in vivo. Misoprostol also reduced TNF-alpha production within the uterus during infection. The intrauterine injection of misoprostol did not enhance mortality from infection by the vaginal commensal bacterium Lactobacillus crispatus. In vitro, misoprostol suppressed macrophage TNF-alpha and chemokine generation following C. sordellii or peptidoglycan challenge, impaired leukocyte phagocytosis of C. sordellii, and inhibited uterine epithelial cell human beta-defensin expression. These immunosuppressive effects of misoprostol, which were not shared by mifepristone, correlated with the activation of the G(s) protein-coupled E prostanoid (EP) receptors EP2 and EP4 (macrophages) or EP4 alone (uterine epithelial cells). Our data provide a novel explanation for postabortion sepsis leading to death and also suggest that PGE(2), in which production is exaggerated within the reproductive tract during pregnancy, might be an important causal determinant in the pathogenesis of more common infections of the gravid uterus.
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Affiliation(s)
- David M Aronoff
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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REBOREDO MERCEDES, Kramer MG, Smerdou C, Prieto J, De Las Rivas J. TRANSCRIPTOMIC EFFECTS OF TET-ON AND MIFEPRISTONE INDUCIBLE SYSTEMS IN MOUSE LIVER. Hum Gene Ther 2008. [DOI: 10.1089/hgt.2008.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Yang B, Trump RP, Shen Y, McNulty JA, Clifton LG, Stimpson SA, Lin P, Pahel GL. RU486 did not exacerbate cytokine release in mice challenged with LPS nor in db/db mice. BMC Pharmacol 2008; 8:7. [PMID: 18474108 PMCID: PMC2396158 DOI: 10.1186/1471-2210-8-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 05/12/2008] [Indexed: 01/08/2023] Open
Abstract
Background Glucocorticoids down-regulate cytokine synthesis and suppress inflammatory responses. The glucocorticoid receptor (GR) antagonist RU486 may exacerbate the inflammatory response, and concerns over this exacerbation have limited the development and clinical use of GR antagonists in the treatment of diabetes and depression. We investigated the effects of RU486 on serum cytokines in db/db mice and on lipopolysaccharide (LPS)-induced circulating TNFα levels in both normal AKR mice and diet-induced obese (DIO) C57BL/6 mice. Results Chronic treatment of db/db mice with RU486 dose-dependently decreased blood glucose, increased serum corticosterone and ACTH, but did not affect serum MCP-1 and IL-6 levels. LPS dose-dependently increased serum TNFα in both AKR and C57BL/6 DIO mice, along with increased circulating corticosterone and ACTH. Pretreatment of the mice with RU486 dose-dependently suppressed the LPS induced increases in serum TNFα and further increased serum corticosterone. Conclusion RU486 at doses that were efficacious in lowering blood glucose did not exacerbate cytokine release in these three mouse models. RU486 actually suppressed the lower dose LPS-mediated TNFα release, possibly due to the increased release of glucocorticoids.
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Affiliation(s)
- Baichun Yang
- Department of Metabolic Molecular Pharmacology, Research & Development, GlaxoSmithKline, Research Triangle Park, USA.
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Cohen AL, Bhatnagar J, Reagan S, Zane SB, D'Angeli MA, Fischer M, Killgore G, Kwan-Gett TS, Blossom DB, Shieh WJ, Guarner J, Jernigan J, Duchin JS, Zaki SR, McDonald LC. Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion. Obstet Gynecol 2007; 110:1027-33. [PMID: 17978116 DOI: 10.1097/01.aog.0000287291.19230.ba] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To better understand the risk of fatal toxic shock caused by Clostridium sordellii in women who had a recent medical abortion with mifepristone and misoprostol. METHODS We performed active and passive surveillance for cases of toxic shock associated with medical or spontaneous abortion. To identify the cause of toxic shock, immunohistochemical assays for multiple bacteria were performed on formalin-fixed surgical and autopsy tissues. We extracted DNA from tissues, performed Clostridium species-specific polymerase chain reaction assays, and sequenced amplified products for confirmation of Clostridium species. RESULTS We report four patients with toxic shock associated with Clostridium species infection after medical or spontaneous abortion. Two women had fatal Clostridium perfringens infections after medically induced abortions: one with laminaria and misoprostol and one with the regimen of mifepristone and misoprostol. One woman had a nonfatal Clostridium sordellii infection after spontaneous abortion. Another woman had a fatal C sordellii infection after abortion with mifepristone and misoprostol. All four patients had a rapidly progressive illness with necrotizing endomyometritis. CONCLUSION Toxic shock after abortion can be caused by C perfringens as well as C sordellii, can be nonfatal, and can occur after spontaneous abortion and abortion induced by medical regimens other than mifepristone and misoprostol. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adam L Cohen
- Prevention and Response Branch, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Geny B, Khun H, Fitting C, Zarantonelli L, Mazuet C, Cayet N, Szatanik M, Prevost MC, Cavaillon JM, Huerre M, Popoff MR. Clostridium sordellii lethal toxin kills mice by inducing a major increase in lung vascular permeability. THE AMERICAN JOURNAL OF PATHOLOGY 2007; 170:1003-17. [PMID: 17322384 PMCID: PMC1864880 DOI: 10.2353/ajpath.2007.060583] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
