Oxytocin versus a combination of tranexamic acid and ethamsylate in reducing intraoperative bleeding during abdominal myomectomy: a randomized clinical trial

OBJECTIVE

Myomectomy is the preferred surgical approach to manage uterine fibroids. However, uterine fibroids are highly vascular tumors and, consequently, extremely susceptible to problems from myomectomy-related hemorrhage. Hence, we aim to compare oxytocin efficacy and safety profile versus tranexamic acid (TA) with ethamsylate for reducing bleeding during myomectomy.

METHODS

This randomized, double-blinded multicenter study was performed between 20th August 2020 and 20th October 2020 at El-Galaa Teaching Hospital, El Hussein University Hospital, Al-Azhar University Hospitals of Assiut, and Al-Azhar University Hospitals of Damietta. One hundred and eighty patients were enrolled and divided into three groups: group (1) received an injection of 30 IU of oxytocin in 500 ml of normal saline; group (2) received injections of 1 g of TA, 250 mg of Ethamsylate, and 110 ml of normal saline IV; and group (3) received an injection of 110 ml of normal saline IV just before surgical incision.

RESULTS

In 180 premenopausal women, oxytocin and TA with ethamsylate had no significant value in lowering intraoperative blood loss compared with the placebo for abdominal myomectomy (666.25 ± 183.03, 630.72 ± 145.83, and 646.67 ± 168.92, respectively (P = 0.506)). Non-significant trends were observed for a reduction in operation time (P = 0.760), intra/postoperative blood transfusion (P = 0.624), hospital stay (P = 0.986), postoperative fever (P = 0.659), and wound infection (P = 1).

CONCLUSION

Oxytocin and TA with ethamsylate had no significant value in lowering intraoperative blood loss compared with the placebo for abdominal myomectomy which opens a new question about the role of the use of the hemostatic drug during myomectomy especially in centers with limited resources and had higher rates.

TRIAL REGISTRATION

The study was registered on Pan African Clinical Trials Registry with the following number: PACTR202008739887429 and was approved on 24/08/2020.

Lidocaine vs. tramadol vs. placebo wound infiltration for post-cesarean section pain relief: a randomized controlled trial

OBJECTIVES

In low-income settings, postoperative pain relief could be challenging as a high patient/nurse ratio limits pain assessment and adequate analgesics administration. The multi-center prospective double-blinded parallel randomized controlled trial was done to compare lidocaine, tramadol, and placebo (saline) intraoperative wound infiltration to relieve post-cesarean section wound pain during the first 24 h.

METHODS

Ninety-nine cases were equally randomized into three groups, each containing 33 pregnant women undergoing cesarean section under general anesthesia. During operation, the wound was infiltrated subcutaneously with 20 mL of 2% lidocaine solution in the first group, 2 mg/kg tramadol in the second group, and saline in the third group. The primary outcome was to assess the postoperative pain at 2, 4, 6, 12, and 24 h by the Yes-No-Don't Know (YNDK) Scale, while the secondary outcome was to assess the need for further postoperative analgesia.

RESULTS

Wound infiltration with lidocaine or tramadol was effective in pain relief, and both were superior to placebo. Wound infiltration with tramadol was superior to lidocaine in pain relief at 2 h and up to 24 h.

CONCLUSIONS

Wound infiltration with tramadol has a more prolonged pain relief effect than lidocaine in post-cesarean section pain relief in patients performing cesarean section under general anesthesia lasting up to 24 h, and both are superior to placebo in pain relief.

Effect of Intra Uterine Granulocyte Colony Stimulating Factor vs. Human Chorionic Gonadotropin at Ovum Pick Up Day on Pregnancy Rate in IVF/ICSI Cases With Recurrent Implantation Failure

Objective

Recurrent implantation failure is defined as failure to achieve clinical pregnancy after the transfer of four or more good-quality embryos in a minimum of three fresh or frozen cycles in a woman aged less than 40 years. The objective is to compare between the effect of intrauterine G-CSF, hCG, and saline solution injection (as placebo) at the day of ovum pick-up on clinical pregnancy, chemical pregnancy, implantation, and miscarriage rates in patients with recurrent implantation failure undergoing IVF/ICSI.

