Building Blocks for the Long-acting and Permanent Contraceptives Coordinated Registry Network

Objectives

A multistakeholder expert group under the Women’s Health Technology Coordinated Registry Network (WHT-CRN) was organized to develop the foundation for national infrastructure capturing the performance of long-acting and permanent contraceptives. The group, consisting of representatives from professional societies, the US Food and Drug Administration, academia, industry and the patient community, was assembled to discuss the role and feasibility of the CRN and to identify the core data elements needed to assess contraceptive medical product technologies.

Design

We applied a Delphi survey method approach to achieve consensus on a core minimum data set for the future CRN. A series of surveys were sent to the panel and answered by each expert anonymously and individually. Results from the surveys were collected, collated and analyzed by a study design team from Weill Cornell Medicine. After the first survey, questions for subsequent surveys were based on the analysis process and conference call discussions with group members. This process was repeated two times over a 6-month time period until consensus was achieved.

Results

Twenty-three experts participated in the Delphi process. Participation rates in the first and second round of the Delphi survey were 83% and 100%, respectively. The working group reached final consensus on 121 core data elements capturing reproductive/gynecological history, surgical history, general medical history, encounter information, long-acting/permanent contraceptive index procedures and follow-up, procedures performed in conjunction with the index procedure, product removal, medications, complications related to the long-acting and/or permanent contraceptive procedure, pregnancy and evaluation of safety and effectiveness outcomes.

Conclusions

The WHT-CRN expert group produced a consensus-based core set of data elements that allow the study of current and future contraceptives. These data elements influence patient and provider decisions about treatments and include important outcomes related to safety and effectiveness of these medical devices, which may benefit other women’s health stakeholders.

EXOGENOUS Sex Hormones and Sex Hormone Receptor Modulators in COVID-19: Rationale and Clinical Pharmacology Considerations

Male patients with coronavirus disease 2019 (COVID-19) fare much worse than female patients in COVID-19 severity and mortality according to data from several studies. Because of this sex disparity, researchers hypothesize that the use of exogenous sex hormone therapy and sex hormone receptor modulators might provide therapeutic potential for patients with COVID-19. Repurposing approved drugs or drug candidates at late-stage clinical development could expedite COVID-19 therapy development because their clinical formulation, routes of administration, dosing regimen, clinical pharmacology, and potential adverse events have already been established or characterized in humans. A number of exogenous sex hormones and sex hormone receptor modulators are currently or will be under clinical investigation for COVID-19 therapy. In this review, we discuss the rationale for exogenous sex hormones and sex hormone receptor modulators in COVID-19 treatment, summarize ongoing and planned clinical trials, and discuss some of the clinical pharmacology considerations on clinical study design. To inform clinical study design and facilitate the clinical development of exogenous sex hormones and sex hormone receptor modulators for COVID-19 therapy, clinical investigators should pay attention to clinical pharmacology factors, such as dosing regimen, special populations (i.e., geriatrics, pregnancy, lactation, and renal/hepatic impairment), and drug interactions.

Pentosan associated retinal pigmentary changes: FDA's perspective on an emerging postmarketing safety finding

INTRODUCTION AND HYPOTHESIS

Recent publications describe pigmentary changes in the retina associated with the use of pentosan polysulfate sodium, the only FDA-approved oral agent for relief of bladder pain or discomfort associated with interstitial cystitis.

METHODS

To evaluate this association, we reviewed data from the FDA Adverse Event Reporting System and published case reports and observational studies.

RESULTS

The totality of clinical and epidemiology evidence does not resolve the question of causation between pentosan use and retinal pigmentary changes; however, several elements support a potential association.

CONCLUSION

Here, we provide our perspective on the available evidence the agency weighed when retinal pigmentary changes were added to pentosan labeling. It is important for urogynecologists prescribing pentosan to be aware of this potential association and be vigilant about assessing eye health in pentosan users.

0976 Temporal Associations Between Sleep And Suicidality In Ultra-high Risk Adolescents And College Students During An Intensive Longitudinal Study

Introduction

Studies consistently demonstrate a link between subjective sleep disturbances and the continuum of suicidality, although this evidence primarily comes from retrospective, cross-sectional studies using limited items to assess sleep. Longitudinal assessment of well-defined and measured sleep/wake behaviors with high-risk individuals are needed to enhance the specificity of near-term suicide risk detection and render concrete targets for suicide prevention.

