Effectiveness of a three-day communication skills course in changing nurses' communication skills with cancer/palliative care patients: a randomised controlled trial

This multi-centre, two-armed parallel-group pragmatic randomised controlled trial (RCT) evaluated the effectiveness of a 3-day communication skills course in changing nurses' communication skills. The primary outcome was the change in the nurses' communication skills score from pre-course to 12 weeks post-course. The main secondary outcome was the change in the nurses' level of confidence in communicating with patients. A total of 172 nurses were randomised to the course or control. The communication skills score for the intervention group increased by 3.4 points post-course but decreased in the control by 0.05 points (between-group difference in change: 3.41, 95% CI: 2.16-4.66, P < 0.001). Confidence scores increased by 18.16 points for the intervention group but decreased 0.7 points in the control (between-group difference in change: 18.86, 95% CI: 13.39-24.34, P < 0.001). This RCT contributes to the evidence base on the effectiveness of communication skills training in cancer and palliative care.

A comparison of women's, providers' and ultrasound assessments of pregnancy duration among termination of pregnancy clients in South Africa

OBJECTIVE

To compare providers' and women's estimates of duration of pregnancy with ultrasound estimates for determining medical abortion eligibility.

DESIGN

Cross-sectional study.

SETTING

Public termination of pregnancy (TOP) services in three provinces.

SAMPLE

A total of 673 women attending the above services for TOP.

METHODS

Women participating in a medical abortion feasibility study in South Africa provided estimates of pregnancy duration and date of last menstrual period (LMP). Each woman also had clinical and ultrasound exams. We compared estimates using the four methods, calculating the proportion of women in the 'caution zone' (< or = 8 weeks gestation by woman or provider estimate and > 8 weeks by ultrasound).

MAIN OUTCOME MEASURES

Mean gestational age by each method; difference between provider and LMP estimates and ultrasound estimates; and percentage of women in the 'caution zone'.

RESULTS

Women's estimates of pregnancy duration were 19 days fewer than ultrasound estimates (95% CI = -27 to 63). Mean provider- and LMP-based estimates were two (95% CI = -30 to 35) and less than one day(s) (95% CI = -46 to 51) fewer than ultrasound estimates. Comparing provider and ultrasound estimates, 15% of women were in the 'caution zone'; this fell to 12% if estimates of 9 weeks or fewer were considered acceptable.

CONCLUSIONS

Provider estimates of gestational age were sufficiently accurate for determining eligibility for medical abortion. LMP-based estimates were also accurate on average, but included more extreme differences from ultrasound estimates. Medical abortion could be provided in TOP facilities without ultrasound or with ultrasound on referral.

Reducing maternal mortality due to elective abortion: Potential impact of misoprostol in low-resource settings

Over 99% of deaths due to abortion occur in developing countries. Maternal deaths due to abortion are preventable. Increasing the use of misoprostol for elective abortion could have a notable impact on maternal mortality due to abortion. As a test of this hypothesis, this study estimated the reduction in maternal deaths due to abortion in Africa, Asia and Latin America. The estimates were adjusted to changes in assumptions, yielding different possible scenarios of low and high estimates. This simple modeling exercise demonstrated that increased use of misoprostol, an option for pregnancy termination already available to many women in developing countries, could significantly reduce mortality due to abortion. Empirical testing of the hypothesis with data collected from developing countries could help to inform and improve the use of misoprostol in those settings.

Advance provision of emergency contraception for pregnancy prevention (full review)

BACKGROUND

Emergency contraception can prevent pregnancy when taken after unprotected intercourse. Obtaining emergency contraception within the recommended time frame is difficult for many women. Advance provision, in which women receive a supply of emergency contraception before unprotected sex, could circumvent some obstacles to timely use.

OBJECTIVES

To summarize randomized controlled trials evaluating advance provision of emergency contraception to explore effects on pregnancy rates, sexually transmitted infections, and sexual and contraceptive behaviors.

SEARCH STRATEGY

In August 2006, we searched CENTRAL, EMBASE, POPLINE, MEDLINE via PubMed, and a specialized emergency contraception article database. We also searched reference lists and contacted experts to identify additional published or unpublished trials.

SELECTION CRITERIA

We included randomized controlled trials comparing advance provision and standard access, which was defined as any of the following: counseling which may or may not have included information about emergency contraception, or provision of emergency contraception on request at a clinic or pharmacy.

DATA COLLECTION AND ANALYSIS

We evaluated all identified titles and abstracts found for potential inclusion. Two reviewers independently abstracted data and assessed study quality. We entered and analyzed data using RevMan 4.2.8. We calculated odds ratios with 95% confidence intervals for dichotomous data and weighted mean differences with 95% confidence intervals for continuous data.