Methods

This prospective, double blind, parallel, randomized controlled trial included 150 patients equally divided into 3 groups, each containing 50 individuals. Subjects in Group 1 received intrauterine injections of G-CSF; Group 2: received intrauterine injections of 500 IU of hCG; and Group 3 received intrauterine injections of saline solution as placebo. The primary outcome measure is clinical pregnancy rate. Secondary outcomes are biochemical pregnancy, implantation, and miscarriage rates.

Results

Clinical pregnancy, biochemical pregnancy, and implantation rates were highest in the group given G-CSF and lowest in the group administered saline solution; miscarriage rates were not significantly different between the groups.

Conclusions

Intrauterine administration of G-CSF at a dose of 100 µg/1.0 cc at the time of ovum pick-up is associated with better clinical pregnancy, chemical pregnancy, and implantation rates as compared with intrauterine saline solution administration. Further studies are needed to determine the optimum timing of intrauterine administration of G-CSF that achieves the best results, and longer follow-up is needed to determine take-home baby percentages.

Transverse versus longitudinal blunt extension of the uterine incision during cesarean section in women with a uterine scar of previous cesarean delivery: A randomized controlled trial

OBJECTIVE

To compare two different blunt extension techniques of the lower segment transverse uterine incision at cesarean delivery in women with a uterine scar of previous cesarean delivery.

METHODS

Study design: Prospective single-blinded parallel multi-center randomized controlled trial involving 392 cases equally divided into two groups. Group one had their incision extended transversely, while group two had their incision extended longitudinally.

OUTCOME MEASURES

The primary outcome was the unintended extension of the uterine incision, while the secondary outcomes included the need for additional stitches to achieve hemostasis, the drop in hemoglobin level, uterine vessels injury, and the need for blood transfusion.

RESULTS

No significant difference between the transverse and longitudinal extension of the uterine incision during cesarean section as regards unintended uterine extension (P=0.860), uterine vessel injury (P=0.501), and cases requiring blood transfusion (P=0.814). Significantly lower drop in hemoglobin level (P≤0.001) and significantly less need for additional stitches (P≤0.001) in cases with the longitudinal extension of uterine incision.

CONCLUSION

In women with a uterine scar of previous cesarean delivery, the blunt longitudinal extension of the uterine incision in the lower segment cesarean section didn't differ from the blunt transverse extension as regards unintended uterine extension but is associated with less hemoglobin drop and less need for additional stitches as compared to transverse extension of the incision. Further studies are needed to assess the long-term complications of both techniques.

Relationship Between Ano-vaginal Distance and Bacterial Vaginosis (Cross-sectional Study)

Bacterial vaginosis is a vaginal condition caused by the overgrowth of anaerobic bacteria, owing to a shift in the vaginal microbial ecosystem. The aim of the study is to investigate the relationship between the ano-vaginal distance and the risk of developing bacterial vaginosis. In this cross-sectional study, the ano-vaginal distance was measured in 100 women participants complaining of vaginal discharge, divided into two groups. Group (1) consisted of 74 women who were negative for bacterial vaginosis, and group (2) consisted of 26 women who had bacterial vaginosis based on Amsel criteria. The negative cases for bacterial vaginosis had significantly longer ano-vaginal distance as compared with those who had bacterial vaginosis (3.85 ± 0.54 versus 3.38 ± 1.02). A positive correlation was detected between ano-vaginal distance and the risk of developing bacterial vaginosis. Further extensive studies are required to investigate this finding in different population groups.

Nicotinic receptors mediate stress-nicotine detrimental interplay via dopamine cells' activity

Epidemiological studies report strong association between mood disorders and tobacco addiction. This high comorbidity requires adequate treatment but the underlying mechanisms are unknown. We demonstrate that nicotine exposure, independent of drug withdrawal effects, increases stress sensitivity, a major risk factor in mood disorders. Nicotine and stress concur to induce long-lasting cellular adaptations within the dopamine (DA) system. This interplay is underpinned by marked remodeling of nicotinic systems, causing increased ventral tegmental area (VTA) DA neurons' activity and stress-related behaviors, such as social aversion. Blocking β2 or α7 nicotinic acetylcholine receptors (nAChRs) prevents, respectively, the development and the expression of social stress-induced neuroadaptations; conversely, facilitating α7 nAChRs activation specifically in the VTA promotes stress-induced cellular and behavioral maladaptations. Our work unravels a complex nicotine-stress bidirectional interplay and identifies α7 nAChRs as a promising therapeutic target for stress-related psychiatric disorders.