When intraperitoneally injected into Swiss mice, Clostridium sordellii lethal toxin reproduces the fatal toxic shock syndrome observed in humans and animals after natural infection. This animal model was used to study the mechanism of lethal toxin-induced death. Histopathological and biochemical analyses identified lung and heart as preferential organs targeted by lethal toxin. Massive extravasation of blood fluid in the thoracic cage, resulting from an increase in lung vascular permeability, generated profound modifications such as animal dehydration, increase in hematocrit, hypoxia, and finally, cardiorespiratory failure. Vascular permeability increase induced by lethal toxin resulted from modifications of lung endothelial cells as evidenced by electron microscopy. Immunohistochemical analysis demonstrated that VE-cadherin, a protein participating in intercellular adherens junctions, was redistributed from membrane to cytosol in lung endothelial cells. No major sign of lethal toxin-induced inflammation was observed that could participate in the toxic shock syndrome. The main effect of the lethal toxin is the glucosylation-dependent inactivation of small GTPases, in particular Rac, which is involved in actin polymerization occurring in vivo in lungs leading to E-cadherin junction destabilization. We conclude that the cells most susceptible to lethal toxin are lung vascular endothelial cells, the adherens junctions of which were altered after intoxication.
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Affiliation(s)
- Blandine Geny
- Unités des Bactéries Anaérobies et Toxines, Paris, France.
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Creinin MD, Schreiber CA, Bednarek P, Lintu H, Wagner MS, Meyn LA. Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion: a randomized controlled trial. Obstet Gynecol 2007; 109:885-94. [PMID: 17400850 DOI: 10.1097/01.aog.0000258298.35143.d2] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Mifepristone and oral misoprostol are typically used for medical abortion in women up to 49 days of gestation, with a 36- to 48-hour interval between the medications. Alternative routes of misoprostol administration allow for use beyond 49 days of gestation. We designed this randomized, noninferiority trial to compare the efficacy, adverse effects, and acceptability of misoprostol 800 mcg vaginally administered simultaneously with, or 24 hours after, mifepristone 200 mg orally for abortion in women up to 63 days of gestation. METHODS The 1,128 participants swallowed mifepristone 200 mg and were then randomized to self-administer misoprostol intravaginally immediately in the office (group 1) or 24 hours later at home (group 2). Subjects returned for an evaluation, including transvaginal ultrasonography, 7+/-1 days after initiating treatment. Women who had not aborted were offered a second dose of misoprostol and returned for another evaluation in approximately 1 week. A phone contact was also attempted approximately 5 weeks after treatment. Treatment was considered a failure if a suction aspiration was performed for any indication. RESULTS The complete abortion rate for group 1 (95.1%, 95% confidence interval [CI] 93.0-96.8%) was statistically noninferior to that for group 2 (96.9%, 95% CI 95.1-98.2%) (P=.003). The abortion rates between groups did not significantly differ by gestational age. Adverse effects were mostly similar, although nausea, diarrhea, and warmth or chills were significantly more common in group 1. CONCLUSION Mifepristone 200 mg and misoprostol 800 mcg vaginally used simultaneously is as effective for abortion as compared with regimens using a 24-hour dosing interval. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00269568 LEVEL OF EVIDENCE I.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics, Gynecology and Reproductive Sciences and Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213-3180, USA.
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Aldape MJ, Bryant AE, Stevens DL. Clostridium sordellii infection: epidemiology, clinical findings, and current perspectives on diagnosis and treatment. Clin Infect Dis 2006; 43:1436-46. [PMID: 17083018 DOI: 10.1086/508866] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Accepted: 07/17/2006] [Indexed: 12/27/2022] Open
Abstract
Clostridium sordellii infections pose difficult clinical challenges and are usually fatal. Most commonly, these infections occur after trauma, childbirth, and routine gynecological procedures, but they have recently been associated with medically induced abortions and injection drug use. We report 2 fatal cases, one of which was associated with minor trauma, and the other of which was associated with normal childbirth, and we summarize the clinical features of 43 additional cases of reported C. sordellii infection. Of these 45 cases, 8 (18%) were associated with normal childbirth, 5 (11%) were associated with medically induced abortion, and 2 (0.4%) were associated with spontaneous abortion. The case-fatality rate was 100% in these groups. Ten (22%) of the C. sordellii infections occurred in injection drug users, and 50% of these patients died. Other cases of C. sordellii infection (in 19 patients [43%]) occurred after trauma or surgery, mostly in healthy persons, and 53% these patients died. Overall, the mortality rate was 69% (31 of 45 patients). Eighty-five percent of all patients with fatal cases died within 2-6 days of initial infection, and nearly 80% of fatal cases developed leukemoid reactions. Rapid diagnostic tests and improved treatments are needed to reduced the morbidity and mortality associated with this devastating infection.
