Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster-randomised non-inferiority community trial

OBJECTIVE

To assess whether secondary prevention, which preemptively treats women with above-average postpartum bleeding, is non-inferior to universal prophylaxis.

DESIGN

A cluster-randomised non-inferiority community trial.

SETTING

Health sub-centres and home deliveries in the Bijapur district of Karnataka, India.

POPULATION

Women with low-risk pregnancies who were eligible for delivery with an Auxiliary Nurse Midwife at home or sub-centre and who consented to be part of the study.

METHODS

Auxiliary Nurse Midwifes were randomised to secondary prevention using 800 mcg sublingual misoprostol administered to women with postpartum blood loss ≥350 ml or to universal prophylaxis using 600 mcg oral misoprostol administered to all women during the third stage of labour.

MAIN OUTCOME MEASURES

Postpartum haemoglobin ≤7.8 g/dl, mean postpartum blood loss and postpartum haemoglobin, postpartum haemorrhage rate, transfer to higher-level facilities, acceptability and feasibility of the intervention.

RESULTS

Misoprostol was administered to 99.7% of women as primary prevention. In secondary prevention, 92 (4.7%) women had postpartum bleeding ≥350 ml, of which 90 (97.8%) received misoprostol. The proportion of women with postpartum haemoglobin ≤7.8 g/dl was 5.9 and 8.8% in secondary and primary prevention clusters, respectively [difference -2.9%, one-sided 95% confidence interval (CI) <1.3%]. Postpartum transfer and haemorrhage rates were low (<1%) in both groups. Shivering was more common in primary prevention clusters (P = 0.013).

CONCLUSION

Secondary prevention of postpartum haemorrhage with misoprostol is non-inferior to universal prophylaxis based on the primary outcome of postpartum haemoglobin. Secondary prevention could be a good alternative to universal prophylaxis as it medicates fewer women and is an acceptable and feasible strategy at the community level.

TWEETABLE ABSTRACT

Secondary prevention of postpartum haemorrhage with misoprostol is non-inferior to universal prophylaxis.

Degradation of pectins with different degrees of esterification by Bacteroides thetaiotaomicron isolated from human gut flora

A complete human fecal flora and cultures of defined species obtained from fecal flora were investigated in vitro to determine their ability to ferment the dietary fiber pectin. Bacteroides thetaiotaomicron was tested as a pectin-degrading microorganism alone and in coculture with Escherichia coli. Macromolecular pectins with different degrees of esterification were used as substrates in microbial degradation studies. The levels of oligogalacturonic acids formed in batch cultures were estimated during a 24- or 48-h incubation period by using high-performance thin-layer chromatography and high-performance anion-exchange chromatography. The spectrum and the amount of unsaturated oligogalacturonic acids formed as intermediate products of pectin fermentation changed permanently in the culture media during incubation with the complete fecal flora. After 24 h, no oligogalacturonic acids were detected. The pectin-degrading activities of pure cultures of B. thetaiotaomicron were lower than the pectin-degrading activity of a complete fecal flora. Cocultures of B. thetaiotaomicron and E. coli exhibited intermediate levels of degradation activity. In pure cultures of E. coli no pectin-degrading activity was found. Additionally, the rate of pectin degradation was affected by the degree of esterification of the substrate. Saturated oligogalacturonic acids were not found during pectin fermentation. The disappearance of oligogalacturonic acids in the later stages of fermentation with both the complete fecal flora and B. thetaiotaomicron was accompanied by increased formation of short-chain fatty acids.

Interaction between food components and drugs. Part 6: Influence of starch degradation products on propranolol transport

Interactions between different starch degradation products and propranolol (P) were studies using permeation experiments and affinity capillary electrophoresis (ACE). In the presence of maltooligosaccharides (MO), the transport of P across artificial lipid membranes was retarded. The most intensive interaction with the drug was found in the presence of the not-debranched MO from maize starch. The electrophoretic mobility mu of the drug was decreased in dependence of the MO concentration. However calculation of equilibrium binding constants from the ACE experiments was not possible because of the relatively weak influence of starch degradation products on the electrophoretic behaviour of the drug. With both methods the same tendency in strength of interactions between the different MO and P was found. Molecular parameters of the MO and their viscosity play a role in the interactions and in the decreased permeation of the drug.

