Factors associated with health services utilization in patients with systemic lupus erythematosus: a systematic review

OBJECTIVES

SLE patients require varying levels of health services since disease severity and activity differ among individuals. Understanding the factors associated with health service utilisation would be useful in improving equitable access. It would also help to identify modifiable factors and current good practices so as to improve quality of care and thus reduce utilisation. Thus, the objective of this review is to identify factors associated with health services utilisation.

METHODS

Five electronic databases (PubMed, PsycINFO, EMBASE, International Pharmaceutical Abstract, Web of Science) and bibliographies of short-listed articles were searched. All indicators of health service utilisation (physician and specialist visits, hospitalisations, direct costs) and alternative medicine utilisation were accepted as outcomes in primary studies. Two authors independently selected the studies based on pre-specified inclusion and exclusion criteria.

RESULTS

Of 1,276 papers retrieved from electronic and hand searches, 25 were finally selected and reviewed in totality, of which 13 were cross-sectional, 5 were prospective, and 7 were retrospective studies. A variety of service types (e.g. outpatient visits, hospitalisations, etc.) and factors (e.g. demographic, socioeconomic, laboratory indices, etc.) were evaluated. Type of health insurance, poorer physical functioning and greater disease severity were found to be associated with higher utilisation across several studies.

CONCLUSION

Modifying the choice or coverage of health insurance plans of SLE patients is a possible option in improving equitable access. Better management of patient reported outcomes such as physical functioning and timely management of SLE to reduce disease severity may reduce health services utilisation in the long term.

Surgical excision for challenging upper limb nerve sheath tumours: a single centre retrospective review of treatment results

OBJECTIVE

To review the accuracy of different investigation modalities for upper limb nerve sheath tumours and the resulting surgical outcomes, and propose a standard algorithm to deal with such tumours to minimise complications.

DESIGN

Retrospective review.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All patients with upper limb nerve sheath tumours being excised in our hospital from 1999 to 2008.

MAIN OUTCOME MEASURES

The accuracy rate of different investigations, as well as corresponding neurological deficits after excision and recurrence rates.

RESULTS

A total of 23 (10 male and 13 female) patients, aged between 28 and 72 (mean, 46) years, underwent excision of 25 lesions during the study period. The mean duration of symptom was 2.5 years and tumour size ranged from 1 to 10.5 cm (mean, 2.6 cm). A majority (80%) presented with a typical triad; only one had a true neurological deficit. Twenty-two ultrasonography and 20 magnetic resonance images were obtained, with a diagnostic accuracy of 77% and 100%, respectively. Eight fine-needle aspiration cytology examinations and two core biopsies were performed, which had respective accuracy rates of 13% and 100%. Fifteen patients experienced neurological deficits after the operation; three showed spontaneous recovery. Among 12 patients with long-term residual neurological sequelae, five had both motor and sensory deficits and four had moderate-to-severe disability. No recurrence was reported.

CONCLUSION

Nerve sheath tumours in the hand need to be managed with care. Among the different investigation modalities, magnetic resonance imaging was considered to be the gold standard. Yet ultrasonography is still the most easily accessible and least invasive investigation in public hospital setting. Complications are liable to ensue even if patients are managed by hand specialists. Thus, well-planned operations and detailed discussions with the patient are important prerequisites before operation.

Adrenomedullin regulates sperm motility and oviductal ciliary beat via cyclic adenosine 5'-monophosphate/protein kinase A and nitric oxide

Cilium and flagellum beating are important in reproduction and defects in their motion are associated with ectopic pregnancy and infertility. Adrenomedullin (ADM) is a polypeptide present in the reproductive system. This report demonstrates a novel action of ADM in enhancing the flagellar/ciliary beating of human spermatozoa and rat oviductal ciliated cells. At the concentration found in the seminal plasma, it increases the progressive motility of spermatozoa. ADM binds to its classical receptor, calcitonin receptor-like receptor/receptor activity-modifying protein complex on spermatozoa. ADM treatment increases the protein kinase A activities, the cyclic adenosine monophosphate, and nitric oxide levels of spermatozoa and oviductal cells. Pharmacological activators and inhibitors confirmed that the ADM-induced flagella/ciliary beating was protein kinase A dependent. Whereas nitric oxide donors had no effect on sperm motility, they potentiated the motility-inducing action of protein kinase A activators, demonstrating for the first time the synergistic action of nitric oxide and protein kinase A signaling in flagellar/ciliary beating. The ADM-induced motility enhancement effect in spermatozoa also depended on the up-regulation of intracellular calcium, a known key regulator of sperm motility and ciliary beating. In conclusion, ADM is a common activator of flagellar/ciliary beating. The study provides a physiological basis on possible use of ADM as a fertility regulation drug.