Methods

Participants (N=46) included ultra-high-risk adolescents (N=29 ages 12-18) and college students (N=17 ages 18-24). For up to 12 weeks, participants wore an actigraph to yield objective data on sleep/wake, and concurrently completed daily cellphone-based ratings of subjective sleep and suicidality. Generalized estimating equations were used to examine the association between sleep parameters (subjective and objective) and the odds of next-day suicidal outcomes (i.e., passive death wish [PDW], suicidal ideation, suicidal intent) controlling for age, gender, and depression severity.

Results

Significant quadratic relationships were observed between actigraphy-derived total sleep time (TST) and probability of next-day PDW (Z=3.7, p=0.0002), suicidal ideation (Z=2.1, p=0.04), and suicidal intent (Z=2.78, p=0.006), with increasing suicidality at low and high values of TST. Low sleep efficiency (<75%) was associated with increased odds of next-day PDW (OR=1.24, Z=2.07, p=0.038). Subjectively (sleep diary measures), low sleep quality (<50 on 100-point scale) was associated with increased odds of next-day suicidal ideation (OR=1.57, Z=3.42, p<0.001), and longer sleep onset latency (>20 minutes) with next-day suicidal intent (OR=3.00, Z=2.37, p=0.018).

Conclusion

Poor sleep health may signal increasing suicide risk, and are modifiable risk factors. We document a significant temporal association whereby objectively-derived short and long TST and low sleep efficiency, as well as subjective sleep quality and sleep onset latency, predicts next day’s suicidality. Further understanding of the temporal association between sleep and suicidality may hold promise to inform real-time monitoring and preventive strategies. Interventions targeting these factors may therefore help reduce suicidality in high-risk youth.

Support

American Foundation for Suicide Prevention; University of Pittsburgh Clinical and Translational Science Institute

Surgical site infections after hysterectomy among HIV-infected women in the HAART era: a single institution's experience from 1999-2012

OBJECTIVE

We sought to determine risk factors associated with surgical site infection (SSI) among a cohort of human immunodeficiency virus (HIV)-infected women undergoing hysterectomy during the era of highly active antiretroviral therapy.

STUDY DESIGN

This is a retrospective study of HIV-infected women who underwent a hysterectomy for benign indications at a tertiary care center. Electronic medical records were reviewed from January 1999 through December 2012. SSI was defined using Centers for Disease Control and Prevention criteria.

RESULTS

There were 77 HIV-infected women who underwent a hysterectomy: 47 (61%) were abdominal; 16 (21%) were laparoscopic or robot-assisted; and 14 (18%) were vaginal. Acquired immune deficiency syndrome was diagnosed in 58% of patients, and 75% of patients self-reported use of highly active antiretroviral therapy at the time of surgery. There were 17 (22%) SSIs; 5 (29%) superficial incisional wound infections, 3 (18%) vaginal cuff cellulitis, and 9 (53%) pelvic abscesses were diagnosed. After multivariable logistic regression, preoperative albumin level (adjusted odds ratio [aOR], 0.14; 95% confidence interval [CI], 0.02-0.86) and minimally invasive hysterectomy (aOR, 0.16; 95% CI, 0.03-0.84) were associated with decreased SSI. Preoperative absolute CD4 count was not associated with SSI (aOR, 0.99; 95% CI, 0.99-1).

CONCLUSION

Low preoperative serum albumin levels and abdominal hysterectomy are associated with increased risk of SSIs in HIV-infected women.

Prevalence of the metabolic syndrome in patients presenting to the university hospital of the West Indies: a need to adopt proactive screening and specific management policy

Studies have shown that the metabolic syndrome (MetS), a major risk factor for the development of Type 2 diabetes mellitus and cardiovascular disease, is higher among psychiatric patients on antipsychotic medications than the general population. While studies on the prevalence of MetS in the Jamaican adult population have been undertaken, no such study has been done on the corresponding psychiatric population. The purpose of this study was to determine the prevalence of MetS in a Jamaican adult psychiatric inpatient population. The study group comprised thirty-eight patients with a primary DSM-IV-TR Axis 1 diagnosis. Criteria for the diagnosis of MetS were the presence of any three or more of five factors as defined by using the International Diabetes Federation (IDF) and American Heart Association/National Heart Lung and Blood Institute (AHA/NHLBI) consensus agreement. The prevalence of MetS in this cohort was 28.9% and was associated with significantly higher abdominal obesity (p = 0.010), elevated blood pressure (p = 0.000), elevated triglycerides (p = 0.019) and low high density lipoprotein-cholesterol (p = 0.016) when compared with patients not diagnosed with MetS. Metabolic syndrome was common in this group of psychiatric patients and likely represents a pathway to the future development of Type 2 diabetes mellitus and cardiovascular disease. Screening and continuous monitoring will allow for early intervention and possibly prevention of increased morbidity and mortality in this vulnerable population.