MAIN RESULTS

Eight randomized controlled trials met our criteria for inclusion, representing 6389 patients in the United States, China and India. Advance provision did not decrease pregnancy rates (OR 1.0; 95% CI: 0.78 to 1.29 in studies for which we included twelve month follow-up data; OR 0.91; 95% CI: 0.69 to 1.19 in studies for which we included six month follow-up data; OR 0.49; 95% CI: 0.09 to 2.74 in a study with three month follow up data), despite increased use (single use: OR 2.52; 95% CI 1.72 to 3.70; multiple use: OR 4.13; 95% CI 1.77 to 9.63) and faster use (weighted mean difference (WMD) -14.6 hours; 95% CI -16.77 to -12.4 hours). Advance provision did not lead to increased rates of sexually transmitted infections (OR 0.99; 95% CI 0.73 to 1.34), increased frequency of unprotected intercourse, nor changes in contraceptive methods. Women who received emergency contraception in advance were equally as likely to use condoms as other women.

AUTHORS' CONCLUSIONS

Advance provision of emergency contraception did not reduce pregnancy rates when compared to conventional provision. Advance provision does not negatively impact sexual and reproductive health behaviors and outcomes. Women should have easy access to emergency contraception, because it can decrease the chance of pregnancy. However, the interventions tested thus far have not reduced overall pregnancy rates in the populations studied.

Primary endoluminal stenting of transplant renal artery stenosis from cadaver and non-heart-beating donor kidneys

This study evaluated the efficacy of primary endovascular stenting in cases of transplant renal artery stenosis (TRAS) from cadaver and non-heart-beating donor kidneys. Patients with TRAS (n = 13) from a single-centre transplant population (n = 476) were treated by primary percutaneous angioplasty and endovascular stenting. The short-term efficacy of this intervention is demonstrated in terms of serum creatinine, glomerular filtration rate (GFR) biochemical, anti-hypertensive medications and mean arterial blood pressure control. Stenting for TRAS was performed in male (n = 10) and female (n = 3) recipients. The median age at transplantation was 55 yr (range 10-67 yr). Stenting occurred at a median duration of 410 d post-transplantation (range 84-5799 d). Mean serum creatinine (pre, 247 micromol/L; post, 214 micromol/L; p = 0.002), GFR (pre, 82.6 mL/min; post, 100.9 mL/min; p < 0.001), arterial blood pressure (pre, 104 mmHg; post, 97 mmHg; p = 0.036) and the number of anti-hypertensive medications required (pre, 3.4; post, 3.0; p = 0.002) showed significant improvement after post-endovascular therapy. There were no serious complications encountered. Primary endovascular stenting of TRAS produces a significant improvement in biochemical parameters of renal graft function and in blood pressure stability, with the benefit of low patient morbidity and single arterial puncture. Primary endoluminal stenting of TRAS is a safe and effective procedure for the treatment of TRAS.

Postinfectious gastroparesis related to autonomic failure: a case report

BACKGROUND AND AIM

Severe dysautonomia may be secondary to viral infections, resulting in impaired autoimmune, cardiovascular, urinary and digestive dysfunction. Herein, we present a case of a 31-year-old white female patient who had severe gastroparesis related to autonomic failure following an episode of acute gastroenteritis. This seems to be the first report providing thorough assessment of the enteric and autonomic nervous system by analysis of full-thickness small intestinal biopsies, cardiovagal testing and autopsy.

HOSPITAL COURSE

This patient affected by a severe gastroparesis was treated with antiemetics, prokinetics, analgesics and gastric electrical stimulation to control symptoms. Nutritional support was made using jejunal feeding tube and, in the final stage of disease, with total parenteral nutrition. Autonomic studies revealed minimal heart rate variability and a disordered Valsalva manoeuvre although the enteric nervous system and the smooth muscle layer showed a normal appearance. Hospital courses were complicated by episodes of bacteraemia and fungemia. Serum antiphospholipid antibodies were noted but despite anticoagulation, she developed a pulmonary embolism and shortly thereafter the patient died. Autopsy revealed acute haemorrhagic Candida pneumonia with left main pulmonary artery thrombus. Sympathetic chain analysis revealed decreased myelinated axons with vacuolar degeneration and patchy inflammation consistent with Guillain-Barre syndrome. The evaluation of the enteric nervous system in the stomach and small bowel revealed no evidence of enteric neuropathy or myopathy.