Squash Yellow Leaf Curl Virus: A New Whitefly-Transmitted Poty-Like Virus

A severe yellow and leaf curl disease affecting field squash was found in the Batinah region of the Sultanate of Oman. The symptoms appear as small yellow spots, diffuse veinal yellowing, and leaf curling of young leaves. The inciting virus was easily transmitted by mechanical inoculation and by the whitefly Bemisia tabaci in a semi-persistent manner. The host range of the virus was restricted to two cucurbit species. Leaf dip preparations contained few flexuous particles about 700 to 750 nm long. Pinwheel-like inclusion bodies were observed in thin sections of diseased squash tissues. Serological tests by enzyme-linked immunosorbent assay showed that the virus is serologically related to watermelon mosaic virus-2, but not to zucchini yellow mosaic virus or papaya ring spot virus (watermelon strain). In view of these properties, this virus is considered to be a newly described virus and is tentatively named squash yellow leaf curl virus.

Effects of resistant starch on the colon in healthy volunteers: possible implications for cancer prevention

Recent evidence suggests that resistant starch (RS) is the single most important substrate for bacterial carbohydrate fermentation in the human colon. During two 4-wk periods. 12 healthy volunteers consumed a controlled basal diet enriched with either amylomaize starch (55.2 +/- 3.5 g RS/d; high-RS diet) or available cornstarch (7.7 +/- 0.3 g RS/d; low-RS diet). Approximately 90% of the RS consumed disappeared during intestinal passage; increased fermentation was verified by elevated breath-hydrogen excretion. During the high-RS diet, fecal wet and dry weight increased 49% and 56%, respectively (P < or = 0.005), whereas stool water content did not change significantly. Fecal concentrations and daily excretion of short-chain fatty acids were not different in the two study periods. During the high-RS diet, bacterial beta-glucosidase activity decreased by 26% (P < or = 0.05). Fecal concentrations of total and secondary bile acids were significantly lower during the high-RS than during the low-RS period [a decrease of 30% (P < or = 0.05) and 32% (P < or = 0.01), respectively, in total and secondary bile acids] whereas concentrations of primary bile acids were unaffected by RS consumption. During the high-RS diet, fecal concentrations of total neutral sterols decreased by 30% (P < or = 0.005) and fecal concentrations of 4-cholesten-3-one decreased by 36% (P < or = 0.05). These data suggest that RS has potentially important effects on bacterial metabolism in the human colon that may be relevant for cancer prevention.

Characterization of fat replacers

Effects of commercial fat replacers on rheological properties of emulsions have been studied under a second-order design. The corresponding functions of regression have been calculated to describe the measured effects mathematically. On the basis of a figured three-dimensional plan of response, combinations of variables (fat, fat replacer, water) could be determined showing a similar consistency to the corresponding full-fat foodstuff.

[Biotinidase deficiency--a progressive metabolic disease in children with seizures and ataxia]

Biotinidase deficiency is the primary biochemical defect in late-onset multiple carboxylase deficiency and an autosomal recessive disorder and characterized by seizures, ataxia, alopecia and skin rash. We describe a colorimetric semiquantitative method for screening for biotinidase activity from dried samples of whole blood spotted on filter papers. The administration of biotin to affected children can be a lifesaving procedure and can prevent irreversible neurologic damage.

Emigration of polymorphonuclear leucocytes into the intestinal lumen of the neonatal piglet in response to challenge with K88-positive Escherichia coli

The emigration of neutrophils from the blood of neonatal piglets into the intestinal lumen in response to a K88-positive strain of Escherichia coli was investigated. The pig herd used was of known genetic susceptibility to K88-positive E coli and had recently experienced an outbreak of neonatal diarrhoea. Neutrophil emigration depended on certain factors. Neutrophils emigrated into ligated loops in susceptible piglets sucking immune colostrum from susceptible dams but not into loops in colostrum deprived resistant piglets or piglets sucking non-immune colostrum from resistant dams. In susceptible, colostrum deprived piglets neutrophils in intestinal contents were only associated with severe lesions. Large numbers of neutrophils which appeared at several foci on the villi were observed in three of six resistant piglets that sucked immune colostrum from susceptible dams. It was concluded that neutrophil emigration into the intestinal lumen of piglets could occur in response to K88-positive E coli and resulted not from the presence or absence of the intestinal K88-receptor but from the ingestion of immune colostrum.