Decriminalization of marijuana: is this a realistic public mental health policy for Jamaica?

Marijuana has potential benefits and adverse effects. Despite its popularity in Jamaica, decriminalization may not be possible given the international and regional obligations of Jamaica.

Extramammary Paget's disease of the axilla: an unusual case

Extramammary Paget's disease is a rare lesion, often involving the skin of the genital or perianal regions. Less commonly, it has been reported to affect the skin of the axilla. There are very few other cases of extramammary Paget's disease reported in the literature, and the appropriate use of newer techniques such as magnetic resonance imaging and sentinel lymph node biopsy in this setting is not well-studied. We present a case of extramammary Paget's disease of the axilla, and discuss the known literature regarding this rare disease.

Randomized Pilot Study Comparing Rates of Endocervical Cell Recovery between Conventional Pap Smears and Liquid-Based Cytology in a Pregnant Population

OBJECTIVE.: To determine whether liquid-based cytology improves Pap smear adequacy, as defined by the presence of endocervical cells, compared with conventional cytology during pregnancy. MATERIALS AND METHODS.: A randomized pilot study was conducted between May 2001 and May 2002. Patients presenting for their first prenatal visit were randomized to receive either a conventional Pap smear or a liquid-based smear (ThinPrep). Rates of endocervical cell recovery and cytologic results were compared between the groups. RESULTS.: Eighty-one patients were enrolled in the study. There were no differences between the groups in age (p = .40), parity (p = .62), gestational age (p = .14), history of abnormal pap (p = .08), previous treatment of neoplasia (p = 1.00), and tobacco use (p = .67). Adequacy of the standard pap versus the liquid-based smear was not different between the two groups (90.5% vs 82.1%, respectively;p = .34). CONCLUSIONS.: The results of this pilot study show that rates of endocervical cell recovery in a pregnant population are not statistically different using conventional or liquid-based cytology. Further research is indicated to assess the utility of the more expensive ThinPrep technology in this population.

The accuracy of clinical evaluation of posterior vaginal wall defects

We retrospectively reviewed 106 cases of defect-directed rectocele repair. Preoperative standardized evaluation of rectovaginal septum support was performed. Support defects were identified at surgery by visually identifying breaks in the rectovaginal fascia. Clinical and surgical findings were compared using the chi2 test. Logistic regression analysis was used to identify predictive variables. Clinical examination concurred with surgical findings in 59.4% (63/106) and differed in 40.6% (43/106). Predictors of agreement between clinical examination and intraoperative findings were the presence of multiple defects in the rectovaginal fascia at surgery (OR 4.42, 95% CI 1.89, 10.35) and stage II or III prolapse (OR 0.0007, 95% CI 0.00059, 0.003 and 0.0003, 95% CI 0.00033, 0.0017, respectively). The sensitivity and positive predictive value for all defects was less than 40%. The inaccuracy of clinical examination emphasizes the need to develop new clinical and/or imaging methods to evaluate posterior vaginal support defects.

Estimation of cumulative exposure to organophosphate sheep dips in a study of chronic neurological health effects among United Kingdom sheep dippers

OBJECTIVES

To derive a method for retrospectively estimating cumulative exposure to organophosphate (OP) pesticides among a cross section of United Kingdom sheep dippers, as part of a wider epidemiological study of neurological abnormality within this group of workers.

METHODS

A hygiene study of dipping sessions at 20 farms using diazinon based dips was carried out by two experienced occupational hygienists. Observations on the exposure of people to concentrate and dilute dip were recorded throughout each dipping session, together with the other relevant factors including the use and condition of protective clothing. Concentrations of urinary metabolites of diazinon were used to measure actual exposure to OPs. To estimate exposure in the subsequent epidemiological study, an occupational exposure history questionnaire was developed using results from the hygiene study and an empirical exposure model.

RESULTS

In the hygiene study, increased urinary metabolites were associated with the handling of concentrate dip and exposure to dilute dip wash through splashing. Very few dippers wore the recommended protective clothing. The handling of concentrate dip was the principal source of exposure to OPs. Dipping task was used as a surrogate for splashing of dilute dip in retrospective exposure estimation. In the epidemiological study, cumulative exposure to OP sheep dips was highly correlated with the total number of dipping days, but not with age.

