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Shah S, Morris H, Thiagarajah S, Gordon A, Sharma S, Haslam P, Garcia J, Ali F. Handling 'carbon footprint' in orthopaedics. Ann R Coll Surg Engl 2024. [PMID: 38563077 DOI: 10.1308/rcsann.2023.0052] [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: 04/04/2024] Open
Abstract
INTRODUCTION The National Health Service contributes 4%-5% of England and Wales' greenhouse gases and a quarter of all public sector waste. Between 20% and 33% of healthcare waste originates from a hospital's operating room, and up to 90% of waste is sent for costly and unneeded hazardous waste processing. The goal of this study was to quantify the amount and type of waste produced during a selection of common trauma and elective orthopaedic operations, and to calculate the carbon footprint of processing the waste. METHODS Waste generated for both elective and trauma procedures was separated primarily into clean and contaminated, paper or plastic, and then weighed. The annual carbon footprint for each operation at each site was subsequently calculated. RESULTS Elective procedures can generate up to 16.5kg of plastic waste per procedure. Practices such as double-draping the patient contribute to increasing the quantity of waste. Over the procedures analysed, the mean total plastic waste at the hospital sites varied from 6 to 12kg. One hospital site undertook a pilot of switching disposable gowns for reusable ones with a subsequent reduction of 66% in the carbon footprint and a cost saving of £13,483.89. CONCLUSIONS This study sheds new light on the environmental impact of waste produced during trauma and elective orthopaedic procedures. Mitigating the environmental impact of the operating room requires a collective drive for a culture change to sustainability and social responsibility. Each clinician can have an impact upon the carbon footprint of their operating theatre.
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Affiliation(s)
- S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, UK
| | - H Morris
- East Midlands North Training Rotation, UK
| | - S Thiagarajah
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, UK
| | - A Gordon
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - S Sharma
- Barnsley Hospital NHS Foundation Trust, UK
| | - P Haslam
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, UK
- Sheffield Children's NHS Foundation Trust, UK
| | - J Garcia
- Chesterfield Royal Hospital NHS Foundation Trust, UK
| | - F Ali
- Sheffield Children's NHS Foundation Trust, UK
- Chesterfield Royal Hospital NHS Foundation Trust, UK
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2
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Overton ET, Richmond G, Rizzardini G, Thalme A, Girard PM, Wong A, Porteiro N, Swindells S, Reynes J, Noe S, Harrington C, Español CM, Acuipil C, Aksar A, Wang Y, Ford SL, Crauwels H, van Eygen V, Van Solingen-Ristea R, Latham CL, Thiagarajah S, D'Amico R, Smith KY, Vandermeulen K, Spreen WR. Long-acting cabotegravir and rilpivirine dosed every 2 months in adults with HIV-1 infection: 152-week results from ATLAS-2M, a randomized, open-label, Phase 3b, noninferiority study. Clin Infect Dis 2023; 76:1646-1654. [PMID: 36660819 PMCID: PMC10156123 DOI: 10.1093/cid/ciad020] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/07/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Cabotegravir (CAB) + rilpivirine (RPV) dosed intramuscularly monthly or every 2 months is a complete long-acting (LA) regimen for the maintenance of HIV-1 virologic suppression. Here, we report the ATLAS-2M study Week 152 results. METHODS ATLAS-2M is a Phase 3b, randomized, multicenter study assessing the efficacy and safety of CAB+RPV LA every 8 weeks (Q8W) vs. every 4 weeks (Q4W). Virologically suppressed (HIV-1 RNA <50 copies/mL) individuals were randomized to receive CAB+RPV LA Q8W or Q4W. Endpoints included the proportion of participants with plasma HIV-1 RNA ≥50 copies/mL and <50 copies/mL, incidence of confirmed virologic failure (CVF; two consecutive measurements of ≥200 copies/mL), safety, and tolerability. RESULTS 1045 participants received CAB+RPV LA (Q8W, n=522; Q4W, n=523). CAB+RPV LA Q8W demonstrated noninferior efficacy vs. Q4W dosing, with 2.7% (n=14) and 1.0% (n=5) of participants having HIV-1 RNA ≥50 copies/mL, respectively. The adjusted treatment difference in proportions was 1.7% (95% CI 0.1 to 3.3), meeting the pre-specified noninferiority threshold of 4%. At Week 152, 87% of participants maintained HIV-1 RNA <50 copies/mL (Q8W, 87% [n=456]; Q4W, 86% [n=449]). Overall, 12 (2.3%) participants in the Q8W arm and two (0.4%) participants in the Q4W arm had CVF. Eight and 10 participants with CVF had treatment-emergent resistance-associated mutations to RPV and integrase inhibitors, respectively. Safety profiles were comparable, with no new safety signals observed since Week 48. CONCLUSIONS These data demonstrate the durability of virologic suppression with CAB+RPV LA Q8W or Q4W for ∼3 years, and confirm the long-term efficacy, safety, and tolerability of CAB+RPV LA as a complete regimen for the maintenance of HIV-1 virologic suppression.
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Affiliation(s)
- Edgar T Overton
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, United States; North American Medical Affairs, ViiV Healthcare, Durham, NC, United States
| | - Gary Richmond
- Department of Medicine, Broward Health Medical Center, Fort Lauderdale, FL, United States
| | - Giuliano Rizzardini
- Department of Infectious Diseases, Fatebenefratelli Sacco Hospital, Milan, Italy and School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anders Thalme
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Pierre-Marie Girard
- Department of Infectious and Tropical Diseases and Inserm, University of Paris, St-Antoine Hospital, Paris, France
| | - Alexander Wong
- Department of Medicine, University of Saskatchewan, Regina, Canada
| | | | - Susan Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Jacques Reynes
- Department of Infectious Diseases, Montpellier University Hospital, Montpellier, France and Inserm, University of Montpellier, Montpellier, France
| | - Sebastian Noe
- HIV Research and Clinical Care Center, MVZ München Am Goetheplatz, Munich, Germany
| | - Conn Harrington
- Clinical Development, ViiV Healthcare, Durham, NC, United States
| | | | - Carolina Acuipil
- Research & Development, ViiV Healthcare, Durham, NC, United States
| | | | - Yuanyuan Wang
- Development Biostatistics, GSK, Collegeville, PA, United States
| | - Susan L Ford
- Clinical Pharmacology Modeling and Simulation, GSK, Durham, NC, United States
| | - Herta Crauwels
- Clinical Pharmacology, Janssen Research & Development, Beerse, Belgium
| | - Veerle van Eygen
- Clinical Microbiology and Immunology, Janssen Research & Development, Beerse, Belgium
| | | | - Christine L Latham
- Translational Medicine Research, ViiV Healthcare, Durham, NC, United States
| | | | - Ronald D'Amico
- Research & Development, ViiV Healthcare, Durham, NC, United States
| | - Kimberly Y Smith
- Research & Development, ViiV Healthcare, Durham, NC, United States
| | - Kati Vandermeulen
- Department of Infectious Diseases, Janssen Research & Development, Beerse, Belgium
| | - William R Spreen
- Research & Development, ViiV Healthcare, Durham, NC, United States
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3