Frozen-thawed embryo transfer cycles

OBJECTIVE

To review the outcomes of frozen-thawed embryo transfer cycles. DESIGN. Retrospective review.

SETTING

Tertiary assisted reproduction centre, Hong Kong.

PATIENTS

Subfertile patients undergoing frozen-thawed embryo transfer between July 2005 and December 2007.

MAIN OUTCOME MEASURES

Clinical and ongoing pregnancy rates.

RESULTS

A total of 983 frozen-thawed embryo transfer cycles performed during the study period were reviewed. The clinical pregnancy and ongoing pregnancy rates were 35% and 30%, respectively. Factors associated with successful outcome included younger maternal age (<=35 years) and 4 or more blastomeres at replacement, but not the method of insemination, the cause of subfertility, or the type of frozen-thawed embryo transfer cycle. The overall multiple pregnancy rate was 18%. For cycles with a single embryo replaced, embryos having 4-cell or higher stages at replacement gave an ongoing pregnancy rate of 25%, whereas those with less than 4 cells had a significantly lower ongoing pregnancy rate of 5% only. Blastomere lysis after thawing significantly reduced the clinical pregnancy and ongoing pregnancy rates of cycles with one embryo replaced.

CONCLUSIONS

Clinical pregnancy and ongoing pregnancy rates of frozen-thawed embryo transfer cycles were 35% and 30%, respectively. Higher pregnancy rates were associated with younger maternal age (<=35 years), blastomere numbers of 4 or more, and no blastomere lysis after thawing.

Stability of morphine sulphate in saline under simulated patient administration conditions

OBJECTIVE

To study the stability of morphine sulphate solutions under simulated administration conditions in a patient-controlled analgesic device.

METHOD

Concentrations of 1 mg/ml and 10 mg/ml morphine sulphate in saline were monitored over 16 days under slow continuous delivery from Deltec Medication cassettes kept in the dark at a controlled temperature of 32 degrees C and a humidity between 36 and 38%. The morphine concentrations in the samples, collected at 0, 1, 2, 5, 6, 7, 9, 12, 14 and 16 days, were measured by a stability indicating high-performance liquid chromatographic method.

RESULTS

Throughout the study period, the reservoir concentrations varied within 10% of their initial values and there was no chromatographic evidence of degradation. However, the pH of both reservoirs decreased with time, but morphine is expected to be stable within the observed pH range.

CONCLUSION

This study demonstrated that the concentrating effect due to evaporation under the storage conditions described, over 16 days, was not of significance and the product was stable.

Rapidly reversible cardiomyopathy associated with chronic ipecac ingestion

Ipecac, an over-the-counter emetic agent, has been a drug of choice for abuse by patients with eating disorders. Its alkaloid emetine has been associated with serious cardiac toxicity; however, the dose effect has not been well established. We present a patient with anorexia and bulimia nervosa who ingested ipecac chronically and developed the characteristic manifestations of ipecac toxicity. Unexpectedly, her induced left ventricular dysfunction returned to normal after only 10 days of withholding the drug. This finding, in contrast with the findings of other reports, establishes that ipecac cardiomyopathy can be readily reversible. The cumulative experience thus far, nonetheless, provides no discernible pattern of the effect of ipecac on the myocardium. Thus, in the continuum of poisoning, the point at which the myocardium becomes irreversibly damaged is undetermined. With continued abuse, potentially lethal outcome, and limited experience with ipecac cardiotoxicity, further investigation and perhaps heightened restriction of the drug are warranted.

Chromosomal anomalies and Y-microdeletions among Chinese subfertile men in Hong Kong

OBJECTIVE

To report the type and frequency of chromosomal anomalies and Y-microdeletions among Hong Kong Chinese subfertile men with sperm concentrations lower than 5 million/mL. DESIGN. Retrospective study.

SETTING

A reproductive centre in Hong Kong.

PARTICIPANTS

A total of 295 Chinese subfertile men who underwent both karyotyping and Y-microdeletion studies from 2000 to 2007 were categorised as having non-obstructive azoospermia (n=71), very severe oligospermia (sperm concentration>0 and <or=2 million/mL, n=158), and severe oligospermia (sperm concentration>2 and <5 million/mL, n=66).

MAIN OUTCOME MEASURES

Karyotyping and Y-microdeletion studies.