CONCLUSIONS

Sheep dip concentrate is the most important source of OP exposure among sheep dippers and estimates of exposure to OPs during routine dipping should take due account of exposure to concentrate dip as well as to the dilute dip wash. The observed use of recommended protective clothing by most subjects was insufficient to allow a proper empirical assessment of its effectiveness.

Kinetic mechanism of acetyl-CoA synthase: steady-state synthesis at variable Co/Co2 pressures

Steady-state initial rates of acetyl-CoA synthesis (upsilon/[E(tot)]) catalyzed by acetyl-CoA synthase from Clostridium thermoaceticum (ACS) were determined at various partial pressures of CO and CO2. When [CO] was varied from 0 to 100 microM in a balance of Ar, rates increased sharply from 0.3 to 100 min(-1). At [CO] > 100 microM, rates declined sharply and eventually stabilized at 10 min(-1) at 980 microM CO. Equivalent experiments carried out in CO2 revealed similar inhibitory behavior and residual activity under saturating [CO]. Plots of upsilon/[E(tot)] vs [CO2] at different fixed inhibitory [CO] revealed that Vmax/[E(tot)] (kcat) decreased with increasing [CO]. Plots of upsilon/[E(tot)] vs [CO2] at different fixed noninhibitory [CO] showed that Vmax/[E(tot)] was insensitive to changes in [CO]. Of eleven candidate mechanisms, the simplest one that fit the data best had the following key features: (a) either CO or CO2 (at a designated reductant level and pH) activate the enzyme (E' + CO right arrow over left arrow E, E' + CO2/2e-/2H+ right arrow over left arrow E); (b) CO and CO2 are both substrates that compete for the same enzyme form (E + CO right arrow over left arrow ECO, E + CO2/2e-/2H+ right arrow over left arrow ECO, and ECO --> E + P); (c) between 3 and 5 molecules of CO bind cooperatively to an enzyme form different from that to which CO2 and substrate CO bind (nCO + ECO right arrow over left arrow (CO)nECO), and this inhibits catalysis; and (d) the residual activity arises from either the (CO)nECO state or a heterogeneous form of the enzyme. Implications of these results, focusing on the roles of CO and CO2 in catalysis, are discussed.

Retrospective collection of exposure data from industry: results from a feasibility study in the United Kingdom

In the United Kingdom the Health and Safety Executive for some years has stored chemical exposure data in their National Exposure Database. However, it has been difficult to persuade industry and other organizations to contribute to this resource. The aim of this project was to devise a cost-effective method of obtaining occupational exposure data on chemicals from U.K. industry and other sources. Five strategies were used to identify data for three different substances: toluene, acrylonitrile, and ethylene oxide. In total, 810 organizations were contacted and over 45 percent responded. However, only 40 had relevant exposure data. Almost equal numbers of acceptable measurements were identified for toluene and acrylonitrile (2,770 and 2,000 respectively) with lesser ethylene oxide data (800). These measurements were drawn from a wide range of industries and are probably representative of measurements made by U.K. industry, although most of the data were from companies employing more than 100 people. During the second phase of the project, more than 3,000 measurements and associated contextual information were collected (499 for toluene, 1,516 for acrylonitrile, and 17 for ethylene oxide, with a further 1,004 measurements for 1 of 27 substances collected simultaneously with one of the above). The costs of identifying and collecting exposure data ranged from ł7 to ł380 per valid measurement, depending on the source of the data. We suggest that, rather than trying to retrospectively collect data, it is likely to be more cost-effective to enlist a number of occupational hygiene consults and industrial organizations to prospectively provide anonymized exposure measurements for inclusion in the Health and Safety Executives National Exposure Database.

Regulation of hexokinase II and glycogen synthase mRNA, protein, and activity in human muscle

Insulin regulates the activity of key enzymes of glucose metabolism in skeletal muscle by altering transcription or translation or by producing activity-altering modifications of preexisting enzyme molecules. Because of the small size of percutaneous muscle biopsies, these phenomena have been difficult to study in humans. This study was performed to determine how physiological hyperinsulinemia regulates the activities of hexokinase (HK), glycogen synthase (GS), and GLUT-4 in human skeletal muscle in vivo. We determined mRNA abundance, protein content, and activities for these proteins in muscle biopsies before and after a hyperinsulinemic clamp in normal subjects. HK I, HK II, GS, and GLUT-4 were expressed in muscle. HK II accounted for 80% of total HK activity and was increased by insulin from a basal value of 2.11 +/- 0.26 to 3.35 +/- 0.47 pmol.min-1.mg protein-1 (P < 0.05); HK I activity was unaffected. Insulin increased GS activity from 3.85 +/- 0.82 to 6.06 +/- 0.49 nmol.min-1.mg-1 (P < 0.01). HK II mRNA was increased 3.3 +/- 1.3-fold (P < 0.05) by insulin infusion. HK I, GS, and GLUT-4 mRNA and protein were unaffected. Because insulin infusion increased HK II but not GS mRNA, we conclude that HK II and GS may be regulated by insulin by different mechanisms in human skeletal muscle.