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Patel P, Ford SL, Baker M, Meyer C, Garside L, D'Amico R, Van Solingen‐Ristea R, Crauwels H, Polli JW, Seal C, Yagüe Muñoz I, Thiagarajah S, Birmingham E, Spreen WR, Baugh B, van Wyk J, Vannappagari V. Pregnancy outcomes and pharmacokinetics in pregnant women living with
HIV
exposed to long‐acting cabotegravir and rilpivirine in clinical trials. HIV Med 2022; 24:568-579. [PMID: 36411596 DOI: 10.1111/hiv.13439] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/19/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Limited data exist on pregnant women living with HIV exposed to cabotegravir + rilpivirine (CAB + RPV). Outcomes in pregnant participants exposed to CAB + RPV, and pharmacokinetic washout data in those exposed to CAB + RPV long-acting (LA) with live births, are presented. METHODS Women exposed to one or more doses of CAB + RPV (oral/LA) from ViiV Healthcare-sponsored phase 2b/3/3b clinical trials and the compassionate use programme who became pregnant were included. Upon pregnancy in the trial programme, CAB + RPV was discontinued, an alternative antiretroviral regimen was initiated, and quarterly pharmacokinetic sampling for 52 weeks post-last injection was obtained. CAB + RPV continuation or alternative antiretroviral regimen initiation was decided by pregnant compassionate use programme participants and their treating physicians. RESULTS As of 31 March 2021, 25 pregnancies following CAB + RPV exposure at conception were reported (five oral, 20 LA), including four who conceived during pharmacokinetic washout following treatment discontinuation. There were eight elective abortions, six miscarriages (five in first trimester), one ectopic pregnancy, and 10 live births (one oral, nine LA), including one infant born with congenital ptosis. Among participants exposed to CAB + RPV LA at conception with live births, plasma CAB and RPV washout concentrations during pregnancy were within the range of those observed in non-pregnant women. CONCLUSION In this first analysis of pregnancy outcomes following CAB + RPV exposure at conception, 10 live births, including one with congenital anomaly, were reported. Plasma CAB and RPV washout concentrations during pregnancy were within the range of those in non-pregnant women. Pregnancy surveillance within ViiV Healthcare-sponsored clinical trials is ongoing, with dedicated pregnancy studies planned.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ciara Seal
- GlaxoSmithKline Collegeville Pennsylvania USA
| | | | | | | | | | - Bryan Baugh
- Janssen Research & Development Titusville New Jersey USA
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Patel P, Thomas R, Hamady M, Hague J, Raja J, Tan T, Bloom S, Richards T, Weiss C, Prechtl C, Smith C, Thiagarajah S, Fiorentino F, Markakis H, Ahmed AR. O102 We know about left gastric artery embolisation and will embio provide the next solution to treat obesity? Br J Surg 2022. [DOI: 10.1093/bjs/znac242.102] [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: 11/05/2022]
Abstract
Abstract
Introduction
Left gastric artery embolisation (LGAE) is a minimally invasive procedure which has shown promising results for weight loss in recent studies and could play a key role as a treatment option in-between our current tier-3 and tier-4 services. Imperial College NHS Trust will sponsor the EMBIO trial, the first multi-centre double blinded randomised controlled trial comparing LGAE vs Placebo procedure to evaluate its efficacy on weight loss and obesity related comorbidities over a 12 month follow up period. Here, we perform a systematic review of the existing literature.
Methods
9 studies were reviewed. Studies which investigated weight loss as a % +- Ghrelin % change at 3,6 and 12 months were included as these pre-defined time points correlate with the EMBIO protocol. 6 studies met our inclusion criteria, 5 single arm studies and 1 single blinded RCT.
Results
N=62 patients were included in our analysis. Mean weight loss reported was 8.5%, 8.8% and 10% at 3, 6 and 12 months respectively post LGAE. Ghrelin levels reduced by 36%, 16.2% and 16.5% at 3, 6 and 12 months respectively post LGAE. To date, the only reported adverse events recorded include superficial gastric erosions healed on endoscopy by day 90 and one case of subclinical pancreatitis.
Conclusion
LGAE potentially offers a day case procedure under local anaesthesia and sedation to treat obesity and its metabolic complications. The EMBIO trial will provide level 1 evidence to confirm if LGAE is a viable intervention for obesity and evaluate its safety profile.
Take-home message
Left gastric artery embolisation could be the perfect solution to treat obesity in between existing tier-3 and tier-4 treatments.
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Affiliation(s)
| | | | | | | | - J Raja
- University College Hospital
| | | | | | - T Richards
- University of Western Australia , Perth , Australia
| | - C Weiss
- Johns Hopkins University , Baltimore, Maryland USA
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D’Amico R, Benn P, Thiagarajah S, Ford SL, Birmingham E, Upadhyay OR, Garside L, Van Solingen-Ristea R, Vandermeulen K, Spreen W. 833. Efficacy and Safety of Long-Acting Cabotegravir + Rilpivirine in Participants with HIV/HCV Co-infection: ATLAS-2M 48-Week Results. Open Forum Infect Dis 2021. [PMCID: PMC8643858 DOI: 10.1093/ofid/ofab466.1029] [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] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The phase IIIb ATLAS-2M study demonstrated non-inferiority of long-acting (LA) cabotegravir (CAB) + rilpivirine (RPV) dosed every 8 weeks (Q8W) compared with every 4 weeks (Q4W) for maintenance of virologic suppression. Hepatitis C virus (HCV) co-infection occurs in ~6% of people with HIV due to shared modes of transmission. We report efficacy and safety of CAB + RPV LA in participants with HIV/HCV co-infection in ATLAS-2M.
Methods
Participants with HIV-1 RNA < 50 c/mL receiving CAB + RPV LA Q4W (transitioned from ATLAS [NCT02951052]) or oral comparator ART were randomized 1:1 to receive CAB + RPV LA Q4W or Q8W. Baseline HCV RNA was assessed by polymerase chain reaction. Participants with symptomatic chronic HCV infection requiring treatment within 12 months or liver enzymes not meeting entry criteria were excluded. Week 48 assessments included proportion with HIV-1 RNA ≥50 and < 50 c/mL (Snapshot algorithm), general and hepatic safety, and pharmacokinetics.
Results
HIV/HCV co-infection was present in 10 (1%) of 1045 participants, 60% of whom were female at birth. At Week 48, 9/10 (90%) and 972/1035 (94%) participants with HIV/HCV co-infection and HIV mono-infection, respectively, had HIV-1 RNA < 50 c/mL (adjusted difference, 4.1; 95% CI, −14.5 to 22.6). No participants with HIV/HCV co-infection had HIV-1 RNA ≥50 c/mL (vs 14/1035 [1%] with HIV mono-infection) or confirmed virologic failure through Week 48 (vs 10 [1%] with HIV mono-infection); 1/10 (10%) discontinued for reasons other than adverse events (AEs). Excluding injection site reactions (ISRs), AEs and serious AEs were reported in 4 (40%) and 0 participants with HIV/HCV co-infection, respectively; the only AE reported in >1 participant was injection site pain (n=5; 50%). In participants with HIV/HCV co-infection, all ISRs were grade 1/2; none led to withdrawal. No hepatic laboratory abnormalities were reported in participants with HIV/HCV co-infection through Week 48; rates were low in those with HIV mono-infection (Table). Plasma CAB and RPV concentrations were similar between groups.
Conclusion
CAB + RPV LA was effective and well tolerated in this small cohort of participants with HIV and asymptomatic HCV co-infection.
