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Pesola F, Smith KM, Phillips-Waller A, Przulj D, Griffiths C, Walton R, McRobbie H, Coleman T, Lewis S, Whitemore R, Clark M, Ussher M, Sinclair L, Seager E, Cooper S, Bauld L, Naughton F, Sasieni P, Manyonda I, Hajek P. Safety of e-cigarettes and nicotine patches as stop-smoking aids in pregnancy: Secondary analysis of the Pregnancy Trial of E-cigarettes and Patches (PREP) randomized controlled trial. Addiction 2024; 119:875-884. [PMID: 38229538 DOI: 10.1111/add.16422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/16/2023] [Indexed: 01/18/2024]
Abstract
AIMS The aim of this study was to examine the safety of e-cigarettes (EC) and nicotine patches (NRT) when used to help pregnant smokers quit. DESIGN A recent trial of EC versus NRT reported safety outcomes in the randomized arms. We conducted a further analysis based on product use. SETTING Twenty-three hospitals in England and a stop-smoking service in Scotland took part. PARTICIPANTS The participants comprised 1140 pregnant smokers. INTERVENTIONS We compared women using and not using EC and NRT regularly during pregnancy. MEASUREMENTS Measurements included nicotine intake compared with baseline, birth weight, other pregnancy outcomes, adverse events, maternal respiratory symptoms and relapse in early abstainers. FINDINGS Use of EC was more common than use of NRT (47.3% vs 21.6%, P < 0.001). Women who stopped smoking (abstainers) and used EC at the end-of-pregnancy (EOP) reduced their salivary cotinine by 45% [49.3 ng/ml, 95% confidence interval (CI) = -79.8 to -10]. Only one abstainer used NRT at EOP. In dual users, cotinine increased by 19% (24 ng/ml, 95% CI = 3.5-68). In women reporting a reduction of at least 50% in cigarette consumption, cotinine levels increased by 10% in those using nicotine products and by 9% in those who did not. Birth weights in dual users and exclusive smokers were the same (3.1 kg). Birth weight in abstainers using either nicotine product was higher than in smokers [3.3 kg, standard deviation (SD) = 0.7] versus 3.1 kg, SD = 0.6; difference = 0.15 kg, 95% CI = 0.05-0.25) and not different from abstainers not using nicotine products (3.1 kg, SD = 0.8). Abstainers and smokers using nicotine products had no worse pregnancy outcomes or more adverse events than abstainers and smokers not using them. EC users reported more improvements than non-users in cough [adjusted relative risk (aRR) = 0.59, 95% CI = 0.37-0.93] and phlegm (aRR = 0.53, 95% CI = 0.31-0.92), controlling for smoking status. EC or NRT use had no association with relapse. CONCLUSIONS Regular use of e-cigarettes or nicotine patches by pregnant smokers does not appear to be associated with any adverse outcomes.
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Affiliation(s)
- Francesca Pesola
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Katie Myers Smith
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Anna Phillips-Waller
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Dunja Przulj
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | - Robert Walton
- Blizard Institute, Queen Mary University of London, London, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Tim Coleman
- Centre for Academic Primary Care, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Centre for Academic Primary Care, University of Nottingham, Nottingham, UK
| | - Rachel Whitemore
- Centre for Academic Primary Care, University of Nottingham, Nottingham, UK
| | - Miranda Clark
- Centre for Academic Primary Care, University of Nottingham, Nottingham, UK
| | - Michael Ussher
- Division of Population Health Sciences and Education, St George's, University of London and Institute of Social Marketing and Health, University of Stirling, Stirling, UK
| | - Lesley Sinclair
- Usher Institute and SPECTRUM Consortium, University of Edinburgh, Edinburgh, UK
| | - Emily Seager
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Sue Cooper
- Centre for Academic Primary Care, University of Nottingham, Nottingham, UK
| | - Linda Bauld
- Usher Institute and SPECTRUM Consortium, University of Edinburgh, Edinburgh, UK
| | - Felix Naughton
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Peter Sasieni
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Isaac Manyonda
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Peter Hajek
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Hajek P, Przulj D, Pesola F, Griffiths C, Walton R, McRobbie H, Coleman T, Lewis S, Whitemore R, Clark M, Ussher M, Sinclair L, Seager E, Cooper S, Bauld L, Naughton F, Sasieni P, Manyonda I, Myers Smith K. Author Correction: Electronic cigarettes versus nicotine patches for smoking cessation in pregnancy: a randomized controlled trial. Nat Med 2023; 29:2957. [PMID: 36344702 PMCID: PMC10667089 DOI: 10.1038/s41591-022-02099-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Peter Hajek
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Dunja Przulj
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Francesca Pesola
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
| | - Chris Griffiths
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Robert Walton
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Tim Coleman
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Rachel Whitemore
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Miranda Clark
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Michael Ussher
- Division of Population Heath Sciences and Education, St Georges, University of London, London, UK
- Institute of Social Marketing and Health, University of Stirling, Stirling, UK
| | - Lesley Sinclair
- Usher Institute and SPECTRUM Consortium, University of Edinburgh, Edinburgh, UK
| | - Emily Seager
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Sue Cooper
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Linda Bauld
- Usher Institute and SPECTRUM Consortium, University of Edinburgh, Edinburgh, UK
| | - Felix Naughton
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Peter Sasieni
- The Cancer Research UK and King's College London Cancer Prevention Trials Unit, King's College London, London, UK
| | | | - Katie Myers Smith
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Przulj D, Pesola F, Myers Smith K, McRobbie H, Coleman T, Lewis S, Griffith C, Walton R, Whitemore R, Clark M, Ussher M, Sinclair L, Seager E, Cooper S, Bauld L, Naughton F, Sasieni P, Manyonda I, Hajek P. Helping pregnant smokers quit: a multi-centre randomised controlled trial of electronic cigarettes versus nicotine replacement therapy. Health Technol Assess 2023; 27:1-53. [PMID: 37840301 PMCID: PMC10599072 DOI: 10.3310/agth6901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Background Some pregnant smokers try e-cigarettes, but effectiveness and safety of such use are unknown. Objectives To compare effectiveness and safety of nicotine patches and e-cigarettes in pregnancy. Design A pragmatic multi-centre randomised controlled trial. Setting Twenty-three hospitals across England, and a Stop Smoking Service in Scotland. Participants One thousand one hundred and forty pregnant daily smokers (12-24 weeks' gestation) motivated to stop smoking, with no strong preference for using nicotine patches or e-cigarettes. Interventions Participants in the e-cigarette arm were posted a refillable e-cigarette device with two 10 ml bottles of tobacco-flavoured e-liquid (18 mg nicotine). Participants in the nicotine patches arm were posted a 2-week supply of 15 mg/16-hour nicotine patches. Supplies were provided for up to 8 weeks. Participants sourced further supplies themselves as needed. Participants in both arms received support calls prior to their target quit date, on the quit date, and weekly for the next 4 weeks. Outcome measures The primary outcome was validated prolonged abstinence at the end of pregnancy. Participants lost to follow-up or not providing biochemical validation were included as non-abstainers. Secondary outcomes included self-reported abstinence at different time points, treatment adherence and safety outcomes. Results Only 55% of self-reported abstainers mailed back useable saliva samples. Due to this, validated sustained abstinence rates were low (6.8% vs. 4.4% in the e-cigarettes and nicotine patches arms, respectively, risk ratio = 1.55, 95% confidence interval 0.95 to 2.53; Bayes factor = 2.7). In a pre-specified sensitivity analysis that excluded abstainers using non-allocated products, the difference became significant (6.8% vs. 3.6%, risk ratio = 1.93, 95% confidence interval 1.14 to 3.26; Bayes factor = 10). Almost a third of the sample did not set a target quit date and the uptake of support calls was low, as was the initial product use. At end of pregnancy, 33.8% versus 5.6% of participants were using their allocated product in the e-cigarettes versus nicotine patches arm (risk ratio = 6.01, 95% confidence interval 4.21 to 8.58). Regular use of e-cigarettes in the nicotine patches arm was more common than use of nicotine replacement products in the e-cigarette arm (17.8% vs. 2.8%). Rates of adverse events and adverse birth outcomes were similar in the two study arms, apart from participants in the e-cigarette arm having fewer infants with low birthweight (<2500 g) (9.6% vs. 14.8%, risk ratio = 0.65, 95% confidence interval 0.47 to 0.90; Bayes factor = 10.3). Limitations Low rates of validation reduced the study power. A substantial proportion of participants did not use the support on offer sufficiently to test its benefits. Sample size may have been too small to detect differences in less frequent adverse effects. Conclusions E-cigarettes were not significantly more effective than nicotine patches in the primary analysis, but when e-cigarettes use in the nicotine patches arm was accounted for, e-cigarettes were almost twice as effective as patches in all abstinence outcomes. In pregnant smokers seeking help, compared to nicotine patches, e-cigarettes are probably more effective, do not pose more risks to birth outcomes assessed in this study and may reduce the incidence of low birthweight. Future work Routine monitoring of smoking cessation and birth outcomes in pregnant women using nicotine patches and e-cigarettes and further studies are needed to confirm these results. Trial registration This trial is registered as ISRCTN62025374 and Eudract 2017-001237-65. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Dunja Przulj
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Francesca Pesola
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Katie Myers Smith
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Tim Coleman
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Christopher Griffith
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Robert Walton
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | - Miranda Clark
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Ussher
- Population Health Research Institute, St George's University of London, London, UK; Institute of Social Marketing and Health, University of Stirling, Stirling, UK
| | - Lesley Sinclair
- Usher Institute and SPECTRUM Consortium, Centre for Population Health Sciences, Old Medical School, Edinburgh, UK
| | - Emily Seager
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Sue Cooper
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Linda Bauld
- Usher Institute and SPECTRUM Consortium, Centre for Population Health Sciences, Old Medical School, Edinburgh, UK
| | - Felix Naughton
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Peter Sasieni
- The Cancer Research UK and King's College London Cancer Prevention Trials Unit, King's College London, Institute of Psychiatry, London, UK
| | - Isaac Manyonda
- St George's University Hospital NHS Foundation Trust, London, UK
| | - Peter Hajek
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Sirkeci F, Moss J, Belli AM, McPherson K, Daniels J, Manyonda I, Middleton L, Cheed V, Wu O, Lumsden MA. Effects on heavy menstrual bleeding and pregnancy of uterine artery embolization (UAE) or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: The FEMME randomized controlled trial. Int J Gynaecol Obstet 2023; 160:492-501. [PMID: 36511801 PMCID: PMC10107788 DOI: 10.1002/ijgo.14626] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/13/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine treatment options (myomectomy vs. uterine artery embolization (UAE)) for women wishing to avoid hysterectomy. METHODS A multicenter randomized controlled trial was conducted on 254 women and data were collected on fibroid-specific quality of life (UFS-QOL), loss of menstrual blood, and pregnancy. RESULTS At 4 years, the mean difference in the UFS-QOL was 5.0 points (95% confidence interval (CI) -1.4 to 11.5; P = 0.13) in favor of myomectomy. This was not statistically significant as it was at 2 years. There were no differences in bleeding scores, rates of amenorrhea, or heavy bleeding. Of those who were still menstruating, the majority reported regular or fairly regular periods: 36 of 48 (75%) in the UAE group and 30 of 39 (77%) in the myomectomy group. Twelve women after UAE and six women after myomectomy became pregnant (4 years) with seven and five live births, respectively (hazard ratio 0.48, 95% CI 0.18-1.28). There was no difference between the levels of hormones associated with the uterine reserve in each group. CONCLUSION Leiomyoma are common in reproductive-aged women, causing heavy menses and subfertility. Among women with uterine fibroids, myomectomy resulted in better fibroid-related quality of life at 4 years, compared with UAE but the treatments decreased menstrual bleeding equally. There was also no significant difference in the impact of treatment on ovarian reserve.