Aclarubicin (aclacinomycin A) in the treatment of relapsing acute leukaemias

Forty patients with relapsing acute leukaemias were treated with aclacinomycin A (aclarubicin, ACM), 25 mg/m2 i.v. daily for 7 days. Twenty-nine patients with acute myeloid (AML) and five with acute lymphoblastic (ALL) leukaemia were evaluable. The overall response rate was 29.5%. Eight complete (CR) and one partial (PR) remissions were achieved in AML (31%). A high CR rate was induced in patients treated at first relapse without prior reinduction (6/12 patients). A small proportion of leukaemias resistant to daunorubicin or doxorubicin responded to ACM (3/17 patients). Median remission duration was 5.5 months (range: 2-9 months). The most common toxic effects were nausea, vomiting, stomatitis and diarrhoea. Acute cardiotoxic effects were documented in three patients. Congestive cardiomyopathy was not observed despite prior treatment with anthracyclines. We conclude that the present dose scheduling of ACM is effective in the treatment of relapsing AML and that it should be introduced in combined chemotherapy in phase III trials to compare its activity to that of daunorubicin or doxorubicin.

[Distribution of free carboxyl groups in native pectins from fruits and vegetables]

Pectins from 18 kinds of fruit and vegetable are extracted with ammonium oxalate from the alcohol-insoluble substance and fractioned on DEAE-Sephacell. All the fruit pectins as well as tomato and sunflower pectin have in their distribution of the esterification degree a concentration maximum in the highly esterified range, that is above an esterification degree of 60%. With lower esterification degrees the concentration decreased continuously. Vegetable pectins from cucumbers, celery, and tomato-paprika (sweet, red) have their maximum within an esterification range of 50-60%. The carboxyl groups are randomly distributed in all these preparations. As against that, vegetable pectins from red and white cabbage, cauliflower, large radish and carrots have in addition to a pectin fraction with randomly distributed carboxyl groups another one, pectin molecules of which have blocks of free carboxyl groups. The latter fraction may constitute up to 50% of the pectin.

[Characterization of polygalacturonase covalently bonded to Sepharose]

For the soluble endo-polygalacturonase (EC 3.2.1.15.) from Aspergillus spec., investigated in the present work, the defined substrate turnover U at 50% loss of viscosity if 0.2% and is independent on the reaction temperature. In the case of the covalently-bonded enzyme, the following linear equation applies to U, depending on the specific activity A and in the limits from A = O [U] and Amax: U = [U] + S square root of A. U is influenced by the kind of linkage, the conditions of immobilization and the properties of the carrier: it is a measure of the postulated conformational change of the polygalacturonase. The characteristic limiting value for the substrate turnover at A = O [U] is also temperature-independent and proves to be a true increment of binding, whereas Amax depends essentially on the porosity of the carrier. Polygalacturonase-sepharose complexes with a real substrate turnover U of 3--20% were prepared by varying systematically the kind of linkage and the specific activity A. It was found that with increasing U these complexes were, as a rule, inhibited to a lesser extent by a non-competitive pectinase inhibitor than the soluble polygalacturonase. Furthermore, their ability to liberate or enrich oligomeric galacturonic acids with a degree of polymerization greater than 3 was markedly reduced.