Disclosures
Ronald D’Amico, DO, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Paul Benn, MB ChB FRCP, ViiV Healthcare (Employee) Shanker Thiagarajah, MB ChB, GlaxoSmithKline (Employee, Shareholder) Susan L. Ford, PharmD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Eileen Birmingham, MD, MPH, Janssen Research and Development (Employee, Shareholder) Ojesh R. Upadhyay, MPH, MBA, GlaxoSmithKline (Employee) Louise Garside, PhD, GlaxoSmithKline (Employee) Rodica Van Solingen-Ristea, MD, Janssen Research and Development (Employee)ViiV Healthcare (Employee) Kati Vandermeulen, M.SC., Janssen Research and Development (Employee) William Spreen, PharmD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee)
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Affiliation(s)
| | - Paul Benn
- ViiV Healthcare, Research Triangle Park, NC
| | | | - Susan L Ford
- GlaxoSmithKline, London, England, United Kingdom
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Patel P, Ford SL, Baker M, Meyer C, Garside L, D’Amico R, Van Solingen-Ristea R, Crauwels H, Polli J, Seal C, Thiagarajah S, Birmingham E, Spreen W, Baugh B, Bosse M, Vannappagari V. 885. Pregnancy Outcomes and Pharmacokinetics in Pregnant Women Living with HIV Exposed to Long-Acting Cabotegravir and Rilpivirine in Clinical Trials. Open Forum Infect Dis 2021. [PMCID: PMC8644735 DOI: 10.1093/ofid/ofab466.1080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Limited data exist among women living with HIV who become pregnant while exposed to long-acting (LA) cabotegravir (CAB) and rilpivirine (RPV). We report outcomes in pregnant participants and LA pharmacokinetic (PK) tail data in pregnant women exposed to CAB+RPV with live births. Methods Women of reproductive potential exposed to ≥ 1 dose of CAB+RPV (oral/LA) from ViiV-sponsored Phase 2/3/3b clinical treatment studies and the compassionate use program were included in this analysis and pregnancies identified. Per protocol, upon identification of pregnancy, CAB+RPV was discontinued and an alternative regimen initiated, with continued quarterly PK sampling for 52 weeks post last injection during long-term safety follow-up (LTFU). Descriptive characteristics of pregnant women and birth outcomes and available CAB and RPV PK during pregnancy for those with live births are summarized. Results As of March 31, 2021, 26/325 women of reproductive potential (age 18–49 years) became pregnant while exposed to CAB+RPV (5 oral, 21 LA [including 3 following LA discontinuation]). There were 11 live births (1 oral, 10 LA), of which 10 had no reported congenital abnormalities and 1 had reported congenital ptosis, in a pre-term infant with intrauterine growth restriction. There were 9 elective terminations and 6 miscarriages (5 in first 9 weeks of gestation). Ten women exposed to intramuscular CAB+RPV LA became pregnant with subsequent live birth outcomes, including 3 infants conceived during the PK tail in LTFU. All women were virologically suppressed at time of pregnancy identification. In women becoming pregnant on LA dosing, plasma CAB and RPV concentrations during pregnancy were within the range of expected concentrations in non-pregnant women. Two of 10 women with live births exposed to CAB+RPV LA continued LA therapy during pregnancy (compassionate use program participants). Conclusion Pregnancy outcomes in women exposed to CAB+RPV at conception are consistent with earlier findings. There was 1 reported congenital anomaly among 11 live births. CAB and RPV PK tail in pregnancy was within the expected range for non-pregnant women. Ongoing monitoring of birth defects within the antiretroviral pregnancy registry and pregnancy surveillance within the treatment program continues. Disclosures Parul Patel, PharmD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Susan L. Ford, PharmD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Mark Baker, PhD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Claudia Meyer, MBChB, MRCP, MSc, FRCPath, DTM&H, GlaxoSmithKline (Employee, Shareholder) Louise Garside, PhD, GlaxoSmithKline (Employee) Ronald D’Amico, DO, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Rodica Van Solingen-Ristea, MD, Janssen Research and Development (Employee)ViiV Healthcare (Employee) Herta Crauwels, PhD, Janssen (Employee) Joseph Polli, PhD, FAAPS, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Ciara Seal, BS, GlaxoSmithKline (Employee, Shareholder) Shanker Thiagarajah, MB ChB, GlaxoSmithKline (Employee, Shareholder) Eileen Birmingham, MD, MPH, Janssen Research and Development (Employee, Shareholder) William Spreen, PharmD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Bryan Baugh, MD, Janssen, Johnson & Johnson (Employee, Shareholder) Matthew Bosse, DO, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Vani Vannappagari, MBBS, MPH, PhD, ViiV Healthcare Limited (Employee)
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Affiliation(s)
| | | | - Mark Baker
- ViiV Healthcare, Research Triangle Park, NC
| | | | | | | | | | - Herta Crauwels
- Janssen Research and Development, Antwerpen, Oost-Vlaanderen, Belgium
| | | | - Ciara Seal
- GlaxoSmithKline, Research Triangle Park, NC
| | | | - Eileen Birmingham
- Janssen Research and Development, Antwerpen, Oost-Vlaanderen, Belgium
| | | | - Bryan Baugh
- Janssen Research & Development, LLC, Beerse, Antwerpen, Belgium
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Orkin C, Oka S, Philibert P, Brinson C, Bassa A, Gusev D, Degen O, García JG, Morell EB, Tan DHS, D'Amico R, Dorey D, Griffith S, Thiagarajah S, St Clair M, Van Solingen-Ristea R, Crauwels H, Ford SL, Patel P, Chounta V, Vanveggel S, Cutrell A, Van Eygen V, Vandermeulen K, Margolis DA, Smith KY, Spreen WR. Long-acting cabotegravir plus rilpivirine for treatment in adults with HIV-1 infection: 96-week results of the randomised, open-label, phase 3 FLAIR study. Lancet HIV 2021; 8:e185-e196. [PMID: 33794181 DOI: 10.1016/s2352-3018(20)30340-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is a need for more convenient, less frequent treatment to help address challenges associated with daily oral HIV treatment in people living with HIV, including stigma, pill burden, drug-food interactions, and adherence. The phase 3 ATLAS and FLAIR studies showed non-inferiority of long-acting cabotegravir and rilpivirine dosed every 4 weeks compared with standard oral therapy for the maintenance of virological suppression in adults with HIV-1 over 48 weeks. We present the 96-week findings. METHODS FLAIR is a randomised, phase 3, open-label, multicentre study done in 11 countries investigating whether switching to long-acting cabotegravir and rilpivirine is non-inferior to daily dolutegravir, abacavir, and lamivudine in virologically suppressed adults living with HIV-1. Antiretroviral therapy (ART)-naive participants received induction therapy with daily oral dolutegravir (50 mg), abacavir (600 mg), and lamivudine (300 mg) for 20 weeks. After 16 weeks, participants with less than 50 HIV-1 RNA copies per mL were randomly assigned (1:1) to continue the standard of care regimen (standard care group) or switch to receive daily oral cabotegravir 30 mg and rilpivirine 25 mg for at least 4 weeks followed by long-acting cabotegravir 400 mg and rilpivirine 600 mg, administered as two 2 mL intramuscular injections, every 4 weeks for at least 96 weeks (long-acting group). Randomisation was stratified by baseline (preinduction) HIV-1 RNA (<100 000 or ≥100 000 copies per mL) and sex at birth and used GlaxoSmithKline-verified randomisation software (RandAll NG, version 1.3.3) for treatment assignment. The primary endpoint was the proportion of participants with plasma HIV-1 RNA of 50 copies per mL or more assessed as per the US Food and Drug Administration (FDA) Snapshot algorithm at week 48, which has been reported previously. Here, we report the proportion of participants with 50 or more HIV-1 RNA copies per mL using the FDA Snapshot algorithm at week 96 (intention-to-treat population; non-inferiority margin 6%). The trial is registered with ClinicalTrials.gov, NCT02938520. FINDINGS Between Oct 27, 2016, and March 24, 2017, 809 participants were screened. 631 (78%) participants entered the induction phase and 566 (70%) were randomly assigned to either the standard care group (283 [50%] participants) or the long-acting group (283 [50%]). Median age was 34 years (IQR 29 to 43), 62 (11%) were 50 years or older, 127 (22%) were women (sex at birth), and 419 (74%) were white. At week 96, nine (3%) participants in each arm had 50 or more HIV-1 RNA copies per mL, with an adjusted difference of 0·0 (95% CI -2·9 to 2·9), consistent with non-inferiority established at week 48. Across both treatment groups, adverse events leading to withdrawal were infrequent (14 [5%] participants in the long-acting group and four [1%] in the standard care group). Injection site reactions were the most common adverse event, reported by 245 (88%) participants in the long-acting group; their frequency decreased over time. Median injection site reaction duration was 3 days (IQR 2 to 4), and 3082 (99%) of 3100 reactions were grade 1 or 2. No deaths occurred during the maintenance phase. INTERPRETATION The 96-week results reaffirm the 48-week results, showing long-acting cabotegravir and rilpivirine continued to be non-inferior compared with continuing a standard care regimen in adults with HIV-1 for the maintenance of viral suppression. These results support the durability of long-acting cabotegravir and rilpivirine, over an almost 2-year-long period, as a therapeutic option for virally suppressed adults with HIV-1. FUNDING ViiV Healthcare and Janssen Research and Development.