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Affiliation(s)
- Fusun Sirkeci
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester NHS Foundation Trust, Manchester, UK
| | - John Moss
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Anna M Belli
- Department of Radiology, St George's Hospital and Medical School, London, UK
| | - Klim McPherson
- Department of Primary Care, University of Oxford, Oxford, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Isaac Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London, UK
| | - Lee Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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5
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Hajek P, Przulj D, Pesola F, Griffiths C, Walton R, McRobbie H, Coleman T, Lewis S, Whitemore R, Clark M, Ussher M, Sinclair L, Seager E, Cooper S, Bauld L, Naughton F, Sasieni P, Manyonda I, Myers Smith K. Electronic cigarettes versus nicotine patches for smoking cessation in pregnancy: a randomized controlled trial. Nat Med 2022; 28:958-964. [PMID: 35577966 PMCID: PMC9117131 DOI: 10.1038/s41591-022-01808-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/31/2022] [Indexed: 01/26/2023]
Abstract
Nicotine replacement therapy, in the form of nicotine patches, is commonly offered to pregnant women who smoke to help them to stop smoking, but this approach has limited efficacy in this population. Electronic cigarettes (e-cigarettes) are also used by pregnant women who smoke but their safety and efficacy in pregnancy are unknown. Here, we report the results of a randomized controlled trial in 1,140 participants comparing refillable e-cigarettes with nicotine patches. Pregnant women who smoked were randomized to e-cigarettes (n = 569) or nicotine patches (n = 571). In the unadjusted analysis of the primary outcome, validated prolonged quit rates at the end of pregnancy in the two study arms were not significantly different (6.8% versus 4.4% in the e-cigarette and patch arms, respectively; relative risk (RR) = 1.55, 95%CI: 0.95-2.53, P = 0.08). However, some participants in the nicotine patch group also used e-cigarettes during the study. In a pre-specified sensitivity analysis excluding abstinent participants who used non-allocated products, e-cigarettes were more effective than patches (6.8% versus 3.6%; RR = 1.93, 95%CI: 1.14-3.26, P = 0.02). Safety outcomes included adverse events and maternal and birth outcomes. The safety profile was found to be similar for both study products, however, low birthweight (<2,500 g) was less frequent in the e-cigarette arm (14.8% versus 9.6%; RR = 0.65, 95%CI: 0.47-0.90, P = 0.01). Other adverse events and birth outcomes were similar in the two study arms. E-cigarettes might help women who are pregnant to stop smoking, and their safety for use in pregnancy is similar to that of nicotine patches. ISRCTN62025374.
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Affiliation(s)
- Peter Hajek
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Dunja Przulj
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Francesca Pesola
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
| | - Chris Griffiths
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Robert Walton
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Tim Coleman
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Rachel Whitemore
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Miranda Clark
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Michael Ussher
- Division of Population Heath Sciences and Education, St Georges, University of London, London, UK
- Institute of Social Marketing and Health, University of Stirling, Stirling, UK
| | - Lesley Sinclair
- Usher Institute and SPECTRUM Consortium, University of Edinburgh, Edinburgh, UK
| | - Emily Seager
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Sue Cooper
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Linda Bauld
- Usher Institute and SPECTRUM Consortium, University of Edinburgh, Edinburgh, UK
| | - Felix Naughton
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Peter Sasieni
- The Cancer Research UK and King's College London Cancer Prevention Trials Unit, King's College, London, UK
| | | | - Katie Myers Smith
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Abstract
Surgical menopause (iatrogenic menopause) happens when both ovaries are removed before the natural "switching off" of ovarian function; it can cause premature ovarian insufficiency where the menopause occurs in women before the age of 40. Surgical menopause is associated with a sudden reduction of ovarian sex steroid production rather than a gradual one as is the case in natural menopause. In women who have undergone bilateral salpingo-oophorectomy (BSO) before the natural age of menopause, strong consideration should be given to giving hormone replacement therapy (HRT) till the natural age of menopause at least. Sexual function and sexual desire are altered post-BSO, especially in younger women hence part of HRT prescription must include consideration of androgen too.
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Affiliation(s)
- Ouma C Pillay
- Department of Obstetrics & Gynaecology, St George´s University Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Isaac Manyonda
- Department of Obstetrics and Gynecology, St George's, University of London, London / St George´s University Hospitals NHS Foundation Trust, United Kingdom
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Daniels J, Middleton LJ, Cheed V, McKinnon W, Rana D, Sirkeci F, Manyonda I, Belli AM, Lumsden MA, Moss J, Wu O, McPherson K. Uterine artery embolisation versus myomectomy for premenopausal women with uterine fibroids wishing to avoid hysterectomy: the FEMME RCT. Health Technol Assess 2022; 26:1-74. [PMID: 35435818 DOI: 10.3310/zdeg6110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced quality of life. For women wishing to retain their uterus and who do not respond to medical treatment, myomectomy and uterine artery embolisation are therapeutic options. OBJECTIVES We examined the clinical effectiveness and cost-effectiveness of uterine artery embolisation compared with myomectomy in the treatment of symptomatic fibroids. DESIGN A multicentre, open, randomised trial with a parallel economic evaluation. SETTING Twenty-nine UK hospitals. PARTICIPANTS Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolisation were recruited. Women were excluded if they had significant adenomyosis, any malignancy or pelvic inflammatory disease or if they had already had a previous open myomectomy or uterine artery embolisation. INTERVENTIONS Participants were randomised to myomectomy or embolisation in a 1 : 1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic. Embolisation of the uterine arteries was performed under fluoroscopic guidance. MAIN OUTCOME MEASURES The primary outcome was the Uterine Fibroid Symptom Quality of Life questionnaire (with scores ranging from 0 to 100 and a higher score indicating better quality of life) at 2 years, adjusted for baseline score. The economic evaluation estimated quality-adjusted life-years (derived from EuroQol-5 Dimensions, three-level version, and costs from the NHS perspective). RESULTS A total of 254 women were randomised - 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolisation (98 underwent embolisation). Information on the primary outcome at 2 years was available for 81% (n = 206) of women. Primary outcome scores at 2 years were 84.6 (standard deviation 21.5) in the myomectomy group and 80.0 (standard deviation 22.0) in the uterine artery embolisation group (intention-to-treat complete-case analysis mean adjusted difference 8.0, 95% confidence interval 1.8 to 14.1, p = 0.01; mean adjusted difference using multiple imputation for missing responses 6.5, 95% confidence interval 1.1 to 11.9). The mean difference in the primary outcome at the 4-year follow-up time point was 5.0 (95% CI -1.4 to 11.5; p = 0.13) in favour of myomectomy. Perioperative and postoperative complications from all initial procedures occurred in similar percentages of women in both groups (29% in the myomectomy group vs. 24% in the UAE group). Twelve women in the uterine embolisation group and six women in the myomectomy group reported pregnancies over 4 years, resulting in seven and five live births, respectively (hazard ratio 0.48, 95% confidence interval 0.18 to 1.28). Over a 2-year time horizon, uterine artery embolisation was associated with higher costs than myomectomy (mean cost £7958, 95% confidence interval £6304 to £9612, vs. mean cost £7314, 95% confidence interval £5854 to £8773), but with fewer quality-adjusted life-years gained (0.74, 95% confidence interval 0.70 to 0.78, vs. 0.83, 95% confidence interval 0.79 to 0.87). The differences in costs (difference £645, 95% confidence interval -£1381 to £2580) and quality-adjusted life-years (difference -0.09, 95% confidence interval -0.11 to -0.04) were small. Similar results were observed over the 4-year time horizon. At a threshold of willingness to pay for a gain of 1 QALY of £20,000, the probability of myomectomy being cost-effective is 98% at 2 years and 96% at 4 years. LIMITATIONS There were a substantial number of women who were not recruited because of their preference for a particular treatment option. CONCLUSIONS Among women with symptomatic uterine fibroids, myomectomy resulted in greater improvement in quality of life than did uterine artery embolisation. The differences in costs and quality-adjusted life-years are very small. Future research should involve women who are desiring pregnancy. TRIAL REGISTRATION This trial is registered as ISRCTN70772394. FUNDING This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, and will be published in full in Health Technology Assessment; Vol. 26, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - William McKinnon
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Dikshyanta Rana
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Fusun Sirkeci
- Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London, UK
| | - Isaac Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London, UK
| | - Anna-Maria Belli
- Department of Radiology, St George's Hospital and Medical School, London, UK
| | | | - Jonathan Moss
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Klim McPherson
- Department of Primary Care, University of Oxford, Oxford, UK
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Das R, Wale A, Renani SA, Ratnam L, Mailli L, Chun JY, Das S, Duggal B, Manyonda I, Belli AM. Randomised Controlled Trial of Particles Used in Uterine fibRoid Embolisation (PURE): Non-Spherical Polyvinyl Alcohol Versus Calibrated Microspheres. Cardiovasc Intervent Radiol 2022; 45:207-215. [PMID: 34984488 PMCID: PMC8807446 DOI: 10.1007/s00270-021-02977-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 08/18/2021] [Indexed: 11/30/2022]
Abstract
Purpose The PURE study is a randomised controlled trial (RCT) comparing the clinical and MRI outcomes of patients treated with non-spherical polyvinyl alcohol, ns-PVA (Contour PVA–Boston Scientific–355–500 & 500–700 microns) versus calibrated hydrogel microspheres (Embozene–Varian Inc–700 & 900 microns) for symptomatic uterine fibroids. Materials and Methods Prospective, ethically approved non-sponsored RCT in 84 patients in a single UK tertiary IR unit, ISRCTN registry trial number ISRCTN18191539 in 2013 and 2014. All patients with symptomatic fibroid disease were eligible. UAE followed a standardised protocol with UFS-QOL and contrast-enhanced MRI before and 6 months post UAE. Outcome measures included: (1) Uterine Fibroid Symptom and Quality of Life questionnaire (UFS-QOL). (2) Percentage total and dominant fibroid infarction. (3) Uterine and dominant fibroid volume reduction. (4) Volume of embolics. Results Sixty-three patients completed the QOL follow-up (33 ns-PVA vs 30 Embozenes), the groups were equivalent at baseline. Patients were followed up for 6 months following UAE. There was no significant difference in symptom scores or HR-QOL between ns-PVA and Embozenes, p = 0.67 and 0.21, respectively. 92.7% of patients treated with ns-PVA achieved > 90% dominant fibroid infarction versus 61.8% treated with Embozenes (p = 0.0016). 66% of patients treated with ns = PVA achieved > 90% total fibroid percentage infarction compared with 35% in the Embozene group (p = 0.011). The mean vials/syringes used were 5.2 with Embozenes versus 4.1 using PVA (p = 0.08). Conclusion The PURE study informs IRs regarding the efficacy of embolic agents in UAE, with superior fibroid infarction on MRI using ns-PVA versus Embozenes however no significant difference in clinical outcomes at 6 months after UAE. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-021-02977-0.
