A prostaglandin E2 receptor antagonist prevents pregnancies during a preclinical contraceptive trial with female macaques

STUDY QUESTION

Can administration of a prostaglandin (PG) E2 receptor 2 (PTGER2) antagonist prevent pregnancy in adult female monkeys by blocking periovulatory events in the follicle without altering menstrual cyclicity or general health?

SUMMARY ANSWER

This is the first study to demonstrate that a PTGER2 antagonist can serve as an effective non-hormonal contraceptive in primates.

WHAT IS KNOWN ALREADY

The requirement for PGE2 in ovulation and the release of an oocyte surrounded by expanded cumulus cells (cumulus-oocyte expansion; C-OE) was established through the generation of PTGS2 and PTGER2 null-mutant mice. A critical role for PGE2 in primate ovulation is supported by evidence that intrafollicular injection of indomethacin in rhesus monkeys suppressed follicle rupture, whereas co-injection of PGE2 with indomethacin resulted in ovulation.

STUDY DESIGN, SIZE, DURATION

First, controlled ovulation protocols were performed in adult, female rhesus monkeys to analyze the mRNA levels for genes encoding PGE2 synthesis and signaling components in the naturally selected pre-ovulatory follicle at different times after the ovulatory hCG stimulus (0, 12, 24, 36 h pre-ovulation; 36 h post-ovulation, n = 3-4/time point). Second, controlled ovarian stimulation cycles were utilized to obtain multiple cumulus-oocyte complexes (COCs) from rhesus monkeys to evaluate the role of PGE2 in C-OE in vitro (n = 3-4 animals/treatment; ≥3 COCs/animal/treatment). Third, adult cycling female cynomolgus macaques were randomly assigned (n = 10/group) to vehicle (control) or PTGER2 antagonist (BAY06) groups to perform a contraceptive trial. After the first treatment cycle, a male of proven fertility was introduced into each group and they remained housed together for the duration of the 5-month contraceptive trial that was followed by a post-treatment reversibility trial.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Quantitative real-time PCR, COC culture and expansion, immunofluorescence/confocal microscopy, enzyme immunoassay, contraceptive trial, ultrasonography, complete blood counts, serum biochemistry tests and blood lipid profiles.

MAIN RESULTS AND THE ROLE OF CHANCE

Several mRNAs encoding proteins involved in PGE2 synthesis, metabolism and signaling increase (P < 0.05) in the periovulatory follicle after administration of an ovulatory hCG bolus. PGE2 signaling through PTGER2 induces cumulus cell expansion and production of hyaluronic acid, which are critical events for fertilization. Moreover, chronic administration of a selective PTGER2 antagonist resulted in a significant (P < 0.05 versus vehicle-treated controls) contraceptive effect without altering steroid hormone patterns or menstrual cyclicity during a 5-months contraceptive trial. Fertility recovered as early as 1 month after ending treatment.

LIMITATIONS, REASONS FOR CAUTION

This is a proof-of-concept study in a non-human primate model. Further investigations are warranted to elucidate the mechanism(s) of PTGER2 antagonist action in the primate ovary. Although PTGER2 antagonist treatment did not produce any obvious undesirable effects, improvements in the mode of administration, as well as the efficacy of these compounds, are necessary to consider such a contraceptive for women.

WIDER IMPLICATIONS OF THE FINDINGS

Monitoring as well as improving the efficacy and safety of female contraceptives is an important public health activity. Even though hormonal contraceptives are effective for women, concerns remain regarding their side-effects and long-term use because of the widespread actions of such steroidal products in many tissues. Moreover, some women cannot take hormones for medical reasons. Thus, development of non-hormonal contraceptives for women is warranted.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by Bayer HealthCare Pharmaceuticals, The Eunice Kennedy Shriver NICHD Contraceptive Development and Research Center (U54 HD055744), NIH Office of the Director (Oregon National Primate Research Center P51 OD011092), and a Lalor Foundation Postdoctoral Basic Research Fellowship (MCP). The use of the Leica confocal was supported by grant number S10RR024585. Some of the authors (N.B., A.R., K.-H.F., U.F., B.B. and B.L.) are employees of Bayer Healthcare Pharma.

