Regimens of misoprostol with mifepristone for early medical abortion: a randomised trial

OBJECTIVE

To compare the efficacy, adverse effects and acceptability of the three most common misoprostol regimens used with mifepristone for medical abortion.

DESIGN

Randomised nonblinded trial.

SETTING

Three clinics associated with major research universities in Canada; two in major urban areas and one in a periurban area.

POPULATION

Women of reproductive age.

METHODS

Consenting women presenting for abortion services with gestations less than 56 days and who met inclusion criteria were given 200 mg mifepristone orally and then randomised into three misoprostol study groups: (group I) 400 micrograms of oral misoprostol, (group II) 600 micrograms of oral misoprostol, and (group III) 800 micrograms of vaginal misoprostol. Misoprostol was self-administered at home 24-48 hours following mifepristone, and participants were instructed to take a second similar misoprostol dose at 24 hours after the initial dose if bleeding was less than a normal menstrual period.

MAIN OUTCOME MEASURES

Successful abortion without surgery was 94.1%, with no significant differences across the three study groups (94.7% in group I, 93.4% in group II, and 94.3% in group III; P= 0.975).

RESULTS

Efficacy and adverse effects did not differ significantly across the three study groups. Pain increased significantly across the study and the gestational age groups and was associated with lower acceptability.

CONCLUSIONS

There appears to be a range of safe and effective options for early medical abortion with mifepristone including a choice between oral and vaginal administration of misoprostol.

Outcomes and health status of patients undergoing usual care for highly emetogenic chemotherapy

18591

Background: Chemotherapy-induced nausea and vomiting (CINV) remains a significant issue for patients, especially management of delayed symptoms. The Perugia 2004 antiemetic guidelines recommended that anthracycline/cyclophosphamide (A/C) combination regimens be considered as high risk emetogenic potential. The aim of our study was to determine the extent of CINV, and effect on quality of life for chemotherapy-naïve patients in a practice-based environment. Methods: Eligible patients were receiving their 1st cycle of high risk emetogenic or carboplatin chemotherapy, administered with “standard care” (5HT3 antagonist + dexamethasone) antiemetics (use of NK1 antagonists excluded). Patients completed a daily diary for 5 days post chemotherapy, capturing data on CINV activity and rescue medications usage. Emesis and nausea-specific health status was measured by the Functional Living Index - Emesis (FLIE); general health status was assessed using a 100mm VAS (EQVAS). Results: Of 74 patients, 42 received an A/C regimen, 16 cisplatin and 16 carboplatin. Overall complete response (no vomiting, no use of rescue antiemetics during the study period) was 60% in patients receiving carboplatin, 24% A/C and 21% cisplatin. During the delayed phase, mean total emesis episodes for carboplatin was 0.6, A/C 2.21 and cisplatin 4.08. Patients receiving carboplatin reported less delayed nausea, and better outcomes for FLIE and EQVAS scores. Treatment with either A/C or cisplatin was associated with similar deterioration in nausea control across the study period, and similar impact on FLIE scores (see table ). Conclusions: Our results are consistent with the recommendation that A/C regimens be considered highly emetogenic, with similar impact on patient symptoms and quality of life compared with cisplatin. Delayed CINV remains a target for antiemetic intervention. Similar studies need to be repeated in patients receiving additional NK1 antagonists to assess their impact on CINV outside clinical trials.

[Table: see text]

[Table: see text]

Knowledge and attitudes about abortion legislation and abortion methods among abortion clients in Latvia

OBJECTIVE

To assess knowledge of abortion legislation and knowledge and attitudes about medical and surgical abortion among women seeking a legal abortion in Latvia.

METHODS

Data are drawn from a survey of 371 abortion clients from 16 purposively selected abortion clinics in Latvia. A semi-structured questionnaire was used to collect socio-demographic data and information on women's knowledge of and attitudes toward abortion law and abortion methods.

RESULTS

Most women knew that abortion is legal either under any (53%) or certain (37%) circumstances. Almost one third (31%) of women interviewed were aware of medical abortion. After hearing a description of medical abortion, respondents felt the method as described would be advantageous because it could avoid a surgical intervention (33%) or found it simple, easy, convenient, or natural (12%). Women were concerned that the method might not be completely effective (38%) or be associated with side-effects (22%).

CONCLUSIONS

Respondents were interested in medical abortion as a less invasive option to surgical abortion. Efforts should be undertaken to inform women about the safety and efficacy of the method.

