Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial

OBJECTIVE

To assess the benefits and safety of early human fibrinogen concentrate in postpartum haemorrhage (PPH) management.

DESIGN

Multicentre, double-blind, randomised placebo-controlled trial.

SETTING

30 French hospitals.

POPULATION

Patients with persistent PPH after vaginal delivery requiring a switch from oxytocin to prostaglandins.

METHODS

Within 30 minutes after introduction of prostaglandins, patients received either 3 g fibrinogen concentrate or placebo.

MAIN OUTCOME MEASURES

Failure as composite primary efficacy endpoint: at least 4 g/dl of haemoglobin decrease and/or transfusion of at least two units of packed red blood cells within 48 hours following investigational medicinal product administration. Secondary endpoints: PPH evolution, need for haemostatic procedures and maternal morbidity-mortality within 6 ± 2 weeks after delivery.

RESULTS

437 patients were included: 224 received FC and 213 placebo. At inclusion, blood loss (877 ± 346 ml) and plasma fibrinogen (4.1 ± 0.9 g/l) were similar in both groups (mean ± SD). Failure rates were 40.0% and 42.4% in the fibrinogen and placebo groups, respectively (odds ratio [OR] = 0.99) after adjustment for centre and baseline plasma fibrinogen; (95% CI 0.66-1.47; P = 0.96). No significant differences in secondary efficacy outcomes were observed. The mean plasma FG was unchanged in the Fibrinogen group and decreased by 0.56 g/l in the placebo group. No thromboembolic or other relevant adverse effects were reported in the Fibrinogen group versus two in the placebo group.

CONCLUSIONS

As previous placebo-controlled studies findings, early and systematic administration of 3 g fibrinogen concentrate did not reduce blood loss, transfusion needs or postpartum anaemia, but did prevent plasma fibrinogen decrease without any subsequent thromboembolic events.

TWEETABLE ABSTRACT

Early systematic blind 3 g fibrinogen infusion in PPH did not reduce anaemia or transfusion rate, reduced hypofibrinogenaemia and was safe.

Drug cutaneous side effect: focus on skin ulceration

Skin ulcers are defined as tissue loss interesting the deeper layers of the dermis and hypodermis, with low tendency to spontaneous healing. They cause disability related to pain, risk of infection and amputation, chronic management, requiring working absence with notably economic burden. The major cause is often related to underlying vascular disease, infections, tumors, autoimmunity, trauma, even if literature occasionally reported several cases of drug inducing skin ulceration. Most of drugs involved are chemotherapy agents and more recently molecular target therapies. Evidences supporting these drugs as the major cause of skin ulcers include delay of onset after therapy initiation, improvement after withdrawal of the drug, recurrence after its reintroduction and, sometimes, simultaneous occurrence of other skin lesions that have previously been reported to be associated with these agents. Attention should be reserved to patients undergoing antineoplastic agents, especially if previously affected by predisposing comorbidities, considering such side effect as possible differential diagnosis for skin ulceration in neoplastic patients.

Alcohol and tobacco consumption affect the oral carriage of Candida albicans and mutans streptococci

This study sought to determine if there is a relationship between the consumption of alcohol and tobacco and oral colonization by mutans streptococci and Candida species. Subjects were recruited from the University Dental Clinic of CEU Cardenal Herrera University (Moncada, Valencia). Information on alcohol and tobacco consumption was obtained by questionnaire. Individual stimulated saliva samples from 105 patients were obtained and selective media was used to isolate and quantify mutans streptococci and Candida spp. colony forming units per millilitre of saliva (CFU ml(-1) ). Samples were stratified by duration and quantity of alcohol and tobacco consumption. Alcohol consumption statistically significantly decreased oral carriage of mutans streptococci, whereas there was no effect on Candida albicans colonization levels. Tobacco users were found to harbour elevated levels of C. albicans; however, there was no observed effect on bacterial colonization by mutans streptococci. The carriage of other species investigated, such as Candida krusei, Candida tropicalis and lactobacilli, do not show a response to the consumption of the stimulants analysed. Microbial colonization of the oral cavity changes in a species-specific manner in response to dietary and social habits such as drinking alcohol and smoking.

SIGNIFICANCE AND IMPACT OF THE STUDY

In this paper, we evaluate the effect of alcohol and tobacco consumption on key species of the oral microflora. Our results show species-specific changes in two major opportunistic pathogens, such as Candida albicans and mutans streptococci, whereas other members of oral microflora are not affected by the consumption of the stimulants studied. We believe this original paper will contribute to raise awareness among the dental community towards a more personalized oral health assessment, taking in consideration alcohol and tobacco consumption in the prevention of specific oral and systemic pathologies.

