Buprenorphine treatment of pregnant opioid--dependent women: maternal and neonatal outcomes

This open-label prospective study examined maternal and neonatal safety and efficacy outcome measures during and following prenatal buprenorphine exposure. Three opioid-dependent pregnant women received 8 or 12 mg sublingual buprenorphine tablets daily for 15-16 weeks prior to delivery. Results showed that buprenorphine in combination with comprehensive prenatal care was safe and effective in these women. Prenatal exposure to buprenorphine resulted in normal birth outcomes, a mean of 4.33 days (minimum possible=4) hospitalization, and a 'relatively mild' neonatal abstinence syndrome comprised primarily of tremors (disturbed), hyperactive moro and shortened sleep after feeding. The infants required no pharmacological treatment. Onset of neonatal abstinence signs occurred within the first 12 h after birth, peaked by 72 h and returned to below pre-12 h levels by 120 h. It is concluded that buprenorphine has potential utility for the treatment of pregnant opioid-dependent women.

Effect of academic affiliation and obstetric volume on clinical outcome and cost of childbirth

OBJECTIVE

To determine whether the academic affiliation and obstetric volume of the delivering hospital has an impact on clinical and economic outcomes.

METHODS

We performed a cross-sectional analysis of data for all births in the State of Maryland during 1996. Acute hospital discharge data were obtained from the publicly available Maryland Health Services Cost Review Commission database. Institutions were classified as community hospitals, community teaching hospitals, and academic medical centers. Principal outcome variables included cesarean birth and complication rates, total hospital charges, and length of stay.

RESULTS

A total of 63,143 cases were identified for analysis. The cesarean delivery rate was lower among academic medical centers, compared with community teaching hospitals and community hospitals (18.4% compared with 24.3% and 21.2%, respectively). After adjustment for patient case-mix, the adjusted odds ratio (OR) for cesarean birth was 0.66 at academic medical centers and 1.23 at community teaching hospitals compared with community hospitals (P <.01). Rates of episiotomy and serious complications were lower at academic medical centers compared with community hospitals. Adjusted total hospital charges were lower and length of stay was shorter for community hospitals compared with academic medical centers ($2937 compared with $3564 and 2.2 days compared with 2.5 days, respectively).

CONCLUSION

Hospital academic affiliation was an important predictor of clinical outcomes. Better clinical outcomes were found primarily among patients at academic medical centers, although these institutions demonstrated moderately higher resource utilization, compared with community hospitals.

Human embryonic germ cell derivatives express a broad range of developmentally distinct markers and proliferate extensively in vitro

Human pluripotent stem cells (hPSCs) have been derived from the inner cell mass cells of blastocysts (embryonic stem cells) and primordial germ cells of the developing gonadal ridge (embryonic germ cells). Like their mouse counterparts, hPSCs can be maintained in culture in an undifferentiated state and, upon differentiation, generate a wide variety of cell types. Embryoid body (EB) formation is a requisite step in the process of in vitro differentiation of these stem cells and has been used to derive neurons and glia, vascular endothelium, hematopoietic cells, cardiomyocytes, and glucose-responsive insulin-producing cells from mouse PSCs. EBs generated from human embryonic germ cell cultures have also been found to contain a wide variety of cell types, including neural cells, vascular endothelium, muscle cells, and endodermal derivatives. Here, we report the isolation and culture of cells from human EBs as well as a characterization of their gene expression during growth in several different culture environments. These heterogeneous cell cultures are capable of robust and long-term [>70 population doublings (PD)] proliferation in culture, have normal karyotypes, and can be cryopreserved, clonally isolated, and stably transfected. Cell cultures and clonal lines retain a broad pattern of gene expression including simultaneous expression of markers normally associated with cells of neural, vascular/hematopoietic, muscle, and endoderm lineages. The growth and expression characteristics of these EB-derived cells suggest that they are relatively uncommitted precursor or progenitor cells. EB-derived cells may be suited to studies of human cell differentiation and may play a role in future transplantation therapies.

The Filshie clip for laparoscopic adnexal surgery

BACKGROUND

Gynecologic endoscopic procedures are increasingly common and require the ability to control large vascular structures.

