Intrauterine device and upper-genital-tract infection

Concern about upper-genital-tract infection related to intrauterine devices (IUDs) limits their wider use. In this systematic review I summarise the evidence concerning IUD-associated infection and infertility. Choice of an inappropriate comparison group, overdiagnosis of salpingitis in IUD users, and inability to control for the confounding effects of sexual behaviour have exaggerated the apparent risk. Women with symptomless gonorrhoea or chlamydial infection having an IUD inserted have a higher risk of salpingitis than do uninfected women having an IUD inserted; however, the risk appears similar to that of infected women not having an IUD inserted. A cohort study of HIV-positive women using a copper IUD suggests that there is no significant increase in the risk of complications or viral shedding. Similarly, fair evidence indicates no important effect of IUD use on tubal infertility. Contemporary IUDs rival tubal sterilisation in efficacy and are much safer than previously thought.

Late adult onset chorea with typical pathology of Hallervorden-Spatz syndrome

Senile chorea is a well recognised but poorly understood clinical entity characterised by a slowly progressive, generalised chorea in elderly people without mental deterioration or a clear underlying cause. The Hallervorden-Spatz syndrome is typically thought of as a paediatric condition with extrapyramidal features and dementia. However, it has been described in adults usually presenting with parkinsonism plus dementia. An elderly woman with slowly progressive chorea without dementia was found at postmortem to have the pathological features originally described by Hallervorden and Spatz. This association has not previously been reported.

Abortion surveillance at CDC: creating public health light out of political heat

In the late 1960s, states began to liberalize their abortion laws, and a new era in women's health began. Under the leadership of Jack Smith, the Centers for Disease Control and Prevention (CDC) established a voluntary abortion surveillance system that provided the first nationwide information on the numbers and characteristics of women having abortions. Studies of abortion morbidity done by the CDC revealed that suction curettage was safer than sharp curettage, local anesthesia was safer than general anesthesia, free-standing clinics were safer than hospitals, and dilation and evacuation (D&E) was safer than the alternative of labor induction for early second-trimester abortions. This evidence, which contradicted traditional medical tenets, rapidly changed the practice of abortion in the United States. CDC also established a surveillance system for abortion deaths. This demonstrated a rapid improvement in the safety of abortion in the early 1970s. Lessons learned from mortality investigations helped to change practice as well.Today, more is known about the epidemiology of abortion than any other operation in the history of medicine. In the midst of strident debate over the abortion issue, CDC abortion surveillance data have helped to guide judicial rulings, legislative actions, and Surgeon General's reports, which have supported safer choices for women of reproductive age. When medical historians of the future look back on this century, the increasing availability of safe, legal abortion will stand out as a public health triumph.

Antibiotic prophylaxis for intrauterine contraceptive device insertion

BACKGROUND

Concern about the risk of upper genital tract infection (pelvic inflammatory disease) often limits use of the IUD, a highly effective contraceptive. Prophylactic antibiotic administration around the time of induced abortion significantly reduces the risk of postoperative endometritis.(Sawaya, 1996) Since the risk of IUD-related infection is limited to the first few weeks to months after insertion,(Lee, 1983; Farley, 1992) contamination of the endometrial cavity at the time of insertion(Mishell, 1966) appears to be the mechanism, rather than the IUD or string itself. Thus, antibiotic administration before IUD insertion might reduce the risk of upper genital tract infection from passive introduction of bacteria at insertion.

OBJECTIVES

To assess the effectiveness of prophylactic antibiotic administration before IUD insertion in reducing IUD-related complications and discontinuations within three months of insertion. The primary outcome was pelvic inflammatory disease (four reports) or early removals of the device (two reports).

SEARCH STRATEGY

We searched both MEDLINE and EMBASE, handsearches of journals through CENTRAL, and lists of references. We also wrote to international experts in the field to identify unpublished studies.

SELECTION CRITERIA

We included randomized controlled trials using any antibiotic compared with a placebo. We found four such trials; two had pilot study data available.

