Congenital continuous retrograde basilar flow suggests type B interrupted aortic arch in a neonate: A case report

Reversed flow in the basilar artery can be acquired or congenital. Acquired reversed flow in the basilar artery can result from acute thrombosis of the basilar artery or retrograde vertebral artery flow. Congenital continuous retrograde basilar artery flow has not been described. We report a 2-day-old male presenting with hypocalcemic seizures which led us to obtain a Duplex echoencephalogram. An echocardiogram was subsequently ordered. In the coronal plane through the anterior fontanelle, retrograde flow was seen in the basilar artery and the right vertebral artery. In the axial plane through the temporal window, the flow was anteroposterior in both posterior communicating arteries. In the posterior cerebral arteries, the flow was retrograde in the P1 segment and anterograde in the P2 and P3 segments. An interrupted aortic arch was suspected. The echocardiogram showed a large perimembranous ventricular septal defect with bidirectional shunting, a hypoplastic and bicuspid aortic valve, an aortic arch interrupted between the left common carotid artery and the left subclavian artery (type B interrupted aortic arch), and a 5 mm patent ductus arteriosus with predominant right to left flow. Because of the patency of the large patent ductus arteriosus, our patient showed no sign of posterior circulation insufficiency. Prostaglandin E1 therapy was initiated immediately. Diagnosis of DiGeorge syndrome was proven. The infant underwent interrupted aortic arch repair and anterograde flow was established in the basilar artery. We conclude that congenital asymptomatic continuous retrograde flow in the basilar artery and left vertebral artery is a medical emergency as it implies the presence of type B interrupted aortic arch with large patent ductus arteriosus in a neonate.

Doppler Ultrasonographic Evaluation of Erectile Dysfunction in a Northern Nigerian Tertiary Hospital

Background

Colour duplex Doppler is a noninvasive tool for the evaluation of the vascular mechanism of erectile dysfunction (ED). It can be used to determine the integrity of the vascular mechanism and to differentiate between arterial and venous insufficiency.

Objectives

To identify the vasculogenic causes of ED and subclassify them into arteriogenic, venogenic, or mixed to assist in predicting the clinical outcome.

Materials and Methods

A retrospective study was conducted at the Department of Radiology, ABUTH Zaria, from records of patients who had presented to the Doppler suite with symptoms of ED available between July 2020 and August 2022.

Results

A total of 23 patients were involved in this study. The age range was 25-66 years. The majority of the patients were seen in age groups 51-60 years and 41-50 years with 48% (11) and 22% (5), respectively. Only 3 (13%) of the patients were found to have normal penile Doppler study, 12 (52%) patients were found to have arteriogenic, and another 4 (17.4%) patients were found to have venogenic cause. In four (17.4%) patients, there was mixed/inconclusive picture. Among the nine (39%) patients with Peyronie's disease, only one showed normal Doppler study. The incidence of vasculogenic cause of ED was found to increase with age.

Conclusions

The colour Doppler study is an important noninvasive nonionizing radiation tool for swift evaluation of penile erectile function and, thus, helps in classifying ED causes into structural, vascular, or possibly psychogenic, hence guiding the clinicians on the therapeutic options.

Cumulative Dose of Prostaglandin E1 Determines Gastrointestinal Adverse Effects in Term and Near-Term Neonates Awaiting Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

This study aimed to assess the association between treatment characteristics of prostaglandin E1 including initiation time and duration, maximal and cumulative doses, and adverse effects.

DESIGN

A retrospective cohort study in which medical records of neonates with duct-dependent lesions were studied for treatment parameters and adverse effects. Multivariable logistic regression model was applied for testing the effect PGE1 variables on outcomes.

MAIN OUTCOME MEASURES

The primary outcomes of this study were association of adverse effects of PGE1 treatment with maximal dose, cumulative dose, and treatment duration. The secondary outcomes included safety of feeding in infants treated with PGE1.

RESULTS

Eighty-two infants with duct-dependent lesions receiving PGE1 were included. Several infants who received early PGE1 treatment required ventilation support. Feeds were ceased more often as the cumulative dose and duration of PGE1 treatment increased. Gastrointestinal adverse effects were significantly associated with the cumulative dose of PGE1 and treatment duration. Apneas, hyperthermia, and tachycardia were associated with maximal dose. Our data did not demonstrate a difference in the incidence of NEC associated with characteristics of PGE1 treatment.

CONCLUSION

Cumulative PGE1 dose is associated with gastrointestinal adverse effects in neonates. Lower doses should be considered in neonates expecting prolonged PGE1 treatment.

Effects of Antiplatelet Drugs on Platelet-Dependent Coagulation Reactions

Activated platelets are involved in blood coagulation by exposing phosphatidylserine (PS), which serves as a substrate for assembling coagulation complexes. Platelets accelerate fibrin formation and thrombin generation, two final reactions of the coagulation cascade. We investigated the effects of antiplatelet drugs on platelet impact in these reactions and platelet ability to expose PS. Washed human platelets were incubated with acetylsalicylic acid (ASA), ticagrelor, ASA in combination with ticagrelor, ruciromab (glycoprotein IIb-IIIa antagonist), or prostaglandin E1 (PGE1). Platelets were not activated or activated by collagen and sedimented in multiwell plates, and plasma was added after supernatant removal. Fibrin formation (clotting) was monitored in a recalcification assay by light absorbance and thrombin generation in a fluorogenic test. PS exposure was assessed by annexin V staining using flow cytometry. Ticagrelor (alone and in combination with ASA), ruciromab, and PGE1, but not ASA, prolonged the lag phase and decreased the maximum rate of plasma clotting and decreased the peak and maximum rate of thrombin generation. Inhibition was observed when platelets were not treated with exogenous agonists (activation by endogenous thrombin) and pretreated with collagen. Ticagrelor (alone and in combination with ASA), ruciromab, and PGE1, but not ASA, decreased PS exposure on washed platelets activated by thrombin and by thrombin + collagen. PS exposure on activated platelets in whole blood was lower in patients with acute coronary syndrome receiving ticagrelor + ASA in comparison with donors free of medications. These results indicate that antiplatelet drugs are able to suppress platelet coagulation activity not only in vitro but also after administration to patients.

Retained needles during intracavernosal self-injection for erectile dysfunction treatment: a case report and systematic literature review

Introduction

Although the breakage and entrapment of the needles inside the penis during intracavernosal self-injection for erectile dysfunction treatment is a rare complication, when it happens, it can cause significant distress and anxiety to the patients who experience it.

Aims

Our work aims to report a case of retained penile needle and to compare it with similar cases in the literature to define the risk factors and the best practice to prevent and treat this complication.

Methods

We are reporting successful surgical removal of a deeply retained penile needle with the aid of intraoperative fluoroscopy after an unsuccessful attempt of ultrasound-guided removal in the emergency room. We searched the PubMed and Embase databases for similar cases and compared the findings across all the cases.

Results

In our case, the needle was initially superficial; however, excessive manipulation in the emergency room resulted in deep displacement into the corpus cavernosum. We were able to successfully localize the needle using intraoperative fluoroscopic guidance. The needle was then surgically removed via a small skin incision with minimal dissection of cavernosal tissue. We identified 15 reported cases of retained penile needles in the literature and performed a comprehensive comparison among all the cases. It is critical to search for specialized treatment with a urologist to avoid great damage due to erroneous manipulation of the corpora cavernosa.

Conclusion

Selecting patients with good manual dexterity is essential to avoid breakage and entrapment of penile needles during intracavernosal self-injection for erectile dysfunction treatment. The management of retained penile needles should be individualized depending on the clinical picture at the time of presentation. It is critical to avoid excessive manipulation as it can push the needle deeper into the penis and make the extraction more demanding.

Induction of Labor in Twins-Double Trouble?