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Affiliation(s)
- Chloe Orkin
- Department of Immunobiology, Queen Mary University, London, UK.
| | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Patrick Philibert
- Department for Internal Medicine and Infectious Diseases, Hôpital Européen, Marseille, France
| | | | - Ayesha Bassa
- Mzansi Ethical Research Centre, Middelburg, South Africa
| | - Denis Gusev
- State Medical Center for the Prevention and Control of AIDS and Infectious Diseases, St Petersburg, Russia; St Petersburg State Budgetary Health Care Institution, St Petersburg, Russia
| | - Olaf Degen
- Infectious Diseases Unit, Outpatient Center, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Juan González García
- Department for Internal Medicine, Hospital La Paz Institute for Health Research, Hospital Universitario La Paz, Madrid, Spain
| | - Enrique Bernal Morell
- Sección de Enfermedades Infecciosas, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Darrell H S Tan
- Division of Infectious Diseases, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Ronald D'Amico
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | - David Dorey
- Biostatistics, GlaxoSmithKline, Mississauga, ON, Canada
| | - Sandy Griffith
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | | | - Marty St Clair
- Translational Medical Research, ViiV Healthcare, Research Triangle Park, NC, USA
| | | | - Herta Crauwels
- Infectious Diseases & Vaccines, Janssen Research & Development, Beerse, Belgium
| | - Susan L Ford
- Clinical Pharmacology, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Parul Patel
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | | | - Simon Vanveggel
- Global Development, Janssen Research & Development, Beerse, Belgium
| | - Amy Cutrell
- Research Statistics, ViiV Healthcare, Research Triangle Park, NC, USA
| | - Veerle Van Eygen
- Infectious Diseases & Vaccines, Janssen Research & Development, Beerse, Belgium
| | - Kati Vandermeulen
- Infectious Diseases & Vaccines, Janssen Research & Development, Beerse, Belgium
| | - David A Margolis
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | - Kimberly Y Smith
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | - William R Spreen
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
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8
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Grover CS, Thiagarajah S. A snapshot of stroke from miri hospital. Med J Malaysia 2014; 69:268-272. [PMID: 25934957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
UNLABELLED Our objective was to study the profile of cerebrovascular accidents and proportion of cerebral haemorrhage (CH) among stroke patients. This project was designed after we observed higher incidence of CH in Miri hospital as compared to conventionally reported data. METHODS This was a prospective observational study conducted from 1st June 2008 to 31st May 2009. All patients admitted in both male and female wards of the Medical Unit with the first incidence of a stroke were recruited for analysis. CT scan brain was done in all patients. RESULTS Total admissions in one year in the medical department were 3204 patients, both male and female together, out of which 215 were due to a first incidence of stroke; Stroke accounted for 6.7% of admissions and 16.8% of deaths in medical unit. 139 (64.7%) were ischaemic strokes and 76 (35.3%) were cerebral haemorrhages. The incidence of CH (35.3%) was high compared to regional data. 71.7% (154) patients had preexisting hypertension. Higher incidence of hypertension, diabetes mellitus and aspirin intake was noted in the ischaemic group. Also compliance to treatment for hypertension was better in the Ischaemic group with more defaults in CH category (P<0.01). Significantly more deaths were noted in patients with higher systolic blood pressure on presentation, poor Glasgow Coma Scale (GCS) and those with dysphagia. CONCLUSION Every third stroke was due to cerebral hemorrhage; CH patients were largely unaware of their hypertension or were altogether treatment naïve or defaulters while compliance was far better in ischaemic stroke category.
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Affiliation(s)
- C S Grover
- Miri Hospital, Department of Medicine, Jalan Cahaya, 98000, Miri, Sarawak 98000 Malaysia.
| | - S Thiagarajah
- Miri Hospital, Department of Medicine, Jalan Cahaya, 98000, Miri, Sarawak 98000 Malaysia
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Lindner C, Thiagarajah S, Wilkinson JM, Wallis GA, Cootes TF. Fully automatic segmentation of the proximal femur using random forest regression voting. IEEE Trans Med Imaging 2013; 32:1462-1472. [PMID: 23591481 DOI: 10.1109/tmi.2013.2258030] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Extraction of bone contours from radiographs plays an important role in disease diagnosis, preoperative planning, and treatment analysis. We present a fully automatic method to accurately segment the proximal femur in anteroposterior pelvic radiographs. A number of candidate positions are produced by a global search with a detector. Each is then refined using a statistical shape model together with local detectors for each model point. Both global and local models use Random Forest regression to vote for the optimal positions, leading to robust and accurate results. The performance of the system is evaluated using a set of 839 images of mixed quality. We show that the local search significantly outperforms a range of alternative matching techniques, and that the fully automated system is able to achieve a mean point-to-curve error of less than 0.9 mm for 99% of all 839 images. To the best of our knowledge, this is the most accurate automatic method for segmenting the proximal femur in radiographs yet reported.
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Affiliation(s)
- C Lindner
- Centre for Imaging Sciences, The University of Manchester, M13 9PT Manchester, UK.
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Coppola D, Thiagarajah S, Qiu H, Hough D. Regarding "A Risperidone-induced Prolactinoma Resolved When A Woman with Schizoaffective Disorder Switched to Ziprasidone: A Case Report". Innov Clin Neurosci 2013; 10:12-16. [PMID: 23556137 PMCID: PMC3615507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Danielle Coppola
- Drs. Coppola, Qiu, and Hough are with Janssen Research and Development, LLC, Raritan, New Jersey; Dr. Thiagarajah is with Janssen-Cilag, Ltd, High Wycombe, United Kingdom
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Soueid A, Oudit D, Thiagarajah S, Laitung G. The pain of surgery: pain experienced by surgeons while operating. Int J Surg 2009; 8:118-20. [PMID: 19944192 DOI: 10.1016/j.ijsu.2009.11.008] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 10/25/2009] [Accepted: 11/17/2009] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The operating theatre can be a dreaded experience not only for the patient but also occasionally for the surgeon. We sought to investigate the prevalence of pain experienced by surgeons while operating. METHODS One hundred and thirty anonymous questionnaires were sent to surgical consultants in the Britain. RESULTS The response rate was 60% and 63 experienced pain while operating. The back and neck were the most common areas of pain (36 & 30 consultants respectively), followed by the hand (24 consultants). Nearly 80% described pains on a regular basis. Table height was the most common cause of pain (35%), followed by the use of microscopes (27%) and standing (22%). Nearly 43% of the consultants will take a break from surgery because of their symptoms, and 4 took sick leave in direct relation to pain experienced as a result of operating. However only 27% took measures to reduce their symptoms and 65% never sought any help or advice and only one consultant informed the occupational health department. CONCLUSION Many surgeons will experience pain while operating due to positioning or the instruments they use, however there are no guidelines from occupational health departments or training courses to help minimise these symptoms.
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Affiliation(s)
- A Soueid
- Department of Plastic & Reconstructive Surgery, West Midlands Deanery, Birmingham, United Kingdom.