RESULTS

The prevalence of chromosomal anomalies and Y-microdeletions in the study population were 8.5% (25/295; 95% confidence interval, 5.6-12.3%) and 6.4% (19/295; 3.9-9.9%), respectively. The total prevalence of chromosomal anomalies and Y-microdeletions was 13.2% (39/295; 95% confidence interval, 9.6-17.6%) as five cases of non-obstructive azoospermia showed both Y structural alterations and AZFbc deletion. The corresponding figures for chromosomal anomalies in the groups with non-obstructive azoospermia, very severe oligospermia, and severe oligospermia were 21.1% (15/71; 95% confidence interval, 12.3-32.4%), 5.7% (9/158; 2.6-10.5%), and 1.5% (1/66; 0.0-8.2%). While for Y-microdeletions they were 8.5% (6/71; 3.2-17.5%), 8.2% (13/158; 4.5-13.7%) and 0% (0/66; 0.0-4.4%), respectively. The respective overall prevalence rates for chromosomal anomalies and Y-microdeletions in these groups were: 22.5% (16/71; 13.5-34.0%), 13.9% (22/158; 8.9-20.3%), and 1.5% (1/66; 0.0-8.2%).

CONCLUSIONS

Our findings strongly support the recommendation for both karyotyping and Y-microdeletion analyses in subfertile men with sperm concentrations of 2 million/mL or lower before they undergo assisted reproduction treatment.

Effects of silymarin on the resolution of liver fibrosis induced by carbon tetrachloride in rats

Silymarin, a standardized extract of the milk thistle (Silybum marianum), has a long tradition as a herbal remedy, and was introduced as a hepatoprotective agent a few years ago. However, the therapeutic effects of silymarin remain undefined. Carbon tetrachloride (CCl4) is a xenobiotic used extensively to induce oxidative stress and is one of the most widely used hepatic toxins for experimental induction of liver fibrosis in the laboratory. In this study, we investigated the restoration of the CCl4-induced hepatic fibrosis by high dose of silymarin in rats. After treatment with oil (as normal group; n = 6) or CCl4 [as model (n = 7) and therapeutic (n = 7) groups] by intragastric delivery for 8 weeks for the induction of liver fibrosis, the rats in the normal and model group were administered orally normal saline four times a week for 3 weeks whilst the therapeutic group received silymarin (200 mg/kg). The histopathological changes were observed with Masson staining. The results showed that the restoration of the CCl4-induced damage of liver fibrosis in the therapeutic group was significantly increased as compared to that in the model group. Moreover, silymarin significantly decreased the elevation of aspartate aminotransferase (AST), alanine aminotransferase, and alkaline phosphatase in serum, and also reversed the altered expressions of alpha-smooth muscle actin in liver tissue. Therefore, these findings indicated that silymarin may have the potential to increase the resolution of the CCl4-induced liver fibrosis in rats.

Needle aponeurotomy for Dupuytren's contracture

PURPOSE

To review the efficacy and safety of needle aponeurotomy for Dupuytren's contracture in Chinese patients.

METHODS

Seven men and one woman aged 50 to 80 (mean, 67) years underwent needle aponeurotomy for Dupuytren's contracture. Five were manual workers and the other 3 were retired. Their chief complaints were difficulty moving the fingers, clumsiness of the hand, and occasional pain in the palm. No patient had any family history of Dupuytren's contracture.

RESULTS

41 points were released in 13 fingers (3 middle, 3 ring, and 7 little). Immediately after release, the respective mean flexion contracture correction of the metacarpophalangeal and proximal interphalangeal joints were 50 (from 50 to 0) and 35 (from 46 to 11) degrees. At 22-month follow-up, the respective mean residual flexion contracture of both joints were 12 and 27 degrees; the corresponding long-term improvements were 70 and 41%. No patient had a wound complication or neurovascular injury. All had a normal score for Disabilities of the Arm, Shoulder, and Hand.

CONCLUSION

For Chinese patients with Dupuytren's contracture, needle aponeurotomy is safe and effective. Long-term correction is better maintained in metacarpophalangeal than proximal interphalangeal joints (70 vs 41%).

The impact of psychological abuse by an intimate partner on the mental health of pregnant women

Objective

The objective of this first population-based study in Hong Kong was to assess the impact of psychological abuse by an intimate partner on the mental health of pregnant women.

Design

Survey.

Setting

Antenatal clinics in seven public hospitals in Hong Kong.

Population

Three thousand two hundred and forty-five pregnant women.

Methods

The Abuse Assessment Screen (AAS) and demographic questionnaires were administered face-to-face at 32–36 weeks of gestation. At 1 week postpartum, the AAS, Edinburgh Postnatal Depression Scale and SF-12 Health Survey were administered by telephone.