METHOD

The Filshie clip is a silicone-lined, titanium occlusive device, originally designed and Food and Drug Administration (FDA) approved for surgical contraception. This device also has the potential for occluding vascular structures during laparoscopic surgery.

EXPERIENCE AND RESULTS

We describe a salpingectomy, an excision of bilateral hydrosalpinges, and a salpingo-oopherectomy. We performed all procedures laparoscopically using this device as the primary modality for assuring hemostasis.

CONCLUSION

The Filshie clip is a useful and economical device for assuring hemostasis during gynecologic endoscopic surgery.

Economic and clinical outcomes of microlaparoscopic and standard laparoscopic sterilization. A comparison

OBJECTIVE

To compare micro-laparoscopic surgical sterilization and standard laparoscopic sterilization with respect to cost effectiveness and patient preferences.

STUDY DESIGN

A retrospective study of all laparoscopic surgical sterilizations performed under general anesthesia at Johns Hopkins Bayview Medical Center--16 micro-laparoscopies and 34 standard laparoscopies. Cases selected for review were limited to patients undergoing surgical contraception and not requiring additional, concurrent procedures. Laparoscopic surgical sterilization was performed using a double-puncture technique with silicone band application. In each case either a standard, 10-mm laparoscope or a 2-mm micro-laparoscope was used, and the procedure was performed under general anesthesia. Postoperative pain management was achieved by nonsteroidal antiinflammatory drugs and/or narcotic analgesia. All cases were performed by residents under faculty supervision. Medical records and hospital billing records were reviewed, and a standardized telephone interview was conducted to assess postoperative quality of life and patient satisfaction.

RESULTS

Both techniques were comparable in cost effectiveness. There was no significant difference in operating room time, average operating room costs, average ancillary department costs, instrument and supply costs, or length of stay. Postoperative discomfort was significantly less with microlaparoscopy (P = .05), and patient satisfaction was higher in the microlaparoscopy group.

CONCLUSION

Microlaparoscopy and the standard laparoscopic approach for surgical sterilization are associated with similar hospital charges. Postoperative pain and overall patient satisfaction were significantly better with microlaparoscopy than standard laparoscopy.

Partner effects on a woman's intention to conceive: 'not with this partner'

CONTEXT

Current definitions of pregnancy intention that are useful at aggregate levels are weak at the individual level. This is especially true in social contexts where childbearing and pregnancy often occur within casual or transient relationships.

METHODS

Extensive data on lifetime partnerships and sexual behaviors, including pregnancies and births, from 250 low-income women who had experienced a total of 839 pregnancies are used to explore correlates of intention to conceive, as well as the extent to which women attribute their intentions to a current partnership.

RESULTS

Some 57% of reported pregnancies were unintended. Overall, 21% of the women had not wished to conceive at least one of their pregnancies with the partner who impregnated them; that proportion rose to 33% among women who had had only unintended pregnancies. Even among women who had had no unintended pregnancies, 18% had had at least one conception that they had not wanted with their partner at the time of conception. Women were less likely to say they had not wanted to conceive with a particular partner if they were living with that partner than if they were not. The likelihood of not having wanted a pregnancy with a given partner rose with the lifetime number of serious partners. Pregnancies that were not wanted with a particular partner were more than twice as likely to end in abortion as were those that were (33% vs. 14%).

CONCLUSIONS

Among these women, the desire to avoid childbearing relates more to the couple involved in the conception than to abstract notions of completed family size. It would therefore be useful to include items pertaining to partner relationships in future studies of pregnancy intention.