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Abstract
OBJECTIVE We sought to determine whether biochemical testing is a valuable adjunct to ultrasonography in selecting patients with fetal choroid plexus cysts for amniocentesis. STUDY DESIGN The study population consists of 128 patients who had fetal choroid plexus cysts detected during ultrasonography performed between 18 and 22 weeks' gestation. The patients had genetic counseling, and amniocentesis and biochemical testing were offered to all patients. The data were analyzed by dividing the patients into 3 groups. Group 1 had targeted ultrasonography only, group 2 had ultrasonography and maternal serum alpha-fetoprotein testing, and group 3 had ultrasonography and triple-screen (maternal serum alpha-fetoprotein, human chorionic gonadotropin, and estriol) testing. Outcome was determined by fetal karyotype or by neonatal examination by a pediatrician for patients who declined amniocentesis. RESULTS There were 25 patients in group 1. Isolated choroid plexus cysts were detected in 20 fetuses, and all had normal outcomes. Additional anomalies were detected in 5 fetuses. Two had normal karyotypes, and 3 had trisomy 18. There were 52 patients in group 2. The maternal serum alpha-fetoprotein levels were normal in 44 patients, 41 of whom had isolated fetal choroid plexus cysts. Of these 44 patients, 40 had normal outcomes, and 1 patient had a fetus with trisomy 18. The remaining 3 patients with normal maternal serum alpha-fetoprotein levels had additional fetal anomalies on ultrasonography, but the karyotypes were normal. The maternal serum alpha-fetoprotein levels were abnormal in 8 patients, of whom 6 had fetuses with isolated choroid plexus cysts and normal karyotypes. Two patients had additional fetal anomalies detected on ultrasonography and had abnormal karyotypes, 1 with trisomy 21 and 1 with trisomy 18. There were 51 patients in group 3. Results of the triple screen were normal in 32 patients. The choroid plexus cysts were isolated in 29 of the 32 patients, and all 29 fetuses had normal karyotypes. The other 3 patients with normal triple-screen results had additional fetal anomalies on ultrasonography. One fetus had normal chromosomes, and 2 had trisomy 18. The remaining 19 patients had abnormal triple-screen results. Among them, 16 fetuses had isolated choroid plexus cysts, 13 of whom were normal, 2 had trisomy 18, and 2 had a de novo unbalanced translocation. The remaining 3 fetuses had additional anomalies, and all 3 fetuses had trisomy 18. There were 14 fetuses with significant chromosomal abnormalities. Nine mothers were <35 years old, and 5 were >/=35 years old. CONCLUSIONS This study shows the following: (1) The triple screen is a useful adjunct to targeted ultrasonography in selecting patients with fetal choroid plexus cysts for amniocentesis. (2) A normal triple-screen result and the absence of additional fetal anomalies on ultrasonography reliably exclude an underlying chromosomal abnormality, and amniocentesis is not indicated. (3) If the triple-screen result is abnormal, additional anomalies are seen on ultrasonography, or the mother is aged >/=35 years, then fetal karyotyping is recommended. (4) Patients who decline fetal karyotyping should have follow-up ultrasonography in 34 weeks' time.
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Affiliation(s)
- A Sullivan
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, USA
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Abstract
OBJECTIVE The purpose of this study was to determine the effect of corticosteroids on platelet counts and liver functions in women with pregnancies complicated by the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. STUDY DESIGN The study group consisted of 93 patients between 24 and 34 weeks' gestation diagnosed with HELLP syndrome. All were given intramuscular injections of either betamethasone or dexamethasone. The 3 most common regimens used were 12 mg of intramuscular betamethasone administered twice 12 hours apart, 12 mg of intramuscular betamethasone administered twice 24 hours apart, and 6 mg of intramuscular dexamethasone administered 4 times 6 hours apart. Precorticosteroid and postcorticosteroid platelet counts and liver function test results were compared. The differences in improvement in hematologic abnormalities among the 3 corticosteroid regimens were also analyzed. RESULTS The hematologic abnormalities seen in the 93 patients with HELLP syndrome improved after the administration of corticosteroids. The platelet count increased by 23.3 x 10(3)/microL (P <.001). A statistically significant decrease was seen in liver enzyme levels. The alanine aminotransferase decreased by 31.6 IU/L, the aspartate aminotransferase decreased by 52.1 IU/L, and the alkaline phosphatase decreased by 7.6 IU/L. Of the 3 regimens used, 2 doses of 12 mg of intramuscular betamethasone given every 12 hours improved the liver function to the greatest degree. CONCLUSIONS This study demonstrates that corticosteroids produce a significant improvement in the hematologic abnormalities associated with HELLP syndrome. Two doses of betamethasone given 12 hours apart was the most effective corticosteroid regimen.
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Affiliation(s)
- M J Tompkins
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia, USA
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Rosenthal RJ, Friedman RL, Kahn AM, Martz J, Thiagarajah S, Cohen D, Shi Q, Nussbaum M. Reasons for intracranial hypertension and hemodynamic instability during acute elevations of intra-abdominal pressure: observations in a large animal model. J Gastrointest Surg 1998; 2:415-25. [PMID: 9843600 DOI: 10.1016/s1091-255x(98)80031-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.4] [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] [Indexed: 01/31/2023]
Abstract
In previous studies we reported that an acute elevation in intra-abdominal pressure (IAP) is responsible for the elevation in intracranial pressure (ICP) and mean blood pressure (MBP). Thus far, the reasons for the increased ICP during an acute elevation in IAP and the combined effects of increased IAP and ICP on hemodynamics have not been reported. Five large animals (swine) were studied. Each animal served as its own control. A subarachnoid screw was placed for ICP monitoring. The jugular vein, femoral vein, and femoral artery were cannulated. ICP, MBP, central venous pressure above (CVPA) and below (CVPB) the diaphragm, and PaC02 were monitored after a pneumoperitoneum with C02 was established at 5, 15, and 30 mm Hg of IAP. Cavography was performed to evaluate the morphology of the inferior vena cava at different increments of IAP. Measurements were obtained in reverse Trendelenburg (group 1), supine (group 2), and Trendelenburg (group 3) positions. Multiple regression analysis was used to examine the effects of IAP and positioning in separate models with different blood pressures as dependent variables. Increased IAP significantly increased CVPA, CVPB, ICP, and MBP. There were no changes in cerebral perfusion pressure. The change in position (from group 1 to group 3) significantly increased CVPA and decreased the CVPB. Cavograms performed on animals in the supine position with increased IAP showed a narrowing of the IVC at the level of the diaphragm. Increases in IAP will increase ICP and MBP without altering the cerebral perfusion pressure. A mechanical effect mediated by compression of the inferior vena cava at the level of the diaphragm with increased central venous pressure and decreased drainage from the lumbar plexus and central nervous system is responsible for this effect.
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Affiliation(s)
- R J Rosenthal
- Department of Surgery, Institute of Neurology and Neurosurgery, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY, USA
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Thiagarajah S, Thiagarajah CK. Create a party mood for a smooth anesthetic induction of children. Anesthesiology 1998; 89:802. [PMID: 9743431 DOI: 10.1097/00000542-199809000-00051] [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: 11/26/2022]
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Thiagarajah S, Stroud CB, Vavelidis F, Schnorr JA, Schnatterly PT, Ferguson JE. Elevated maternal serum alpha-fetoprotein levels: what is the risk of fetal aneuploidy? Am J Obstet Gynecol 1995; 173:388-91; discussion 391-2. [PMID: 7544067 DOI: 10.1016/0002-9378(95)90257-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Our purpose was to present the findings of a project to determine the efficacy of including routine fetal karyotyping in the investigation of an elevated maternal serum alpha-fetoprotein concentration. STUDY DESIGN Targeted ultrasonographic examinations were performed in 658 patients with elevated maternal serum alpha-fetoprotein levels. The scans were normal in 557 women, of whom 427 consented to amniocentesis; 435 fetuses were karyotyped. In the 101 patients with abnormal ultrasonographic examinations 75 had fetal karyotyping. RESULTS In the 435 fetuses with normal scans, two had karyotypic anomalies, a 47,XYY and an inherited balanced translocation. Three fetuses with normal karyotypes and high amniotic fluid alpha-fetoprotein levels had congenital nephrosis. In the 101 patients with abnormal scans, 75 fetuses were karyotyped. There were four aneuploidies. Among the 26 patients with abnormal scans who declined amniocentesis one fetus with multiple anomalies was karyotyped after delivery and triploidy was discovered. CONCLUSIONS These results provide little justification for including fetal karyotyping in the investigation of elevated maternal serum alpha-fetoprotein when the targeted ultrasonographic examination is normal. When it is abnormal, selective rather than routine karyotyping is more appropriate.