Main outcome measures

Intimate partner violence, postnatal depression and health-related quality of life.

Results

Two hundred and ninety six (9.1%) of the participants reported abuse by an intimate partner in the past year. Of those abused, 216 (73%) reported psychological abuse only and 80 (27%) reported physical and/or sexual abuse. Forty six (57.5%) in the physical and/or sexual abuse group also reported psychological abuse. Women in the psychological abuse only group had a higher risk of postnatal depression compared with nonabused women (adjusted OR: 1.84, 95% CI: 1.12–3.02). They were also at a higher risk of thinking about harming themselves (adjusted OR: 3.50, 95% CI: 1.49–8.20) and had significantly poorer mental health-related quality of life (P < 0.001). The higher risks of postnatal depression and thinking of harming themselves were not observed in the physical and/or sexual abuse group although significantly poorer mental health-related quality of life (P < 0.001) was observed.

Conclusions

Psychological abuse by an intimate partner against pregnant women has a negative impact on their mental health postdelivery. Furthermore, psychological abuse in the absence of physical and/or sexual abuse can have a detrimental effect on the mental health of abused women. The findings underscore the importance of screening pregnant women for abuse by an intimate partner and the need for developing, implementing and evaluating interventions to address psychological abuse.

Please cite this paper as: Tiwari A, Chan K, Fong D, Leung W, Brownridge D, Lam H, Wong B, Lam C, Chau F, Chan A, Cheung K, Ho P. The impact of psychological abuse by an intimate partner on the mental health of pregnant women. BJOG 2008;115:377–384.

Effects of nerve growth factor for retinal cell survival in experimental retinal detachment

PURPOSE

To investigate the neuron protective effect of recombined nerve growth factor (rNGF) on retinal cell damage induced by experimental retinal detachment.

METHODS

Experimental retinal detachment models were created in Sprague-Dawley rats by subretinal injection of sodium hyaluronate. Intravitreal injection of rNGF (5 microg/eye) or phosphate-buffered saline (PBS) was separately applied every 4 days after retinal detachment. The rat eyes were then observed and sacrificed at various time points. Morphologic changes were observed by light microscopy, electron microscopy, and cell counts. Apoptosis of retinal cells was detected by TUNEL assay.

RESULTS

After retinal detachment, most eyes from NGF-treated groups showed better organized structure of retinal cells than those from the PBS-treated control groups. Cell counts indicated that the nuclei numbers in the outer nuclear layer (ONL), inner nuclear layer (INL), and ganglion cell layer (GCL) of NGF-treated groups were significantly more than those from PBS-treated control group (p < 0.05) after retinal reattachment. TUNEL-positive cells were identified in ONL, INL, and GCL. They peaked at the fourth day after retinal detachment in both the NGF-treated groups and the control groups. But the cell counts of apoptosis revealed that the NGF-treated retina had less TUNEL-positive cells than the control groups (p < 0.05).

CONCLUSIONS

The results showed that intravitreal injection of exogenous NGF can protect retinal cells from degeneration and apoptosis in experimental retinal detachment. It may exert its neuroprotection effect by preventing the apoptosis of retinal cells after retinal detachment.

Misoprostol: pharmacokinetic profiles, effects on the uterus and side-effects

Misoprostol, a synthetic prostaglandin E1 analogue, is commonly used for medical abortion, cervical priming, the management of miscarriage, induction of labor and the management of postpartum hemorrhage. It can be given orally, vaginally, sublingually, buccally or rectally. Studies of misoprostol's pharmacokinetics and effects on uterine activity have demonstrated the properties of the drug after various routes of administration. These studies can help to discover the optimal dose and route of administration of misoprostol for individual clinical applications. Misoprostol is a safe drug but serious complications and teratogenicity can occur with unsupervised use.

Treatment of incomplete abortion and miscarriage with misoprostol

A literature review was conducted to determine whether misoprostol is an effective treatment for incomplete abortion and, if so, to recommend an appropriate regimen. All English language articles published before October 2007 using misoprostol in at least one of the study arms were reviewed to determine the efficacy of misoprostol when used to treat incomplete abortion in the first trimester. All available unpublished data previously presented at international scientific meetings were also reviewed. Sufficient evidence was found in support of misoprostol as a safe and effective means of non-surgical uterine evacuation. A single dose of misoprostol 600 microg oral is recommended for treatment of incomplete abortion in women presenting with a uterine size equivalent to 12 weeks gestation.