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Affiliation(s)
- Raj Das
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK.
| | - Anita Wale
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Seyed Ameli Renani
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Lakshmi Ratnam
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Leto Mailli
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Joo-Young Chun
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Sourav Das
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Balpreet Duggal
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Isaac Manyonda
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Anna-Maria Belli
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
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Manyonda I, Sinai Talaulikar V, Pirhadi R, Ward J, Banerjee D, Onwude J. Could Perimenopausal Estrogen Prevent Breast Cancer? Exploring the Differential Effects of Estrogen-Only Versus Combined Hormone Replacement Therapy. J Clin Med Res 2022; 14:1-7. [PMID: 35211211 PMCID: PMC8827222 DOI: 10.14740/jocmr4646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/17/2022] [Indexed: 12/02/2022] Open
Abstract
Breast cancer is the commonest cancer among women in the western world, accounting for up to 30% of all cancers in women. There is a long-standing controversy about the potential link to hormone replacement therapy (HRT), with large observational studies suggesting that HRT increases the risk, while the Women’s Health Initiative (WHI), a prospective, randomized placebo-controlled trial, has reported several times over a period of 20 years that combined (estrogen and progestogen) HRT increases the risk, while estrogen-only HRT given to women who have had a prior hysterectomy, is associated with a significantly reduced risk of developing breast cancer. Evidence from the randomized trial shows a significant reduction in both incidence of and mortality from breast cancer in women who took estrogen replacement therapy; this message needs to be presented clearly and robustly so that it can help women with decision making when considering HRT for menopause.
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Affiliation(s)
- Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George’s University Hospitals NHS Foundation Trust/St George’s, University of London, London, UK
| | - Vikram Sinai Talaulikar
- Reproductive Medicine Unit, EGA Wing, University College London Hospital, London NW1 2BU, UK
- Corresponding Author: Vikram Sinai Talaulikar, Reproductive Medicine Unit, EGA Wing, University College London Hospital, London NW1 2BU, UK.
| | - Roxanna Pirhadi
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford CM1 1SQ, UK
| | - John Ward
- St George’s, University of London, London, UK
| | - Dibyesh Banerjee
- Department of Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Joseph Onwude
- The Chelmsford Private Day Surgery Hospital, Fenton House, Chelmsford CM2 0PP, UK
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10
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Daniels J, Middleton LJ, Cheed V, McKinnon W, Sirkeci F, Manyonda I, Belli AM, Lumsden MA, Moss J, Wu O, McPherson K, On Behalf Of The Femme Trial Collaborative Group. Uterine artery embolization or myomectomy for women with uterine fibroids: Four-year follow-up of a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol X 2021; 13:100139. [PMID: 34877531 PMCID: PMC8633559 DOI: 10.1016/j.eurox.2021.100139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To examine the quality of life experienced by women with symptomatic uterine fibroids who had been treated with UAE in comparison to myomectomy. We report the four-year follow-up of the FEMME randomised trial. Two-year follow-up data has been previously reported. Study Design Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolization were recruited from 29 UK hospitals. Women were excluded if they had significant adenomyosis, any malignancy, pelvic inflammatory disease or had had a previous open myomectomy or uterine artery embolization. Participants were randomised to myomectomy or embolization in a 1:1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic, according to clinician preference. Embolization of the uterine arteries was performed according to local practice, under fluoroscopic guidance. The primary outcome measure was the Uterine Fibroid Symptom Quality of Life questionnaire, adjusted for baseline score and reported here at four years post-randomisation. Subsequent procedures for fibroids, pregnancy and outcome were amongst secondary outcomes. Trial registration ISRCTN70772394 https://doi.org/10.1186/ISRCTN70772394 Results 254 women were randomized, 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolization (98 underwent embolization). At four years, 67 (53%) and 81 (64%) completed UFS-QoL quality of life scores. Mean difference in the UFS-QoL at 4 years was 5.0 points (95% CI −1.4 to 11.5; p = 0.13) in favour of myomectomy. There were 15 pregnancies in the UAE group and 7 in the myomectomy group, with a cumulative pregnancy rate to four years of 15% and 6% respectively (hazard ratio: 0.48; 95% CI 0.18–1.28). The cumulative repeat procedure rate to four years was 24% in the UAE group and 13% in the myomectomy group (hazard ratio: 0.53; 95% CI 0.27–1.05). Conclusions Myomectomy resulted in greater improvement in quality of life compared with uterine artery embolization, although by four years, this difference was not statistically significant. Missing data may limit the generalisability of this result. The numbers of women becoming pregnant were too small draw a conclusion on the effect of the procedures on fertility.
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Affiliation(s)
- Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham NG7 2RD, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
| | - William McKinnon
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
| | - Fusun Sirkeci
- Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London E11 1NR, UK
| | - Isaac Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London SW17 0QT, UK
| | - Anna-Maria Belli
- Department of Radiology, St George's Hospital and Medical School, London SW17 0QT, UK
| | | | - Jonathan Moss
- School of Medicine, University of Glasgow, Glasgow G31 2ER, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8RZ, UK
| | - Klim McPherson
- Department of Primary Care, University of Oxford, OX3 9DU, UK
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11
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Newson L, Manyonda I, Lewis R, Preissner R, Preissner S, Seeland U. Sensitive to Infection but Strong in Defense-Female Sex and the Power of Oestradiol in the COVID-19 Pandemic. Front Glob Womens Health 2021; 2:651752. [PMID: 34816207 PMCID: PMC8593953 DOI: 10.3389/fgwh.2021.651752] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
The incidence of SARS-CoV2 infections is around 15% higher in premenopausal women compared to age matched men, yet the fatality rate from COVID-19 is significantly higher in men than women for all age strata. Sex differences have also been observed in recent epidemics including severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), with SARS-CoV 2 virus infection sex differences appear more dramatic. The regulation and expression of the angiotensin converting enzyme 2 (ACE2) is the key for this special coronavirus SARS-CoV-2 to enter the cell. 17β-oestradiol increases expression level and activity of angiotensin converting enzyme-2 (ACE2) and the alternative signaling pathway of Ang II via the angiotensin II receptor type II (AT2R) and the Mas receptor is more dominant in female sex than in male sex. Maybe a hint to explain the higher infection risk in women. The same hormonal milieu plays a major role in protecting women where morbidity and mortality are concerned, since the dominant female hormone, oestradiol, has immune-modulatory properties that are likely to be protective against virus infections. It is also known that the X chromosome contains the largest number of immune-related genes, potentially conferring an advantage to women in efficient immune responsiveness. Lifestyle factors are also likely to be contributory. Premenopausal women could possibly face higher exposure to infection (hence higher infection rates) because economic conditions are often less favorable for them with less opportunity for home office work because of jobs requiring mandatory attendance. Due to the additional task of childcare, it is likely that contact times with other people will be longer. Women generally make healthier lifestyle choices, thus reducing the disease burden that confers high risk of mortality in COVID-19 infected men. This narrative review aims to present key concepts and knowledge gaps on the effects of oestrogen associated with SARS-CoV2 infection and COVID-19 disease.
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Affiliation(s)
- Louise Newson
- Newson Health Ltd, Winton House, Stratford-upon-Avon, United Kingdom
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Rebecca Lewis
- Newson Health Ltd, Winton House, Stratford-upon-Avon, United Kingdom
| | - Robert Preissner
- Institute of Physiology and Science-IT, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Saskia Preissner
- Department Oral and Maxillofacial Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ute Seeland
- Institute of Physiology and Science-IT, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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12
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Rana D, Wu O, Cheed V, Middleton LJ, Moss J, Lumsden MA, McKinnon W, Daniels J, Sirkeci F, Manyonda I, Belli AM, McPherson K. Uterine artery embolisation or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: a cost-utility analysis of the FEMME trial. BJOG 2021; 128:1793-1802. [PMID: 34053154 DOI: 10.1111/1471-0528.16781] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the cost-effectiveness of uterine artery embolisation (UAE) and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy. DESIGN Economic evaluation alongside the FEMME randomised controlled trial. SETTING 29 UK hospitals. POPULATION Premenopausal women who had symptomatic uterine fibroids amenable to UAE or myomectomy wishing to avoid hysterectomy. 254 women were randomised to UAE (127) and myomectomy (127). METHODS A within-trial cost-utility analysis was conducted from the perspective of the UK NHS. MAIN OUTCOME MEASURES Quality-adjusted life years (QALYs) measured using the EuroQoL EQ-5D-3L, combined with costs to estimate cost-effectiveness over 2 and 4 years of follow-up. RESULTS Over a 2-year time horizon, UAE was associated with higher mean costs (difference £645; 95% CI -1381 to 2580) and lower QALYs (difference -0.09; 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the 4-year time horizon. Thus, UAE was dominated by myomectomy. Results of the sensitivity analyses were consistent with the base case results for both years. Over 2 years, UAE was associated with higher costs (difference £456; 95% CI -1823 to 3164) and lower QALYs (difference -0.06; 95% CI -0.11 to -0.02). CONCLUSIONS Myomectomy is a cost-effective option for the treatment of uterine fibroids. The differences in costs and QALYs are small. Women should be fully informed and have the option to choose between the two procedures.
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Affiliation(s)
- D Rana
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - O Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - V Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - L J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J Moss
- School of Medicine, University of Glasgow, Glasgow, UK
| | - M-A Lumsden
- School of Medicine, University of Glasgow, Glasgow, UK
| | - W McKinnon
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - F Sirkeci
- Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London, UK
| | - I Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London, UK
| | - A-M Belli
- Department of Radiology, St George's Hospital and Medical School, London, UK
| | - K McPherson
- Department of Primary Care, University of Oxford, Oxford, UK
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13
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Manyonda I, Talaulikar V, Pirhadi R, Ward J, Banerjee D, Onwude J. Perimenopausal estrogen could prevent breast cancer - For: Estrogen replacement therapy and breast cancer. BJOG 2021; 128:1384. [PMID: 33755295 DOI: 10.1111/1471-0528.16686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/02/2020] [Accepted: 12/14/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK.,St George's, University of London, London, UK
| | - Vikram Talaulikar
- Reproductive Medicine Unit, EGA Wing, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - Roxanna Pirhadi
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Second Floor William Harvey Building, Bishop Hall Lane, Chelmsford, CM1 1SQ, UK
| | - John Ward
- St George's, University of London, London, UK
| | - Dibyesh Banerjee
- Department of Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Joseph Onwude
- The Chelmsford Private Day Surgery Hospital, Fenton House, 85-89 New London Road, Chelmsford, CM2 0PP, UK
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14
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Middelkoop MA, Harmsen MJ, Manyonda I, Mara M, Ruuskanen A, Daniels J, Mol BWJ, Moss J, Hehenkamp WJK, Wu O. Uterine artery embolization versus surgical treatment in patients with symptomatic uterine fibroids: Protocol for a systematic review and meta-analysis of individual participant data. Eur J Obstet Gynecol Reprod Biol 2020; 256:179-183. [PMID: 33246202 DOI: 10.1016/j.ejogrb.2020.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/06/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Uterine fibroids are the most common benign tumours in women of the reproductive age. Symptoms of heavy menstrual bleeding, abdominal discomfort and infertility may seriously affect a woman's quality of life. Uterine artery embolization is a safe and effective alternative treatment to hysterectomy or myomectomy for symptomatic uterine fibroids. Which treatment provides the highest quality of life, least complications, symptom reduction and least chance intervention, has not been established and might depend on strict patient selection. This study aims to identify which specific subgroups benefit most of each treatment by analyzing individual participant data derived from randomized controlled trials of women undergoing embolization or surgical treatment. This study will primarily assess the effectiveness of both treatment groups by evaluating the effect on quality of life of embolization in comparison to surgery on specific patient and fibroid characteristics and the possible need for re-intervention for fibroid-related symptoms. DATA SOURCES PubMed/MEDLINE, Embase and The Cochrane Library were searched up to August 2020. STUDY ELIGIBILITY CRITERIA We will collect individual participant data from randomized controlled trials that studied clinical and procedural outcomes of premenopausal women with symptomatic uterine fibroids, who were randomized between uterine artery embolization and surgery. STUDY APPRAISAL AND SYNTHESIS METHODS Individual participant data from all eligible trials will be sought and analysed according to intention-to-treat principle. Risk of Bias will be done by using version 2 of the Cochrane tool for Risk of Bias in randomized trials. Subgroup analyses to explore the effect of e.g. age, fibroid characteristics and fibroid complaints will be performed, if data is available. This individual patient data meta-analysis will be analysed according to a one-stage model.