OBJECTIVE

To determine and compare the safety and efficacy of different methods of induction of labor in twin gestations and their effect on maternal and neonatal outcomes.

METHODS

A retrospective observational cohort study was conducted at a single university-affiliated medical center. Patients with a twin gestation undergoing induction of labor at >32 + 0 weeks comprised the study group. Outcomes were compared to patients with a twin gestation at >32 + 0 weeks who went into labor spontaneously. The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, postpartum hemorrhage, uterine rupture, 5 min APGAR < 7, and umbilical artery pH < 7.1. A subgroup analysis comparing outcomes for the induction of labor with oral prostaglandin E1 (PGE1), IV Oxytocin ± artificial rupture of membranes (AROM), and extra-amniotic balloon (EAB)+ IV Oxytocin was performed. Data were analyzed using Fisher's exact test, ANOVA, and chi-square tests.

RESULTS

268 patients who underwent induction of labor with a twin gestation comprised the study group. 450 patients with a twin gestation who went into labor spontaneously comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, neonatal birthweight, birthweight discordancy, and non-vertex second twin. There were significantly more nulliparas in the study group compared to the control group (23.9% vs. 13.8% p < 0.001). The study group was significantly more likely to undergo a cesarean delivery of at least one twin (12.3% vs. 7.5% OR, 1.7 95% CI 1.04-2.85 p = 0.03). However, there was no significant difference in the rate of operative vaginal delivery (15.3% vs. 19.6% OR, 0.74, 95% CI 0.5-1.1 p = 0.16), PPH (5.2% vs. 6.9% OR, 0.75 95% CI 0.39-1.42 p = 0.37), 5-min APGAR scores < 7 (0% vs. 0.2% OR, 0.99 95%CI 0.99-1.00 p = 0.27), umbilical artery pH < 7.1 (1.5% vs. 1.3% OR, 1.12 95% CI 0.3-4.0), or combined adverse outcome (7.8% vs. 8.7% OR, 0.93 95% CI 0.6-1.4 p = 0.85). Furthermore, there were no significant differences in the rates of cesarean delivery or combined adverse outcomes in patients undergoing induction with oral PGE1 compared to IV Oxytocin ± AROM (13.3% vs. 12.5% OR, 1.1 95% CI 0.4-2.0 p = 1.0) (7% vs. 9.3% OR, 0.77 95% CI 0.5-3.5 p = 0.63 ) or EAB+ IV Oxytocin (13.3% vs. 6.9% OR, 2.1 95% CI 0.1-2.1 p = 0.53) (7% vs. 6.9% OR, 1.4 95% CI 0.15-3.5 p = 0.5) or between patients undergoing induction of labor with IV Oxytocin ± AROM and EAB+ IV Oxytocin (12.5% vs. 6.9% OR, 2.1 95% CI 0.1-2.4 p = 0.52) (9.3% vs. 6.9% OR, 0.98 95% CI 0.2-4.7 p = 0.54). There were no cases of uterine rupture in our study.

CONCLUSIONS

Induction of labor in twin gestations is associated with a two-fold increased risk of cesarean delivery, although this is not associated with adverse maternal or neonatal outcomes. Furthermore, the method of induction of labor used does not affect the chances of success nor the rate of adverse maternal or neonatal outcomes.

Lipid microsphere-coated PGE1 improves peritoneal transport and reduces inflammation in peritoneal dialysis: A randomized clinical pilot trial

OBJECTIVE

To evaluate the effects of lipid microspheres coated with prostaglandin E1 (lipo-PGE1) on peritoneal transport function and inflammation in patients with end-stage renal disease undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

In total, 89 patients were randomly allocated to the lipo-PGE1 and control groups. All the patients received conventional treatment, and those in the lipo-PGE1 group received lipo-PGE1 intravenously for 2 weeks. The levels of β2-microglobulin (β2-MG), cystatin C, albumin, urea, creatinine, interleukin-6 (IL-6), matrix metalloproteinase-2 (MMP-2), and high-sensitivity C-reactive protein (hs-CRP) were measured before and at 1 and 2 weeks after treatment.

RESULTS

In the lipo-PGE1 group, the peritoneal clearance rates of β2-MG, cystatin C, and albumin were significantly increased comparing with pre-treatment values, and the IL-6 appearance rate (AR) in the peritoneal dialysate and the serum levels of IL-6 and hs-CRP were markedly decreased (p < 0.05). The lipo-PGE1 group had significantly higher peritoneal clearance rates of β2-MG and cystatin C and lower IL-6 AR in the peritoneal dialysate than the control group (p < 0.05).

CONCLUSIONS

Lipid microspheres coated with prostaglandin E1 may increase the peritoneal clearance of moderately sized molecules and macromolecules with insignificant effect on the clearance of small molecules. The reduction in IL-6 level following treatment with lipo-PGE1 may alleviate inflammation.

Evaluation of the sensitivity of different doses of vasoactive drugs in diagnosing erectile dysfunction in impotent patients: a prospective case-control study

Introduction

Erectile dysfunction (ED) is one of the most common sexual disorders worldwide affecting about 30 million men in the United States, and an estimated 100 million men worldwide. Penile duplex doppler ultrasound (PDDU) is performed using an intracavernosal injection (ICI) of a vasoactive agent to demonstrate both arterial insufficiency and veno-occlusive dysfunction. This article aims to evaluate the sensitivity of different doses of different vasoactive agents used to diagnose ED in impotent patients.

Material and methods

This study recruited 90 subjects with ED and 100 healthy subjects as controls. All of the subjects were assessed using the International Index of Erectile Function score (IIEF-5) while degree of erection was assessed by the Erection Hardness Score (EHS). Two penile duplex tests were done for each candidate two weeks apart.

Results

None of the sample population achieved a normal clinical response (EHS >2) to 10 ug PGE1. In contrast, 60 controls (60%) had a normal response (EHS >2) to 10 ug PGE1. This difference in response between the sample and control populations to 10 ug PGE1 was of high statistical significance 11 (p <0.001). In contrast, 54 (60%) out of the 90 cases had normal clinical response (EHS >2) to 0.25cc Trimix (everywhere). Interestingly, 96 controls (96%) demonstrated normal response (EHS >2) to 0.25cc Trimix. This difference in response between the sample and control populations to 0.25 cc Trimix was also of high statistical significance (p <0.001).

Conclusions

Our study demonstrated a statistically significant association between the response to Trimix over PGE1 and peak systolic velocity (PSV) and end diastolic velocity (EDV). Thus, we conclude that 0.25 cc Trimix is more sensitive than 20 ug PGE1 in diagnosing ED for impotent patients and also provides a more potent response.

Prostaglandin E1 Is an Efficient Molecular Tool for Forest Leech Blood Sucking

From a survival perspective, it is hypothesized that leech saliva exhibits certain physiological effects to ensure fast blood-feeding, including analgesia, anesthesia, and anti-inflammation to stay undetected by the host and vasodilatation and anti-hemostasis to ensure a steady, rapid, and sustained blood flow to the feeding site. Many anti-hemostatic compounds have been identified in leech saliva, such as hirudin, calin, and bdellin A. However, no specific substance with direct vasodilatory and anti-inflammatory function has been reported from forest leech saliva. Herein, using activity-guided analysis, prostaglandin E1 (PGE1) was identified for the first time as an efficient molecular tool for forest leech blood sucking. The structure of PGE1 was analyzed by nuclear magnetic resonance spectroscopy and high-resolution electrospray ionization mass spectroscopy. PGE1 was found to be primarily distributed in the leech salivary gland (1228.36 ng/g body weight). We also analyzed how forest leech PGE1 affects platelet aggregation, skin vascular permeability, bleeding time, and pain. Results indicated that PGE1 efficiently inhibited platelet aggregation induced by adenosine diphosphate (ADP) (5 μM) with an IC50 of 21.81 ± 2.24 nM. At doses of 10, 100 nM, and 1 μM, PGE1 increased vascular permeability by 1.18, 5.8, and 9.2 times. It also prolonged bleeding time in a concentration-independent manner. In the formalin-induced mouse paw pain model, PGE1 suppressed acute pain. To the best of our knowledge, this is the first report on PGE1 in invertebrates. The functions of PGE1, such as vasodilation, platelet aggregation inhibition, anti-inflammation, and pain alleviation, may facilitate the ingestion of host blood by leeches.