High mobility group box 1 is a novel substrate of dipeptidyl peptidase-IV

AIMS/HYPOTHESIS

High mobility group box 1 (HMGB1) is a cytokine with a key role in tissue regeneration and angiogenesis. Previous studies have shown that topical application of HMGB1 to skin wounds of mouse models of diabetes enhanced vessel density and accelerated wound healing, suggesting that diabetes may affect endogenous HMGB1 functions. Dipeptidyl peptidase IV (DPP-IV/CD26) is a protease whose activity is increased in diabetes and whose inhibition improves glucose tolerance. Since HMGB1 contains potential DPP-IV cleavage sites, we determined whether HMGB1 may be a substrate for DPP-IV and whether DPP-IV-mediated cleavage may alter the biological activity of HMGB1.

METHODS

Reversed phase HPLC, mass spectrometry and western blot analyses were performed to analyse and identify HMGB1 peptides generated following DPP-IV digestion. HMGB1 angiogenic functions in the presence of DPP-IV were evaluated in vitro and in vivo. HMGB1 protein was detected in the serum of type 2 diabetic patients before and after treatment with DPP-IV inhibitors.

RESULTS

DPP-IV cleaved HMGB1 at its N-terminal region and affected its angiogenic functions. Specifically, DPP-IV inhibited HMGB1-induced endothelial cell migration and capillary-like structure formation, as well as HMGB1-mediated vascular network formation in Matrigel implants in mice. We had previously found that HMGB1 promoted endothelial cell migration through activation of extracellular regulated kinase signalling pathway. Here we showed that such an effect was abolished in the presence of DPP-IV. Finally, the N-terminal truncated form of HMGB1 was detected in the serum of type 2 diabetic patients, in whom DPP-IV inhibitors enhanced the levels of full-length HMGB1.

CONCLUSIONS/INTERPRETATION

DPP-IV cleaves HMGB1 and, via this mechanism, inhibits HMGB1 angiogenic activity. Treatment with DPP-IV inhibitors may enhance HMGB1 activity in diabetic patients, thereby improving angiogenesis in this condition.

[Accidents among ambulance employees: epidemiologic features]

The accidents have been esteemed that are verified in four years in a group of 824 employees. The study has underlined a meaningful percentage (30.1%) of road accidents. This suggests the opportunity of contemplate preventive actions: corrected maintenance of the ambulance, control of the conditions of environmental comfort, organization of the job, individualization of conditions that reduces the attention and the concentration, as the use of alcohol and of other substances.

Acute effects of aflatoxins on guinea pig isolated ileum

Previous studies on the aflatoxins have focused mainly on their chronic toxic effects. In this study we investigated the acute gastrointestinal effects of four common aflatoxins on isolated guinea pig ileum. AFB(1) (EC(50) 4.6+/-0.4 microM) and AFB(2) (EC(50)17+/-4.4 microM) contracted isolated guinea pig ileum in a dose-dependent manner, whereas AFG(1) and AFG(2) evoked no contractions. Atropine (5.9 nM 11.8 and 23.6 nM) antagonized AFB(1)-induced contractions in a dose-dependent manner. Pretreatment with the nicotinic ganglionic blocker, hexamethonium (up to 55 microM), left AFB(1)-induced contractions unchanged. In contrast, tetrodotoxin (0.3 microM), blocked AFB(1) contractile activity. The two inhibitors of ACh release, morphine (0.3 microM) and clonidine (0.4 microM), antagonized EC(50) AFB(1)-induced contractions, and apamin, a drug that increases neuronal excitability, facilitated the EC(50) AFB(1)-induced contractile effect. The choline uptake blocker, hemicholinium (17.4 microM) markedly reduced AFB(1)-induced contractions. These results suggest that aflatoxins induce their contractile effect indirectly through the cholinergic system by stimulating acetylcholine release from the postganglionic parasympathetic nerve endings. The acute actions of aflatoxins on isolated guinea pig ileum could explain their acute gastrointestinal effects in humans and animals.

[Intraoperative lactic acidosis, can it be treated? Clinico-experimental, prospective, sequential study]

OBJECTIVE

To verify the efficacy and absence of risk attributable to therapy with alkaline solutions for correction of lactic acidosis and to demonstrate the usefulness of L-carnitine in converting lactate into pyruvate in conditions of good blood oxygenation.

DESIGN

Prospective study on a consecutive series of patients subdivided into three groups following the use of: alkalinizing therapy (group I), L-carnitine (group II), or saline solution (group III). Groups 1 and 2 were further subdivided into subgroups "a" and "b" according to the type of alkalinizing agent and of L-carnitine somministration.

SETTING

Teaching Hospital-Torrette di Ancona.

PATIENTS

65 patients submitted to major vascular surgery with aortic clamping in the time period between January 1992 and August 1993.