Rates of childhood trauma in a sample of patients with schizophrenia as compared with a sample of patients with non-psychotic psychiatric diagnoses

Despite strong evidence of high rates of childhood and adult trauma in schizophrenia, the area remains under-researched. Our objectives in the study were first, to examine the rates of exposure to childhood, adult and lifetime (child plus adult) trauma in a population with schizophrenia and a population with non-psychotic psychiatric diagnoses and second, to examine the effect of trauma on the symptoms of schizophrenia. Two groups, those with schizophrenia (n = 40), and those with a non-psychotic diagnosis (n = 30), were recruited. Data were collected for demographic, psychiatric and trauma histories for all participants and on psychosocial functioning and psychiatric symptomatology for the patients with schizophrenia. Childhood exposure to trauma was significantly more common in the schizophrenia group (t = 5.196, df = 68, p < 0.001, Eta squared = 0.28), with the strongest relationship being childhood physical assault. In the schizophrenia group a history of trauma was significantly related to poor communication skills (r = -0.529, p < 0.001) and depressive symptoms (r = 0.443, p = 0.004). Evidence that childhood exposure to trauma is more common in a population with schizophrenia is consistent with other studies and raises the possibility that such trauma is of etiological importance. Further research is required to replicate those findings, to elucidate possible pathways by which the experience of trauma may contribute to the development of schizophrenia, and to explore the relationship between a history of childhood trauma and the experience of depressive symptoms in schizophrenia.

Early Experience and Sex Interact to Influence Limbic-Hypothalamic-Pituitary-Adrenal-Axis Function After Acute Alcohol Administration in Rhesus Macaques (Macaca mulatta)

BACKGROUND

Studies in rodents demonstrate sex differences in neuroendocrine stress axis activity after treatment with alcohol. In abstinent alcoholics, atypical depressives, and individuals with posttraumatic stress disorder, limbic-hypothalamic-pituitary-adrenal (LHPA)-axis activity is often blunted; among females in these patient populations, however, resistance to glucocorticoid feedback and increased pituitary reactivity is observed. Early parental loss is a major life stressor and is a risk factor for both affective disturbances and LHPA-axis abnormalities later in life. We wanted to determine whether sex and early life parental absence would interact to influence alcohol-induced alterations in LHPA-axis activity after exposure to ethanol in macaques.

METHODS

Animals were reared with their mothers in social groups (MR, n = 94) or without adults in peer-only groups (PR, n = 79). At 5 years of age, they received an intravenous infusion of alcohol (2-2.2 g/kg), and the effects of alcohol, sex, and rearing condition on ACTH and cortisol levels were analyzed by ANOVA.

RESULTS

Peer-reared females had higher ACTH levels than did PR males, MR females, and MR males after alcohol infusion. Alcohol-induced cortisol levels were not affected by sex and rearing condition.

CONCLUSIONS

These findings suggest that there are sex differences in glucocorticoid negative feedback, pituitary responsivity, or release of ACTH secretagogues among individuals exposed to early life stress and emphasize the importance of considering sex effects when studying LHPA-axis dysregulation in alcoholism and other stress-related neuropsychiatric disorders.

Breast cancer in adolescents and young women

Breast cancer is very rare in adolescents and very young women. Less than 1% of all breast cancer cases occur before the age of 30 years (Natl Cancer Inst Monogr 16 (1994) 69). Invasive breast cancer occurring in women before the age of 35 years has a more aggressive biological behaviour and is associated with a worse prognosis than in older premenopausal women. Breast cancers in these young women are more frequently poorly differentiated, oestrogen-receptor (ER)-negative, have lymphovascular invasion and high proliferating fractions. Breast-conserving surgery in women <35 years old is associated with a higher risk of local recurrence than in older women. All young women should be considered at moderate-high risk by virtue of their age alone and offered adjuvant therapy. The long-term toxicity of adjuvant therapies is a particular concern when treating these women. The implications of possible fertility impairment and premature menopause require consideration when discussing adjuvant chemotherapy and endocrine therapy. Adolescents and young women are particularly vulnerable to emotional distress and psychosocial problems and should be provided with appropriate support. Young women who are at a potential high-risk of developing breast cancer such as those with germline mutations of BRCA1, BRCA2, TP53, PTEN or who have previously received mantle irradiation for Hodgkin's disease need close follow-up and are candidates for screening from a young age.

Does Timing of Adjuvant Chemotherapy for Early Breast Cancer Influence Survival?