Determination of biogenic and fossil CO(2) emitted by waste incineration based on (14)CO(2) and mass balances

A field application of the radiocarbon ((14)C) method was developed to determine the ratio of biogenic vs. fossil CO(2) emissions from waste-to-energy plants (WTE). This methodology can be used to assign the Kyoto relevant share of fossil CO(2) emissions, which is highly relevant for emission budgets and emission trading. Furthermore, heat and electricity produced by waste incinerators might be labelled depending on the fossil or biogenic nature of the primary energy source. The method development includes representative on-site CO(2) absorption and subsequent release in the laboratory. Furthermore, a reference value for the (14)C content of pure biogenic waste (f(M,bio)) was determined as 1.130+/-0.038. Gas samples for (14)CO(2) analysis were taken at three WTEs during one month each. Results were compared to an alternative approach based on mass and energy balances. Both methods were in excellent agreement and indicated a fraction of biogenic CO(2) slightly above 50%.

Observations of long-lived anthropogenic halocarbons at the high-Alpine site of Jungfraujoch (Switzerland) for assessment of trends and European sources

Anthropogenic halocarbons, such as chlorofluorocarbons (CFCs), hydrochlorofluorocarbons (HCFCs), hydrofluorocarbons (HFCs), bromocarbons (halons) and long-lived chlorinated solvents have been measured continuously at the high-Alpine site of Jungfraujoch (Switzerland) since January 2000. Chloro- and bromo-containing halocarbons are responsible for the stratospheric ozone depletion and will be globally banned from usage within the next years. With the exception of the stable CFC-12 (CF2 Cl2), all major CFCs and chlorinated solvents show a negative trend in recent years in their background concentrations at Jungfraujoch. HCFCs, as their first-generation substitute, are still increasing with a few percent per year. However, the frequency and the strength of HCFCs pollution events, which are caused by regional European emissions, are already declining. This can be seen as a sign of the impending ban of these gases within the next years in Europe. On the other hand, HFCs as the second-generation substitutes, are increasing with relative rates of at least 10% per year (e.g. almost 5 ppt per year for HFC-134a). An allocation of European sources was attempted by combining measured concentrations with trajectories of air masses reaching the Jungfraujoch during pollution events. Potential source regions could be detected in Italy, France, Spain and Germany.

An evaluation of the current radiative forcing benefit of the Montreal Protocol at the high-Alpine site Jungfraujoch

A combination of reconstructed histories, long-term time series and recent quasi-continuous observations of non-CO2 greenhouse gases at the high-Alpine site Jungfraujoch is used to assess their current global radiative forcing budget and the influence of regulations due to the Montreal Protocol on Substances that Deplete the Ozone Layer in terms of climate change. Extrapolated atmospheric greenhouse gases trends from 1989 assuming a business-as-usual scenario, i.e. no Montreal Protocol restriction, are presented and compared to the observations. The largest differences between hypothetical business-as-usual mixing ratios and current atmospheric observations over the last 16 years were found for chlorinated species, in particular methyl chloroform (CH3CCl3) at 167 to 203 ppt and chlorofluorocarbon-12 (CFC-12) at 121 to 254 ppt. These prevented increases were used to estimate the effects of their restrictions on the radiative forcing budget. The net direct effect due to the Montreal Protocol regulations reduces global warming and offsets about 14 to 30% of the positive greenhouse effect related to the major greenhouse gases CO2, CH4, N2O and also SF6, and about 12 to 22% of the hypothetical current radiative forcing increase without Montreal Protocol restrictions. Thus, the Montreal Protocol succeeded not only in reducing the atmospheric chlorine content in the atmosphere but also dampened global warming. Nevertheless, the Montreal Protocol controlled species still add to global warming.