CONCLUSION

A Guillain-Barre-like disease with gastroparesis following acute gastroenteritis is supported by physiological and autonomic studies with histological findings.

Misoprostol use in obstetrics and gynecology in Brazil, Jamaica, and the United States

OBJECTIVES

To investigate current clinical use of misoprostol for the treatment of a range of reproductive health indications by providers in Brazil, Jamaica, and the United States.

METHODS

Using a 'snowball' sampling technique, we surveyed 228 gynecologists and obstetricians in Brazil (n=123), Jamaica (n=52), and the United States (n=53).

RESULTS

Providers use misoprostol for labor induction (46%), postpartum hemorrhage (8%), intra-uterine fetal death (61%), cervical priming (21%), missed abortion (57%), and incomplete abortion (16%) as well as first and second trimester abortion induction (27% and 13%, respectively).

CONCLUSIONS

There is considerable variation in the regimens used; moreover, the regimens commonly used in clinical practice often differ from those recommended in the medical literature. While misoprostol is an appealing alternative for many reproductive health indications in developing countries, the varied regimens and lack of registration raise critical medical and policy questions.

Emergency contraception: randomized comparison of advance provision and information only

OBJECTIVE

To determine whether multiple courses of emergency contraceptive therapy supplied in advance of need would tempt women using barrier methods to take risks with their more effective ongoing contraceptive methods.

METHODS

We randomly assigned 411 condom users attending an urban family planning clinic in Pune, India, to receive either information about emergency contraception along with three courses of therapy to keep in case of need, or to receive only information, including that about the locations where they could obtain emergency contraception if needed. For up to 1 year, women returned quarterly for follow-up, answering questions about unprotected intercourse, emergency contraceptive use, pregnancies, sexually transmitted infections, and acceptability.

RESULTS

Women given advance supplies reported unprotected intercourse at rates nearly identical to those among women given only information (0.012 versus 0.016 acts per month). Among those who did have unprotected intercourse, however, supply recipients were nearly twice as likely (79% versus 44%) to have taken emergency contraception, although numbers were too small to permit statistically significant inferences. No women used emergency contraception more than once during the study, even though everyone in the advance-supplies group had extra doses available. All women found knowing about emergency contraception useful, and all those receiving only information wished they had received supplies as well.

CONCLUSION

Multiple emergency contraception doses supplied in advance did not tempt condom users to risk unprotected intercourse. After unprotected intercourse, however, those with pills on hand used them more often. Women found advance provision useful.

Women's willingness to participate in microbicide trials in Northern Thailand

To assess women's interests and concerns regarding participation in trials of microbicides in Chiang Rai, Thailand, we administered structured questionnaires. Before answering the questionnaire, women attended an educational session on microbicides and clinical trials. Of 370 participants, 82% correctly answered 8 or more of the 11 overall comprehension questions, indicating an adequate knowledge base among the women from which to answer questions about attitudes toward microbicide trials. The most common motivations for participating in a trial were "getting tested for HIV" and "doing something good for women's health." The greatest barrier to participation was women's fear that if they proposed use of a microbicide, their husbands might feel protected and thereby have more sex partners. Overall, 6.2% said they would be "definitely willing to participate," and 66.8% said they wanted to participate but wanted to think about it. Most women previously unacquainted with the concept of microbicides or clinical trial design displayed adequate knowledge of these subjects after the short educational session. If women's initial reactions are validated by actual willingness, surveys could prove valuable for selecting sites for microbicide trials, estimating enrollment rates, and tailoring trials to make them most acceptable to women.

Acceptability and feasibility of Micralax applicators and of methyl cellulose gel placebo for large-scale clinical trials of vaginal microbicides

OBJECTIVE(S)

To evaluate the feasibility and acceptability of the Micralax applicator and of methyl cellulose placebo gel for use in vaginal microbicide clinical trials.

DESIGN

A two-centre prospective study following women for 2 months.

SETTING

Two primary health care clinics in South Africa.

PATIENTS, PARTICIPANTS

Female volunteers (n = 28) 18 years or older who were HIV negative and had no clinically detectable genital tract abnormalities or reproductive tract infections.

INTERVENTIONS

Participants used pre-filled Micralax applicators to apply methyl cellulose gel every other day, as well as up to 1 h before to every episode of vaginal sex.

MAIN OUTCOME MEASURE(S)

Consistency in the weight of gel dispensed per application; side-effects attributed to applicator or gel use; and acceptability of the applicator and of the gel.