Therapeutic considerations in patients with refractory neurosarcoidosis

OBJECTIVE

To assess the effectiveness of alternative treatments for patients with refractory neurosarcoidosis.

DESIGN

Nonrandomized, retrospective patient survey.

SETTING

Multicenter, involving patients cared for by their primary physicians and neurologists, and referred for management advice to a neurology consultant.

INTERVENTIONS

Patients were treated with corticosteroids and alternative treatments, including azathioprine, cyclosporine, cyclophosphamide, chlorambucil, methotrexate, and radiation therapy.

RESULTS

Prednisone dosage was successfully tapered to 10 to 20 mg/d without worsening symptoms in 10 (38%) of the 26 patients studied. Six (23%) patients had improved conditions while receiving alternative medication and nine (35%) patients' conditions remained stable with no further progression of their symptoms. Radiotherapy was beneficial for one of three patients. Four (15%) patients did not respond to alternative treatment and died of worsening symptoms or infection. Adverse effects of the alternate medications resolved on discontinuing treatment with the offending agent.

CONCLUSION

Alternative treatment is an effective adjunct to corticosteroid therapy for some patients with refractory neurosarcoidosis. Clinical deterioration may occur despite combined therapy. Choice of alternative therapy should be determined, in part, by its potential adverse effects.

The treatment of neurosarcoidosis with cyclosporine

Six patients with refractory neurosarcoidosis were enrolled in a 12-month open-label trial to investigate the safety and efficacy of cyclosporine therapy. Patients were stabilized on a corticosteroid dose, randomized to a low-dose or high-dose cyclosporine group (with appropriate target whole blood cyclosporine levels) for 6 months, and assessed by prospectively defined studies. The corticosteroid dose was adjusted as clinically tolerated. We found that the corticosteroid dose could be lowered to 30% to 58% of the initial stabilization dose in conjunction with cyclosporine therapy, at the time of maximal clinical and laboratory improvement. However, four patients deteriorated while using corticosteroids and cyclosporine; one of these patients died. At the time of clinical deterioration, the prednisone dose ranged from 6 to 22.5 mg daily (or the equivalent). No serious toxic effects developed from cyclosporine therapy. Cyclosporine treatment is a reasonably safe and effective adjunct to corticosteroid therapy for patients with refractory neurosarcoidosis, although clinical deterioration can occur despite combination therapy.

Enterobius egg granuloma of the vulva and peritoneum: review of the literature

Two cases of Enterobius granuloma containing eggs only are reported. The first case involved the vulva, where no such granuloma has been reported previously. The coexistence of peritoneal granuloma and rectal adenocarcinoma in the second case suggests the possibility of direct penetration of the damaged colonic wall by the parasite, as emphasized by several previous reports of neoplastic involvement and perforation of the intestinal wall in cases of ectopic infections. The diagnostic criteria of Enterobius eggs granuloma, which might be a diagnostic dilemma for pathologists who are not familiar with such criteria, are described herein.

Recurrent Hodgkin's disease in the breast. Diagnosis of a case by fine needle aspiration and immunocytochemistry

Recurrent Hodgkin's disease involving the breast in a 17-year-old girl was diagnosed by fine needle aspiration (FNA) biopsy of a solitary mass that developed one year after "curative" radiation. Benign breast disease and breast carcinoma were ruled out upon cytologic examination of the FNA smears, which contained diagnostic Reed-Sternberg cells and the characteristic polymorphic background elements. Follow-up immunoperoxidase staining for Leu-M1 on destained smears confirmed the diagnosis. Definitive therapeutic measures were initiated after the FNA diagnosis.

Abdominal pain from intestinal duplication

Intestinal duplication is a rare cause of abdominal pain in adults, and may elude diagnosis prior to exploratory laparotomy. We describe a 20-year-old man who had severe abdominal pain with an ileal duplication complicated by a penetrating ulcer within ectopic gastric mucosa.