Derivation of pluripotent stem cells from cultured human primordial germ cells

Human pluripotent stem cells would be invaluable for in vitro studies of aspects of human embryogenesis. With the goal of establishing pluripotent stem cell lines, gonadal ridges and mesenteries containing primordial germ cells (PGCs, 5-9 weeks postfertilization) were cultured on mouse STO fibroblast feeder layers in the presence of human recombinant leukemia inhibitory factor, human recombinant basic fibroblast growth factor, and forskolin. Initially, single PGCs in culture were visualized by alkaline phosphatase activity staining. Over a period of 7-21 days, PGCs gave rise to large multicellular colonies resembling those of mouse pluripotent stem cells termed embryonic stem and embryonic germ (EG) cells. Throughout the culture period most cells within the colonies continued to be alkaline phosphatase-positive and tested positive against a panel of five immunological markers (SSEA-1, SSEA-3, SSEA-4, TRA-1-60, and TRA-1-81) that have been used routinely to characterize embryonic stem and EG cells. The cultured cells have been continuously passaged and found to be karyotypically normal and stable. Both XX and XY cell cultures have been obtained. Immunohistochemical analysis of embryoid bodies collected from these cultures revealed a wide variety of differentiated cell types, including derivatives of all three embryonic germ layers. Based on their origin and demonstrated properties, these human PGC-derived cultures meet the criteria for pluripotent stem cells and most closely resemble EG cells.

Cost-effectiveness of treatment for drug-abusing pregnant women

Neonatal intensive care unit (NICU) and drug treatment costs were compared in two groups of pregnant drug abusing women: 100 admissions to a multidisciplinary treatment program and active in care at the time of delivery and 46 controls not entering drug treatment. Clinical measures included urine toxicology at delivery, infant birthweight. Apgar scores and need for and duration of NICU services. Cost measures included drug treatment and NICU costs. Treatment patients showed better clinical outcome at delivery, with less drug use and higher infant estimated gestational age, birthweight and Apgar scores. Infants of treatment patients were also less likely to require NICU services and, for those that did, had a shorter stay. When total cost was examined (including drug treatment), mean net savings for treatment subjects was $4644 per mother/infant pair. The study demonstrates the cost-effectiveness of treatment for pregnant drug abusing women, with savings in NICU costs exceeding costs of drug treatment.

Contraceptive outcomes among post-partum and post-abortal adolescents

Between January 1992 and January 1993, there were 280 teens (ages 13-18) who either delivered a baby or terminated a pregnancy at Johns Hopkins Bayview Medical Center. Of these, 92 chose to contracept with Norplant implants, and 188 chose another method including "no" method. In July 1993, telephone interviews were conducted with 37 of those who chose Norplant implants and 41 of the non-Norplant implants users. After 1 year, 47% of oral contraceptive (COC) users had discontinued the method compared to only 16% of Norplant implants users (P < 0.03). Reasons for discontinuation centered on side effects for both groups but with some COC and condom users, discontinuing use due to "forgetfulness" or failure (pregnancy). Among the COC group (which was the most common choice after Norplant implant), 25% of the adolescents had experienced a subsequent unplanned pregnancy compared to 0% of the Norplant implant group (P < 0.01). Norplant implants were clearly an acceptable and effective contraceptive for these post-partum and post-abortal teens, who articulated a high motivation to avoid a subsequent unplanned pregnancy. However, it is clearly not the only method teens will choose to use, and more attention must be paid to adequate counseling of those choosing another method.

Obstetrics and gynecology

Emergency contraception could reduce the number of unintended pregnancies by 1.7 million. The best approach to oral contraception is education and not limitation, but it is unlikely that there will be any increase in contraceptive availability in the near future. Routine ultrasonography in low-risk pregnancies does not appear to be cost-effective.

Comparison of adolescent and adult experiences with Norplant levonorgestrel contraceptive implants

OBJECTIVE

To compare acceptability, tolerance of side effects, and continuation rates among adolescent and adult Norplant accepters.

METHODS

An 18-month observational study was conducted of 136 adolescents and 542 adults who received Norplant at the Francis Scott Key Medical Center in Baltimore, Maryland. Data were collected from the following: a self-administered history form completed at the preinsertion visit, a self-administered follow-up form completed at routine follow-up visits, problem-visit chart review, and telephone contact for patients noncompliant with follow-up appointments.