Low-dose prostaglandin E1 is safe and effective for critical congenital heart disease: is it time to revisit the dosing guidelines?

INTRODUCTION

Prostaglandin E1 is used to maintain ductal patency in critical congenital heart disease (CHD). The standard starting dose of prostaglandin E1 is 0.05 µg/kg/minute. Lower doses are frequently used, but the efficacy and safety of a low-dose regimen of prostaglandin E1 has not been established.

METHODS

We investigated neonates with critical CHD who were started on prostaglandin E1 at 0.01 µg/kg/minute. We reviewed 154 consecutive patients who were separated into three anatomical groups: obstruction to systemic circulation, obstruction to pulmonary circulation, and inadequate mixing (d-transposition of the great arteries). Treatment failure rates and two commonly reported side effects, respiratory depression and seizure, were studied.

RESULTS

A total of 26 patients (17%) required a dose increase in prostaglandin E1. Patients with pulmonary obstruction were more likely to require higher doses than patients with systemic obstruction (15/49, 31% versus 9/88, 10%, p = 0.003). Twenty-eight per cent of patients developed respiratory depression and 8% of patients needed mechanical ventilation. Prematurity (<37 week gestation) was the primary risk factor for respiratory depression. No patient required dose escalation or tracheal intubation while on transport. No patient had a seizure attributed to prostaglandin E1.

CONCLUSIONS

Prostaglandin E1 at an initial and maintenance dose of 0.01 µg/kg/minute was sufficient to maintain ductal patency in 83% of our cohort. The incidence of respiratory depression requiring mechanical ventilation was low and was mostly seen in premature infants. Starting low-dose prostaglandin E1 at 0.01 µg/kg/minute is a safe and effective therapy for critical CHD.

Prostaglandin E1 attenuates post‑cardiac arrest myocardial dysfunction through inhibition of mitochondria‑mediated cardiomyocyte apoptosis

Post‑cardiac arrest myocardial dysfunction (PAMD) is a leading cause of death in patients undergoing resuscitation patients following cardiac arrest (CA). Although prostaglandin E1 (PGE1) is a clinical drug used to mitigate ischemia injury, its effect on PAMD remains unknown. In the present study, the protective effects of PGE1 on PAMD were evaluated in a rat model of CA and in a hypoxia‑reoxygenation (H/R) in vitro model. Rats were randomly assigned to CA, CA+PGE1 or sham groups. Asphyxia for 8 min followed by cardiopulmonary resuscitation were performed in the CA and CA+PGE1 groups. PGE1 was intravenously administered at the onset of return of spontaneous circulation (ROSC). PGE1 treatment significantly increased the ejection fraction and cardiac output within 4 h following ROSC and improved the survival rate, compared with the CA group. Moreover, PGE1 inactivated GSK3β, prevented mitochondrial permeability transition pore (mPTP) opening, while reducing cytochrome c and cleaved caspase‑3 expression, as well as cardiomyocyte apoptosis in the rat model. To examine the underlying mechanism, H/R H9c2 cells were treated with PGE1 at the start of reoxygenation. The changes in GSK3β activity, mPTP opening, cytochrome c and cleaved caspase‑3 expression, and apoptosis of H9c2 cells were consistent with those noted in vivo. The results indicated that PGE1 attenuated PAMD by inhibiting mitochondria‑mediated cardiomyocyte apoptosis.

Prostaglandin E1 protects cardiomyocytes against hypoxia-reperfusion induced injury via the miR-21-5p/FASLG axis

Background: Prostaglandin-E1 (PGE1) is a potent vasodilator with anti-inflammatory and antiplatelet effects. However, the mechanism by which PGE1 contributes to the amelioration of cardiac injury remains unclear.

Methods: The present study was designed to investigate how PGE1 protects against hypoxia/reoxygenation (H/R)-induced injuries by regulating microRNA-21-5p (miR-21-5p) and fas ligand (FASLG). Rat H9C2 cells and isolated primary cardiomyocytes were cultured under hypoxic conditions for 6 h (6H, hypoxia for 6 h), and reoxygenated for periods of 6 (6R, reoxygenation for 6 h), 12, and 24 h, respectively. Cells from the 6H/6R group were treated with various doses of PGE1; after which, their levels of viability and apoptosis were detected.

Results: The 6H/6R treatment regimen induced the maximum level of H9C2 cell apoptosis, which was accompanied by the highest levels of Bcl-2-associated X protein (Bax) and cleaved-caspase-3 expression and the lowest level of B-cell lymphoma 2 (Bcl-2) expression. Treatment with PGE1 significantly diminished the cell cytotoxicity and apoptosis induced by the 6H/6R regimen, and also decreased expression of IL-2, IL-6, P-p65, TNF-α, and cleaved-caspase-3. In addition, we proved that PGE1 up-regulated miR-21-5p expression in rat cardiomyocytes exposed to conditions that produce H/R injury. FASLG was a direct target of miR-21-5p, and PGE1 reduced the ability of H/R-injured rat cardiomyocytes to undergo apoptosis by affecting the miR-21-5p/FASLG axis. In addition, we proved that PGE1 could protect primary cardiomyocytes against H/R-induced injuries.

Conclusions: These results indicate that PGE1 exerts cardioprotective effects in H9C2 cells during H/R by regulating the miR-21-5p/FASLG axis.

DGLA from the Microalga Lobosphaera Incsa P127 Modulates Inflammatory Response, Inhibits iNOS Expression and Alleviates NO Secretion in RAW264.7 Murine Macrophages

Microalgae have been considered as a renewable source of nutritional, cosmetic and pharmaceutical compounds. The ability to produce health-beneficial long-chain polyunsaturated fatty acids (LC-PUFA) is of high interest. LC-PUFA and their metabolic lipid mediators, modulate key inflammatory pathways in numerous models. In particular, the metabolism of arachidonic acid under inflammatory challenge influences the immune reactivity of macrophages. However, less is known about another omega-6 LC-PUFA, dihomo-γ-linolenic acid (DGLA), which exhibits potent anti-inflammatory activities, which contrast with its delta-5 desaturase product, arachidonic acid (ARA). In this work, we examined whether administrating DGLA would modulate the inflammatory response in the RAW264.7 murine macrophage cell line. DGLA was applied for 24 h in the forms of carboxylic (free) acid, ethyl ester, and ethyl esters obtained from the DGLA-accumulating delta-5 desaturase mutant strain P127 of the green microalga Lobosphaera incisa. DGLA induced a dose-dependent increase in the RAW264.7 cells’ basal secretion of the prostaglandin PGE1. Upon bacterial lipopolysaccharide (LPS) stimuli, the enhanced production of pro-inflammatory cytokines, tumor necrosis factor alpha (TNFα) and interleukin 1β (IL-1β), was affected little by DGLA, while interleukin 6 (IL-6), nitric oxide, and total reactive oxygen species (ROS) decreased significantly. DGLA administered at 100 µM in all forms attenuated the LPS-induced expression of the key inflammatory genes in a concerted manner, in particular iNOS, IL-6, and LxR, in the form of free acid. PGE1 was the major prostaglandin detected in DGLA-supplemented culture supernatants, whose production prevailed over ARA-derived PGE2 and PGD2, which were less affected by LPS-stimulation compared with the vehicle control. An overall pattern of change indicated DGLA’s induced alleviation of the inflammatory state. Finally, our results indicate that microalgae-derived, DGLA-enriched ethyl esters (30%) exhibited similar activities to DGLA ethyl esters, strengthening the potential of this microalga as a potent source of this rare anti-inflammatory fatty acid.