Letrozole vs. Placebo Pretreatment in the Medical Management of First Trimester Missed Miscarriage: a Randomized Controlled Trial

Introduction

Misoprostol is used for the medical management of miscarriage as it is more effective in the early stages of pregnancy. Letrozole has an anti-estrogen effect and is used for the pretreatment of miscarriage with misoprostol.

Aim

The aim of this study was compare the efficacy and safety of letrozole with placebo pretreatment in the medical management of first trimester missed miscarriage.

Design

This was a prospective randomized case-control study.

Patients and Methods

Four hundred and thirty-eight women were randomly divided into two groups of 219; the placebo group received placebo tablets twice daily for 3 days, followed by 800 micrograms of misoprostol vaginally on the fourth day of enrolment, while the letrozole group received letrozole 10 mg twice daily for three days followed by 800 micrograms misoprostol administered vaginally. Symptoms and side effects were recorded, and the women advised to return to hospital if they experienced severe pain or bleeding or intolerable side effects and to report to hospital for a check-up one week after misoprostol administration. Ultrasound was done seven days after misoprostol administration to monitor outcomes. Surgical evacuation was carried out if medical management failed.

Results

There were significant differences between the two groups, with better outcomes found for the letrozole group in terms of rates of complete miscarriage, onset of vaginal bleeding, and interval between induction and onset of expulsion (p < 0.001). A higher rate of nausea and vomiting was reported for the letrozole group (p = 0.002). Differences between groups with regard to pre- and post-termination hemoglobin levels, fever, severe pain and severe bleeding needing evacuation were not statistically significant.

Conclusion

Adding letrozole to misoprostol improves the success rate and decreases the interval between induction and expulsion in cases of first trimester miscarriage; however, nausea and vomiting is higher with letrozole.

Role of topical oxytocin in improving vaginal atrophy in postmenopausal women: a randomized, controlled trial

OBJECTIVE AND DESIGN

Prospective randomized controlled trial to test the effectiveness of topical oxytocin gel to improve vaginal atrophy in postmenopausal women.

PATIENTS AND METHODS

A total of 140 postmenopausal women presenting with vaginal atrophy and who satisfied the inclusion and exclusion criteria were randomized into two groups each of 70 patients; they received intravaginal oxytocin gel or placebo gel for 30 days. Serum estrogen level, visual, colposcopic and histological vaginal examination were performed before and after treatment.

RESULTS

Forty-seven out of 70 women in the oxytocin gel group improved after treatment and none in the placebo group (p = 0.001). Forty-five participants in the oxytocin group and seven in the placebo group reported relief of dyspareunia (p = 0.001). Thirty-four participants in the oxytocin group and seven in the placebo group reported relief of soreness (p = 0.001). There was no significant difference between the circulating levels of estradiol in both groups before and after treatment (p = 0.4 and 0.6 for the oxytocin group and the placebo group, respectively).

CONCLUSION

Oxytocin gel is useful in the restoration of the vaginal epithelium in cases of postmenopausal atrophic vaginitis. Further studies with a longer follow-up period are required to test the long-term effects of oxytocin as a treatment for vaginal atrophy.

Viral-mediated expression of a constitutively active form of cAMP response element binding protein in the dentate gyrus increases long term synaptic plasticity

The transcription factor cAMP response element binding protein (CREB) is a key player in synaptic plasticity and learning. Phosphorylation of CREB induced by neuronal activity leads to gene transcription, a process thought to contribute to memory formation. We have previously reported that increasing CREB activity in glutamatergic CA1 pyramidal neurons or in dentate gyrus (DG) granule cells is sufficient to enhance hippocampal-dependent memory formation. This enhancement correlates with an increase in CA1 glutamatergic synaptic plasticity. However, the effects of increasing CREB activity on DG glutamatergic plasticity have not been investigated. To address this issue, we boosted CREB-dependent transcription in DG granule cells in vivo via viral mediated expression of a constitutively active form of CREB (CREBCA). Using in vitro extracellular field recordings of infected slices, we observed an increase in long-term potentiation (LTP) while short-term plasticity and basic synaptic transmission remained unaffected. These data demonstrate that boosting CREB activity in DG granule cells is sufficient to enhance LTP and suggest that this enhancement participates in the formation of better memories.