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Affiliation(s)
- Mei-An Middelkoop
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Marissa J Harmsen
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, United Kingdom
| | - Michal Mara
- Department of Obstetrics and Gynaecology, Division of Minimally Invasive Surgery, General Faculty Hospital and 1st Medical Faculty of Charles University, Apolinarska 18, 128 00, Prague 2, Czech Republic
| | - Anu Ruuskanen
- Department of Clinical Radiology, Kuopio University Hospital, P.O. Box 1777, 70211, Kuopio, Finland
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Jonathan Moss
- Department of Interventional Radiology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, United Kingdom
| | - Wouter J K Hehenkamp
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom
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Abstract
The apparent gender differences in favor of women in the risk of contracting and dying from coronavirus disease 2019 (COVID-19), and the fact that such trends have also been observed in recent epidemics including severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), have prompted the obvious question: Are the reasons life-style or biological? True, women generally make healthier lifestyle choices as compared to men. Women do not smoke or drink as much as men, and they have a lower burden of those diseases (heart disease, diabetes or chronic lung conditions) that are known to be significant factors in the higher death rates among men with COVID-19. But there is compelling evidence for a role for biological factors. Genes are likely to play an important role. The X chromosome, of which women possess two, contains the largest number of immune-related genes of the whole human genome, theoretically giving women double the advantage over men in mounting an efficient and rapid immune response. A fundamental difference between women and men is their hormonal milieu, and it is not unreasonable to suppose that the dominant female hormone estrogen could influence the response to infection. In this paper we evaluate the evidence and mechanisms by which estrogen could provide protection to women from a variety of viruses, perhaps including the coronavirus that causes COVID-19.
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Affiliation(s)
- Roxanna Pirhadi
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Second Floor William Harvey Building, Bishop Hall Lane, Chelmsford CM1 1SQ, UK
| | - Vikram Sinai Talaulikar
- Reproductive Medicine Unit, EGA Wing, University College London Hospital, 235 Euston Road, London NW1 2BU, UK
| | - Joseph Onwude
- The Chelmsford Private Day Surgery Hospital, Fenton House, 85-89 New London Road, Chelmsford CM2 0PP, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust/St George's, University of London, London, UK
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Manyonda I, Belli AM, Lumsden MA, Moss J, McKinnon W, Middleton LJ, Cheed V, Wu O, Sirkeci F, Daniels JP, McPherson K. Uterine-Artery Embolization or Myomectomy for Uterine Fibroids. N Engl J Med 2020; 383:440-451. [PMID: 32726530 DOI: 10.1056/nejmoa1914735] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Uterine fibroids, the most common type of tumor among women of reproductive age, are associated with heavy menstrual bleeding, abdominal discomfort, subfertility, and a reduced quality of life. For women who wish to preserve their uterus and who have not had a response to medical treatment, myomectomy and uterine-artery embolization are therapeutic options. METHODS We conducted a multicenter, randomized, open-label trial to evaluate myomectomy, as compared with uterine-artery embolization, in women who had symptomatic uterine fibroids and did not want to undergo hysterectomy. Procedural options included open abdominal, laparoscopic, or hysteroscopic myomectomy. The primary outcome was fibroid-related quality of life, as assessed by the score on the health-related quality-of-life domain of the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire (scores range from 0 to 100, with higher scores indicating a better quality of life) at 2 years; adjustment was made for the baseline score. RESULTS A total of 254 women, recruited at 29 hospitals in the United Kingdom, were randomly assigned: 127 to the myomectomy group (of whom 105 underwent myomectomy) and 127 to the uterine-artery embolization group (of whom 98 underwent embolization). Data on the primary outcome were available for 206 women (81%). In the intention-to-treat analysis, the mean (±SD) score on the health-related quality-of-life domain of the UFS-QOL questionnaire at 2 years was 84.6±21.5 in the myomectomy group and 80.0±22.0 in the uterine-artery embolization group (mean adjusted difference with complete case analysis, 8.0 points; 95% confidence interval [CI], 1.8 to 14.1; P = 0.01; mean adjusted difference with missing responses imputed, 6.5 points; 95% CI, 1.1 to 11.9). Perioperative and postoperative complications from all initial procedures, irrespective of adherence to the assigned procedure, occurred in 29% of the women in the myomectomy group and in 24% of the women in the uterine-artery embolization group. CONCLUSIONS Among women with symptomatic uterine fibroids, those who underwent myomectomy had a better fibroid-related quality of life at 2 years than those who underwent uterine-artery embolization. (Funded by the National Institute for Health Research Health Technology Assessment program; FEMME Current Controlled Trials number, ISRCTN70772394.).
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Affiliation(s)
- Isaac Manyonda
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Anna-Maria Belli
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Mary-Ann Lumsden
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Jonathan Moss
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - William McKinnon
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Lee J Middleton
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Versha Cheed
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Olivia Wu
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Fusun Sirkeci
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Jane P Daniels
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
| | - Klim McPherson
- From St. George's Hospital and Medical School (I.M., A.-M.B.) and Whipps Cross Hospital (F.S.), London, the University of Glasgow, Glasgow (M.-A.L., J.M., O.W.), the University of Birmingham, Birmingham (W.M., L.J.M., V.C.), the University of Nottingham, Nottingham (J.P.D.), and the University of Oxford, Oxford (K.M.) - all in the United Kingdom
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17
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Pirhadi R, Sinai Talaulikar V, Onwude J, Manyonda I. It is all in the name: The importance of correct terminology in hormone replacement therapy. Post Reprod Health 2020; 26:142-146. [PMID: 32390508 DOI: 10.1177/2053369120924175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The global increase in life expectancy to 74 years for women, while the median age of the menopause remains at 51 years, means that an increasing number of women will live a significant portion of their adult lives in the menopause. The WHI publications in 2003/4 reported on the dangers of hormone replacement therapy, in particular with respect to breast cancer and dementia risk. This resulted in a dramatic reduction in hormone replacement therapy prescription and use. However, the findings from the WHI studies have been re-appraised, and the new perspective is reflected in the guidance published by NICE in 2015 in which they recommended that more women be offered hormone replacement therapy as the benefits are now perceived to outweigh the risks for most women. However, controversy continues to surround hormone replacement therapy, and there are probably few areas in medicine where the misuse of terminology causes quite as much confusion as in hormone replacement therapy. Commonly used terms such as 'menopausal hormone therapy' and 'hormone replacement therapy' lack specificity and there is an urgent need for correct terminology to accurately describe the hormones replaced.
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Affiliation(s)
- Roxanna Pirhadi
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford, UK
| | | | - Joseph Onwude
- The Chelmsford Private Day Surgery Hospital, Chelmsford, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynecology, St George's University Hospitals NHS Foundation Trust/St George's, University of London, London, UK
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18
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Manyonda I, S Talaulikar V, Pirhadi R, Onwude J. Progestogens are the problem in hormone replacement therapy: Time to reappraise their use. Post Reprod Health 2019; 26:26-31. [PMID: 31875415 DOI: 10.1177/2053369119876490] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Combined (estrogen and a progestogen) hormone replacement therapy (cHRT) is associated with an increased risk of breast cancer, while estrogen replacement therapy is not. Whatever the underlying mechanism, it is the progestogen in cHRT that seems to increase the risk. Fear of breast cancer is a major limiting factor in the use of hormone replacement therapy, and when women discontinue cHRT because of side effects, the latter are often attributable to the progestogen component. cHRT is given to women with an intact uterus to protect against the effects of un-opposed estrogen such as an increased risk of endometrial cancer. Estrogen replacement therapy suffices for women with a prior hysterectomy. There is a clear distinction in risk and side effect profile between cHRT and estrogen replacement therapy. Apart from being the most effective treatment for menopausal symptoms, estrogen prevents osteoporosis, and may also have a potential role in prevention of Alzheimer’s Dementia, now the biggest killer of women in the United Kingdom. Evidence also suggests that progestogens could compromise the dementia-preventative effect of estrogen. Given the immense therapeutic and preventative potential of estrogen, the use of progestogens in cHRT needs re-appraisal. The levonorgestrel intrauterine system (LNg-IUS) could reduce breast cancer risk while protecting the endometrium. Other approaches to the safe use of progestogens await research.
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Affiliation(s)
- Isaac Manyonda
- Department of Obstetrics and Gynecology, St Georgés University Hospitals NHS Foundation Trust/St George's, University of London, London, UK
| | - Vikram S Talaulikar
- Reproductive Medicine Unit, EGA Wing, University College London Hospital, London, UK
| | - Roxanna Pirhadi
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford, UK
| | - Joseph Onwude
- The Chelmsford Private Day Surgery Hospital, Chelmsford, UK
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19
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Mailli L, Auyoung EY, Angileri SA, Ameli-Renani S, Ratnam L, Das R, Chun JY, Das S, Manyonda I, Belli AM. Predicting the Fibroid-Migratory Impact of UAE: Role of Pre-embolization MRI Characteristics. Cardiovasc Intervent Radiol 2019; 43:453-458. [PMID: 31650245 PMCID: PMC6997258 DOI: 10.1007/s00270-019-02348-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/30/2019] [Indexed: 11/20/2022]
Abstract
Aim To investigate potential factors on MR imaging that could be used to predict migration of uterine fibroids post-UAE. Methods and Materials We retrospectively reviewed patients referred for UAE having pre-procedural and 6 months post-procedural MRI, at a tertiary centre, over a 1-year period. Pre- and post-UAE images were reviewed in 64 women by two radiologists to identify the sub-type, dimensions, and infarction rate of each dominant fibroid. The shortest distance between the fibroid and the endometrial wall was measured to determine intramural fibroid movement. Paired sample T tests and two-sample T tests were used to compare between pre- and post-embolization variations and between migrated and non-migrated intramural fibroids, respectively. After preliminary results suggested potential predictors of intramural fibroids migration, we tested our findings against the non-dominant intramural fibroids in the same patients. Results Review of images revealed 35 dominant intramural fibroids, of which eight migrated to become submucosal fibroids, while five were either partially or completely expelled. These 13 migrated fibroids had a shorter pre-procedural minimum endometrial distance (range 1–2.4 mm) and greater maximum fibroid diameter (range 5.1–18.1 cm), when compared to non-migrating fibroids. On image reassessment, the migrated non-dominant intramural fibroids had a minimum endometrial distance and maximum fibroid diameter within the same range. Conclusion Intramural fibroids with a minimum endometrial distance less than 2.4 mm and a maximum fibroid diameter greater than 5.1 cm have a high likelihood of migrating towards the endometrial cavity after UAE.