DATA COLLECTION AND ANALYSIS

DATA EXTRACTION

We used searches of MEDLINE, EMBASE, and handsearches of journals available through CENTRAL. We also reviewed lists of references in original research and in review articles. We wrote to experts to identify unpublished trials and made telephone calls to authors to supply missing information. Two independent reviewers abstracted data. We assessed the validity of each study using methods suggested in the Cochrane Handbook.

DATA SYNTHESIS

We generated 2x2 tables for the principal outcome measures. We used the Peto modified Mantel-Haenszel technique to calculate odds ratios and assessed statistical heterogeneity between studies.

MAIN RESULTS

The odds ratios for pelvic inflammatory disease associated with use of prophylactic doxycycline or azithromycin compared with placebo or no treatment was 0.89 (95%CI 0.53-1.51). Use of prophylaxis was associated with a small reduction in unscheduled vists to the provider (OR 0.82; 95% CI 0.70-0.98). Use of doxycycline or azithromycin had little effect on the likelihood of removal of the IUD within 90 days of insertion (OR 1.05; 95% CI 0.68-1.63). Significant heterogeneity did not exist between studies.

REVIEWER'S CONCLUSIONS

Use of either doxycycline 200 mg or azithromycin 500 mg by mouth before IUD insertion confers little benefit. While the reduction in unscheduled visits to the provider was marginally significant, the cost-effectiveness of routine prophylaxis remains questionable. A uniform finding in these trials was the low risk of IUD-associated infection, with or without use of antibiotic prophylaxis.

Dementia as the most common presentation of cortical-basal ganglionic degeneration

OBJECTIVE

To evaluate the clinical presentations and dominant symptoms of patients with postmortem proven cortical-basal ganglionic degeneration (CBGD) from one neuropathology center.

BACKGROUND

CBGD is a rare but increasingly recognized condition with clinical and pathologic features that continue to evolve. Attempts have been made to develop clinical criteria to enhance the specificity of diagnosis, but it is not clear what proportion of patients harboring CBGD disease present in the "classical" fashion versus other presentations. Previous large-case series that emphasize a parietal/perceptual-motor presentation may be biased because the cases mainly originate from movement disorder centers.

METHODS

Thirteen cases of pathologically confirmed CBGD with sufficient clinical data were identified from a single neuropathology center between 1981 and 1996.

RESULTS

Before death, only 4 of the 13 patients had a clinical diagnosis of CBGD, 6 had a clinical diagnosis of Alzheimer's disease (AD), 1 had AD and parkinsonism, and 2 had an atypical dementia of the frontotemporal type. Nine of 13 cases had early dementia.

CONCLUSIONS

Dementia was the most common presentation of CBGD in this study. Despite the best efforts to define criteria to enhance the specificity of a diagnosis of CBGD, it is becoming clear that the clinical syndrome that accompanies this disease is quite varied. Unfortunately, patients fulfilling classical diagnostic criteria may represent a minority of those with this pathologic diagnosis.

Clinical features differentiating patients with postmortem confirmed progressive supranuclear palsy and corticobasal degeneration

Progressive supranuclear palsy (PSP) and cortocobasal degeneration (CBD) are often clinically confused with each other because they share a rapid disease progression, parkinsonism that responds poorly or transiently to levodopa therapy, and associated signs (e.g., ocular abnormalities, pyramidal signs and cognitive involvement). To improve the accuracy in diagnosing these disorders, this study examined the clinical features of 51 patients pathologically diagnosed with PSP and CBD. Logistic regression analysis identified two sets of predictors (models) for CBD patients, one consisting of asymmetric parkinsonism, cognitive disturbances at onset and instability and falls at first clinic visit, and the other one of asymmetric parkinsonism, cognitive disturbances at symptom onset and speech disturbances. While PSP patients often had severe postural instability at onset, symmetric parkinsonism, vertical supranuclear gaze palsy, speech and frontal lobe-type features, CBD patients presented with lateralized motor (e.g., parkinsonism, dystonia or myoclonus) and cognitive signs (e.g., ideomotor apraxia, aphasia or alien limb). On the other hand, CBD patients presenting with an alternate phenotype characterized by early severe frontal dementia and bilateral parkinsonism were generally misdiagnosed. PSP patients without vertical supranuclear gaze palsy were misdiagnosed. Recognizing the features which differentiate these disorders and the less obvious disease presentations as well as developing an increased index of suspicion will improve the diagnostic accuracy of these disorders.