Purpose: Theoretically, patients with early breast cancer might benefit from starting adjuvant chemotherapy soon after surgery, and this would have important clinical implications. We have addressed this question from a large, single-center database in which the majority of patients received anthracyclines.

Patients and Methods: A total of 1,161 patients from a prospectively maintained database treated with adjuvant chemotherapy for early breast cancer at the Royal Marsden Hospital (London, United Kingdom), including 686 (59%) receiving anthracyclines, were retrospectively analyzed. The disease-free survival (DFS) and overall survival (OS) of the 368 patients starting chemotherapy within 21 days of surgery (group A) were compared with those of the 793 patients commencing chemotherapy ≥ 21 days after surgery (group B). Median follow-up time was 39 months (range, 12 to 147 months).

Results: No significant difference in 5-year DFS was found between the two groups overall (70% for group A v 72% for group B; P = .4) or in any subgroup. Likewise, there was no difference in 5-year OS (82% for group A v 84% for group B; P = .2) or when the interval to the start of chemotherapy was considered as a continuous variable (P = .4).

Conclusion: We have been unable to identify any significant survival benefit from starting adjuvant chemotherapy early after surgery, either overall or in any subset of patients.

Serotonin transporter gene polymorphism, differential early rearing, and behavior in rhesus monkey neonates

A polymorphism in the serotonin (5-HT) transporter gene regulatory region (5-HTTLPR) is associated with measures of 5-HT transporter (5-HTT) expression and 5-HT-mediated behaviors in humans. An analogous length variation of the 5-HTTLPR has been reported in rhesus monkeys (rh5-HTTLPR). A retrospective association study was conducted on 115 rhesus macaque infants either homozygous for the long 5HTTLPR variant (l/l) or heterozygous for the short and long form (l/s). To assess contributions of genotype and early rearing environment, 36 mother-reared monkeys (l/l = 26, l/s = 10) and 79 nursery-reared monkeys (l/l = 54, l/s = 25) were assessed on days 7, 14, 21, and 30 of life on a standardized primate neurobehavioral test designed to measure orienting, motor maturity, reflex functioning, and temperament. Both mother-reared and nursery-reared heterozygote animals demonstrated increased affective responding relative to l/l homozygotes. Nursery-reared, but not mother-reared, l/s infants exhibited lower orientation scores than their l/l counterparts. These results demonstrate the contributions of rearing environment and genetic background, and their interaction, in a nonhuman primate model of behavioral development.

Carboplatin and gemcitabine in metastatic transitional cell carcinoma of the urothelium: effective treatment of patients with poor prognostic features

PURPOSE

To evaluate the activity and toxicity of gemcitabine and carboplatin in consecutive patients presenting with locally advanced or metastatic transitional cell carcinoma of the urothelium (TCC).

PATIENTS AND METHODS

Seventeen consecutive patients referred to a single institution with locally advanced or metastatic TCC were treated with carboplatin AUC 5 on day 1 and gemcitabine 1000 mg/m2 on day 1 and 8 of a 21-day cycle. All patients were assessable for response and toxicity. Minimal eligibility criteria were used to minimize patient selection.

RESULTS

Seventeen patients with measurable stage IV TCC of the urothelium were treated. The median age was 69 years (range 54-78), the median creatinine clearance was 56 ml/min (range 34-90) and 30% of patients had an ECOG performance score of two. Nine patients (53%) had visceral metastases and the majority of patients had multiple sites of metastases. There were three complete responses, seven partial responses, for an overall response rate of 58.8%. Responses were seen at all sites including the liver. One patient had a response within a previously irradiated field and three patients with prior chemotherapy had responses. Median overall survival was 10.5 months and median time to progression was 4.6 months. Toxicity was primarily haematologic with six patients having grade 3 neutropenia and six patients with grade 4 neutropenia. There were five cases of grade 3 and three cases of grade 4 thrombocytopenia. There were no episodes of febrile neutropenia and only one patient required admission for management of toxicity. Thirteen patients required dose reduction or delay due to neutropenia or thrombocytopenia. There were no treatment-related deaths.

CONCLUSION

The combination of carboplatin and gemcitabine is active in metastatic transitional cell carcinoma of the urothelium with manageable toxicity in a relatively elderly group of patients with some poor prognostic features.