Molecular identification and immunohistochemical localization of atrial natriuretic peptide in the heart of the dromedary camel (Camelus dromedarius)

Atrial and B-type natriuretic peptide (ANP and BNP) are cardiac hormones synthesized and secreted by the myoendocrine cells of the heart. They exert potent actions on body fluid balance. Since various body organs including the heart are under high physiological stress during water and food deprivation in the desert nomads, we intended to perform molecular biological and histological studies of ANP in the heart of the dromedary camel Camelus dromedarius. Initially, we isolated cDNAs encoding ANP from the atrium and BNP from the atrium and ventricle of the dromedary camel. Putative mature ANP, deduced from the cDNA sequence, was identical to that of human and pig ANP, but the putative mature BNP was more diverse and was most similar to pig BNP (94% identity). Thus, we used antisera raised against human ANP that did not cross-react with pig BNP in the subsequent immunohistochemical studies. The ANP-expressing myoendocrine cells are most concentrated in the right atrium, to a lesser extent in the left atrium, and almost absent in the left ventricle. The immuno-positive cells are scattered uniformly in each region and are characterized by the presence of immunoreactive granular deposits around the nucleus. The left atrium comprises some ramifications of conductive cells (Purkinje fibers), some of which also contained ANP-immunoreactive granules. At the electron microscopic level, myoendocrine cells possessed secretory granules primarily in the perinuclear zone and a well-developed Golgi apparatus. The present study is the first comprehensive report dealing with the molecular cloning and immunohistochemical localization of ANP in the heart of a desert dwelling mammal.

Transforming growth factor beta (TGFbeta) mediates Schwann cell death in vitro and in vivo: examination of c-Jun activation, interactions with survival signals, and the relationship of TGFbeta-mediated death to Schwann cell differentiation

In some situations, cell death in the nervous system is controlled by an interplay between survival factors and negative survival signals that actively induce apoptosis. The present work indicates that the survival of Schwann cells is regulated by such a dual mechanism involving the negative survival signal transforming growth factor beta (TGFbeta), a family of growth factors that is present in the Schwann cells themselves. We analyze the interactions between this putative autocrine death signal and previously defined paracrine and autocrine survival signals and show that expression of a dominant negative c-Jun inhibits TGFbeta-induced apoptosis. This and other findings pinpoint activation of c-Jun as a key downstream event in TGFbeta-induced Schwann cell death. The ability of TGFbeta to kill Schwann cells, like normal Schwann cell death in vivo, is under a strong developmental regulation, and we show that the decreasing ability of TGFbeta to kill older cells is attributable to a decreasing ability of TGFbeta to phosphorylate c-Jun in more differentiated cells.

Glutamate does not play a major role in controlling bone growth

Bone cells express glutamate-gated Ca2+-permeable N-methyl-D-aspartate (NMDA) receptors and GLAST glutamate transporters. Blocking NMDA receptors has been reported to reduce the number of bone resorption pits produced by osteoclasts, and mechanical loading alters GLAST transporter expression, which should change the extracellular glutamate concentration and NMDA receptor activation. Thus, by analogy with the brain, glutamate is postulated to be an important intercellular messenger in bone, controlling bone formation and resorption. We found that activating or blocking NMDA receptors had no effect on bone formation by rat osteoblasts in culture. The number of resorption pits produced by osteoclasts was reduced by the NMDA receptor blocker MK-801 but not by another blocker AP-5, implying that this effect of MK-801 is unrelated to its glutamate-blocking action. By contrast, MK-801, AP-5, and NMDA had no consistent effect on the volume of pits. In mice with GLAST glutamate transporters knocked out, no differences were detected in mandible and long bone size, morphology, trabeculation, regions of muscle attachment, resorption lacunae, or areas of formation versus resorption of bone, compared with wild-type siblings. These data suggest that glutamate does not play a major role in controlling bone growth.