Bundling a pregnancy test with the Yuzpe regimen of emergency contraception

The recent United States Food and Drug Administration approval of a commercial kit containing the Yuzpe regimen for emergency contraception is a welcome event. Unlike emergency contraceptive pills sold in other countries, however, the United States product has a pregnancy test bundled with the pills. The test could identify existing pregnancies and avoid unnecessary use of the pills, although any protection against lawsuits alleging injury to an embryo is speculative. Conversely, no major medical organization recommends routine pregnancy testing before using emergency contraceptive pills. The test might stigmatize the Yuzpe regimen as being dangerous to an embryo. Difficulty in understanding the pregnancy test instructions could, paradoxically, deter some women from using the pills after having bought them. The bulky size of the pregnancy test reagent stick makes the package indiscreet, and the test adds unnecessary cost to emergency contraception. The greatest usefulness of the test could be to confirm or exclude a pregnancy several weeks after taking the pills, rather than before. If bundling an unnecessary test with emergency contraception is the only way to bring this useful product to the United States market, then the public health benefits could outweigh the disadvantages. However, this approach sets a worrisome precedent and further isolates the United States from the international medical community.

New technologies in cervical cytology screening: a word of caution

Nearly 5000 women in the United States will die of cervical cancer this year and many of those deaths could be prevented. Most incident cases (60%) are associated with absent or deficient screening. Approximately 25% of screening failures are due to errors in cervical sampling or smear interpretation. New techniques for cytology screening such as liquid-based smears and computerized rescreening of slides are being promoted to physicians and the lay public despite limited scientific evaluation. Improving the validity of screening tests is important, but shifting resources for this purpose might cause net harm if the result is fewer screening opportunities for high-risk women. New screening technologies do not address this utilization gap and might widen it by driving the cost of screening out of the reach of high-risk women. Greater decreases in cervical cancer morbidity and mortality would likely result if the same resources were invested in a comprehensive national screening program that targeted women at highest risk.

Treatment of early Parkinson's disease

The early treatment of Parkinson's disease continues to be controversial as our understanding of the etiology of the disease remains incomplete. Ideally an intervention that reverses or protects against further damage to dopaminergic neurons would be initiated once the symptoms of the disease are recognized. Unfortunately, there are no currently available therapies that have been shown to have a major impact on the progression of the disease. However, delaying effective symptomatic therapy beyond a point of significant disability does result in increased mortality. Concerns have been raised regarding the potential toxicity of levodopa on remaining nigral neurons. Although there is little support for this concept, levodopa is associated with important complications. The development of new symptomatic treatments has made the management of early Parkinson's disease even more complex and requires that many different factors be considered prior to initiating therapy in an attempt to minimize current and future disability caused by the disease and its treatment.

Prophylactic antibiotics for intrauterine device insertion: a metaanalysis of the randomized controlled trials

We evaluated the effectiveness of prophylactic antibiotic administration before IUD insertion in reducing the incidence of pelvic inflammatory disease, unscheduled visits back to the clinician, and IUD discontinuations within 3 months of insertion. We performed a metaanalysis of all known randomized controlled trials comparing an antibiotic (either oral doxycycline or azithromycin) versus a placebo or no treatment. Use of prophylaxis significantly reduced the frequency of unscheduled return visits (odds ratio 0.82; 95% CI 0.70, 0.98). The protection against pelvic inflammatory disease was smaller and not statistically significant 0.89 (95% CI 0.53, 1.51). No significant effect on premature IUD discontinuation was evident. Use of either doxycycline or azithromycin before IUD insertion offered little observable benefit in the US. Prophylaxis reduced unscheduled visits and possibly PID in developing countries, which have higher rates of sexually transmitted diseases than in the US. A more important finding in these trials is the low incidence of pelvic inflammatory disease with or without prophylactic antibiotics.