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Affiliation(s)
- Leto Mailli
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK.
| | - Eric Y Auyoung
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Salvatore A Angileri
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, San Paolo Hospital, University of Milan, Milan, Italy
| | - Seyed Ameli-Renani
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Lakshmi Ratnam
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Raj Das
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Joo-Young Chun
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Sourav Das
- Department of Obstetrics and Gynaecology, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Anna-Maria Belli
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
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20
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Goloba M, Raghuraman R, Botros N, Khan U, Klein M, Brown A, Duffy D, Anim-Nyame N, Wang D, Manyonda I, Antonios TF. Early Life Microcirculatory Plasticity and Blood Pressure Changes in Low Birth Weight Infants Born to Normotensive Mothers: A Cohort Study. Am J Hypertens 2019; 32:570-578. [PMID: 30821323 PMCID: PMC6508166 DOI: 10.1093/ajh/hpz034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Capillary rarefaction (CR) is an established hallmark of essential hypertension (EH). The aim of this study was to examine early changes in capillary density (CD) and blood pressure (BP) in low birth weight (LBW) infants who are at risk of developing EH in later life. METHODS We studied 77 LBW infants and 284 normal birth weight (NBW) infants, all born to mothers with normotension, in a longitudinal multicenter study. Intravital capillaroscopy was used to measure functional basal capillary density (BCD) and maximal capillary density (MCD) at birth, 3, 6, and 12 months. RESULTS We found that LBW infants, born preterm and at term, had a significantly higher CD at birth, then underwent significant CR in the 1st 3 months culminating in a CD similar to that seen in NBW infants. NBW infants showed a gradual reduction in CD between birth and 12 months. Non-Caucasian ethnicity and preterm birth were significant predictors of a higher CD at birth. Systolic BP in NBW infants increased significantly from birth to 3 months, and we identified a significant negative correlation between systolic BP and MCD. CONCLUSIONS This study has identified a process of early “accelerated capillary remodeling” in LBW infants, which corrects their higher CD at birth. This remodeling is unlikely to explain the CR seen in adult individuals with, or at risk of developing EH. Further follow-up studies are required to determine the timing and mechanisms involved in CR, which is likely to occur after the 1st year of life but before early adulthood.
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Affiliation(s)
- Muti Goloba
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
- Blood Pressure Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Rajendra Raghuraman
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Nansi Botros
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Uzma Khan
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Monique Klein
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Amelia Brown
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Donovan Duffy
- Neonatal Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Nick Anim-Nyame
- Obstetrics and Gynaecology Department, Kingston Hospital NHS Foundation Trust, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Isaac Manyonda
- Obstetrics and Gynaecology Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Tarek F Antonios
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, UK
- Blood Pressure Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
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21
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Raghuraman RP, Duffy D, Carroll VA, Manyonda I, Antonios TF. Oxygen therapy in premature low birth weight infants is associated with capillary loss and increases in blood pressure: a pilot study. J Hum Hypertens 2019; 34:278-285. [PMID: 31073155 DOI: 10.1038/s41371-019-0211-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/28/2019] [Accepted: 04/15/2019] [Indexed: 11/09/2022]
Abstract
Low birth weight (LBW) and premature birth are known risk factors for future cardiovascular disease and in particular essential hypertension (EH). Capillary rarefaction (CR) is an established hallmark of EH and is known to occur in individuals with a history of LBW. We previously reported that LBW infants do not have CR at birth but rather increased capillary density (CD). We hypothesized that LBW infants undergo a process of accelerated CR in early life, triggered in part by oxygen therapy. We studied 26 LBW infants, of whom 10 infants received oxygen therapy, and compared them to 14 normal birth weight (NBW) infants. We measured CD at 1, 5 and 10 days after birth and again after 40 weeks adjusted gestational age equivalent to birth at full term. We confirmed that LBW infants had higher CD at birth compared to NBW infants and found that significant structural CR occurred at term age in LBW infants who had received oxygen therapy (mean difference -22 capillaries/field, p = 0.007) and in those who did not receive oxygen therapy (mean difference -29 capillaries/field, p < 0.001) compared to baseline at birth. Both LBW groups showed a significant rise in BP at 40 weeks adjusted term age and the rise in systolic (mean difference 24 mm Hg, p < 0.0001) and diastolic BP (mean difference 14 mm Hg, p < 0.001) was more pronounced in the oxygen treated group compared to the nonoxygen group (mean difference 14 mm Hg, p = 0.043 and mean difference = 9 mm Hg p = 0.056 respectively). In conclusion, oxygen therapy in premature LBW infants may induce significant increases in their BP in early life.
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Affiliation(s)
- Rajendra P Raghuraman
- Molecular & Clinical Sciences Research Institute, St. George's, University of London, London, UK
| | - Donovan Duffy
- Neonatal Intensive Care Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Veronica A Carroll
- Molecular & Clinical Sciences Research Institute, St. George's, University of London, London, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Tarek F Antonios
- Molecular & Clinical Sciences Research Institute, St. George's, University of London, London, UK. .,Blood Pressure Unit, St George's University Hospitals NHS Foundation Trust, London, UK.
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22
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Goloba ME, Raghuraman R, Khan U, Brown A, Klein M, Botros N, Duffy D, Wang D, Manyonda I, Antonios TF. Abstract 134: The Effect of Low Birth Weight on the Microcirculation in the 1
St
Year of Life. Hypertension 2018. [DOI: 10.1161/hyp.72.suppl_1.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Capillary rarefaction, defined as a reduction in capillary density, is an established hallmark of essential hypertension. Low birth weight (LBW) infants, known to have an increased risk of developing hypertension as adults, were unexpectedly found to have a significantly higher capillary density at birth when compared to normal birth weight (NBW) infants. We therefore hypothesised that there is a microcirculatory window in the 1
st
year of life of LBW infants, during which a process of extensive capillary loss, known as “hyperpruning”, occurs.
Methods:
The George’s Capillary Rarefaction Offspring Study (G-CROS) is a longitudinal, multi-centre study of which 284 infants were NBW, born at term, and 77 were LBW. Intravital microscopy was used to measure the functional (also known as basal) capillary density (BCD), and the structural (also known as maximal) capillary density (MCD) at birth, 3 months, 6 months and 12 months.
Results:
LBW infants had a significantly higher capillary density at birth when compared to NBW infants (
p
< 0.0001). NBW infants showed a gradual reduction in capillary density between birth and 12 months, with their greatest reduction occurring between birth and 3 months (BCD mean difference
=
-27.62 cap/field, p <0.0001 and MCD mean difference = -31.49 cap/field, p <0.0001). Similarly, the most significant reduction in BCD and MCD, in the LBW cohort, was between birth and 3 months (BCD mean difference
=
-47.01 cap/field,
p
< 0.0001 and MCD mean difference
=
-48.01 cap/field,
p
< 0.0001). However, within this same 3-month interval, LBW infants demonstrated a significantly higher percentage reduction in BCD (mean difference = 7.81%,
p
= 0.0194) and MCD (mean difference = 8.29%,
p
= 0.0361) when compared to NBW infants.
Conclusions:
Once again, LBW infants were shown to have a higher capillary density than NBW infants at birth. However, this study has shown for the first time that there appears to be a microcirculatory window in the first 3 months of life during which LBW infants undergo capillary “hyperpruning”. Further follow-up studies are required to investigate the role of early capillary rarefaction in the pathogenesis of hypertension, as well as the mechanisms orchestrating these early microcirculatory changes.
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Affiliation(s)
| | | | - Uzma Khan
- St George's Univ, London, United Kingdom
| | | | | | | | - Donovan Duffy
- Neonatal Unit, St George’s Univ Hosps NHS Foundation Trust, London, United Kingdom
| | - Duolao Wang
- Dept of Clinical Sciences, Liverpool Sch of Tropical Medicine, Liverpool, United Kingdom
| | - Isaac Manyonda
- Obstetrics & Gynaecology Dept, St George’s Univ Hosps NHS Foundation Trust, London, United Kingdom
| | - Tarek F Antonios
- St George's Univ and St George’s Univ Hosps NHS Foundation Trust, London, United Kingdom
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23
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Daley A, Riaz M, Lewis S, Aveyard P, Coleman T, Manyonda I, West R, Lewis B, Marcus B, Taylor A, Ibison J, Kent A, Ussher M. Physical activity for antenatal and postnatal depression in women attempting to quit smoking: randomised controlled trial. BMC Pregnancy Childbirth 2018; 18:156. [PMID: 29747597 PMCID: PMC5946409 DOI: 10.1186/s12884-018-1784-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 04/26/2018] [Indexed: 12/16/2022] Open
Abstract
Background Antenatal depression is associated with harmful consequences for both the mother and child. One intervention that might be effective is participation in regular physical activity although data on this question in pregnant smokers is currently lacking. Methods Women were randomised to six-weekly sessions of smoking cessation behavioural-support, or to the same support plus 14 sessions combining treadmill exercise and physical activity consultations. Results Among 784 participants (mean gestation 16-weeks), EPDS was significantly higher in the physical activity group versus usual care at end-of-pregnancy (mean group difference (95% confidence intervals (CIs)): 0.95 (0.08 to 1.83). There was no significant difference at six-months postpartum. Conclusion A pragmatic intervention to increase physical activity in pregnant smokers did not prevent depression at end-of-pregnancy or at six-months postpartum. More effective physical activity interventions are needed in this population. Trial registration Current Controlled Trials ISRCTN48600346. The trial was prospectively registered on 21/07/2008.