Visual improvement in a patient with paracentral acute middle maculopathy treated with prostaglandin E1

The authors present the use of prostaglandin E1 (PGE1) for the treatment of an acute paracentral acute middle maculopathy (PAMM). A 78-year-old white female was seen with a sudden loss of vision in her left eye (OS) to 20/200 noted upon awakening. The right eye (OD) saw 20/20. A complete eye exam was done and an ocular coherent tomography revealed retinal thickening and a whitening of the inner nuclear layer in the area of the macula OS. A diagnosis of PAMM in the OS was made. Treatment was immediately started with 70 μg of PGE1 administered over 1.5 hours in the form of a skin cream. A volume of 3.5 cc of skin cream was applied in divided doses to the inner surface of the forearm, rubbed into the skin and allowed to dry. The same 70 μg of PGE1 in 3.5 cc of skin cream was repeated once the next morning. The patient began to see better the second day of treatment with a final visual acuity of 20/20. The OD was unchanged. After 14 months she was stable with no further treatment. PAMM is an ischemic process of the inner retina. PGE1, a potent vasodilator of the microcirculation, when given immediately seemed to be useful in restoring vision in this form of retinal ischemia. Treatment was immediately started with PGE1 in the form of a skin cream with visual improvement. The authors normally use PGE1 intravenously for acute ocular ischemia and would have preferred that here. Intravenous PGE1 was not available and was substituted with the skin cream of PGE1 that worked well for the patient.

The Influence of Prostaglandin E1 and Use of Inhibitor Percentage on the Correlation between the Multiplate and VerifyNow in Patients on Dual Antiplatelet Therapy

Platelet function tests (PFT), such as the Multiple Electrode Analyzer (Multiplate) and VerifyNow, show little concordance in patients using antiplatelet drugs. A major difference between these tests is the use of prostaglandin E1 (PGE1) to inhibit P2Y1-platelet-receptor activation in VerifyNow and is proposed to be of influence in the discrepancy between these tests. We aimed to investigate whether the presence of PGE1 could provide an explanation for the moderate correlation and concordance between Multiplate and VerifyNow by adding PGE1 to the Multiplate ADP assay, also known as the ADP-high sensitivity (ADP-HS) assay. We also aimed to investigate whether the difference in baseline platelet function as measured by the VerifyNow and Multiplate could (partly) explain the moderate correlation between the tests, by plotting ADP assay results against baseline function as measured by the corresponding device, which is expressed as the 'inhibitor percentage.' Fifty-one patients who underwent percutaneous coronary intervention (PCI) received dual antiplatelet therapy and were considered to have a high risk of ischemic or bleeding complications were included. The addition of 20 µl PGE1 in the Multiplate resulted in a significant reduction in Arbitrary Aggregation Units, but did not improve correlation with the VerifyNow. The correlation between VerifyNow and Multiplate inhibitor percentage was moderate. Based on these results, we concluded that neither PGE1 nor the calculation of the inhibitor percentage greatly influenced the correlation between PFTs.

Treatment algorithm for idiopathic sudden sensorineural hearing loss based on epidemiologic surveys of a large Japanese cohort

Background: To date, there have been few conventional algorithms for the treatment of idiopathic sudden sensorineural hearing loss (SSNHL), as there have been only limited reports with high evidence levels.Objectives: To propose an evidence- and trend-based treatment algorithm for SSNHL.Methods: We referred not only to the evidence for each treatment, but also to trends related to treatment selection in Japan based on epidemiologic surveys, and considered the balance of the advantages and disadvantages with regard to each patient's condition.Results: We propose an algorithm that begins with the grade of SSNHL severity as the prognosis of SSNHL is strongly related to the severity of hearing loss. We selected systemic corticosteroid therapy as the first-line therapy, and Intra-tympanic corticosteroid therapy as salvage therapy. We also proposed the use of prostaglandin E1 with corticosteroids for the treatment of SSNHL patients with severe hearing loss. According to the data obtained from an epidemiologic survey, we decided time limits for the application of each treatment.Conclusion: An algorithm for the treatment for SSNHL is presented according to the results of epidemiologic surveys in Japan. It is expected that this algorithm can provide a guide to choosing the suitable treatment for SSNHL patients.

Efficacy comparison of titrated oral solution of misoprostol and intravenous oxytocin on labour induction in women with full-term pregnancy

A double-blind randomised trial was conducted on women with gestational age of 40-42 weeks of pregnancy and Bishop score of more than 5. The first group received oxytocin infusion and the second group received a titrated oral solution of misoprostol. Then, the two groups were compared by the primary outcome (the number of deliveries in the first 24 hours of intervention). The two groups did not have any significant difference in maternal and gestational age at the time of intervention, primary Bishop score, parity and neonatal weight. The number of deliveries in the first 24 hours was greater in the misoprostol group. Duration of onset of intervention to proper contractions was longer in the misoprostol group. However, the number of deliveries between 6-12 hours, 12-18 hours and 18-24 hours after induction was greater in the misoprostol group. The incidence of tachysystole and meconium was greater in the misoprostol group.Impact statementWhat is already known on this subject? Labour induction is widely used where the continuation of pregnancy might be dangerous for the mother or the baby. Of the various methods used for induction, misoprostol which is a prostaglandin E1 analogue has been reviewed more in recent years. Misoprostol has various routes of administration but in most studies only vaginal administration has been evaluated, leaving us with limited data about oral administration.What do the results of this study add? Oral misoprostol is a suitable method for labour induction and can be used as an alternative to oxytocin.What are the implications of these findings for clinical practice and/or further research? Misoprostol is not expensive, has a long shelf life, accessible in underdeveloped countries and rural areas and has several routes of administrations such as oral, sublingual and vaginal. Despite the fact that the oral route of misoprostol has a fast absorption and easier administration, there are relatively few studies assessing the the use of the oral route of misoprostol. Misoprostol is a suitable method for Labour induction and it has the potentials of being used as an alternative for oxytocin, however, the optimum dosages, the preferred route of administration, the maximum dose, the maximum time for administration, and maternal and neonatal safety should be studied more.

Prostaglandin E1 Alleviates Cognitive Dysfunction in Chronic Cerebral Hypoperfusion Rats by Improving Hemodynamics

Compensatory vascular mechanisms can restore cerebral blood flow (CBF) but fail to protect against chronic cerebral hypoperfusion (CCH)-mediated neuronal damage and cognitive impairment. Prostaglandin E1 (PGE1) is known as a vasodilator to protect against ischemic injury in animal models, but its protective role in CCH remains unclear. To determine the effect of PGE1 on cerebral hemodynamics and cognitive functions in CCH, bilateral common carotid artery occlusion (BCCAO) was used to mimic CCH in rats, which were subsequently intravenously injected with PGE1 daily for 2 weeks. Magnetic resonance imaging, immunofluorescence staining and Morris water maze (MWM) were used to evaluate CBF, angiogenesis, and cognitive functions, respectively. We found that PGE1 treatment significantly restored CBF by enhancing vertebral artery dilation. In addition, PGE1 treatment increased the number of microvascular endothelial cells and neuronal cells in the hippocampus, and decreased the numbers of astrocyte and apoptotic cells. In the MWM test, we further showed that the escape latency of CCH rats was significantly reduced after PGE1 treatment. Our results suggest that PGE1 ameliorates cognitive dysfunction in CCH rats by enhancing CBF recovery, sustaining angiogenesis, and reducing astrocyte activation and neuronal loss.