RESULTS

Over a 2 month follow-up period the 22 women completing the study reported no adverse events related to gel or applicator use. The Micralax applicator proved acceptable. The gel was not too messy and did not reduce sexual frequency or pleasure. On average, the applicator dispensed 4.7 ml per use (close to the 4 ml planned).

CONCLUSIONS

The Micralax applicator performs well as a delivery system for potential vaginal microbicides; and methyl cellulose is an appropriate placebo for future microbicide trials.

Paget's disease of the breast

Paget's disease of the breast is a rare disorder of the nipple-areola complex that is often associated with an underlying in situ or invasive carcinoma. A change in sensation of the nipple-areola, such as itching and burning, is a common presenting symptom. Objectively, eczematoid changes of the nipple-areola complex are common. The later stages of Paget's disease of the breast are characterized by ulceration and destruction of the nipple-areola complex. Eczematoid changes of the nipple-areola complex and persisting soreness or itching, without obvious reason, is a suspicious symptom for Paget's disease of the breast and calls for thorough evaluation, including mammography. Exfoliative cytology with demonstration of Paget's cells may be useful, but a negative finding does not exclude Paget's disease of the breast. Surgical biopsy is the diagnostic standard and therefore the diagnosis should always be confirmed by open (surgical) biopsy. The histogenesis of Paget's disease of the breast continues to be debated. The epidermotropic theory holds that Paget's cells are ductal carcinoma cells that have migrated from the underlying breast parenchyma to the nipple epidermis. According to the in situ transformation theory, the Paget's cells arise as malignant cells in the nipple epidermis independent from any other pathologic process within the breast parenchyma. This theory has been proposed to explain those cases in which there is no underlying mammary carcinoma or when there is a carcinoma remote from the nipple-areola complex. Each of these theories is plausible; however, treatment approaches differ markedly depending on the theory of histogenesis. Mastectomy has been considered the standard of care in the management of patients with Paget's disease of the breast. Nowadays, however, some patients with Paget's disease of the breast are candidates for breast-conserving therapy. Patients must be selected carefully on an individual basis. Until there is a better understanding of the relationship of Paget's disease of the breast to the underlying cancer the surgeon should understand the natural history and behaviour of this lesion and be aware of both the risks of under- and over-treating patients with Paget's disease of the breast.

Transurethral resection of the prostate: failure patterns and surgical outcomes in patients with symptoms refractory to alpha-antagonists

BACKGROUND

alpha-Antagonists (AAs) are ineffective in some men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Transurethral resection of the prostate (TURP) may be required. Reasons for AA failure and surgical outcomes in these patients have not been reported.

METHODS

We retrospectively reviewed cases of TURP for LUTS due to bladder outlet obstruction from 1995 to 1998. The TURP patients in whom AA therapy had failed (group 1) were compared with those who had symptomatic BPH but were not taking AAs (group 2). Comorbid conditions that might influence treatment results were considered, as were sizes of resection and pathologic results.

RESULTS

No differences occurred between groups 1 (n = 38) and 2 (n = 25) in age, length of postoperative follow-up, or resection size. However, outcomes were poorer in group 1 than in group 2. A trend toward greater comorbidity that might lead to voiding dysfunction, though not statistically significant, was seen in group 1.

CONCLUSIONS

Postoperative results of TURP may be less successful after AA therapy failure. This may be due to preoperative risk factors that affect voiding function rather than to prostatic size.

Preliminary safety and acceptability of a carrageenan gel for possible use as a vaginal microbicide

OBJECTIVE

We sought to determine the safety and acceptability of vaginal gel formulation PC-503 among low risk, abstinent women. The active ingredient was 2% pharmaceutical grade lambda carrageenan, a sulphated polymer that is generally recognised as safe by the US Food and Drug Administration.

METHODS

35 women in five sites applied 5 ml of the PC-503 gel vaginally once a day for 7 days while abstaining from sexual intercourse. Visual vaginal examinations were performed on days 1, 4, and 8. STI testing and vaginal pool Gram stain preparations were done on days 1 and 8. Participants were asked about product acceptability.

RESULTS

34 of the 35 women enrolled completed 7 days' use. Following product use, five reported mild symptoms including "bladder fullness," "genital warmth," or discomfort, and lower abdominal pain, and one had moderate pale yellow cervical discharge. Using the Nugent criteria, three women had bacterial vaginosis (BV) before and after use; three had BV before but not after, and two had BV after but not before. Most of the women found PC-503 to be pleasant or neutral in feel and smell and considered extra lubrication to be an advantage; however, one third found it to be messy.