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Affiliation(s)
- M J Aldape
- Veterans Affairs Medical Center, Boise, ID 83702, USA.
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Grimes DA. Risks of mifepristone abortion in context. Contraception 2006; 74:174-5 author reply175-6. [PMID: 16860058 DOI: 10.1016/j.contraception.2005.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Accepted: 11/18/2005] [Indexed: 11/15/2022]
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Sitruk-Ware R. Mifepristone and misoprostol sequential regimen side effects, complications and safety. Contraception 2006; 74:48-55. [PMID: 16781261 DOI: 10.1016/j.contraception.2006.03.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 03/13/2006] [Accepted: 03/20/2006] [Indexed: 11/24/2022]
Abstract
Exhibiting a strong affinity to the progesterone and the glucocorticoid receptors, mifepristone exert competitive antagonism to these hormones both in in vitro and in animal experiments. Due to its antiprogesterone activity, it was proposed that mifepristone be used for the termination of early human pregnancy. Mifepristone, at a dose of 600 mg initially used alone, was then used with a subsequent low dose of prostaglandin that led to a success rate of 95% as a medical method for early termination of pregnancy (TOP), and the occurrence of continuing pregnancy was reduced to <or=1%. Its use was extended to other indications, such as cervical dilatation prior to surgical TOP in the first trimester, therapeutic TOP for medical reasons beyond the first trimester and for labor induction in case of fetal death in utero. The efficacy and safety of this treatment have been confirmed based on its use for over 15 years since its first approval in France and with close adherence to the approved recommendations. This article describes the toxicology studies conducted in animals as well as the safety follow-up and side effects reported with use of the compound when used with misoprostol in the main indication that is currently approved in 31 countries. Special emphasis is given to the rare but relevant safety issues, that is, heavy uterine bleeding, pelvic infections and continuing pregnancies. The rationale for warnings and contraindications for use of the product are also explained.
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Affiliation(s)
- Regine Sitruk-Ware
- Center for Biomedical Research, Population Council, Rockefeller University, New York, NY 10021, USA.
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Crockett SA. Risks of mifepristone abortion in context. Contraception 2006; 74:174; author reply 175-6. [PMID: 16860057 DOI: 10.1016/j.contraception.2005.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2005] [Accepted: 11/15/2005] [Indexed: 11/17/2022]
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Harrison DJ, Gary MM. Authors' Reply. Ann Pharmacother 2006. [DOI: 10.1345/aph.1g481e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Donna J Harrison
- Subcommittee on Mifeprex American Association of Prolife Obstetricians and Gynecologists PO Box 414 Eau Claire, Michigan 49111-0414
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Sicard D, Chauvelot-Moachon L. Comment: pathophysiology of mifepristone-induced septic shock due to Clostridium sordellii. Ann Pharmacother 2005; 39:2142-3. [PMID: 16288074 DOI: 10.1345/aph.1g189a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Fischer M, Bhatnagar J, Guarner J, Reagan S, Hacker JK, Van Meter SH, Poukens V, Whiteman DB, Iton A, Cheung M, Dassey DE, Shieh WJ, Zaki SR. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med 2005; 353:2352-60. [PMID: 16319384 DOI: 10.1056/nejmoa051620] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Endometritis and toxic shock syndrome associated with Clostridium sordellii have previously been reported after childbirth and, in one case, after medical abortion. We describe four deaths due to endometritis and toxic shock syndrome associated with C. sordellii that occurred within one week after medically induced abortions. Clinical findings included tachycardia, hypotension, edema, hemoconcentration, profound leukocytosis, and absence of fever. These cases indicate the need for physician awareness of this syndrome and for further study of its association with medical abortion.
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Affiliation(s)
- Marc Fischer
- Centers for Disease Control and Prevention, Atlanta, USA.
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Shukunami KI, Nishijima K, Kotsuji F. Medical vs. surgical management of early pregnancy failure. N Engl J Med 2005; 353:2403-4; author reply 2403-4. [PMID: 16319392 DOI: 10.1056/nejm200512013532216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Murray S, Wooltorton E. Septic shock after medical abortions with mifepristone (Mifeprex, RU 486) and misoprostol. CMAJ 2005; 173:485. [PMID: 16093445 PMCID: PMC1188182 DOI: 10.1503/cmaj.050980] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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