[Immediate results of conservative treatment of patients with unreconstructable critical limb ischaemia and trophic changes]

The purpose of the study was to comparatively assess efficacy of using agents belonging to the group of prostaglandin E1 in comprehensive conservative treatment of patients with unreconstructable critical limb ischaemia and trophic changes by the frequency of major amputation, amputation-free survival, and total mortality by combinations of the WIfI classification during a 6-month follow up period. Our retrospective multicentre study enrolled a total of 109 patients, including 60 men and 49 women, with a mean age of 70±7.3 years. The patients were subdivided into 2 groups. Group 1 patients (n=58) received standard conservative therapy without prostaglandin E1 and group 2 patients (n=51) received similar treatment with the use of prostaglandin E1. The statistical analysis (chi-squared test, Fisher criterion, log-rank test) was carried out with regard to stratification of the patients in the groups by the WIfI component combinations. No statistically significant differences between the groups in the frequency of amputation and total mortality were revealed (p=0.094 and p=0.925, respectively). The use of the WIfI classification system made it possible to single out a cohort of patients (with a WIfI combination of 130) for whom the results of administering prostaglandin E1 statistically significantly differed by the frequency of amputation (p=0.042) and by amputation-free survival (p=0.017). No significant differences by these outcomes were obtained for other combinations analysed. A conclusion was drawn that using prostaglandin E1 in comprehensive conservative treatment decreased the frequency of amputation and increased amputation-free survival in patients presenting with unreconstructable critical limb ischaemia and referred to the category with a combination of 130 according to the WIfI classification.

Successful retrieval of a migrated neonatal ductal stent and strategies to reposition the expanded stent in the duct

A neonatal ductal stent deployed in a straight short conical duct on second postnatal day migrated owing to inadequate ductal constriction. It was successfully retrieved using a larger balloon and redeployed in the duct again. Intravenous indomethacin prevented further stent migration. This is the first report of successful transcatheter retrieval and repositioning of a migrated expanded neonatal ductal stent.

Targeting chronic myeloid leukemia stem cells: can transcriptional program be a druggable target for cancers?

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm resulting from acquisition of constitutively active BCR-ABL protein tyrosine kinase in a hematopoietic stem cell (HSC). Though tyrosine kinase inhibitors (TKIs) have changed a fatal disease into manageable disease, most patients cannot discontinue TKI treatment due to persistence of TKI-resistant leukemia stem cells (LSCs). Much effort has been made to find out factors or pathways specifically operating in LSCs to selectively target LSCs, with some promising results at least in preclinical models. In this article, we briefly review the role of Wnt/β-catenin signaling and its related factors in CML LSCs, especially focusing on Tcf1/Lef1 transcription factors, major effectors of Wnt/β-catenin pathway, of which transcriptional program have recently been shown to be targetable with prostaglandin E1.

Visual field improvement in non-arteritic posterior ischemic optic neuropathy in a patient treated with intravenous prostaglandin E1 and steroids

Non-arteritic posterior ischemic optic neuropathy (NA-PION) is a disorder of reduced blood flow to the retrobulbar optic nerve. There is usually an acute loss of visual acuity and field. Previous studies have noted an improvement in visual acuity and in ocular and retrobulbar blood flow with the use of a potent vasodilator of the microcirculation, prostaglandin E1 (PGE1), and steroids. The current report describes immediate improvement in the visual fields and visual acuity in a patient with NA-PION treated with intravenous PGE1 and steroids 66 hours after onset. An 89-year-old white female was first seen in December 2016 with a sudden loss of vision in the right eye. After a complete eye exam and visual fields, the patient was diagnosed with NA-PION. Treatment was immediately started with steroids and intravenous PGE1. This was repeated once again the next morning. Visual acuity in the right eye improved from 1/10 + 1 to 7/10 + 3 at 5 days. The mean deviation of the visual field improved from - 7.10 decibels (dB) with a central scotoma of - 22 dB to - 2.97 dB with a central scotoma of - 19 dB. After 2 weeks, her visual acuity was 7/10 + 1 and visual field testing of the right eye revealed a mean deviation of - 2.54 dB with a central scotoma of - 9 dB. The left eye was unchanged. In cases of NA-PION, PGE1 and steroids should be considered to immediately restore blood flow to help improve visual acuity and visual fields.

Prostaglandin E1 and Its Analog Misoprostol Inhibit Human CML Stem Cell Self-Renewal via EP4 Receptor Activation and Repression of AP-1

Effective treatment of chronic myelogenous leukemia (CML) largely depends on the eradication of CML leukemic stem cells (LSCs). We recently showed that CML LSCs depend on Tcf1 and Lef1 factors for self-renewal. Using a connectivity map, we identified prostaglandin E1 (PGE1) as a small molecule that partly elicited the gene expression changes in LSCs caused by Tcf1/Lef1 deficiency. Although it has little impact on normal hematopoiesis, we found that PGE1 treatment impaired the persistence and activity of LSCs in a pre-clinical murine CML model and a xenograft model of transplanted CML patient CD34⁺ stem/progenitor cells. Mechanistically, PGE1 acted on the EP4 receptor and repressed Fosb and Fos AP-1 factors in a β-catenin-independent manner. Misoprostol, an FDA-approved EP4 agonist, conferred similar protection against CML. These findings suggest that activation of this PGE1-EP4 pathway specifically targets CML LSCs and that the combination of PGE1/misoprostol with conventional tyrosine-kinase inhibitors could provide effective therapy for CML.

Prostaglandin E1 protects coronary microvascular function via the glycogen synthase kinase 3β-mitochondrial permeability transition pore pathway in rat hearts subjected to sodium laurate-induced coronary microembolization

Prostaglandin E1 (PGE1) is used as a pretreatment for ischemia reperfusion injury in many biological systems. However, its value as a pretreatment for coronary microembolization (CME) is unknown. The goal of this study was to determine whether PGE1 would protect against CME. In a CME rat model, we observed microthrombi and early myocardial ischemia, with endothelium appearing exfoliated and mitochondria having irregular morphology and decreased internal complexity. The level of fibrinogen-like protein 2 prothrombinase was increased and superoxide dismutase and catalase levels were decreased. Moreover, mitochondria copy number and mitochondrial permeability transition pore (mPTP) opening were increased. Pretreatment with PGE1 (1 or 2 μg/kg) significantly improved these cardiological deficits, acting via the glycogen synthase kinase 3β (GSK-3β)-mPTP pathway. Unexpectedly, the phosphorylation of Akt at Ser473 decreased in the PGE1 at high dose. Overall, our findings suggested an important role for PGE1 in pretreatment of coronary microvascular dysfunction.

Misoprostol for miscarriage management in a woman with previous five cesarean deliveries: a case report and literature review

Background

Misoprostol is an effective medical method for the management of pregnancy loss. However, data on its efficacy and safety in women with previous cesarean deliveries are limited.

Case presentation

We report a 36-year-old patient, gravida 11 para 6, with a diagnosis of missed miscarriage at 15 weeks of gestation. The patient had a significant obstetric history of previous five cesarean deliveries and uterine rupture. Following patient counseling about the medical and surgical options of managing her miscarriage, the patient opted for medical method. Low-dose misoprostol of 100 µg was inserted vaginally and repeated again after 6 hours. The patient had an uneventful complete miscarriage following the second dose of misoprostol. No uterine rupture, no extra vaginal bleeding, and no blood transfusion were observed.

Conclusion

We conclude that adopting a low-dose misoprostol protocol could be potentially safe and effective in managing second trimester missed miscarriage in women with repeated cesarean deliveries and/or uterine rupture history. Further studies are needed to confirm these results.

Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies

OBJECTIVE

The aim of this systematic review and metaanalysis was to determine the efficacy and safety of cervical ripening agents in the second trimester of pregnancy in patients with previous cesarean delivery.

STUDY DESIGN

Data sources were PubMed, EMBASE, CINAHL, LILACS, Google Scholar, and clinicaltrials.gov (1983 through 2015). Eligibility criteria were cohort or cross-sectional studies that reported on efficacy and safety of cervical ripening agents in patients with previous cesarean delivery. Efficacy was determined based on the proportion of patients achieving vaginal delivery and vaginal delivery within 24 hours following administration of a cervical ripening agent. Safety was assessed by the risk of uterine rupture and complications such as retained placental products, blood transfusion requirement, and endometritis, when available, as secondary outcomes. Of the 176 studies identified, 38 met the inclusion criteria. Of these, 17 studies were descriptive and 21 studies compared the efficacy and safety of cervical ripening agents between patients with previous cesarean and those with no previous cesarean. From included studies, we abstracted data on cervical ripening agents and estimated the pooled risk differences and risk ratios with 95% confidence intervals. To account for between-study heterogeneity, we estimated risk ratios based on underlying random effects analyses. Publication bias was assessed via funnel plots and across-study heterogeneity was assessed based on the I(2) measure.

RESULTS

The most commonly used agent was PGE1. In descriptive studies, PGE1 was associated with a vaginal delivery rate of 96.8%, of which 76.3% occurred within 24 hours, uterine rupture in 0.8%, retained placenta in 10.8%, and endometritis in 3.9% in patients with ≥1 cesarean. In comparative studies, the use of PGE1, PGE2, and mechanical methods (laminaria and dilation and curettage) were equally efficacious in achieving vaginal delivery between patients with and without prior cesarean (risk ratio, 0.99, and 95% confidence interval, 0.98-1.00; risk ratio, 1.00, and 95% confidence interval, 0.98-1.02; and risk ratio, 1.00, and 95% confidence interval, 0.98-1.01; respectively). In patients with history of ≥1 cesarean the use of PGE1 was associated with higher risk of uterine rupture (risk ratio, 6.57; 95% confidence interval, 2.21-19.52) and retained placenta (risk ratio, 1.21; 95% confidence interval, 1.03-1.43) compared to women without a prior cesarean. However, the risk of uterine rupture among women with history of only 1 cesarean (0.47%) was not statistically significant (risk ratio, 2.36; 95% confidence interval, 0.39-14.32), whereas among those with history of ≥2 cesareans (2.5%) was increased as compared to those with no previous cesarean (0.08%) (risk ratio, 17.55; 95% confidence interval, 3.00-102.8). Funnel plots did not demonstrate any clear evidence of publication bias. Across-study heterogeneity ranged from 0-81%.

CONCLUSION

This systematic review and metaanalysis provides evidence that PGE1, PGE2, and mechanical methods are efficacious for achieving vaginal delivery in women with previous cesarean delivery. The use of prostaglandin PGE1 in the second trimester was not associated with significantly increased risk for uterine rupture among women with only 1 cesarean; however, this risk was substantially increased among women with ≥2 cesareans although the absolute risk appeared to be relatively small.

Prostaglandin E1 inhibits endocytosis in the β-cell endocytosis

Prostaglandins inhibit insulin secretion in a manner similar to that of norepinephrine (NE) and somatostatin. As NE inhibits endocytosis as well as exocytosis, we have now examined the modulation of endocytosis by prostaglandin E1 (PGE1). Endocytosis following exocytosis was recorded by whole-cell patch clamp capacitance measurements in INS-832/13 cells. Prolonged depolarizing pulses producing a high level of Ca(2+) influx were used to stimulate maximal exocytosis and to deplete the readily releasable pool (RRP) of granules. This high Ca(2+) influx eliminates the inhibitory effect of PGE1 on exocytosis and allows specific characterization of the inhibitory effect of PGE1 on the subsequent compensatory endocytosis. After stimulating exocytosis, endocytosis was apparent under control conditions but was inhibited by PGE1 in a Pertussis toxin-sensitive (PTX)-insensitive manner. Dialyzing a synthetic peptide mimicking the C-terminus of the α-subunit of the heterotrimeric G-protein Gz into the cells blocked the inhibition of endocytosis by PGE1, whereas a control-randomized peptide was without effect. These results demonstrate that PGE1 inhibits endocytosis and Gz mediates the inhibition.

Inhaled pulmonary vasodilators for persistent pulmonary hypertension of the newborn: safety issues relating to drug administration and delivery devices

Treatment for persistent pulmonary hypertension of the newborn (PPHN) aims to reduce pulmonary vascular resistance while maintaining systemic vascular resistance. Selective pulmonary vasodilation may be achieved by targeting pulmonary-specific pathways or by delivering vasodilators directly to the lungs. Abrupt withdrawal of a pulmonary vasodilator can cause rebound pulmonary hypertension. Therefore, use of consistent delivery systems that allow for careful monitoring of drug delivery is important. This manuscript reviews published studies of inhaled vasodilators used for treatment of PPHN and provides an overview of safety issues associated with drug delivery and delivery devices as they relate to the risk of rebound pulmonary hypertension. Off-label use of aerosolized prostacyclins and an aerosolized prostaglandin in neonates with PPHN has been reported; however, evidence from large randomized clinical trials is lacking. The amount of a given dose of aerosolized drug that is actually delivered to the lungs is often unknown, and the actual amount of drug deposited in the lungs can be affected by several factors, including patient size, nebulizer used, and placement of the nebulizer within the breathing circuit. Inhaled nitric oxide (iNO) is the only pulmonary vasodilator approved by the US Food and Drug Administration for the treatment of PPHN. The iNO delivery device, INOmax DS_IR®IR, is designed to constantly monitor NO, NO₂, and O₂ deliveries and is equipped with audible and visual alarms to alert providers of abrupt discontinuation and incorrect drug concentration. Other safety features of this device include two independent backup delivery systems, a backup drug cylinder, a battery that provides up to 6 hours of uninterrupted medication delivery, and 27 alarms that monitor delivery, dosage, and system functions. The ability of the drug delivery device to provide safe, consistent dosing is important to consider when selecting a pulmonary vasodilator.

Development, Optimization, and Characterization of PEGylated Nanoemulsion of Prostaglandin E1 for Long Circulation

Lipo-PGE1 is the most widely used formulation of PGE1 in clinic. However, PGE1 is easier to leak out from lipo-PGE1 and this will lead to the phlebophlogosis when intravenous injection. The stability of lipo-PGE1 in storage and in vivo is also discounted. The aim of this study is to develop a long-circulating prostaglandin E1-loaded nanoemulsion modified with 1,2-distearoyl-sn-glycero-3-phosphoethanolamine-N-[methoxy(polyethylene glycol)-2000] (DSPE-PEG) to improve the stability and pharmacokinetics profiles of lipo-PGE1. PEGylated PGE1 nanoemulsion was prepared using a dispersing-homogenized method. The stability of nanoemulsion in 1 month was investigated. Pharmacokinetic studies were employed to evaluate the in vivo profile of the optimized nanoemulsion. The optimized nanoemulsion PGE1-PEG2000(1%)-NE showed an oil droplet size <100 nm with a surface charge of -14 mV. Approximately, 97% of the PGE1 was encapsulated in the nanoemulsion. The particle size, zeta potential, and drug loading of PGE1-PEG2000(1%)-NE were stable in 1 month. After PGE1-PEG2000(1%)-NE was intravenously administered to rats, the area under curve (AUC) and half-life of PGE1 were, respectively, 1.47-fold and 5.98-fold higher than those of lipo-PGE1 (commercial formulation). PGE1-PEG2000(1%)-NE was an ideal formulation for prolonging the elimination time of PGE1. This novel parenteral colloidal delivery system of PGE1 has a promising potential in clinic use.