Assessment of three different mortality prediction models in four well-defined critical care patient groups at two points in time: a prospective cohort study

BACKGROUND AND OBJECTIVE

Mortality prediction systems have been calculated and validated from large mixed ICU populations. However, in daily practice it is often more important to know how a model performs in a patient subgroup at a specific ICU. Thus, we assessed the performance of three mortality prediction models in four well-defined patient groups in one centre.

METHODS

A total of 960 consecutive adult patients with either severe head injury (n = 299), multiple injuries (n = 208), abdominal aortic aneurysm (n = 267) or spontaneous subarachnoid haemorrhage (n = 186) were included. Calibration, discrimination and standardized mortality ratios were determined for Simplified Acute Physiology Score II, Mortality Probability Model II (at 0 and 24 h) and Injury Severity Score. Effective mortality was assessed at hospital discharge and after 1 yr.

RESULTS

Eight hundred and fifty-five (89%) patients survived until hospital discharge. Over all four patient groups, Mortality Probability Model II (24 h) had the best predictive accuracy (standardized mortality ratio 0.62) and discrimination (area under the receiver operating characteristic curve 0.9), but Simplified Acute Physiology Score II performed well for patients with subarachnoid haemorrhage. Overall calibration was poor for all models (Hosmer-Lemeshow Type C-values between 20 and 26). Injury Severity Score had the worst discrimination in trauma patients. All models over-estimated hospital mortality in all four patient groups, and these estimates were more like the mortality after 1 yr.

CONCLUSIONS

In our surgical ICU, Mortality Probability Model II (24 h) performed slightly better than Simplified Acute Physiology Score II in terms of overall mortality prediction and discrimination; Injury Severity Score was the worst model for mortality prediction in trauma patients.

Subcellular distribution of epothilones in human tumor cells

Epothilones are a new class of natural and potent antineoplastic agents that stabilize microtubules. Although 12,13-epoxide derivatives are potent antiproliferative agents, the activities of the corresponding 12,13-olefin analogs are significantly decreased. These data were confirmed for two new analogs, 6-propyl-EpoB (pEB) and 6-propyl-EpoD (pED), in comparison with the natural compounds EpoB/EpoD, by using human A431, MCF7, and MDR1-overexpressing NCI/Adr cells. By using tritiated pEB/pED, compound uptake, release, and nuclear accumulation were investigated in A431 and NCI/Adr cells. In these cells, epothilones can principally be recognized and exported by Verapamil-sensitive efflux pumps, which are not identical to MDR1. The degree of export depends on the structure, olefin vs. epoxide-analog, and also on the intracellular drug concentration. The accumulation of pED used at 3.5 or 70 nM, respectively, was increased in the presence of 10 microM Verapamil in both cell lines 2- to 8-fold. In contrast, the intracellular levels of pEB were affected by Verapamil only at 3.5 nM pEB in NCI/Adr (2-fold) and not in A431 cells. In addition, strong nuclear accumulation was observed for pEB (40-50%) but not paclitaxel or pED (5-15%) in both cell lines. Our study suggests that differences in growth inhibitory efficacy between epoxide and olefin analogs may be based on different mechanisms of drug accumulation and subcellular distribution.

Severe head injury: should expected outcome influence resuscitation and first-day decisions?

An early 'prognosis' based on initial findings can influence clinical decisions. To evaluate the quality of first-day outcome prediction based on either clinical or neuroradiological information, we prospectively examined 100 consecutive severely head-injured patients from the surgical intensive care unit. The prognoses were always made by the same experienced neurosurgeon and neuroradiologist according to a contracted Glasgow Outcome Scale (GOS). Every patient's outcome was predicted according to a three-class GOS within 24 h after injury. Correct 'first-day' prognoses were made in 59 and 56% of the cases by the neuroradiologist and neurosurgeon, respectively. In those instances where the prognoses made by the clinician and the radiologist coincided, the prognoses were correct for 73% of the patients. Based on accepted criteria, the neuroradiologist tended to overpredict favorable outcomes and missed many of the unfavorable outcomes (dead or vegetative) whereas the clinician overestimated unfavorable outcomes. Our study showed that outcome prognosis of patients with severe head injury has limited accuracy when made within 24 h after the injury, although an improvement in accuracy occurred when there was agreement between clinical and radiological predictions. Even with sophisticated clinical and radiological technologies, it is not possible to predict outcome on the first day after the accident with sufficient accuracy to guide early management.