INTERVENTIONS

During aortic clamping patients of: group I received 2 mEq:kg of bicarbonate or tromentamolo according to the specific subgroup. Group II received a bolus of 2 g of L-carnitine, patients of group IIb received further 2 g of carnitine in continuous perfusion until the end of surgery. Group III received no pharmacological intervention.

MEASUREMENTS

HR BP, arterial blood gases and lactic acid levels were measured at 12 pre-determined times.

RESULTS

Only a neutralizing effect of alkalinizing therapy was observed, whereas the lactic acid measurements demonstrated no significant differences between the different groups.

CONCLUSIONS

These results confirm the data of other Authors concerning the good compliance of alkalinizing therapy, however, there was demonstrated no clear evidence of its effective usefulness. No metabolic stimulation due to L-canitina could be demonstrated in our experimental conditions.

Expression of mouse brain soluble guanylyl cyclase and NO synthase during ontogeny

The spatial and temporal distribution of soluble guanylyl cyclase and nitric oxide synthase mRNA was determined during embryonic and postnatal development of the mouse brain. This was achieved by in situ hybridization of specific probes for soluble beta 1 guanylyl cyclase subunit and nitric oxide synthase mRNA on mouse brain sections at late fetal development (19-day embryo) and different stages of postnatal development (3, 7, 15 days, and adult). In the embryo, soluble guanylyl cyclase transcripts are weakly expressed in the central nervous system. Following birth their expression increases in the striatum and neocortex, and they are widely distributed in the adult brain (layer II and V-VI of the cortex, olfactory bulb, striatum, Purkinje cell layer of the cerebellum). In contrast, nitric oxide synthase mRNA was expressed in several embryonic structures of the brain (different layers of the cortical neuroepithelium, colliculi neuroepithelium, pons), and markedly reduced at early postnatal stage, except in the accessory olfactory bulb and pediculopontine nuclei. Nitric oxide synthase transcripts progressively appear, within two weeks following birth, in the striatum and the cerebral cortex but they were specifically confined to isolated cells. During this period, this mRNA also increased in hippocampus, in discrete nuclei (hypothalamus, pontine) and in the molecular layer of the cerebellum. The situation in the adult was similar to the one observed at 15 days. These results show a general lack of regional colocalization of soluble guanylyl cyclase and NOS mRNA during ontogeny, thus suggesting an independent regulation of the related genes.

An ultrastructural study of epithelium differentiation in the human fetal fallopian tube

The epithelial structure of the developing human fetal Fallopian tube has been studied systematically by parallel light, transmission and scanning electron microscopy. The specimens for this study were collected from spontaneous abortions at the 14th, 18th, 20th and 22nd weeks and from cases of intrauterine fetal death at the 24th and 31st weeks (hydrocephalus). The epithelium lining the wall of the female genital ducts was pseudostratified in a columnar fashion. It consisted of differentiating ciliated and microvillous cells and some degenerating elements. Microvillous cells-by far the most abundant in the early phases of tubal development-often showed a solitary cilium. Ciliated elements, though always less numerous than microvillous cells, were more densely concentrated on the developing fimbriae and at the uterotubal junction than in the ampulla. On the mucosal surface of the same regions, rounded intercellular holes delimited many crypts, from which ciliated elements sometimes sprouted. Notable aspects of cell proliferation and ciliogenesis were commonly observed and are likely to be related to circulating estrogens. These ultrastructural data indicate that the typical pattern of the adult oviduct is already sketched in fetal life. Furthermore, a strategic gathering of cilia was noted primarily at the sites of the developing oviduct, which will serve to mediate the passage of sperm and/or ova and promote fertilization in adult life.

[Validity of the V/Q index in the monitoring of critical patients]

The Authors have controlled the validity of VQI to quantify pulmonary shunt (Qs/Qt). The survey involved (group A) patients who had undergone major surgery and (group B) patients hospitalized in ICU for cardiorespiratory failure. Four subgroups were identified in both the groups according to different values of SaO2. A good correlation, already described by Räsänen, was comproved in the groups and subgroups. However a progressive reduction of the coefficient of correlation from the lower to the higher values of SaO2 was noted. Finally the differences observed between group A and group B, are supposed to be dependent on a greater variability of haemoglobin, in the surgical group, in relation to the time of evaluation.

[Preliminary verification of a mathematical model for evaluating the operative risk in a personal caseload]

The authors applied a mathematical model of evaluation of operative risk to a group of patients undergoing general and obstetric-gynecologic surgery. They verified that all risk factors identified by this mathematical model really influenced operative morbidity and mortality in the present study too. In this univariate analysis, anesthetic technique was found to influence patients' outcome, so it must be included in multivariate analysis protocols. Therefore, this mathematical model showed to be of value in assessing operative risk factors.