Possible involvement of AMP-activated protein kinase in PGE1-induced synthesis of osteoprotegerin in osteoblasts

AMP-activated protein kinase (AMPK) is firmly established as a central regulator of cellular energy homeostasis. We have previously reported that prostaglandin E₁ (PGE₁) stimulates the synthesis of osteoprotegerin through p38 mitogen-activated protein (MAP) kinase and stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK) in osteoblast-like MC3T3-E1 cells. The present study investigated the involvement of AMPK in PGE₁-induced osteoprotegerin synthesis in MC3T3-E1 cells. The levels of osteoprotegerin were measured using an enzyme-linked immunosorbent assay, while the phosphorylation of AMPK, acetyl-CoA carboxylase, p38 MAP kinase and SAPK/JNK were analyzed by western blotting. In addition, the mRNA expression levels of osteoprotegerin were determined by a reverse transcription-quantitative polymerase chain reaction. It was revealed that PGE₁ significantly induced the phosphorylation of the α and β subunits of AMPK in a time-dependent manner (P<0.05). In addition, acetyl-CoA carboxylase, a direct substrate of AMPK, was significantly phosphorylated by PGE₁ (P<0.05). Compound C, an AMPK inhibitor, was revealed to suppress the phosphorylation of acetyl-CoA carboxylase, which significantly reduced the release and mRNA expression levels of PGE₁-stimulated osteoprotegerin (P<0.05). However, the PGE₁-induced phosphorylation of p38 MAP kinase and SAPK/JNK were not affected by compound C. The results of the present study indicated that AMPK may positively regulate PGE₁-stimulated osteoprotegerin synthesis in osteoblasts; thus providing novel insight into the regulatory mechanisms underlying bone metabolism.

Cortical hyperostosis as a side-effect of prolonged use of prostaglandins

Cortical hyperostosis is a very uncommon side-effect of prolonged prostaglandin therapy with distinctive radiological signs that may be accompanied by painful swelling of the limbs and responds rapidly to withdrawal of therapy.

Unilateral absence of the pulmonary artery: a report of two cases that presented different clinical courses

We recently diagnosed two cases of isolated unilateral absence of the pulmonary artery just after birth. Through the therapy, we could not prevent obstruction of the pulmonary artery and lead to complications. There have been no symptoms attributed to isolated unilateral absence of the pulmonary artery so far. We should carefully consider the strategy for therapeutic intervention for asymptomatic cases.

Prostaglandin E1 potentiates the effects of P2Y12 blockade on ADP-mediated platelet aggregation in vitro: Insights using short thromboelastography

In addition to adenosine diphosphate (ADP), a number of platelet function tests including the VerifyNow P2Y12 assay (VN-P2Y12) employ prostaglandin E1 (PGE1) to improve specificity for P2Y12 blockade by mitigating the contribution of the P2Y1 pathway on ADP-mediated platelet aggregation. Using short thromboelastography (s-TEG), we have previously shown that VN-P2Y12 overestimates the functional effect of clopidogrel in some individuals. We investigated whether PGE1 systematically increases the inhibitory effects of P2Y12 blockade on ADP-mediated platelet aggregation in an in vitro model. Using s-TEG, we measured ADP-induced platelet aggregation either in the presence or absence of PGE1 (11 or 22 nM) in blood samples taken from healthy volunteers pre-incubated with prasugrel active metabolite (PAM; 0, 1, 3 or 10 µM). Individually, both PGE1 (p < 0.02) and PAM (p < 0.0001) inhibited ADP-mediated platelet aggregation in a dose-dependent manner, as expected. Furthermore, inclusion of PGE1 augmented inhibition of ADP-mediated platelet aggregation in response to PAM (p < 0.02) in a dose-dependent manner such that a 10-fold higher dose of PAM was required to attain equivalent inhibition of ADP-mediated platelet aggregation to that achieved by 1 µM PAM in the presence of 11 nM PGE1. In conclusion, PGE1 potentiates the anti-aggregatory effects of P2Y12 blockade on ADP-mediated platelet aggregation. Assays that employ PGE1 with ADP may therefore overestimate therapeutic response to prasugrel in a proportion of individuals, potentially making them unsuitable candidates for guiding delivery of personalized antiplatelet therapy.

Prostaglandin E1 Treatment for Lumbar Spinal Canal Stenosis: Review of the Literature

BACKGROUND

The important pathophysiologic factor of neurogenic intermittent claudication (NIC) in lumbar spinal canal stenosis (LSCS) has been reported to be the reduction in intraneural blood flow and a state of relative ischemia in nerve tissues. Prostaglandin E1 (PGE1) presumably improves symptoms in patients with LSCS by improving the blood flow in the cauda equina and nerve roots through its vasodilation and antiplatelet aggregation effects. The purpose of the study was to summarize the results of previous studies regarding PGE1 treatment for LSCS and to describe the details of PGE1 treatment to all physicians who take care of patients with LSCS.

METHODS

Review of the literature.

RESULTS

There are 3 PGE1-related products that have been used clinically for the treatment of LSCS: PGE1, lipo-PGE1, and limaprost (PGE1 derivative). Experimental studies have been performed to verify the efficacy of PGE1 treatment for LSCS. Many studies have reported clinical outcomes of PGE1 treatment in patients with LSCS. Overall, previous studies examining PGE1 treatment for LSCS demonstrate improvement in several clinical outcome measures such as the visual analog scale, Japanese Orthopaedic Association score, and NIC distance, although most of the studies have only short-term follow-up.

CONCLUSIONS

Based on the results of previous studies, PGE1 treatment may be an option as a conservative treatment for LSCS. However, future studies with high-quality and long-term follow-up are necessary. Future studies also should include refinement of indications, administration period, as well as comparisons between PGE1 treatment and other conservative treatments such as epidural injection.

Does the VerifyNow P2Y12 assay overestimate "therapeutic response" to clopidogrel? Insights using short thrombelastography

In contrast to short thrombelastography (s-TEG) which utilises adenosine diphosphate (ADP) alone, the VerifyNow P2Y12 assay (VN-P2Y12) additionally uses prostaglandin E1 (PGE1) as agonist to assess response to P2Y12 inhibitors. Based upon previous observations, we hypothesised that VN-P2Y12 overestimates the therapeutic effects of clopidogrel. Simultaneous assay with s-TEG and VN-P2Y12 was performed in 43 healthy volunteers and 170 patients either on or off clopidogrel. Furthermore, in 27 patients on clopidogrel 75 mg we compared the effects of adding 22 nM PGE1 to ADP on platelet aggregation in s-TEG to ADP alone. A higher proportion of individuals had a result indicating high platelet reactivity (HPR) with s-TEG than VN-P2Y12 in (i) 43 clopidogrel naïve volunteers (95.3% vs 81.4%, p = NS); (ii) 28 volunteers loaded with clopidogrel 600 mg (39.3% vs 10.7 %, p = < 0.01); (iii) 123 clopidogrel naïve patients (93.5% vs 78%, p = < 0.0001); (iv) 47 patients on clopidogrel 75 mg (42.6% vs 4.3%, p = < 0.0001). In 59 patients loaded with clopidogrel 600 mg/900 mg, a greater proportion had a "therapeutic response" with VN-P2Y12 compared to s-TEG, regardless of the threshold for defining HPR with VN-PY12 (P2Y12 reaction units ≥ 230 or 208). Furthermore, adding PGE1 to ADP in s-TEG potentiated the anti-aggregatory effects of clopidogrel compared with ADP alone. In conclusion, VN-P2Y12 overestimates the functional effects of clopidogrel in some individuals, possibly because it utilises PGE1 in addition to ADP. This could have implications for the ability of VN-P2Y12 to stratify patients as "responders" or "non-responders" to clopidogrel.