Does on-scene resuscitation affect in-hospital "do not resuscitate" decisions and mortality in patients with severe head injuries?

To evaluate the effect of on-scene versus in-hospital resuscitation of patients with severe head injuries with regard to "do not resuscitate" (DNR) decisions and in-hospital mortality, 561 patients were prospectively studied. Patients were grouped according to whether resuscitation initially occurred at the scene of the injury (group 1), in a regional hospital before transfer (group 2), or after direct admission to our neurosurgical center (group 3). The DNR and mortality rates within the first 48 hours (13%, 10%, 10%, respectively) as well as for the entire stay in the surgical intensive care unit (SICU) were comparable for the three groups. It has been pointed out that efficient resuscitation at the scene of the injury may, instead of improving overall outcome, increase morbidity and mortality rates because more severely injured patients now reach the hospital alive. We conclude, however, that primary aggressive treatment at the scene of the injury did not increase DNR and in-hospital mortality rates within the 48-hour follow-up period, nor for the total stay in the SICU. Investigation of long-term outcome will be important to further establish the efficacy of this approach.

[Severe craniocerebral injuries: northwestern Switzerland 1984-1989]

Data from 561 severely head-injured patients treated in a Surgical Intensive Care Unit between 1984 and 1989 are analyzed. Age and sex distribution of the patients was comparable to findings in other studies. More than half of the patients were injured in road accidents, accidents involving cars representing the greatest risk. In 90% of all patients, severe head injury was the primary diagnosis. 60% of the patients were intubated within 30 minutes at the scene of the accident, as opposed to 17% of patients intubated in the emergency room within the same time interval. Patients resuscitated at the scene of the accident and admitted directly by helicopter arrived at the emergency room on average one hour after the accident; for those transported directly by ambulance, without intubation prior to admission, the average time interval was half an hour. Since the time interval between accident and onset of resuscitation is crucial, this difference in transportation times is not considered to be of major importance. Half of the patients who died in the Surgical Intensive Care Unit died within the first 48 hours, usually from primary severe brain damage. In 50% of the 446 patients from the first 4 years of this study the recoveries ranged from good to complete and 28% died. Only 3 (less than 1%) out of 446 patients were alive in a vegetative state, and 8% severely handicapped one year after the accident. Aggressive primary treatment did not increase the number of patients surviving in a vegetative or severely handicapped state.

Prospective endoscopic study of stress erosions and ulcers in critically ill neurosurgical patients: current incidence and effect of acid-reducing prophylaxis

We studied prospectively 40 critically ill neurosurgical patients who required prolonged mechanical ventilation to determine the current incidence of stress-related gastroduodenal erosions and ulcers, and to assess endoscopically the efficacy of acid-reducing prophylactic treatment. Nineteen patients were randomized to receive ranitidine plus antacids if necessary to maintain gastric pH at greater than or equal to 4. The remaining 21 patients were given no drug prophylaxis. Gastric pH was significantly (p less than .001) higher in the treated group: 78% of pH readings were at greater than or equal to 4 as compared to 32% in the control group. However, after five study days, incidence and severity of stress lesions were similar in the two groups: nine patients in each group had more than five erosions, one treated patient had a gastric ulcer, and one control patient had duodenal ulcerations. No patient experienced clinically relevant upper GI bleeding. The lack of severe stress bleeding and the low ulcer rate contrast with results from earlier reports on similar patient populations. Furthermore, drug prophylaxis had no detectable benefit, as assessed endoscopically. These findings suggest that routine stress lesion prophylaxis may not be necessary in critically ill patients with comparable risk factors.