[Mode of action and inhibition of polygalacturonase covalently bound to polysaccharide and glass carriers]

Endo-polygalacturonase (EC 3.2.1.15.) from Aspergillus spec. is much changed as far as its mode of action and the interaction with vegetable inhibitors of pectinase (from green beans and cucumbers) are concerned when it is covalently bound to insoluble carriers (Sepharose, cellulose powder, macroporous glass and nonporous ballotinis). Whereas a 2% degradation of substrate by the soluble enzyme caused a 50% decrease of viscosity of citrus pectic acid, the comparable degradation of substrate was increased to a level of about 10% with the investigated polygalacturonase carrier complexes apparently independent of the properties of the carriers and the kind of binding of the enzyme. In contrast to this the higher degradation of substrate of 15 and 20% respectively which was further stated at a 50% decrease of viscosity is unambiguously connected with the carriers and is in direct correlation with the specific activity of the polygalacturonase carrier complexes. Contrary to the soluble enzyme the covalently bound enzyme produces more lower oligomerous galacturonic acids by an exo-mechanism or by multiple attack already at the beginning of the hydrolysis of pectic acid. During the final stage there is an enrichment of trigalacturonic acid besides mono- and digalacturonic acids independent of the state of solution of the enzyme. It could further be stated that the strong inhibition of the soluble endo-polygalacturonase by selected pectinase inhibitors which was described earlier is reduced by degrees with the enzyme covalently bound to the insoluble carriers.

[Carcino-embryogenic antigen (CEA) in patients with genital tumors (author's transl)]

The concentration of carcino-embryogenic antigen in the serum of healthy women and of patients with different benign and malignant genital tumors was determined before and after treatment. The carcino-embryogenic antigen was elevated to more than 2.5 ng/ml in 11% of the healthy control patients. Patients with carcinoma of the breast had positive CEA tests in 60%. Patients with ovarian cancer had positive CEA tests in 57%, women with carcinoma of the uterine cervix had positive tests in 50% and women with endometrial carcinoma had increased CEA levels in the serum in 38% of the cases. Following treatment the CEA values decreased.

[Umbilical cord AFP values in twins (author's transl)]

The concentration of alpha-fetoprotein (AFP) in the umbilical cord in twins was determined via radioimmunological analysis and compared with the values obtained in single births. Since a close correlation exists between AFP content and gestation age, this method can be used to estimate maturity. The mean concentration of AFP was significantly higher in the umbilical blood of fraturnal twins than in that of identical twins. Genetic factors could play a role here.

[Social psychological aspects of suicide in the old age (author's transl)]

Referring to Emile Durkheim's classical appraoch the normative aspects of suicide are emphasized, regarding suicidal behavior not as a purely individual phenomenon but as always co-determined by the normative expectations of a person's social environment. Starting from the dramatic increase of suicide rates with age combined with a marked decrease in non-letal suicide attempts it is argued that normally suicide-inhibiting social norms become less effective as a person appraoches old age, thus weakening the appellative motivation components of suicidal behavior and strengthening evasive strivings. Results of 2 representative studies are reported which tend to support these as well as a number of more specific hypotheses. Moreover, some aspects in the attitude to younger persons to suicidal acts of old people seem even compatible with the assumption of latent suicide-facilitating expectations.

Premature chromosome condensation in irradiated man

Micronuclei and premature chromosome condensation previously described in mammalian cells exposed to different types of irradiation and chemicals in vitro or in vivo could be demonstrated in cultured lymphocytes derived from chronically low-dose irradiated persons. The usefulness of these findings for biological recording of irradiation effects is suggested.

[Spinning of rapeseed proteins]

Alkaline solutions of a mixture from rapeseed globulin and casein show plastic flow, which is influenced by protein concentration, relation of rapeseed globulin and casein, temperature and time of storage of the protein solution. The sodium hydroxide concentration with a great variability doesn't take effect on the rheological properties. With increasing content of casein in such alkaline solutions of rapeseed globuline and casein results an approach to NEWTONian flow. The spinnability of alkaline solutions of a mixture from rapeseed globulin and casein and the properties of the corresponding spun protein fibers are influenced by protein concentration, relation of rapeseed globulin and casein of the spinning solution and temperature of coagulating bath. The sodium hydroxide content of the spinning solution and the hydrochloric acid concentration of the coagulating bath with a great variability don't take effect. The spinnability of alkaline solutions of a mixture from rapeseed albumin starchsulphate and casein and the properties of the corresponding spun protein fibers compared to rapeseed globulin-casein mixtures are influenced additionally by sodium hydroxide concentration of the spinning solution and hydrochloric acid content of coagulating bath. The favourable influence on the properties of spun rapeseed albuminstarchsulphate-casein fibers isn't increased by a growth of the rapeseed albumin starchsulphate content more then 4% of the protein concentration of the spinning solution.