Identifying intimate partner violence: comparing the Chinese Abuse Assessment Screen with the Chinese Revised Conflict Tactics Scales

OBJECTIVE

To assess the measurement accuracy and the utility of the Chinese Abuse Assessment Screen (AAS).

DESIGN

A cross-sectional study.

SETTING

An antenatal clinic of a public hospital and a community centre in Hong Kong.

SAMPLE

A total of 257 Chinese women consisting of 100 pregnant women and 157 nonpregnant women.

METHOD

The Chinese AAS was administered first, followed by the Chinese Revised Conflict Tactics Scales (CTS2). This was performed in the same sitting, and each participant was interviewed once either at an antenatal clinic (for the pregnant women sample) or at a community centre (for the nonpregnant women sample).

MAIN OUTCOME MEASURES

Estimates of the sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios.

RESULTS

Using the Chinese CTS2 as the standard, the specificity estimates of the Chinese AAS for emotional, physical and sexual abuse were > or = 89%, while the sensitivity estimates varied from 36.3 to 65.8%. The sensitivity improved in the screening for more severe cases (66.7%). The positive predictive values were > or = 80%, and the negative predictive values varied from 66 to 93%. Factors such as the age difference between the couple and the woman's need for financial assistance were found to be associated with intimate partner violence (IPV).

CONCLUSION

The Chinese AAS has demonstrated satisfactory measurement accuracy and utility for identifying IPV when the Chinese CTS2 was used as the standard.

Reversible effects of permeation enhancers on human skin

This study outlines a systematic approach for investigating a desired characteristic of chemicals used to facilitate the permeation of drugs across the skin that is, the reversibility of the permeation enhancement effect. This implies that the vital skin barrier function is restored and not permanently impaired after the application of these enhancers. The reversible effects of two terpene enhancers, (R)-(-)-carvone and eucarvone, on excised human skin were evaluated by in vitro permeation and extraction studies on normal (untreated) and enhancer-pretreated epidermis, respectively. For the permeation studies on normal epidermis, the donor solutions were the model drug, haloperidol (HP, 3mg/ml), in propylene glycol (PG) with or without 5% (w/v) enhancer and for the extraction studies using epidermis pretreated with enhancer, a solution of HP (3mg/ml) in PG was used. The solubilities of the enhancers in 0.03% lactic acid (receptor solution) and of HP in PG (donor solution) were determined to demonstrate that the sink and saturated conditions were maintained in the respective compartments of the flow-through cells throughout the in vitro experiments. (R)-(-)-Carvone cleared out of the skin faster than eucarvone. This could be due to the 4-fold higher skin permeability of (R)-(-)-carvone compared to that of eucarvone. The amount of HP deposited in the epidermis was much lower in the eucarvone-pretreated epidermis than that pretreated with (R)-(-)-carvone. The permeation profile of HP across the enhancer-pretreated skin was 4-fold greater than in the vehicle alone (control), but similar to that across untreated skin with enhancer present in the donor solution, indicating that permeation across the enhancer-pretreated skin did not change. The enhancing effects of both terpenes on the skin were found to be reversible and the permeability of the skin was left intact after the passage of the drug in the vehicle with these enhancers.

Formulation development of transdermal dosage forms: Quantitative structure-activity relationship model for predicting activities of terpenes that enhance drug penetration through human skin

Terpenes and terpenoids have been used as enhancers in transdermal formulations for facilitating penetration of drugs into human skin. Knowledge of the correlation between the human skin penetration effect (HSPE) and the physicochemical properties of these enhancers is important for facilitating the discovery and development of more enhancers. In this work, the HSPE of 49 terpenes and terpenoids were compared by the in vitro permeability coefficients of haloperidol (HP) through excised human skin. A first-order multiple linear regression (MLR) model was constructed to link the permeability coefficient of the drug to the lipophilicity, molecular weight, boiling point, the terpene type and the functional group of each enhancer. The Quantitative Structure-Activity Relationship (QSAR) model was derived from our data generated by using standardized experimental protocols, which include: HP in propylene glycol (PG) of 3 mg/ml as the donor solution containing 5% (w/v) of the respective terpene, the same composition and volume of receptor solution, similar human skin samples, in the same set of automated flow-through diffusion cells. The model provided a simple method to predict the enhancing effects of terpenes for drugs with physicochemical properties similar to HP. Our study suggested that an ideal terpene enhancer should possess at least one or combinations of the following properties: hydrophobic, in liquid form at room temperature, with an ester or aldehyde but not acid functional group, and is neither a triterpene nor tetraterpene. Possible mechanisms revealed by the QSAR model were discussed.