Improving diagnostic accuracy in the transport of infants with suspected duct-dependent congenital heart disease

AIM

To identify factors that distinguish duct-dependent congenital heart disease (DDCHD) from non-DDCHD in newborn infants.

METHOD

A retrospective, cohort study. The Newborn Emergency Transport Service, Victoria (NETS) is a retrieval service for all inter-hospital neonatal transfers, and the Royal Children's Hospital, Melbourne (RCH) is a paediatric cardiac referral centre for the state of Victoria, Australia. All infants ≤10 days and ≥34 weeks gestation with suspected CHD and/or persistent pulmonary hypertension of the newborn (PPHN), transferred by NETS from non-tertiary neonatal units to RCH, over a 4-year period.

RESULTS

Of 142 eligible infants, 81 had DDCHD and 61 had non-DDCHD, of whom 51 had PPHN. Diagnostic accuracy of DDCHD by the NETS team was 77%. Presence of a heart murmur, abnormal pulses, upper and lower limb blood pressure (BP) difference >10 mmHg, cardiomegaly, initial SpO2 of <92%, PaO2 <50 mmHg, and pre-post ductal SpO2 difference >10% were significantly associated with DDHCD on univariate analysis. No single clinical finding was significantly associated with DDCHD on multivariate analysis. Labile SpO2 , abnormal lung parenchyma, mean BP <40 mmHg, pH <7.25, lactate >5 and FiO2 >0.5 were significantly associated with non-DDCHD, but at multivariate analysis only labile SpO2 and mean BP <40 mmHg were associated with non-DDCHD.

CONCLUSIONS

Clinical diagnosis of DDCHD outside of a cardiac centre is challenging. No single factor predicts DDCHD. Combined interpretation of clinical, physiological and x-ray findings may assist.

Prostaglandin E1 increases the blood flow rate of saphenous vein grafts in patients undergoing off-pump coronary artery bypass grafting

OBJECTIVE

To compare the effects of prostaglandin E1 (PGEl) versus placebo on blood flow rate in coronary artery bypass grafts.

DESIGN

A prospective, randomized, double-blinded study.

SETTING

A teaching hospital.

PARTICIPANTS

Forty-six patients with stable angina scheduled for isolated elective OPCAB were recruited and randomized into group PGE1 and group placebo.

INTERVENTION

Following randomization, the patients in the PGE1 group (Group PGE1, n = 23) received a continuous intravenous infusion of PGEl (10 ng/kg/min) after endotracheal intubation and the placebo group (Group placebo, n = 23) received the same volume of normal saline. The infusion administration was removed after leaving the intensive care unit.

MEASUREMENTS AND MAIN RESULTS

The grafts' blood flow rate was measured with a transit time flowmeter at 10 minutes and 30 minutes after coronary artery grafting. The hemodynamic parameters, including mean arterial pressure (MAP), heart rate, and SvO2, VO2I, DO2I, ERO2 monitored by a pulmonary artery catheter, were recorded. The blood flow of the saphenous vein grafts was significantly higher in the PGE1 group than the placebo group at both 10 and 30 minutes after coronary artery grafting. At the 10-minute mark, the graft flow was 54.9 ± 31.4 mL/min versus 47.3 ± 24.6 mL/min in venous nonsequential grafts to the left coronary artery for group PGE1 and placebo (p = 0.000). Corresponding values at 30 minutes were 60.1 ± 27.8 mL/min versus 48.4 ± 26.3 mL/min (p = 0.002). In the venous non-sequential grafts to the right coronary artery, a tendency of blood flow also was found to be higher in the PGE1 group than in the placebo group at 10-minutes (52.7 ± 29.4 mL/min versus 49.3 ± 23.8 mL/min, p = 0.048) and the 30-minutes (58.6 ± 26.5 mL/min, 50.9 ± 25.9 mL/min, p = 0.037). The blood flow rate of the left internal mammary artery (LIMA) grafts in group PGE1 was higher than that in the placebo group but did not reach statistical significance. The VO2I, DO2I, and ERO2 in the 2 groups at the 2 time points did not reach statistical significance. The cardiac index (CI) in group PGE1 was higher than that of the placebo group at T3 and T4 (p = 0.035 and p = 0.012, respectively). The lactate (LAC) at the end of the operation (T2), 4 hours after the operation (T3), and 24 hours after operation (T4) in the placebo group were higher than that of group PGE1 (p = 0.023, p = 0.015, and p = 0.043, respectively). The oxygenation saturation of the mixed venous blood (SvO2) in the 2 groups was decreased but without significant difference.

CONCLUSION

PGE1 significantly increased the flow rate in anastomosed saphenous vein grafts, and its beneficial effects on hemodynamics and oxygen metabolism were observed.

Critical pulmonary stenosis: challenges following surgical correction

A 20-day-old girl was diagnosed with critical pulmonary valvular stenosis with patent ductus arteriosus (PDA). She underwent surgical pulmonary valvotomy and infundibular resection. A trial snaring of the PDA resulted in significant systemic desaturation, and the PDA was left undivided. A continuous infusion of prostaglandin was used to keep the PDA open for the next 8 days. The PDA acted as a "natural systemic-to-pulmonary shunt" to provide pulmonary blood flow until right ventricular compliance and function improved. The various causes of persistent desaturation following pulmonary valvotomy are discussed.

Prostaglandin E1 -containing nanoparticles improve walking activity in an experimental rat model of intermittent claudication

OBJECTIVES

Due to the low stability of lipid emulsions, a lipid emulsion of prostaglandin E1 (Lipo-PGE1 ) necessitates daily intravenous drip infusions. To overcome this issue, we developed nanoparticles containing PGE1 (Nano-PGE1 ). Nano-PGE1 showed a good sustained-release profile of PGE1 from the nanoparticles in vitro, which may permit a longer-lasting therapeutic effect to be achieved. We here examined the pharmacological activity of Nano-PGE1 in a rat experimental model of intermittent claudication induced by femoral artery ligation.

METHODS

The walking activity of the rat was tested on a rodent treadmill. Tissue levels of PGE1 were determined by enzyme immunoassay, and skeletal muscle angiogenesis (capillary growth) was monitored by immunohistochemical analysis.

KEY FINDINGS

PGE1 could be detected in the lesion site one day after the intravenous administration of Nano-PGE1 but not of Lipo-PGE1 . An increased accumulation of Nano-PGE1 in the lesion site compared with control (unlesioned) site was also observed. The ligation procedure reduced the walking activity, which in turn was improved by a single administration of Nano-PGE1 but not of Lipo-PGE1 . The single administration of Nano-PGE1 also stimulated angiogenesis in the skeletal muscle around the ligated artery.

CONCLUSIONS

The findings of this study suggest that Nano-PGE1 improves the walking activity of femoral artery-ligated rats through the accumulation and sustained release of PGE1 .

Effect of prostaglandin E1 on arterial ketone body ratio in hepatectomy

We evaluated the effect of prostaglandin E₁ (PGE₁) administration during hepatectomy on arterial ketone body ratio (AKBR), which is an indicator of liver function, and on other liver functions in the postoperative period. Eighteen patients were divided into two groups: Continuous intravenous administration of PGE₁ (0.02 μg·kg^-1·h^-1) was started immediately before hepatic resection and ceased at the end of operation in nine patients (PGE₁ group); the other nine did not receive PGE₁ (control group). After hepatic resection, a significant increase in AKBR was observed in the PGE₁ group. However, no change was observed in the control group. In the PGE₁ group, total bilirubin and SGOT recovered more rapidly to the preoperative level than in the control group. These findings suggested that PGE₁ might have a protective effect on the liver.