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Affiliation(s)
- Amanda Daley
- Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK.
| | - Muhammad Riaz
- Population Health Research Institute, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health and UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - Tim Coleman
- Division of Primary Care and UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynecology, St George's University of London and St George's NHS Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Robert West
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, UCL, Gower Street, London, WC1E 6BT, UK
| | - Beth Lewis
- School of Kinesiology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Bess Marcus
- Department of Family and Preventive Medicine, University of California, San Diego, CA, 92093-0628, USA
| | - Adrian Taylor
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth Science Park, Plymouth, Devon, PL6 8BX, UK
| | - Judith Ibison
- Institute of Medical and Biomedical Education, St George's University of London, Cranmer Terrace, London, SW17 ORE, UK
| | - Andrew Kent
- Institute of Medical and Biomedical Education, St George's University of London, Cranmer Terrace, London, SW17 ORE, UK
| | - Michael Ussher
- Population Health Research Institute, St George's University of London, Cranmer Terrace, London, SW17 ORE, UK.,Institute for Social Marketing, University of Stirling, Stirling, Stirling, FK9 4LA, UK
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24
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Ussher M, Lewis S, Aveyard P, Manyonda I, West R, Lewis B, Marcus B, Riaz M, Taylor AH, Barton P, Daley A, Essex H, Esliger D, Coleman T. The London Exercise And Pregnant smokers (LEAP) trial: a randomised controlled trial of physical activity for smoking cessation in pregnancy with an economic evaluation. Health Technol Assess 2016; 19:vii-xxiv, 1-135. [PMID: 26491878 DOI: 10.3310/hta19840] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Smoking during pregnancy is the main preventable cause of poor birth outcomes. Improved methods are needed to help women to stop smoking during pregnancy. Pregnancy provides a compelling rationale for physical activity (PA) interventions as cessation medication is contraindicated or ineffective, and an effective PA intervention could be highly cost-effective. OBJECTIVE To examine the effectiveness and cost-effectiveness of a PA intervention plus standard behavioural support for smoking cessation relative to behavioural support alone for achieving smoking cessation at the end of pregnancy. DESIGN Multicentre, two-group, pragmatic randomised controlled trial and economic evaluation with follow-up at the end of pregnancy and 6 months postnatally. Randomisation was stratified by centre and a computer-generated sequence was used to allocate participants using a 1 : 1 ratio. SETTING 13 hospitals offering antenatal care in the UK. PARTICIPANTS Women between 10 and 24 weeks' gestation smoking five or more cigarettes a day before pregnancy and one or more during pregnancy. INTERVENTIONS Participants were randomised to behavioural support for smoking cessation (control) or behavioural support plus a PA intervention consisting of supervised treadmill exercise plus PA consultations. Neither participants nor researchers were blinded to treatment allocation. MAIN OUTCOME MEASURES The primary outcome was self-reported, continuous smoking abstinence between a quit date and end of pregnancy, validated by expired carbon monoxide and/or salivary cotinine. Secondary outcomes were maternal weight, depression, birth outcomes, withdrawal symptoms and urges to smoke. The economic evaluation investigated the costs of the PA intervention compared with the control intervention. RESULTS In total, 789 women were randomised (n = 394 PA, n = 395 control). Four were excluded post randomisation (two had been enrolled twice in sequential pregnancies and two were ineligible and randomised erroneously). The intention-to-treat analysis comprised 785 participants (n = 392 PA, n = 393 control). There was no significant difference in the rate of abstinence at the end of pregnancy between the PA group (7.7%) and the control group (6.4%) [odds ratio for PA group abstinence 1.21, 95% confidence interval (CI) 0.70 to 2.10]. For the PA group compared with the control group, there was a 33% (95% CI 14% to 56%), 28% (95% CI 7% to 52%) and 36% (95% CI 12% to 65%) significantly greater increase in self-reported minutes of moderate- and vigorous-intensity PA from baseline to 1 week, 4 weeks and 6 weeks respectively. Accelerometer data showed that there was no significant difference in PA levels between the groups. There were no significant differences between the groups for change in maternal weight, depression, withdrawal symptoms or urges to smoke. Adverse events and birth outcomes were similar between the groups except for there being significantly more caesarean births in the control group than in the PA group (28.7% vs. 21.3%; p < 0.023). The PA intervention was less costly than the control intervention by £35 per participant. This was mainly attributable to increased health-care usage in the control group. However, there was considerable statistical uncertainty around this estimate. CONCLUSIONS During pregnancy, offering an intervention combining supervised exercise and PA counselling does not add to the effectiveness of behavioural support for smoking cessation. Only 10% of participants had PA levels accessed by accelerometer and it is, therefore, unclear whether or not the lack of an effect on the primary outcome is the result of insufficient increases in PA. Research is needed to identify the smoking populations most suitable for PA interventions and methods for increasing PA adherence. TRIAL REGISTRATION Current Controlled Trials ISRCTN48600346. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 84. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Michael Ussher
- Population Health Research Institute, St George's, University of London, London, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health and UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's, University of London, and St George's Healthcare NHS Trust, London, UK
| | - Robert West
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - Beth Lewis
- School of Kinesiology, University of Minnesota, Minneapolis, MN, USA
| | - Bess Marcus
- Department of Family and Preventive Medicine, University of California, San Diego, San Diego, CA, USA
| | - Muhammad Riaz
- Population Health Research Institute, St George's, University of London, London, UK
| | - Adrian H Taylor
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Pelham Barton
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Amanda Daley
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Holly Essex
- Department of Health Sciences, University of York, York, UK
| | - Dale Esliger
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Tim Coleman
- Division of Primary Care and UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK
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25
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Abstract
Although it has been known for a long time that uterine fibroids respond to changes in sex steroid concentrations, it is the availability of selective progesterone receptor modulators such as ulipristal acetete that has provided the gynecologist with a novel option for medical management of uterine fibroids. Ulipristal acetate is presently licensed in Europe for use in women with symptomatic fibroids up to 3 months prior to surgery and has demonstrated good clinical efficacy and safety for this indication. Future trials will define the long-term safety of this drug and its role in medical management of uterine fibroids.
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Ussher M, Lewis S, Aveyard P, Manyonda I, West R, Lewis B, Marcus B, Riaz M, Taylor A, Daley A, Coleman T. Physical activity for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015; 350:h2145. [PMID: 25976288 PMCID: PMC4431606 DOI: 10.1136/bmj.h2145] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the effectiveness of a physical activity intervention for smoking cessation during pregnancy. DESIGN Parallel group, randomised controlled, multicentre trial. SETTING 13 hospitals in England, April 2009 to January 2014. PARTICIPANTS 789 pregnant smokers, aged 16-50 years and at 10-24 weeks' gestation, who smoked at least one cigarette daily and were prepared to quit smoking one week after enrollment were randomised (1:1); 785 were included in the intention to treat analyses, with 392 assigned to the physical activity group. INTERVENTIONS Interventions began one week before a target quit date. Participants were randomised to six weekly sessions of behavioural support for smoking cessation (control) or to this support plus 14 sessions combining supervised treadmill exercise and physical activity consultations. MAIN OUTCOME MEASURES The primary outcome was continuous smoking abstinence from the target quit date until end of pregnancy, validated by exhaled carbon monoxide or salivary cotinine levels. To assess adherence, levels of moderate-vigorous intensity physical activity were self reported and in a 11.5% (n=90) random subsample of participants, physical activity was objectively measured by an accelerometer. RESULTS No significant difference was found in rates of smoking abstinence at end of pregnancy between the physical activity and control groups (8% v 6%; odds ratio 1.21, 95% confidence interval 0.70 to 2.10). For the physical activity group compared with the control group, there was a 40% (95% confidence interval 13% to 73%), 34% (6% to 69%), and 46% (12% to 91%) greater increase in self reported minutes carrying out physical activity per week from baseline to one week, four weeks, and six weeks post-quit day, respectively. According to the accelerometer data there was no significant difference in physical activity levels between the groups. Participants attended a median of four treatment sessions in the intervention group and three in the control group. Adverse events and birth outcomes were similar between the two groups, except for significantly more caesarean births in the control group than in the physical activity group (29% v 21%, P=0.023). CONCLUSION Adding a physical activity intervention to behavioural smoking cessation support for pregnant women did not increase cessation rates at end of pregnancy. During pregnancy, physical activity is not recommended for smoking cessation but remains indicated for general health benefits. Trial registration Current Controlled Trials ISRCTN48600346.
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Affiliation(s)
- Michael Ussher
- Population Health Research Institute, St George's University of London, London SW17 ORE, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health and UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's University of London and St George's NHS Trust, London, UK
| | - Robert West
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - Beth Lewis
- School of Kinesiology, University of Minnesota, Minneapolis, MN, USA
| | - Bess Marcus
- Department of Family and Preventive Medicine, University of California, San Diego, CA, USA
| | - Muhammad Riaz
- Population Health Research Institute, St George's University of London, London SW17 ORE, UK
| | - Adrian Taylor
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, Devon, UK
| | - Amanda Daley
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Tim Coleman
- Division of Primary Care and UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK
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McPherson K, Manyonda I, Lumsden MA, Belli AM, Moss J, Wu O, Middleton L, Daniels J. A randomised trial of treating fibroids with either embolisation or myomectomy to measure the effect on quality of life among women wishing to avoid hysterectomy (the FEMME study): study protocol for a randomised controlled trial. Trials 2014; 15:468. [PMID: 25432688 PMCID: PMC4258053 DOI: 10.1186/1745-6215-15-468] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 11/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uterine fibroids are the most common tumour in women of reproductive age. By the time they are 50-years-old around 80% of women will have developed one. Of these, around half will experience symptoms which will impact negatively on their quality of life. Hysterectomy is the traditional treatment for women with symptomatic fibroids. For women who do not wish to undergo a hysterectomy, two invasive treatments are commonly available: myomectomy or uterine artery embolization (UAE). DESIGN FEMME is a pragmatic, randomised, open, multi-centre trial examining the quality of life menstruating women with symptomatic fibroids experience after treatment with UAE or myomectomy. METHODS After providing informed consent, 216 women with symptomatic fibroids from 43 NHS Hospital Trusts and Health Boards across the United Kingdom will undergo randomisation by a centralised computer system to treatment by either UAE or myomectomy. A minimisation algorithm will be used in order to balance the groups with respect to the following three parameters: the longest dimension of the largest fibroid, the number of fibroids present, and whether the woman currently desires pregnancy.Using validated questionnaires the women's quality of life will be compared between groups at six months, one year, two years and four years post-procedure, taking into account pre-procedure scores. An economic evaluation will be conducted alongside the trial to determine the cost-effectiveness of UAE compared with myomectomy.Validated diaries will also be used to compare menstrual blood loss at the same time-points. The plasma concentration of Anti-Müllerian hormone (AMH), which will act as a proxy measurement of ovarian reserve, will be recorded before the woman has her procedure and then again at six weeks, six months, and twelve months afterwards. Re-intervention rates will be recorded. DISCUSSION The FEMME trial's primary outcome is the quality of life women with symptomatic uterine fibroids experience two years after they have been treated with either UAE or myomectomy, as measured by the disease-specific Uterine Fibroid Symptom Quality-of-Life (UFS-QoL) questionnaire. TRIAL REGISTRATION Current Controlled Trials registration number: ISRCTN70772394, registered on 2 March 2013.
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Affiliation(s)
| | | | | | | | | | | | | | - Jane Daniels
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK.
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Sinai Talaulikar V, Kronenberger K, Bax BE, Moss R, Manyonda I. Differences in collagen ultrastructure of human first trimester decidua basalis and parietalis: implications for trophoblastic invasion of the placental bed. J Obstet Gynaecol Res 2014; 40:80-8. [PMID: 23937248 DOI: 10.1111/jog.12127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 03/06/2013] [Indexed: 02/05/2023]
Abstract
AIM The human embryo-maternal interface in the first trimester of pregnancy is an area of extensive tissue remodeling. Because collagen is the most abundant constituent of the extracellular matrix of the placental bed, successful invasion must involve its rapid turnover. We compared the nature and distribution of collagen fibrils in decidua basalis and parietalis. METHODS We used a direct-vision hysteroscopic technique to obtain biopsies of the decidua basalis and parietalis from 11 women undergoing pregnancy termination in the first trimester. The biopsies were subjected to light, transmission and scanning electron microscopy, and immunohistochemical studies using mouse monoclonal antibodies against cytokeratin 7 and collagen types I, III and V. RESULTS Collagen fibrils in the stroma of decidua basalis were significantly thicker when compared to those in decidua parietalis (56.48 ± 1.37 nm vs 45.64 ± 0.85 nm; P < 0.0001 [mean ± standard error]) between 9 and 12 weeks gestation, but this difference in thickness was not observed at gestations below 9 weeks. In basalis, the fibrils appeared disrupted at most places surrounding the decidual/trophoblast cells while a uniform regular arrangement was preserved throughout most of parietalis. CONCLUSION There are differences in the ultrastructure of collagen fibrils between basalis and parietalis, with thicker and disrupted fibrils within abundant amorphous tissue in basalis, and thinner uniform fibrils in parietalis. These differences may reflect an adaptive response by decidua or a direct consequence of the invading trophoblast cells.