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Affiliation(s)
- S Thiagarajah
- Department of Obstetrics and Gynecology, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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Ferguson JE, Burkett BJ, Pinkerton JV, Thiagarajah S, Flather MM, Martel MM, Hogge WA. Intraamniotic 15(s)-15-methyl prostaglandin F2 alpha and termination of middle and late second-trimester pregnancy for genetic indications: a contemporary approach. Am J Obstet Gynecol 1993; 169:332-9; discussion 339-40. [PMID: 8362944 DOI: 10.1016/0002-9378(93)90084-v] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Our purpose was to determine whether intraamniotic 15(s)-15-methyl prostaglandin F2 alpha could serve effectively and safely as a surrogate for natural prostaglandin F2 alpha when used to effect middle and late second-trimester pregnancy termination for genetic indications. Further, we sought to compare efficacy and side effects with those found when intravaginal prostaglandin E2 is used. STUDY DESIGN A total of 62 patients received intraamniotic 15(s)-15-methyl prostaglandin F2 alpha and urea, and intracervical laminaria. Case patients at < or = 20 weeks' gestation (n = 32) were compared with case patients at > 20 weeks (n = 30) and with a matched group (n = 64; 1:2 ratio) of control patients in whom cervical laminaria and intraamniotic urea were used with prostaglandin E2 vaginal suppositories. RESULTS The mean induction-to-abortion interval among the case patients (gestational age 16 to 27 weeks) was 13 hours 11 minutes; 60 of 62 (97%) were delivered within 24 hours. There was a statistically significant negative correlation between the induction-to-abortion interval and gestational age (p = 0.04). When patients at < or = 20 weeks and those at > 20 weeks were compared, few differences were noted. The mean induction-to-abortion interval for case patients at < or = 20 weeks was 13 hours 54 minutes versus 19 hours 34 minutes for control patients (p = 0.001). One of 32 (3%) case patients remained undelivered beyond 24 hours compared with 17 of 64 (27%) control patients (p < 0.01). Immediate and delayed complications were uncommon in either group. CONCLUSION Our study demonstrates that 15(s)-15-methyl prostaglandin F2 alpha can serve safely as a surrogate for prostaglandin F2 alpha when used in combination with urea and laminaria for termination of pregnancy. This technique appears safe for use through 27 weeks' gestation; further investigation is encouraged.
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Affiliation(s)
- J E Ferguson
- Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville 22908
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Thiagarajah S, Bergland R. Rekindle an Old Technique. J Neurosurg Anesthesiol 1992; 4:221. [PMID: 15815468 DOI: 10.1097/00008506-199207000-00014] [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: 11/25/2022]
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Abstract
The commonly used vasodilators sodium nitroprusside and nitroglycerine increase the intracranial pressure (ICP). Oxytocin is also a vasodilator although its primary effect is contraction of uterine smooth muscle. We therefore studied the effect of oxytocin on the ICP of cats. Twelve cats were assigned to two equal groups. One group had normal ICP and in the other the ICP was artificially increased by inflating a balloon placed in the extradural space. All of the cats initially received an oxytocin infusion for 15 min. After a period of stabilization, an additional dose of oxytocin was injected as a bolus. Oxytocin administered as an infusion did not change the ICP significantly in any of the cats. Oxytocin administered as a bolus increased the ICP from 27 +/- 4 to 31 +/- 2 mm Hg in the cats with artificially increased ICP. There were no significant changes in the mean blood pressure or heart rate in either group.
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Affiliation(s)
- S Thiagarajah
- Department of Anesthesiology, Beth Israel Medical Center, New York, New York, USA
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Hogge WA, Dungan JS, Brooks MP, Dilks SA, Abbitt PL, Thiagarajah S, Ferguson JE. Diagnosis and management of prenatally detected myelomeningocele: a preliminary report. Am J Obstet Gynecol 1990; 163:1061-4; discussion 1064-5. [PMID: 2206057 DOI: 10.1016/0002-9378(90)91127-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Our experience with 23 cases of fetal myelomeningocele provides preliminary information on the outcome of these infants diagnosed in utero and managed by a multidisciplinary team. The mean age of diagnosis was 23.7 weeks (range, 16 to 34 weeks). Mean gestational age at delivery was 36.9 weeks in the 14 patients who elected to continue their pregnancies. None of the 11 infants with lumbosacral or sacral lesions developed significant ventriculomegaly before term. Of the three patients diagnosed with thoracolumbar lesions, two had progression of ventriculomegaly necessitating early delivery at 32 to 34 weeks of gestation. These preliminary findings suggest that a coordinated prenatal and neonatal approach appears to result in a favorable prognosis for infants with myelomeningocele, but that neonatal complications are common, requiring careful monitoring and aggressive management.
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Affiliation(s)
- W A Hogge
- Department of Obstetrics and Gynecology, University of Virginia Health Sciences Center, Charlottesville
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Thiagarajah S, Henke J, Hogge WA, Abbitt PL, Breeden N, Ferguson JE. Early diagnosis of spina bifida: the value of cranial ultrasound markers. Obstet Gynecol 1990; 76:54-7. [PMID: 2193270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Ultrasonography plays an integral part in the prenatal diagnosis of neural tube defects. However, experienced sonographers with careful evaluation are successful in accurately diagnosing spina bifida only 80-90% of the time. This study was conducted to evaluate the accuracy and reliability of certain cranial ultrasound markers--the "lemon sign," cerebellar abnormalities, microcephaly, and ventriculomegaly--in facilitating the diagnosis of spina bifida in patients referred for prenatal diagnosis. Open spina bifida was diagnosed in 24 of 44 fetuses found to have neural tube defects. The lemon sign and cerebellar abnormalities were identified in all 16 fetuses in whom the diagnosis of spina bifida was made between 16-24 weeks' gestation. In four of these fetuses, the lemon sign and cerebellar abnormalities were noted 1-2 weeks before the spinal defect was identified. Microcephaly was present in 69% and ventriculomegaly in 63% of the cases. In the eight cases diagnosed after 24 weeks' gestation, the lemon sign was less reliable, being noted in only 25% of the fetuses. Ventriculomegaly increased in frequency to 75% and cerebellar abnormalities and microcephaly were present in all. Our findings indicate that these cranial ultrasound markers are extremely reliable for the early diagnosis of spina bifida; their identification should alert ultrasonographers at all skill levels to the possibility of open spina bifida.
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Affiliation(s)
- S Thiagarajah
- Department of Obstetrics and Gynecology, University of Virginia Health Sciences Center, Charlottesville
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Dungan JS, Fernandez MT, Abbitt PL, Thiagarajah S, Howards SS, Hogge WA. Multicystic dysplastic kidney: natural history of prenatally detected cases. Prenat Diagn 1990; 10:175-82. [PMID: 2188249 DOI: 10.1002/pd.1970100307] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
To delineate the natural history of fetal multicystic dysplastic kidneys (MDKs), all cases that were prenatally detected in the Prenatal Diagnosis Center of the University of Virginia from September 1985 to 31 August 1988 were reviewed. All patients were followed through the Center with serial ultrasound evaluations at approximately 4-week intervals, and each liveborn infant was evaluated and followed by one of the authors (S.S.H.). Of the 14 cases detected, ten were detected in the second trimester, the earliest at 16.5 weeks' gestation. Of the nine fetuses with non-lethal disease, there were two cases in which the lesion remained unchanged during observation. Both had an initial diagnosis in the third trimester. In those cases diagnosed in the second trimester (7), all showed an initial increase in the size and number of cysts, followed by involutional changes either in utero (2) or in the neonatal period (3). Two infants had immediate surgical removal of the MDK, one because of respiratory compromise, and the other because of an uncertain diagnosis on renal scan. Abnormalities of the contralateral kidney were found in 7 of 14 fetuses. Five were lethal conditions. Associated non-renal abnormalities were common in bilateral MDK (80 per cent), but rare in unilateral MDK (11 per cent).