High prevalence of asthma in five remote indigenous communities in Australia

Data on the prevalence of asthma in children residing in remote indigenous communities in Australia are sparse, despite the many reports of high prevalence in nonindigenous children of this country. Two previous Australian studies have had poor participation rates, limiting interpretation of their results. A study of children in the Torres Strait and Northern Peninsula Area of Australia was conducted to document the prevalence of asthma symptoms. Five indigenous communities were randomly selected and trained interviewers, who were local indigenous health workers, recruited participants using a house-by-house approach. Information was collected by a structured face-to-face interview based on a standardized questionnaire constructed from the protocol International Study of Asthma and Allergy in Childhood; 1,650 children were included in the study with a 98% response rate. Overall, the prevalence of self-reported ever wheezing was 21%; 12% reported wheezing in the previous year; and 16% reported ever having asthma. There was significant variation in the prevalence of asthma symptoms between communities. It is concluded that there are significant intercommunity variations in the prevalence of asthma symptoms in remote communities and that the prevalence in these communities is as high as in nonindigenous groups.

To be or not to be: recording Aboriginal identity on hospital records

Accurate health information is a key component in the development of health improvement strategies. This paper provides a discussion of the challenges in improving hospital information systems in relation to indigenous patients. Based on interviews with both staff and patients of a major city hospital complex, a picture emerges of the need for bottom-up approaches to understanding perceptions of identity. Indigenous patients were found to be generally comfortable about identifying themselves on hospital records (if asked), but were often not clear why such questions were asked. On the other hand hospital staff were often uncomfortable about asking and were equally not always clear why such information was needed. Issues of accurate hospital record administration are discussed in relation to the attitudes and perceptions of both staff and patients.

Assessment of a two-generation reproductive and fertility study of mercuric chloride in rats

Effects of mercuric chloride (MC) on the reproductive performance of two successive generations of rats was evaluated. F(0) rats were exposed to 0.0:0.0 (males:females), 0.50:0.75 (males:females), 1.00:1.50 (males:females) and 1.50:2.50 (males:females) mg/kg/day MC. Selected parental F(1) males and females were exposed to the same doses received by their parents (F(0)). Significant differences resulting from exposure of the F(0) generation to MC were found in implantation efficiency, fertility, live births and day 4 survival indices, litter size, and the body weight of F(1) pups. However, the continued exposure of the F(1) generation to MC did not affect fertility index or litter size, but did significantly affect implantation efficiency, live births and day 4 survival indices. In F(0) males, body weight and weights of the kidneys, testes, epididymides, prostate and seminal vesicles were significantly different, while in F(1) males, body weight, kidney weight, brain weight, liver weight and the weights of the testes, prostate and seminal vesicles were significantly different. In F(0) females, body weight and the weights of the kidneys, brain and liver were significantly different, while in F(1,) females, body weight, as well as the weights of the kidneys, liver, adrenals, uterus and ovaries were significantly different. These data showed that exposure to MC resulted in more adverse reproductive effects in the first generation and that these effects moderated in the second generation.

Rearing condition and plasma cortisol in rhesus monkey infants

Previous studies comparing plasma cortisol levels in mother-reared and nursery-reared rhesus monkey infants under baseline and stress conditions have reported conflicting findings. Differences in subject age, procedures, and specific rearing history may account for many of the discrepant findings. In the present study, mother-reared infants from large social groups, peer-only reared animals, and infants reared with surrogates and limited peer contact were studied in different test conditions across the first 6 months of life. Infants were sampled under three conditions: following a neonatal assessment at Days 14 and 30, immediately upon capture on Day 60, and after 30-min isolation periods on Days 90, 120, and 150. Mother-reared infants exhibited higher cortisol levels on Days 14 and 30 than did both types of nursery-reared infants. In addition, Day 60 basal values of mother-reared infants were higher than those of both peer-reared and surrogate/peer-reared infants. However, on Days 90, 120, and 150, both mother-reared and peer-reared infants exhibited higher cortisol levels in response to separation and 30-min isolation than did the surrogate/peer-reared infants. These differences may reflect group-specific variations in physical environment, capture time, feeding regimen, or diurnal HPA axis rhythms.

Asthma management in indigenous children of a remote community using an indigenous health model

OBJECTIVE

To describe the management of asthma in children in a remote indigenous community and the delivery of subspecialist service through the indigenous health-care model.

METHODOLOGY

Children referred by indigenous health-care workers were evaluated prospectively by paediatric respiratory physicians, based on a standardized protocol, at a primary health care setting at Thursday Island, Queensland.