RESULTS

The adolescents ranged in age from 13-18 years (mean 16.4), and adults ranged in age from 19-46 (mean 24.7). The mean parity among teenagers was 1.4; among adults, 3.2. Thirty-nine percent of teenagers and 64% of adults had had one or more therapeutic abortions. Forty percent of adolescents and 47% of adults reported at least one contraceptive failure in the past. Both adolescent and adult Norplant accepters made few telephone calls or problem visits because of complaints or side effects. Compliance with routine annual follow-up was poor for adolescents (24 of 136, 18%) and adults (72 of 542, 13%). Follow-up of noncompliant patients revealed low rates of implant removal. Fifteen adolescents (11%) and 60 adults (11%) had Norplant removed. The most common reasons for removal included irregular bleeding, weight gain, headaches, and desire for pregnancy.

CONCLUSIONS

Implant acceptability, continuation, and tolerance of side effects were high and comparable among adolescent and adult accepters. Initial implant users were primarily adolescents or adults who had experienced problems with other forms of reversible contraception. Adherence to scheduled follow-up appointments was poor, regardless of age.

Preliminary experience with Norplant in an inner city population

Norplant, the five-year subdermal contraceptive system, is the first implantable contraceptive method approved for general use in the United States. We describe the preliminary experiences of 246 U.S. women who accepted Norplant between April, 1991 and September, 1991. Norplant was well accepted among this diverse general population. Intensive counselling about side effects, especially menstrual changes, is crucial for patient satisfaction. Although 48% of acceptors experienced menstrual cycle changes and 70% experienced at least one side effect, phone calls and unscheduled visits for problems were infrequent. Adequate counselling about side effects obviates the need for a routine follow-up visit one month after insertion.

Oral contraceptives and breast disease

Epidemiologic data support the hypothesis that the types of OCs used before the mid-1970s protected against most forms of benign breast disease. It is unclear whether current low-dose progestogen OCs will confer the same protection. Further studies are necessary to clarify this. For breast cancer, the relationship is more complex. It is possible that prolonged use of high-dose OCs exert a small increased risk for breast cancer development in women before age 45. Furthermore, prolonged use before a first term pregnancy may result in a small increase in risk for breast cancer before age 45. Studies evaluating the effect of current low-dose OCs are necessary to elucidate what, if any, effect they may have on breast cancer development. Furthermore, as our population ages, studies will be able to determine what effect, if any, may be present in women over age 60, those women with the highest underlying risk of breast cancer. And finally, more research of basic breast tissue physiology and the effect of endogenous and exogenous hormones on this complex organ is needed.

Fertility after contraception or abortion

There is a very small correlation, if any, between the prior use of OCs and congenital malformations, including Down's syndrome. There are few, if any, recent reports on masculinization of a female fetus born to a mother who took an OC containing 1 mg of a progestogen during early pregnancy. However, patients suspected of being pregnant and who are desirous of continuing that pregnancy should not continue to take OCs, nor should progestogen withdrawal pregnancy tests be used. Concern still exists regarding the occurrence of congenital abnormalities in babies born to such women. The incidence of postoperative infection after first trimester therapeutic abortion in this country is low. However, increasing numbers of women are undergoing repeated pregnancy terminations, and their risk for subsequent pelvic infections may be multiplied with each succeeding abortion. The incidence of prematurity due to cervical incompetence or surgical infertility after first trimester pregnancy terminations is not increased significantly. Asherman's syndrome may occur after septic therapeutic abortion. The pregnancy rate after treatment of this syndrome is low. The return of menses and the achievement of a pregnancy may be slightly delayed after OCs are discontinued, but the fertility rate is within the normal range by 1 year. The incidence of postpill amenorrhea of greater than 6 months' duration is probably less than 1%. The occurrence of the syndrome does not seem to be related to length of use or type of pill. Patients with prior normal menses as well as those with menstrual abnormalities before use of OCs may develop this syndrome. Patients with normal estrogen and gonadotropin levels usually respond with return of menses and ovulation when treated with clomiphene. The rate for achievement of pregnancy is much lower than that for patients with spontaneous return of menses. The criteria for defining PID or for categorizing its severity are diverse. The incidence of PID is higher among IUD users than among patients taking OCs or using a barrier method. The excess risk of PID among IUD users, with the exception of the first few months after insertion, is related to sexually transmitted diseases and not the IUD. Women with no risk factors for sexually transmitted diseases have little increased risk of PID or infertility associated with IUD use. There appears to be no increased risk of congenital anomalies, altered sex ratio, or early pregnancy loss among spermicide users. All present methods of contraception entail some risk to the patient. The risk of imparied future fertility with the use of any method appears to be low.(ABSTRACT TRUNCATED AT 400 WORDS)

Vaginal evisceration with pneumoperitoneum. A case report

Vaginal evisceration with pneumoperitoneum occurred in a premenopausal woman.