[Rheology and spinning of alkaline solutions of sunflower seed globulin and casein]

The specific demand of sodium hydroxide is determined for the dissolution of sunflower seed globulin, casein and a mixture of them to equal parts. In low protein-containing solutions it depends for sunflower seed globulin very much on the sodium chloride concentration. From sunflower seed globulin, casein and a mixture of them to equal parts are prepared with sodium hydroxide high protein-containing alkaline solutions. Sunflower seed globulin forms temporally a gel phase. After this phase the solution of sunflower seed globulin shows like casein and a mixture of sunflower seed globulin/casein (I:I) pseudoplastic flow. The flow curves of the pseudoplastic solutions are described mathematically with the OSWALDian power statement. By alkaline solutions of casein and sunflower seed globulin/casein (I:I) the flow exponent n is distributed statistically about 0.9, by solutions of sunflower seed globulin a distribution exists about the mean values n = 0.85 and n = 0.50. lg k depends in all protein solutions on the concentration of protein, sodium chloride, sodium hydroxide and on the temperature and time. For all protein solutions exists a linear relation between the logarithm of viscosity and the reciprocal temperature for lg k and I/T, which is derived normally for NEWTONian flow behaviour. In a suitable scope of spinning for all protein solutions are carried out complete factorial experiment, which guide to regression equations of lg k; in the case of sunflower seed globulin are calculated also a regression equation of the flow exponent n. Going out from the parameters of the spinning process the properties of the spun sunflower seed globulin/casein (I:I) fibers are described.

[Alpha-fetoprotein in assessing obstetric diagnosis (author's transl)]

Radio-immunologic measurement of alpha-fetoprotein is possible in small amounts of blood and amniotic fluid. During the first half of pregnancy the AFP values in maternal serum are lowered when there is fetal abnormality (hydatid cyst, immnent abortion). In the second half of pregnancy high values of AFP also indicate danger to the fetus (Rh-incompatibility). The older the pregnancy the AFP values in amniotic fluid fall. In pathologic pregnancy (hydramnion, anencephaly, trisomy) AFP concentration was normal or raised. Measurement of the AFP level in umbilical cord -- blood provides further diagnostic chances: assessment of the duration of pregnancy and, therefore, of fetal maturity.

[Maternal serum-alpha-fetoprotein for monitoring risk-pregnancies (author's transl)]

This study confirms essentially the results of other investigators who found a good correlation between fetal risk and maternal AFP level. This adds an immuno-chemical technique to well-known methods of monitoring risk-pregnancies (ultra-sound, HPL, estrogenes) which enables us to measure a specific fetal metabolic product, alpha-feto-protein, in amniotic fluid, umbilical blood and maternal serum.

[Fibrin (ogen) Split products of nephropathies]

On healthy individuals fibrin(ogen) split products cannot be demonstrated in the blood. Catabolic products of fibrin and fibrinogen appear in the blood in case of general fibrinolysis, consumption coagulopathy with secondary fibrinolysis as well as local fibrin films with secondary fibrinolysis. The regular routine determination of fibrin(ogen) split products in serum or urine may indicate starting complications of many diseases. The appearance of these split products in case of renal affections indicates acute and active processes on the kidneys themselves; fibrin films appear in case of acute and chronic glomerulonephritis, casting-off crises on renal transplants, EPH gestosis, renal phlebothrombosis, hemolytic-uremic syndrom and occasionally urinary tract infections. The demonstration of fibrin(ogen) split products in serum or urine allows the following conclusions: a) acute and active process on the kidneys themselves; b) HMWS in urine indicate a fibrin film in the kidneys; c) an immediate beginning of an anticoagulation therapy; d) good possibilities to judge the therapeutic effect and by this the further progress of disease.