RESULTS

Forty of the 54 children referred with a provisional diagnosis of asthma did have asthma, with 30% having persistent asthma. Only 59% of parents knew the dose of the medication prescribed and 80% had minimal knowledge of the medications. In 88% of children, the management of asthma was improved by introduction of an appropriate spacer device and changing the dose and type of medications.

CONCLUSIONS

The management of children with asthma in the Torres region can be improved substantially by the use of age appropriate delivery devices and medications, and improving knowledge of asthma. Specialist delivery service to remote indigenous communities can be effectively delivered in partnership with the indigenous health service. The high proportion of persistent asthma in the Torres Straits community in comparison to urbanised Australia raises issues of inequity of appropriate medical service delivery to remote indigenous communities.

Heterogeneous immunosensing using antigen and antibody monolayers on gold surfaces with electrochemical and scanning probe detection

We report the use of antibody and antigen monolayer immunosurfaces as detection elements in a competitive heterogeneous immunoassay employing either electrochemical or scanning probe detection. Antibody or antigen monolayers were prepared by covalent attachment of the desired immunoreagent to a two-component self-assembled monolayer via amide linkages. More specifically, mixed monolayers of a carboxylic acid-terminated thiol (thioctic acid) and a methyl-terminated thiol (butanethiol) were used to control the surface epitope density. The microscopic structure of the resulting antibody and antigen arrays was characterized by AFM (atomic force microscopy). Individual, surface-confined rabbit IgG antibodies could be directly imaged in contact mode. The average height of the capture antibodies was found to be 7.1 nm; the average antibody diameter, after correcting for tip convolution effects, was determined to be between 7 and 10 nm. The surface epitope density could be varied over approximately 2 orders of magnitude by changing the composition of the mixed monolayer. AFM was also used to characterize the antibody-antigen binding characteristics of these immunosurfaces, and an average binding efficiency of 22.8% was measured for rabbit IgG antibody arrays. In the second part of this study, the electrochemical detection scheme originally developed by Heineman and co-workers was adapted to our system. A calibration data set was measured, and the linear least-squares correlation coefficient (R2) was found to be 0.993. Finally, the electrochemical and scanning probe detection modes were directly compared. We find an excellent correlation between the surface density of antibody-antigen complexes measured by AFM and the electrochemical response of the same immunosurfaces.

Burkitt's lymphoma associated with Helicobacter pylori

The association between Helicobacter pylori infection and low grade mucosa-associated lymphoid tissue lymphoma is now widely accepted. In this report, we describe the concurrent development of Burkitt's lymphoma in the stomach of a 53-year-old male with perforated duodenal ulcer and positive H. pylori serology. The temporal relationship between these two events raises the possibility of a causal link between H. pylori infection and this lymphoproliferative disease. In describing this rare case of gastric Burkitt's lymphoma, we consider the evidence that supports this possibility.

Community perceptions of health, illness and care: identifying issues for indigenous communities

Community meetings, interviews with key informants, and focus groups were used to document major health concerns and problems among Indigenous women in Queensland, as part of the Australian Longitudinal Study on Women's Health. In this article, we analyze understandings of "community" as used in Australian health research and among Indigenous women. We then examine health issues as identified and experienced by women and explore the gaps that exist between community concerns, individual health status, and service delivery.

Placental transfer of fentanyl in early human pregnancy

To investigate the transfer of fentanyl across the early human placenta, we have collected samples of maternal blood and fetal fluids and/or blood, simultaneously, between 5 and 22 min following an intravenous bolus of fentanyl (1.5 microg/kg) to the mother. The pregnancies were between 6 and 16 weeks of gestation and scheduled for elective termination of pregnancy under general anaesthesia. Total fentanyl concentration was determined by radioimmunoassay in 11 pairs of first trimester maternal serum and fetal coelomic fluid samples, 14 pairs of maternal serum and amniotic fluid samples, seven series of first trimester maternal serum and coelomic and amniotic fluid samples, and 10 series of early second trimester maternal and fetal sera and amniotic fluid samples. Fentanyl was not detected in coelomic fluid samples at any gestational age and in amniotic fluid samples collected after 12 weeks of gestation. Measurable concentrations of fentanyl were found in maternal serum collected within 15 min after the initial bolus and in fetal serum collected between 10 and 12 min later. These findings indicate that fentanyl is transferred across the early placenta into the amniotic cavity and fetal blood circulation but not into the exocoelomic cavity. The distribution of this molecule inside the early gestational sac is probably influenced by the increased binding by maternal and fetal sera, its short half-life of distribution and the specific biology of the fetal fluid formation and composition.