Benefits and risks of menopausal estrogen and/or progestin hormone use

Current evidence is reviewed here on risks and benefits of estrogen and progestin use by peri- and postmenopausal women in relation to the following conditions: endometrial cancer, breast cancer, osteoporosis, and coronary artery disease (CAD). On balance, estrogen therapy appears to be beneficial for menopausal women, as it probably reduces the risks of CAD and osteoporosis, two of the major causes of mortality and morbidity. Although unopposed estrogen therapy increases the risk of endometrial cancer, that cancer is relatively rare and is not fatal in the vast majority of cases associated with estrogen use. Definitive conclusions about the relation of menopausal estrogens to breast cancer cannot be drawn due to inconsistent evidence to date. Although evidence from randomized controlled trials is lacking, biochemical and clinical evidence suggest that progestin supplementation is associated with a reduction in endometrial cancer risk in women taking menopausal estrogens. Progestin supplementation also may augment the beneficial effects of estrogens in providing protection against osteoporosis, although this effect is not yet well established. There is little direct evidence bearing on the relation of menopausal progestins to breast cancer. Although studies of CAD per se are lacking at present, progestins probably unfavorably alter lipoprotein profiles, thereby increasing a user's risk of CAD. Given the relatively high incidence and mortality of CAD in postmenopausal women, any negative effects on CAD risk could potentially counterbalance beneficial effects on other causes. We conclude that estrogen replacement therapy is of potential benefit to postmenopausal women, but that the question of progestin supplementation requires further study, particularly for CAD risk.

Sexual and reproductive risk factors for invasive squamous cell cervical cancer

A case-control study of 418 women with invasive squamous cell cervical cancer and 704 population controls enabled evaluation of risk factors for this relatively rare cancer. Consistent with an infectious etiology was a pronounced effect of multiple sexual partners, with those reporting 10 or more partners being at a significant threefold excess risk. Early first intercourse also was associated with some residual effect on risk, although the relationship was not linear, nor the explanation readily apparent. Those with multiple births were at significantly elevated risks, even after adjustment for sexual parameters. Menstrual and hygiene factors, including use of tampons, vaginal deodorants, and douching products, were not consistently related to risk. Histories of specific infections involving the genital tract were poor predictors of risk, since few women provided positive responses, but those with nonspecific diseases were at a significant twofold excess risk.

Human axillary secretions influence women's menstrual cycles: the role of donor extract from men

Menstrual cycle lengths of 29.5 +/- 3 days ("normal cycles") are more frequent in women who have weekly coital activity than in women who do not. In order to investigate potential mechanisms controlling the association between heterosexual activity and menstrual cycle length, and in light of the nonhuman literature suggesting that a chemical signal from males could be involved, menstrual cycle lengths of nulliparous women were evaluated following regular application of axillary extract from donor males. Compared to controls receiving only blank/ethanol applications, women receiving axillary extracts for 12.5 to 14.5 weeks showed the following changes: a reduced incidence in variability of cycle lengths; and a reduced proportion of aberrant length cycles.

Human axillary secretions influence women's menstrual cycles: the role of donor extract of females

Menstrual synchrony in human females has previously been demonstrated among women attending a predominantly female university as well as among women attending coeducational universities. In each of these studies, women who spent the most time together were most likely to show the menstrual synchrony. In this experiment, the possibility that substances in axillary secretions might mediate this effect was tested using a prospective, double-blind research design and a combined axillary extract from a group of female donors. Female subjects who reported themselves to have normal (29.5 +/- 3 day) cycles were exposed to the axillary extracts or blank/ethanol for 10 to 13 weeks. Recipients of the axillary extracts showed a significant reduction in "days' difference in menses onset" relative to the donor cycle, no change was evident for recipients of blank/ethanol. These results demonstrate that constituents from the axillary region of donor females can shift the time of menstrual onset of another group to conform with the donors' cycle and that this effect can occur even in the absence of social contact.