Motor neuron disease-inclusion dementia presenting as cortical-basal ganglionic degeneration

The frontotemporal dementias are a group of relatively new and evolving clinical and pathologic entities. The predominant frontal-temporal atrophy causes a variety of clinical syndromes, usually dominated by disturbances in behavior, mood, and speech. The motor neuron disease-inclusion dementia (MNDID) subtype is characterized by the accumulation of specific intraneuronal ubiquitin-immunoreactive inclusions with the complete absence of tau immunoreactivity. We present a patient with the clinical and neuroimaging characteristics of a highly asymmetric neurodegenerative condition distinguished by limb rigidity, bradykinesia, dystonia with an alien limb phenomenon, cortical sensory findings, and limb apraxia. His premorbid diagnosis was cortical-basal ganglionic degeneration but he had the typical histologic features of a frontotemporal dementia of the MNDID subtype.

Patients' understanding of medical risks: implications for genetic counseling

OBJECTIVE

To assess patients' ability to compare magnitudes of Down syndrome risk at maternal ages of 35 and 40 years, expressed as rates or as proportions.

METHODS

We used a self-administered, anonymous questionnaire that posed the same comparison in two different formats: 2.6 versus 8.9 per 1000 women (rates) and one in 384 versus one in 112 women (proportions). The study setting included several university-affiliated obstetrics and gynecology outpatient clinics in San Francisco, California. A total of 633 women, whose primary languages were English, Spanish, or Chinese, participated. The main outcome measure was correct identification of the larger of two risks.

RESULTS

Women were more successful with rates (463 of 633 respondents, 73%) than with proportions (353 of 633 respondents, 56%). A paired analysis, in which each woman served as her own control, found risk assessment to be significantly better with rates than with proportions (P < .001). Women with little formal education had difficulty understanding risks framed either way.

CONCLUSION

The traditional use of proportions to express risk in genetic counseling lacks scientific basis. Rates were easier to understand than proportions, regardless of respondents' age, language, and education.

The alleged association between induced abortion and risk of breast cancer: biology or bias?

The alleged association between induced abortion and breast cancer is one of the most controversial and important questions in women's health today. To help clinicians provide appropriate counseling, we reviewed both the primary data and review articles on this topic. We identified the studies and reviews by using Medline and the reference lists of articles and texts. We then used the U.S. Preventive Services Task Force rating system to evaluate the evidence. Many case-control studies have addressed this question, but their results have been inconsistent. Persistent problems in the case-control studies include selection of an appropriate control group, recall bias (under-reporting of induced abortion by controls), and confounding by other risk factors. Two recent, large cohort studies, which are less susceptible to bias, showed either protection or no effect on breast cancer risk from an induced abortion. At present, level II-2 evidence (cohort and case-control studies) supports a class B recommendation (fair evidence) that induced abortion does not increase a woman's risk of breast cancer later in life.

Teaching critical appraisal to medical students in obstetrics and gynecology

Critical appraisal might be the most important skill to acquire in medical school. Despite its importance, this issue has received little attention in obstetrics and gynecology training. This article describes the approach used at San Francisco General Hospital. We teach critical appraisal in several ways. We provide a series of student seminars that foster critical reading of the literature. Topics range from technology assessment to contraception to sexually transmitted diseases. Evidence-based ward rounds complement the experience. During the rotation, each student formally reviews one topic in women's health using the US Preventive Services Task Force rating system. Although we lack a quantitative assessment of this approach, student feedback has been enthusiastic. Critical appraisal skills enable students to continue their medical education after completion of their formal training.