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Affiliation(s)
- Vikram Sinai Talaulikar
- Department of Obstetrics and Gynaecology, Division of Clinical Sciences, St George's University of London, London, UK
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Zeadna A, Holzer H, Son WY, Demirtas E, Reinblatt S, Dahan MH, Colleselli V, D'Costa E, Wildt L, Seeber B, Kashevarova AA, Skryabin NA, Nikitina TV, Lebedev IN, Bordignon PP, Mugione A, Vanni VS, Vigano P, Papaleo E, Candiani M, Somigliana E, Amodio G, Gregori S, Guo YH, Li R, Wang LL, Chen SL, Chen X, Guo W, Ye DS, Liu YD, Renzini MM, Dal Canto M, Coticchio G, Comi R, Brigante C, Caliari I, Brambillasca F, Merola M, Lain M, Turchi D, Karagouga G, Sottocornola M, Fadini R, Wekker MZ, Mol F, van Wely M, Ankum WM, Mol BW, van der Veen F, Hajenius PJ, van Mello NM, Verlengia C, Alviggi E, Rampini MR, Alfano P, Pergolini I, Marconi D, Iacobelli N, Muzi MC, Gelli G, Alviggi C, Colicchia A, Herraiz-Nicuesa L, Tejera-Alhambra M, Garcia-Segovia A, Ramos-Medina R, Alonso B, Gil-Pulido J, Martin L, Caballero M, Rodriguez-Mahou M, Sanchez-Ramon S, de Jong PG, Kaandorp SP, Di Nisio M, Goddijn M, Middeldorp S, Lledo B, Turienzo A, Ortiz JA, Morales R, Ten J, Llacer J, Bernabeu R, Ramos-Medina R, Garcia-Segovia A, Gil J, Leon JA, Alonso B, Tejera-Alhambra M, Seyfferth A, Aguaron A, Alonso J, de Albornoz EC, Carbone J, Caballero P, Fernandez-Cruz E, Ortiz-Quintana L, Sanchez-Ramon S, Lou YY, Jin F, Zheng YM, Li LJ, Le F, Wang LY, Liu SY, Pan PP, Hu CX, Akoum A, Bourdiec A, Shao R, Rao CV, Scarpellini F, Sbracia M, Jancar N, Bokal EV, Ban-Frangez H, Drobnic S, Korosec S, Pinter B, Salamun V, Yamaguchi M, Honda R, Uchino K, Ohba T, Katabuchi H, Leylek O, Tiras B, Saltik AYSE, Halicigil C, Kavci N, Wiser A, Gilbert A, Nahum R, Orvieto R, Hass J, Hourvitz A, Weissman A, Younes G, Dirnfeld M, Hershko A, Shulma A, Holzer H, Shalom-Paz E, Tulandi T, O'Neill SM, Agerbo E, Kenny LC, Henriksen TB, Kearney PM, Greene RA, Mortensen PB, Khashan AS, Talaulikar VS, Bax BE, Manyonda I, Van Mello N, Mol F, Hajenius PJ, Ankum WM, Mol BW, van der Veen F, van Wely M. Early pregnancy. Hum Reprod 2013. [DOI: 10.1093/humrep/det209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ussher M, Aveyard P, Manyonda I, Lewis S, West R, Lewis B, Marcus B, Taylor AH, Barton P, Coleman T. Physical activity as an aid to smoking cessation during pregnancy (LEAP) trial: study protocol for a randomized controlled trial. Trials 2012; 13:186. [PMID: 23035669 PMCID: PMC3519528 DOI: 10.1186/1745-6215-13-186] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 09/21/2012] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Many women try to stop smoking in pregnancy but fail. One difficulty is that there is insufficient evidence that medications for smoking cessation are effective and safe in pregnancy and thus many women prefer to avoid these. Physical activity (PA) interventions may assist cessation; however, trials examining these interventions have been too small to detect or exclude plausible beneficial effects. The London Exercise And Pregnant smokers (LEAP) trial is investigating whether a PA intervention is effective and cost-effective when used for smoking cessation by pregnant women, and will be the largest study of its kind to date. METHODS/DESIGN The LEAP study is a pragmatic, multi-center, two-arm, randomized, controlled trial that will target pregnant women who smoke at least one cigarette a day (and at least five cigarettes a day before pregnancy), and are between 10 and 24 weeks pregnant. Eligible patients are individually randomized to either usual care (that is, behavioral support for smoking cessation) or usual care plus a intervention (entailing supervised exercise on a treadmill plus PA consultations). The primary outcome of the trial is self-reported and biochemically validated continuous abstinence from smoking between a specified quit date and the end of pregnancy. The secondary outcomes, measured at 1 and 4 weeks after the quit date, and at the end of pregnancy and 6 months after childbirth, are PA levels, depression, self-confidence, and cigarette withdrawal symptoms. Smoking status will also be self-reported at 6 months after childbirth. In addition, perinatal measures will be collected, including antenatal complications, duration of labor, mode of delivery, and birth and placental weight. Outcomes will be analyzed on an intention-to-treat basis, and logistic regression models used to compare treatment effects on the primary outcome. DISCUSSION This trial will assess whether a PA intervention is effective when used for smoking cessation during pregnancy. TRIAL REGISTRATION ISRCTN48600346.
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Affiliation(s)
- Michael Ussher
- Division of Population Health Sciences and Education, St George’s University of London, Cranmer Terrace, London, SW17 ORE, UK
| | - Paul Aveyard
- Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England
| | - Isaac Manyonda
- Division of Population Health Sciences and Education, St George’s University of London, Cranmer Terrace, London, SW17 ORE, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health and UK Centre for Tobacco Control Studies, University of Nottingham, Nottingham, NG5 1 PB, UK
| | - Robert West
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, UCL, Gower Street, London, WC1E 6BT, UK
| | - Beth Lewis
- School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Bess Marcus
- Department of Family and Preventive Medicine, University of California, San Diego, CA, 92093-0628, USA
| | - Adrian H Taylor
- School of Sport and Health Sciences, Sport and Health Sciences, University of Exeter, Exeter, EX1 2 LU, UK
| | - Pelham Barton
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Tim Coleman
- Division of Primary Care and UK Centre for Tobacco Control Studies, University of Nottingham, Nottingham, NG5 1 PB, UK
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Gupta S, Onwude J, Stasi R, Manyonda I. Refusal of blood transfusion by Jehovah's Witness women: a survey of current management in obstetric and gynaecological practice in the U.K. Blood Transfus 2012; 10:462-70. [PMID: 22790271 PMCID: PMC3496240 DOI: 10.2450/2012.0105-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 12/29/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Refusal of blood transfusion by Jehovah's Witness (JW) women poses potential problems for obstetrics worldwide as haemorrhage remains a major cause of maternal morbidity and mortality. There is a general consensus that morbidity and mortality rates in association with childbirth and gynaecological interventions are higher in these women than in the general population. We conducted a postal questionnaire survey of current practice among U.K. consultant obstetricians and gynaecologists to establish the practices that could contribute to poor outcomes in these women. MATERIALS AND METHODS The main variables of interest were: use of a multi-disciplinary approach; the acceptable minimum haemoglobin (Hb) concentration before vaginal delivery and abdominal hysterectomy as low to medium risk scenarios and open myomectomy as a high risk scenario for haemorrhage; Hb concentration thresholds for iron supplementation; and the use of oral iron, intravenous iron, erythropoietin and cell salvage as potential management tools. RESULTS The response rate was 28%. Sixty percent of gynaecologists and 85% of obstetricians reported having a protocol for the management of JW women. Forty-six percent of consultants adopt a multi-disciplinary approach which include anaesthetists and haematologists. A Hb concentration of >11-12 g/dL is considered the minimum acceptable level by a majority (47%) prior to normal delivery and by 42% of gynaecologists prior to abdominal hysterectomy. For open myomectomy 28% of gynaecologists prefer a minimum level of 11-12 g/dL but a further 31% of gynaecologists prefer a minimum level of 12-13 g/dL. DISCUSSION A small but substantial proportion of consultants do not have protocols, operate on JW women with low Hb concentrations, do not use a lower Hb concentration threshold for supplementation, and do not adopt a multi-disciplinary approach, all of which could contribute to the reported poor outcomes in these women.
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Affiliation(s)
| | | | - Roberto Stasi
- Department of Haematology, St. George’s Hospital NHS Trust, London, United Kingdom
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Talaulikar VS, Manyonda I. Progesterone and progesterone receptor modulators in the management of symptomatic uterine fibroids. Eur J Obstet Gynecol Reprod Biol 2012; 165:135-40. [PMID: 22901974 DOI: 10.1016/j.ejogrb.2012.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 06/03/2012] [Accepted: 07/25/2012] [Indexed: 10/28/2022]
Abstract
The majority of symptomatic uterine fibroids are currently treated by surgical interventions (myomectomy or hysterectomy) or radiological treatments (uterine artery embolisation or focussed ultrasound surgery). None of these treatments is a panacea, and what is conspicuous is the lack of an effective long-term medical therapy for a disorder so common among women of reproductive age. It has been known for some time that progesterone and its receptors enhance proliferative activity in fibroids and this has raised the possibility that anti-progestins and (PRMs) could be useful in the medical management of fibroids. Some of the compounds which have produced promising results in recent clinical trials or research studies include mifepristone, CDB-4124 (telapristone), CP-8947, J-867 (asoprisnil) and CDB-2914 (ulipristal acetate or UA). UA has recently completed Phase III clinical trials with very encouraging results, and has now acquired a licence for clinical use in Europe. While considerable research has yet to be done on the long-term safety and efficacy of UA there is nevertheless good reason for optimism on the emergence of effective medical therapy in the form of UA and possibly other PRMs.
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Affiliation(s)
- Vikram Sinai Talaulikar
- Department of Obstetrics & Gynaecology, St. George's Hospital and University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom.
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Talaulikar VS, Bax BE, Page NM, Manyonda I. A novel hysteroscopic technique for the accurate biopsy of decidua parietalis and basalis. Placenta 2012; 33:473-9. [PMID: 22410190 DOI: 10.1016/j.placenta.2012.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 02/22/2012] [Accepted: 02/22/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Discrepancies in the results from studies of early events in human trophoblast invasion of decidua have been acknowledged and are attributed largely to deficiencies in the accuracy of sampling of the decidual tissue used in the research. We describe a novel technique of biopsy of decidua parietalis and basalis that overcomes the issue of accuracy of site of the biopsy. METHODS & RESULTS The technique is applicable to pregnancies undergoing first trimester surgical termination. Following cervical dilatation, a rigid hysteroscope is introduced into the cervical canal. The pressure of the saline distending medium shears the membranes of the gestation sac away from the decidua parietalis, leaving the pregnancy suspended at the site of the early placenta (the decidual basalis). Under direct vision a biopsy forceps is used to sample the decidua parietalis, and then the forceps is introduced beneath the gestation sac to sample the decidua basalis. Morphological and immunohistochemical studies have confirmed the accuracyof site and adequacy of the samples, with a 40% myometrial spiral artery success rate. CONCLUSION This is a simple novel technique of decidual biopsy under direct vision which allows for high accuracy of the site of biopsy material, and therefore has the potential to revolutionize research on trophoblast-decidua interactions during the critical early stages of human pregnancy.