Cardiac arrest and blood ionized calcium levels

Blood ionized and total calcium levels, and pH values were obtained in 12 patients who were being ventilated and given external cardiac massage after having had an out-of-hospital cardiac arrest. On admission they had marked ionized hypocalcemia, with mean ionized calcium levels of 0.67 +/- 0.22 mmol/L, (range, 0.26 to 0.89), but normal total calcium levels. There was a positive correlation between pH and ionized calcium levels (r = 0.71). Of the six patients who were successfully resuscitated, four were discharged and two died; the other six could not be resuscitated and died. By comparison, ionized and total calcium levels obtained within 3 minutes of cardiac arrest were normal in 9 patients who had cardiac arrests in the intensive care unit or during surgery. All were discharged. These data are the first to document the occurrence of severe ionized hypocalcemia after out-of-hospital cardiac arrest. Hypocalcemia appears to be time-dependent and due essentially to extracellular complexing of calcium. Further work is needed to determine whether patients who have out-of-hospital cardiac arrests can benefit from calcium administration.

The hemodynamic effects of heparin and their relation to ionized calcium levels

Heparin complexes calcium in vitro and possesses vasodilating properties when given as an intravenous bolus. To investigate the possibility that these hemodynamic effects could be related to the ability of heparin to induce hypocalcemia in vivo, we studied the response to a bolus of heparin, 300 IU/kg, in 20 patients undergoing cardiopulmonary bypass for cardiac operations. Ionized calcium decreased significantly after heparin administration, as did mean arterial pressure and systemic vascular resistance. In a further nine patients, 125 mg of calcium chloride was given immediately before the heparin bolus. It induced a small rise in calcium levels and maintained the mean arterial pressure at unchanged values. Our data confirm the vasodilating effect of an intravenous bolus of heparin and show that it is related to an acute lowering of ionized calcium levels. When calcium levels are not allowed to drop, the blood pressure is maintained at stable values. We advise slow injection of the heparin bolus and special attention to the ionized calcium levels before cardiopulmonary bypass.

Facilitated determination of ionized calcium

Using a calcium-containing heparin preparation for anticoagulation, we determined [Ca2+], the mean concentration of ionized calcium, in whole blood of 120 healthy blood-donors to be 1.23 (SD 0.04) mmol/L. Similarly, for 50 intensive-care patients selected without conscious bias, the correlation between [Ca2+] in serum (mean 1.15, SD 0.10 mmol/L) and in whole-blood samples anticoagulated with the same heparin preparation (mean 1.15, SD 0.09 mmol/L) was very good (r = 0.95). Storing samples anaerobically on ice for as long as 2 h did not alter whole-blood [Ca2+]. On the other hand, various concentrations of calcium-free heparin preparations all induced a significant decrease in measured [Ca2+]. By using whole-blood samples, rather than plasma or serum, for [Ca2+] determination with a calcium-selective electrode, repetitive measurements can be made with simple handling procedures, facilitating rapid implementation of appropriate therapeutic measures for critically ill patients.

Facilitated determination of ionized calcium

Using a calcium-containing heparin preparation for anticoagulation, we determined [Ca2+], the mean concentration of ionized calcium, in whole blood of 120 healthy blood-donors to be 1.23 (SD 0.04) mmol/L. Similarly, for 50 intensive-care patients selected without conscious bias, the correlation between [Ca2+] in serum (mean 1.15, SD 0.10 mmol/L) and in whole-blood samples anticoagulated with the same heparin preparation (mean 1.15, SD 0.09 mmol/L) was very good (r = 0.95). Storing samples anaerobically on ice for as long as 2 h did not alter whole-blood [Ca2+]. On the other hand, various concentrations of calcium-free heparin preparations all induced a significant decrease in measured [Ca2+]. By using whole-blood samples, rather than plasma or serum, for [Ca2+] determination with a calcium-selective electrode, repetitive measurements can be made with simple handling procedures, facilitating rapid implementation of appropriate therapeutic measures for critically ill patients.