CONCLUSIONS

Vaginal use of PC-503 gel did not cause significant adverse effects in a small number of low risk, sexually abstinent women. Further testing in larger numbers of sexually active women is planned. A smaller volume of gel may be more acceptable to some women.

Misoprostol alone--a new method of medical abortion?

Misoprostol shows promise for early termination of pregnancy. The drug is widely available, inexpensive, and easy to administer. Current evidence on the efficacy of potential regimens for early abortion, though, is hard to decipher and often contradictory. Research on a safe, effective, acceptable regimen of misoprostol alone for early abortion is underway. Available data show a wide range in efficacy of various regimens, and additional research is needed to understand this variability. A framework for additional research on misoprostol alone for medical abortion is presented with a focus on the need to evaluate benefits and risks of new regimens in the context of women's options for termination of pregnancy. We discuss the potential usefulness of a regimen with less efficacy than approved medical abortifacients. Research is needed as well on women's ability to self-diagnose incomplete abortion or ongoing pregnancy and the potential for misoprostol to be used as treatment for incomplete abortion in order to evaluate the benefits and risks of misoprostol-alone regimens.

Men's attitudes towards a potential vaginal microbicide in Zimbabwe, Mexico and the USA

Vaginal microbicides are being developed in an attempt to expand women's and men's options for protecting themselves against HIV and other sexually transmitted infections. Taking account of men's attitudes during product development and introduction could increase the likelihood that products are acceptable and used. To capture the perspectives of urban and rural men from a range of cultural settings, we conducted focus group discussions with taxi drivers and farmers in Zimbabwe, Mexico and the USA. These explored HIV/STD risk perception and prevention strategies, desirable characteristics of vaginal products and of a microbicide, and attitudes towards use of a potential product. Men were generally supportive of the idea of a microbicide; urban somewhat more than rural men. Most thought microbicides would be preferable to condoms though many raised concerns about potential side effects. The men wanted these products to be as inexpensive and readily available as condoms, and differed as to whether a woman should have permission from her partner to use it. For them to be widely used, the men thought these products must not only be safe and effective, but should also have no negative effect on sexual pleasure. When a product becomes available, introductory messages must explain the limits on its effectiveness and encourage use with condoms. Further research is needed on definitions of pleasurable sex and the ramifications of this for microbicide formulation, and on partner communication around issues of sexuality and prevention of infection.

Emergency contraception: a review of the programmatic and social science literature

Many biomedical aspects of emergency contraception have been investigated and documented for >30 years now. A large number of social science questions, however, remain to be answered. In this article, we review the rapidly growing but geographically lopsided literature on this topic. Using computer database searches supplemented by reference reviews and professional correspondence with those active in the field, we gathered literature on the social science and service delivery aspects of emergency contraception published in English up through December 1998, as well as a few unpublished papers from the same time and slightly later, representing regions where published material is practically nonexistent. Methodologically acceptable papers are summarized in our tables and text, and form the basis for suggested improvements in existing emergency contraceptive services. The review also offers ideas for designing new emergency contraception services where they do not yet exist. We conclude by proposing an agenda for further social science research in this area.

Misoprostol used alone for the termination of early pregnancy. A review of the evidence

Increased access to medical methods of abortion could significantly reduce maternal mortality, especially in developing countries. In light of the political and commercial difficulties in distributing the abortifacient mifepristone, the widely studied mifepristone-misoprostol regimen may not be sufficiently available in the near future. Thus, researchers have begun to look for alternative regimens, including regimens using misoprostol alone. This article reviews the current available evidence on the potential of a misoprostol-alone regimen for medical abortion. Although the data are varied and difficult to compare, recent studies indicate that a misoprostol-alone regimen could be safe and effective as a method of medical abortion. Misoprostol is widely marketed around the world for its other indications and is inexpensive, stable in tropical climates, easy to transport, and simple to administer. A misoprostol-alone regimen of medical abortion could thus greatly improve the access to safe medical abortion services by women in developing countries.

Improving women's access to emergency contraception: innovative information and service delivery strategies

Barriers to widespread use of emergency contraception (EC) include lack of knowledge on the part of women and providers, lack of support for the method from providers, and lack of a dedicated product in many countries. This article reviews strategies to improve women's access to EC launched by national or regional health authorities, clinicians, grass-roots health organizations, and women's groups. Information campaigns have targeted women to improve their knowledge of EC and providers to improve their comfort with it. Local groups and individual providers have also provided leaflets or designed innovative service strategies in order to improve women's access to the method. Expanding the scope or number of these programs and introducing them in areas where women do not currently have adequate knowledge of or access to EC will insure that more women will be able to use this method.