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Affiliation(s)
- J S Dungan
- Department of Obstetrics and Gynecology, University of Virginia Health Sciences Center, Charlottesville 22908
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Affiliation(s)
- S Thiagarajah
- Department of Anesthesiology, Beth Israel Medical Center, New York, New York 10003
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Hogge WA, Thiagarajah S, Ferguson JE, Schnatterly PT, Harbert GM. The role of ultrasonography and amniocentesis in the evaluation of pregnancies at risk for neural tube defects. Am J Obstet Gynecol 1989; 161:520-3; discussion 523-4. [PMID: 2476929 DOI: 10.1016/0002-9378(89)90348-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
To assess the relative efficacy of amniocentesis versus targeted (detailed) ultrasonography, 225 patients referred because of an elevated maternal serum alpha-fetoprotein level (79.6%) or a family history of neural tube defect (20.4%) were evaluated. Ultrasonographic examination alone detected all 26 fetal abnormalities (11 cases of anencephaly, 10 cases of open spina bifida, and five other anomalies). Twenty-eight patients declined amniocentesis; all had normal pregnancy outcomes. Of the 167 patients with apparently normal fetal anatomy by sonography, seven had elevated alpha-fetoprotein levels but no acetylcholinesterase in the amniotic fluid. Six of these pregnancies resulted in normal infants; one infant had congenital nephrosis. The remaining 160 patients had normal sonograms with normal amniotic fluid alpha-fetoprotein levels and no fetal malformations at delivery. Although these results suggest that targeted ultrasonography by experienced personnel is a reasonable alternative to amniocentesis in evaluations for neural tube defects, the availability, cost-effectiveness, and diagnostic accuracy of this approach must be well documented in large prospective studies.
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Affiliation(s)
- W A Hogge
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville 22908
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Abbitt PL, Thiagarajah S. Venous sonography for pregnancy-related thrombosis: case report. Va Med 1989; 116:277-8. [PMID: 2669406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Venous sonography offers a reliable, noninvasive way of diagnosing deep venous thrombosis in the lower extremity, a condition with a potentially fatal consequence. It is possible that sonography may underestimate the degree of involvement of the veins. However this is not usually of clinical concern since systemic heparin therapy will be given regardless of the extent of the clot.
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Bourgeois FJ, Harbert GM, Andersen WA, Thiagarajah S, Duffer J, Hendrickx K. Early versus late tocolytic treatment for preterm premature membrane rupture. Am J Obstet Gynecol 1988; 159:742-8. [PMID: 3421274 DOI: 10.1016/s0002-9378(88)80047-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The effect of tocolytic therapy before labor was evaluated in 33 pregnant women with preterm premature rupture of the membranes. Either intravenous magnesium sulfate or oral terbutaline was administered at the time of presentation. Intensive surveillance to detect signs of infection was carried out for all patients. In 29 of the patients in this treatment group who were seen at less than 34 weeks, a significantly longer prolongation of pregnancy was achieved when compared with 24 similar women treated after onset of labor in the hospital (169 hours versus 77 hours, p = 0.05). Duration of infant hospitalization was less for those mothers receiving tocolytic agents before labor. Maternal and infant infection were not different in the two groups; nor was the cesarean section rate. When this treatment group was compared with another control group of 96 women already in labor at presentation, the difference in time from admission to delivery was substantial, but it did not achieve statistical significance. In this group the rate of maternal infection was significantly higher, but newborn morbidity was not. Aggressive early treatment with tocolytic agents in pregnant women with preterm premature membrane rupture is more productive but not more dangerous than conservative management.
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Affiliation(s)
- F J Bourgeois
- Department of Obstetrics and Gynecology, University of Virginia Hospital, Charlottesville
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Thiagarajah S, Simon O. Another use for swivel adaptors. Anesthesiology 1988; 68:655-6. [PMID: 3354918 DOI: 10.1097/00000542-198804000-00054] [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: 01/05/2023]
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Thiagarajah S, Christenson E, Azar I, Lear E, Keats M. THE EFFECT OF TRIMETHAPHAN - NITROPRUSSIDE MIXTURE ON INTRACRANIAL PRESSURE IN CATS. Anesth Analg 1988. [DOI: 10.1213/00000539-198802001-00231] [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: 11/05/2022]
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Abstract
Twelve cats were assigned equally to two groups, one with normal, and the other with artificially-increased intracranial pressure. When suxamethonium was administered to these animals, the intracranial pressure increased in both groups, irrespective of their baseline intracranial pressure. When the same dose of suxamethonium was administered after pretreatment with thiopentone in both groups of animals, the intracranial pressure again increased from the control values.
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Affiliation(s)
- S Thiagarajah
- Department of Anesthesiology, Beth Israel Medical Center, New York, N.Y. 10003
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Abstract
Percutaneous umbilical blood sampling (cordocentesis) provides direct access to the fetal circulation in the second and third trimesters of pregnancy. Seventeen patients underwent this procedure between December 1985 and December 1986 for evaluation of a variety of clinical situations, including nonlethal fetal abnormalities detected by ultrasound, equivocal results of amniocentesis, nonimmune fetal hydrops, and isoimmune disorders. Our experience confirms the efficacy of the procedure and suggests that it may become an important tool for fetal assessment and therapy.
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Affiliation(s)
- W A Hogge
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA 22908
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Thiagarajah S, Azar I, Lear E, Machetnis EM. Intracranial pressure changes during infusions of adenosine triphosphate and sodium nitroprusside. Bull N Y Acad Med 1987; 63:186-92. [PMID: 3472620 PMCID: PMC1629191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Bourgeois FJ, Harbert GM, Paulsen EP, Thiagarajah S. Glycosylated serum protein level as a screening and diagnostic test for gestational diabetes mellitus. Am J Obstet Gynecol 1986; 155:493-6. [PMID: 3752173 DOI: 10.1016/0002-9378(86)90263-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Glycosylated serum protein assay was examined as an alternative to standard glucose screening and glucose tolerance testing. In a comparison of two groups of gravid women having abnormal 1-hour 50 gm glucose screening tests, there was no difference in glycosylated protein level in the group with abnormal glucose tolerance test results (9.4% +/- 2.0%, mean +/- SD; n = 8) versus normal results (9.2% +/- 1.07%, mean +/- SD; n = 11). Furthermore, correlation of glycosylated serum protein level with glucose screening test results was poor (r = 0.185, p = 0.23, n = 17). Glycosylated serum protein assay is not useful in detecting mild metabolic aberrations associated with gestational diabetes.
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Thiagarajah S, Azar I, Lear E, Rudolf D. Effect of diltiazem-induced hypotension on normal and increased intracranial pressure of cats. Can Anaesth Soc J 1986; 33:578-82. [PMID: 3768765 DOI: 10.1007/bf03014263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The commonly used vasodilators sodium nitroprusside and nitroglycerin increase intracranial pressure (ICP) and cause tachycardia. Since diltiazem is also a vasodilator, we designed this experiment in cats to study its effect on intracranial pressure and heart rate (HR). Twelve cats were assigned to two equal groups. One group had normal ICP (N-ICP), while in the other the ICP was raised artificially (AR-ICP) by placing a balloon into the intracranial extradural space. Both groups received an infusion of diltiazem to decrease the mean blood pressure (BP), which was maintained 30 per cent below the baseline value for 15 minutes. Diltiazem caused no significant change in ICP (5.7 +/- 1 to 6.7 +/- 1.5 mmHg, p less than 0.01) in cats with N-ICP while in cats with AR-ICP, the increase from 26.9 +/- 0.5 to 34.0 +/- 1.9 mmHg was significant (p less than 0.006). HR decreased significantly during the diltiazem infusion in both groups.