Ajuba, a cytosolic LIM protein, shuttles into the nucleus and affects embryonal cell proliferation and fate decisions

Cellular adhesive events affect cell proliferation and differentiation decisions. How cell surface events mediating adhesion transduce signals to the nucleus is not well understood. After cell-cell or cell-substratum contact, cytosolic proteins are recruited to clustered adhesion receptor complexes. One such family of cytosolic proteins found at sites of cell adhesion is the Zyxin family of LIM proteins. Here we demonstrate that the family member Ajuba was recruited to the cell surface of embryonal cells, upon aggregate formation, at sites of cell-cell contact. Ajuba contained a functional nuclear export signal and shuttled into the nucleus. Importantly, accumulation of the LIM domains of Ajuba in the nucleus of P19 embryonal cells resulted in growth inhibition and spontaneous endodermal differentiation. The differentiating effect of Ajuba mapped to the third LIM domain, whereas regulation of proliferation mapped to the first and second LIM domains. Ajuba-induced endodermal differentiation of these cells correlated with the capacity to activate c-Jun kinase and required c-Jun kinase activation. These results suggest that the cytosolic LIM protein Ajuba may provide a new mechanism to transduce signals from sites of cell adhesion to the nucleus, regulating cell growth and differentiation decisions during early development.

C-terminal interactions modulate the affinity of GLAST glutamate transporters in salamander retinal glial cells

1. Proteins that interact with the intracellular carboxy termini of neurotransmitter- and voltage-gated ion channels are known to control the subcellular localization of the channels, localize other proteins near those channels, and modulate channel activity. By contrast, little is known about the control of neurotransmitter transporter function by interacting proteins. 2. To competitively disrupt interactions of the C- and N-termini of the GLAST glutamate transporter with other proteins, we dialysed whole-cell patch-clamped retinal glia with peptides identical to the eight amino acids at the C- or N-termini of the transporter, and compared the effect on transporter-mediated currents with dialysis of scrambled versions of the same peptides. 3. Dialysis with the N-terminus peptide had no effect on the maximum glutamate-evoked current nor on the glutamate affinity of the transporter. Dialysis with the C-terminus peptide had no effect on the maximum current, but increased the affinity of the transporter for glutamate (compared with scrambled C-terminus peptide, and with N- and scrambled N-terminus peptides: Km decreased from 16 to 11 microM)). 4. These data suggest that disruption of an interaction between an intracellular protein and the last eight amino acids of the GLAST C-terminus, which have some similarity to the PDZ binding domain of ion channel C-termini, increases the glutamate affinity of GLAST. Thus, the interacting protein decreases the affinity of GLAST transporters. 5. Removing the GLAST C-terminus interaction increases the transporter current by 40 % at low glutamate concentrations. Thus, this interaction may significantly slow the removal of low concentrations of glutamate from the extracellular space, and affect the kinetics of retinal cell light responses.

The structure of mixed cholesterol-phospholipid monolayers spread at the air-water interface as probed by interactions with band 3 protein from erythrocyte membranes

Solubilized band 3 protein from human erythrocyte membranes (the anion transport protein) interacts strongly and specifically with monolayers of cholesterol spread at the air-water interface whereas, at pH 7-10, it shows only moderate interactions with phospholipid monolayers (Klappauf, E. and Schubert, D. (1979) Hoppe-Seyler's Z. Physiol. Chem. 360, 1225-1235). When band 3 protein, at pH 7 and an ionic strength of approx. 100 mM, is added to the subphase of mixed cholesterol-glycerophospholipid monolayers, the changes delta pi in monolayer surface pressure induced by the protein depend on the mole fraction X of sterol in the mixture. However, delta pi (X) only increases with increasing X towards the high values of delta pi that are characteristic of cholesterol monolayers if X greater than 0.67 +/- 0.04; at lower cholesterol content, delta pi (X) is practically identical to the value obtained with the pure glycerophospholipid. With mixtures of coprostanol and glycerophospholipids, the break in the delta pi (X) curves occurs when X = 0.33 +/- 0.03. Cholesterol-sphingomyelin and epicoprostanol-phosphatidylethanolamine mixtures show an increase of delta pi (X) when X greater than 0. The data seem to support earlier claims that cholesterol can form stoichiometric complexes with glycerophospholipids, the stoichiometries revealed by the band 3-monolayer interactions being 2:1 and 1:2. They also show that cholesterol-sphingomyelin complexes, if they should exist, must be structurally different from the cholesterol-glycerophospholipid complexes.

Reorienting staff attitudes toward the dying

After assessing the kind of care it was providing to terminally ill patients and their families, Holy Cross Hospital of Silver Spring (MD) committed itself to a more balanced program of care that included the creation of a thanatology department, implementation of special educational programs for hospital personnel, and exploration of the possibility of establishing a hospice care concept at the hospital.