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Affiliation(s)
- V S Talaulikar
- Department of Obstetrics and Gynaecology, Division of Clinical Sciences, St. George's University of London, Cranmer Terrace, Tooting, London SW17 0RE, UK.
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Talaulikar VS, Gupta S, Manyonda I. Pregnancy after complex myomectomy: neither age of patient nor size, number or location of fibroids should be a barrier. JRSM Short Rep 2012; 3:19. [PMID: 22479682 PMCID: PMC3318241 DOI: 10.1258/shorts.2011.011117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Rosenbluth EM, Wells LM, Sparks AE, Van Voorhis BJ, Reyes-Palomares A, Palomares AR, Medina MA, Ruiz Galdon M, Reyes Engel A, Stanghellini I, Luiselli D, Magli MC, Lang M, Romeo G, Ferraretti AP, Gianaroli L, Gun Eryilmaz O, Sarikaya E, Yilmaz S, Avci A, Ozogul C, Barun S, Genc M, Kitsou C, Kosmas I, Peschos D, Euaggelou A, Lazaros L, Stefos T, Tournaye H, Prapa S, Prapas N, Prapas Y, Zikopoulos K, Georgiou I, Loewke K, Moussavi F, Maddah M, Conaghan J, Ivani K, Suraj V, Chen A, Shen S, Dittrich R, Hoffmann I, Kunzel J, Lotz L, Mueller A, Reissmann C, Hildebrandt T, Hakl J, Unluhan N, Oppelt PG, Beckmann MW, Huszar G, Geerts N, McGrath J, Vanderlick K, Pohl O, Gotteland JP, Bestel E, Sinai Talaulikar V, Manyonda I. TRANSLATIONAL RESEARCH. Hum Reprod 2012. [DOI: 10.1093/humrep/27.s2.92] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Talaulikar VS, Chambers T, Manyonda I. Exploiting the antioxidant potential of a common vitamin: could vitamin C prevent postmenopausal osteoporosis? J Obstet Gynaecol Res 2011; 38:253-7. [PMID: 21827580 DOI: 10.1111/j.1447-0756.2011.01629.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Oxidative stress is thought to play a central role in the pathophysiology of various conditions affecting women's health, including cancer, preeclampsia and osteoporosis. On the back of animal experimentation, we sought to establish whether the oral administration of vitamin C at high doses to postmenopausal women would achieve the plasma antioxidant activity that could prevent osteoporosis. METHODS In our pilot study, we administered vitamin C at a dose of 10 grams daily to eight healthy postmenopausal women over a period of four weeks and measured their serum levels of vitamin C and crosslaps (markers of bone turnover) at baseline and then on a weekly basis. RESULTS We found an initial rise in the plasma levels of vitamin C, but these rapidly fell over four weeks and could not be sustained despite continued therapy, presumably due to limited absorption and possibly even augmented excretion. We found no discernable change in the serum levels of crosslaps in association with the consumption of high doses of vitamin C. CONCLUSION Although vitamin C has antioxidant properties, when given orally, even at a high dose, the serum levels required for it to exhibit antioxidant activity cannot be attained. This approach holds no potential for the use of vitamin C in the prevention of osteoporosis, although other routes of administration could overcome this.
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Affiliation(s)
- Vikram Sinai Talaulikar
- Department of Obstetrics and Gynaecology, St George's Hospital NHS Trust Department of Cellular Pathology, St George's University of London, London, UK
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Talaulikar V, Manyonda I. The myth of vitamins C and E for the prevention of preeclampsia: just when will the penny drop? Am J Obstet Gynecol 2010; 203:e7-8; author reply e8. [PMID: 20723875 DOI: 10.1016/j.ajog.2010.06.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 06/25/2010] [Indexed: 11/19/2022]
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Parthipun AA, Taylor J, Manyonda I, Belli AM. Does Size Really Matter? Analysis of the Effect of Large Fibroids and Uterine Volumes on Complication Rates of Uterine Artery Embolisation. Cardiovasc Intervent Radiol 2010; 33:955-9. [DOI: 10.1007/s00270-010-9842-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Accepted: 03/12/2010] [Indexed: 11/25/2022]
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Divakar H, Kumar N, Manyonda I. O228 Rapid versus slow intravenous iron sucrose administration in pregnant women with iron deficiency anemia in a rural setting in India. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)60600-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kumar N, Divakar H, Manyonda I. P101 Stemming the rising tide of iron deficiency anemia in pregnancy: is intravenous iron sucrose a viable alternative to the failed iron-folate supplementation program in India? Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61592-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Talaulikar V, Gorti M, Manyonda I. Prospective randomised trial comparing gonadotrophin-releasing hormone analogues with triple tourniquets at open myomectomy. BJOG 2009; 116:1531; author reply 1532. [DOI: 10.1111/j.1471-0528.2009.02246.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Divakar H, Kumar N, Manyonda I. P102 Diagnostic criteria influence prevalence rates for gestational diabetes: implications for interventions in an Indian pregnant population. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61593-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Thakar R, Manyonda I, Robinson G, Clarkson P, Stanton S. Total versus subtotal hysterectomy: a survey of current views and practice among British gynaecologists. J OBSTET GYNAECOL 2009; 18:267-9. [PMID: 15512075 DOI: 10.1080/01443619867470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
This paper reports the results of a postal questionnaire, with a response rate of 61 per cent. It is clear from the results that subtotal hysterectomy is an unpopular operation in the United Kingdom. Although a majority of consultants felt that subtotal hysterectomy was less likely to affect urinary, bowel and sexual function, this did not seem to affect decision making. Seventy-eight per cent of female gynaecologists would prefer a total hysterectomy for themselves rather than a subtotal procedure.
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Affiliation(s)
- R Thakar
- Department of Obstetrics and Gynaecology, St George's Hospital, London, UK
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Ussher M, Aveyard P, Coleman T, Straus L, West R, Marcus B, Lewis B, Manyonda I. Physical activity as an aid to smoking cessation during pregnancy: two feasibility studies. BMC Public Health 2008; 8:328. [PMID: 18811929 PMCID: PMC2559842 DOI: 10.1186/1471-2458-8-328] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 09/23/2008] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pharmacotherapies for smoking cessation have not been adequately tested in pregnancy and women are reluctant to use them. Behavioural support alone has a modest effect on cessation rates; therefore, more effective interventions are needed. Even moderate intensity physical activity (e.g. brisk walk) reduces urges to smoke and there is some evidence it increases cessation rates in non-pregnant smokers. Two pilot studies assessed i) the feasibility of recruiting pregnant women to a trial of physical activity for smoking cessation, ii) adherence to physical activity and iii) women' perceptions of the intervention. METHODS Pregnant smokers volunteered for an intervention combining smoking cessation support, physical activity counselling and supervised exercise (e.g. treadmill walking). The first study provided six weekly treatment sessions. The second study provided 15 sessions over eight weeks. Physical activity levels and continuous smoking abstinence (verified by expired carbon monoxide) were monitored up to eight months gestation. RESULTS Overall, 11.6% (32/277) of women recorded as smokers at their first antenatal booking visit were recruited. At eight months gestation 25% (8/32) of the women achieved continuous smoking abstinence. Abstinent women attended at least 85% of treatment sessions and 75% (6/8) achieved the target level of 110 minutes/week of physical activity at end-of-treatment. Increased physical activity was maintained at eight months gestation only in the second study. Women reported that the intervention helped weight management, reduced cigarette cravings and increased confidence for quitting. CONCLUSION It is feasible to recruit pregnant smokers to a trial of physical activity for smoking cessation and this is likely to be popular. A large randomised controlled trial is needed to examine the efficacy of this intervention.
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Affiliation(s)
- Michael Ussher
- Division of Community Health Sciences, St. George's University of London, London, SW17 0RE, UK
| | - Paul Aveyard
- Department of Primary Care and General Practice, University of Birmingham, Edgbaston, B15 2TT, UK
| | - Tim Coleman
- School of Community Health Sciences, Division of Primary Care, Queen's University Medical Centre, Nottingham, NG7 2UH, UK
| | - Lianne Straus
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic de Barcelona, Universitat de Barcelona, Rosselló 132, 4a planta, 08036 Barcelona, Spain
| | - Robert West
- Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 2-16 Torrington Place, London, WC1E 6BT, UK
| | - Bess Marcus
- Department of Community Health and Department of Psychiatry and Human Behavior, Brown University, 121 South Main Street, Providence, Rhode Island, 02903, USA
| | - Beth Lewis
- School of Kinesiology, University of Minnesota, 209 Cooke Hall, 1900 University Ave, Minneapolis, MN 55455, USA
| | - Isaac Manyonda
- Department of Obstetrics and Gynecology, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
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Nama V, Desilva C, Manyonda I. Association between lactate in vaginal fluid and time to spontaneous onset of labour from women with suspected prelabour rupture of the membranes. BJOG 2007; 114:652-3; author reply 653. [PMID: 17439576 DOI: 10.1111/j.1471-0528.2007.01287.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mukhopadhaya N, Manyonda I. The advent of international ‘mail-order’ oocyte donation. BJOG 2007; 114:510. [PMID: 17378827 DOI: 10.1111/j.1471-0528.2006.01252.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OBJECTIVE Oral clindamycin reduced late miscarriage and preterm birth in asymptomatic women with bacterial vaginosis or intermediate flora. We investigated whether clindamycin reduced the incidence of histologic chorioamnionitis as a mechanism for these beneficial effects. METHODS This was a subanalysis of 126 participants from a larger randomized controlled trial. We compared the incidence of histologic chorioamnionitis between the clindamycin and placebo groups. Histologic chorioamnionitis was diagnosed by the presence of polymorphonuclear leukocytes, separately in the amnion and chorion, decidua, fetal surface of the placenta, the walls of fetal chorionic vessels, umbilical cord, or in the subchorionic fibrin layer. Microbiologic cultures were done on swabs from the space between the chorion and amnion layers. RESULTS Histopathologic results were available for 122 placentas, 62 (51%) and 60 (49%) in the clindamycin and placebo groups, respectively. There were no significant differences in inflammation between the groups in the decidua (41% compared with 43%), membranes (25% compared with 41%), fetal vessels (16% compared with 14%), or subchorionic fibrin (32% compared with 34%). Adjusting for gestational age, ethnic origin, or history of miscarriage did not alter the results. There were no significant differences in the outcomes of pregnancy between women with and without inflammation, either before or after adjustment for treatment group. CONCLUSION Although oral clindamycin reduced late miscarriage and preterm birth in women with abnormal vaginal flora, this effect is unlikely to be mediated through a reduction in the incidence of histologic chorioamnionitis. The relatively small size of the groups, however, does not allow us to rule out a real effect, especially given the lower rate of membrane inflammation observed in the clindamycin group. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Austin Ugwumadu
- Department of Obstetrics and Gynecology, St. George's Hospital, London, United Kingdom.
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