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Abstract
Two preeclamptic women became profoundly hypotensive while receiving magnesium sulfate. No evidence of toxic levels was present in either. In both, preeclampsia-induced hypovolemia was extreme. That nontoxic magnesium levels can cause severe hypotension is an alarming possibility. Acknowledgment of this complication and expeditious reversal of the problem is essential.
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Thiagarajah S, Grynsztejn M, Lear E, Azar I. Ventricular arrhythmias after terbutaline administration to patients anesthetized with halothane. Anesth Analg 1986; 65:417-8. [PMID: 3954117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Thiagarajah S. Management of an unsuspected case of malignant hyperpyrexia. Middle East J Anaesthesiol 1986; 8:269-75. [PMID: 3960004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
Effects of magnesium sulfate and ritodrine hydrochloride on cardiovascular physiologic characteristics were studied in 70 human subjects treated for preterm labor. Systemic and uterine hemodynamic effects were investigated in five pregnant rhesus monkeys. Systolic blood pressure was minimally affected by either agent. Diastolic pressure, while not affected by magnesium sulfate, decreased 26.3% during ritodrine therapy. Maternal and fetal heart rates were minimally affected by magnesium sulfate. Ritodrine increased maternal and fetal heart rates significantly. In the monkeys, magnesium sulfate increased uterine and placental blood flows (by the microsphere technique) but failed to alter cardiac output. Ritodrine produced an increase in cardiac output but decreased perfusion pressure. Placental blood flow decreased by an average of 27.6%. Ritodrine would therefore seem contraindicated with a compromised fetal environment. Magnesium sulfate, by not altering perfusion pressure, may have a beneficial effect on uterine hemodynamics. These specific and distinct differences in cardiovascular and hemodynamic effects should be considered when either magnesium sulfate or ritodrine is selected as a tocolytic agent.
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Bourgeois FJ, Pinkerton JA, Andersen W, Thiagarajah S. Antibiotic irrigation prophylaxis in the high-risk cesarean section patient. Am J Obstet Gynecol 1985; 153:197-201. [PMID: 3929609 DOI: 10.1016/0002-9378(85)90113-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Two hundred twenty-three women who underwent cesarean section delivery were studied to assess the effectiveness of operative antibiotic irrigation in preventing postoperative uterine infection. Patients were prospectively randomized into high-risk and low-risk groups according to length of labor, and received irrigation with either a 2 gm solution of cefamandole or normal saline solution, or no irrigation. Infection rates of 48.6% and 54.8% were observed in high-risk patients given either saline solution or no irrigation, respectively. Three of 27 high-risk patients (11.1%) given antibiotic irrigation developed metritis. The authors find this method of preventing infection to be advantageous in terms of both efficacy and minimization of antibiotic exposure.
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Thiagarajah S, Azar I, Lear E, Albert D. Intracranial pressure changes during infusions of verapamil as compared with sodium nitroprusside. Bull N Y Acad Med 1985; 61:650-6. [PMID: 3862459 PMCID: PMC1911865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
Over a 9-month time span, eight gravid women at high risk had fetal heart rate decelerations on nonstress tests (NSTs). This form of antepartum evaluation, the standard at our institution, was performed 918 times on 476 women during this period. Decelerations were required to be between 1 and 10 minutes in duration and less than 90 bpm, or greater than 40 bpm below baseline, for inclusion. Of the eight women (1.7% of the total tested), four had reactive and four nonreactive NSTs. All eight had contraction stress tests (CSTs) that were negative by definition. Of four women allowed to labor, two (50%) required cesarean section for fetal distress. Two instances of fetal death (25%) occurred during observation periods of 36 and 48 hours. Two infants were growth retarded, and two had abnormal cord positions. NSTs showing decelerations of this type, regardless of reactivity or of follow-up CST, are abnormal and should be viewed with alarm. In term pregnancy, such fetuses should be delivered. In preterm pregnancy with nonreactive NSTs, decelerations may also be valid grounds for delivery. Some discrimination is possible in preterm pregnancies when the NST is reactive.
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Thiagarajah S, Bourgeois FJ, Harbert GM, Caudle MR. Thrombocytopenia in preeclampsia: associated abnormalities and management principles. Am J Obstet Gynecol 1984; 150:1-7. [PMID: 6476014 DOI: 10.1016/s0002-9378(84)80100-3] [Citation(s) in RCA: 103] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Severe thrombocytopenia, abnormal liver function, and renal dysfunction may occur as manifestations of preeclampsia. Failure to recognize that this cluster of abnormalities represents a form of preeclampsia may result in erroneous initial diagnoses. Management of 13 such patients has shown a direct correlation between the degree of thrombocytopenia and the measures of liver dysfunction. Platelet counts and liver functions improved prior to delivery in five patients treated with corticosteroids. Management should be directed toward investigation and correction of deranged physiology and appropriate monitoring of maternal-feto-placental status. Early delivery is indicated in patients with progressive thrombocytopenia and in those with evidence of fetal maturity or distress. Provided that the disease process remains stable, consideration should be given in cases of fetal immaturity, to the use of betamethasone therapy. The occurrence of severe thrombocytopenia in 20% of neonates should be a consideration in selecting the mode of delivery.
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Krug EC, Rogol AD, Jarvis WD, Thiagarajah S, Singhas CA. Prolactin secretion by human chorion-decidua in vitro: influences of mode of delivery and agents that modify prostaglandin synthesis. Am J Obstet Gynecol 1983; 147:38-42. [PMID: 6614083 DOI: 10.1016/0002-9378(83)90080-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Prolactin production by human decidua was examined with the use of a short-term tissue explant system. Decidua obtained after normal spontaneous vaginal deliveries produced significantly more prolactin than did tissue obtained after elective repeat cesarean section deliveries in the absence of labor (P less than 0.005). Cytosolic prolactin levels did not differ between the two delivery modes. Oxytocin (4.3 X 10(-11) M to 4.3 X 10(-6) M) and eicosatetraenoic acid (10(-7) M to 10(-4) M) had no effect on prolactin production or storage by decidual tissue. Indomethacin at 10(-4) M reduced only levels of stored prolactin but had no effect on stored or produced prolactin at lower concentrations (10(-7) M to 10(-5) M). Arachidonic acid (10(-4) M) suppressed both production and storage of prolactin (P less than 0.05). Decidual tissue from the two delivery modes did not differ in response to the above agents. Although the exact mechanism(s) remains obscure, these results indicate decidual prolactin production is altered by some aspect of labor. The possible involvement of prostaglandin precursors in mediating this production cannot be excluded.
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Abstract
Mitral valve prolapse (MVP), reported as occurring in up to 17% of healthy individuals, is considered to be the commonest cardiac valvular abnormality. Although the anaesthetic course may be uneventful, complications may arise for the first time in the peri-operative period and include life threatening dysrhythmias, mitral regurgitation and infective endocarditis. Anaesthetic management of three of the seven patients with MVP treated at our institution over a 12-month period is discussed and the literature reviewed.
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50
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Abstract
The efficacy of magnesium sulfate was evaluated as the primary tocolytic agent in the management of patients at risk for premature delivery. One hundred ninety-two patients determined to be 36 weeks' gestation or less were treated. One hundred seven patients (55.7%) received an additional oral beta-mimetic agent once labor was arrested. One hundred nineteen patients had intact membranes and 73 patients had ruptured membranes. Delay of delivery of 48 hours or longer was achieved in 70.6% of the patients with intact membranes and 60.2% of patients with ruptured membranes. Intervening obstetric complications, maternal morbidity, and neonatal septic and respiratory morbidity were increased in patients with ruptured membranes compared to patients with intact membranes. Magnesium sulfate is considered to be effective tocolytic agent having minimal adverse effects in managing patients at risk for premature delivery. Its use in patients with ruptured membranes, as with any tocolytic agent, remains controversial.
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