Long-term use of oral contraceptives and risk of invasive cervical cancer

To evaluate the relationship between use of oral contraceptives and risk of invasive cervical cancer, a case-control study involving 479 patients and 789 population controls was undertaken in 5 geographic regions of the US. Initially, the relationship was obscured by confounding variables, particularly the interval since last Pap smear. Control for this variable as well as for sexual and sociodemographic factors revealed an RR of 1.5 overall, with long-term users (5 or more years) being at a 2-fold higher risk than non-users. Pill associations prevailed for both adenocarcinomas and squamous-cell tumors, and risks were highest for those using pills containing high estrogen potencies. In addition, there was some evidence that pill associations were most pronounced among women who had never used barrier methods of contraception or who had histories of genital infections, suggesting that oral contraceptives may act as co-carcinogens with transmissible agents. Our findings provide further evidence that long-term use of oral contraceptives may have a carcinogenic effect on cervical epithelium, but emphasize the need for careful evaluation of confounding influences.

Sexual behavior and steroid levels among gynecologically mature premenopausal women

Twenty-seven gynecologically mature young women who participated in a 14-week study prospectively recorded daily sexual behavior and basal body temperature data. In addition, they supplied plasma three times during the last cycle of participation. Plasma was analyzed for estradiol (E2), testosterone (T), and progesterone (P) by radioimmunoassay. The levels of circulating sex steroid hormones during the luteal phase were examined in relation to measures of menstrual cycle length, sexual frequency, and coital total. The results indicated the following: (1) women who had weekly sex with men had higher levels of estrogen than women who did not; (2) total amount of coital behavior was not related to any of the hormones assayed; (3) neither T nor P were distinguished by the consistency of sexual behavior or by coital total; and (4) women with aberrant-length cycles tended to have lower levels of E2. Thus, E2 consistently showed relationships to sexual behavior and cycle length, whereas P and T did not.

Sexual behavior frequency and biphasic ovulatory type menstrual cycles

College students whose menarche had occurred 7 years previously, prospectively recorded menstrual and sexual behavior history for 14 weeks as well as basal body temperatures. Regular weekly coital activity associates with the highest incidence of fertile type cycles in this sample of young women as follows: (1) Regular weekly heterosexual behavior was associated with 29.5 +/- 3 day menstrual cycle length. Less frequent sexual activity (sporadic) and celibacy were associated with an increased frequency of aberrantly short and long cycle lengths. (2) Either of two heterosexual behaviors (coitus and/or genital stimulation by a man) were behaviors which were adequate as associates of 29.5 +/- 3 day cycles. (3) Self-stimulation (masturbation to orgasm) was inadequate as an associate of the above-described pattern of menstrual cyclicity. (4) Women with regular weekly coital activity had the highest incidence (90%) of fertile type basal body temperature (BBT) rhythms. Sporadically active women had the next highest incidence (55%) of fertile type BBT rhythms. Celibate women had the lowest incidence (44%) of fertile type BBT's.

Urban black adolescents who obtain contraceptive services before or after their first pregnancy. Psychosocial factors and contraceptive use

This paper compares three groups of urban black teenagers at their enrollment in a contraceptive program and at a one-year follow-up. The groups comprise 263 never-pregnant, postabortion, and postpartum teens ages less than or equal to 17 years at their initial family planning visit. Self-report questionnaires examined attitudes and information about pregnancy and contraceptive use, sources of contraceptive information, sexual and contraceptive experience, family and partner support for contraceptive use, and demographic background factors. Emotional, personality, and psychosocial factors were assessed with standard measures. Age, partner relationships, and items relating to the mother's communication about contraception and pregnancy were significant variables in the outcome of never-pregnant and delivery of pregnancy. Self-esteem was highest in the never-pregnant group. Personality factors, emotional distress, and social adjustment scores were in the normal ranges and did not differ between the groups. Contraceptive use at follow-up was most consistent in the never-pregnant group. These data suggest the need for earlier family involvement in educating and guiding teens together with access to contraceptive services in preventing unwanted adolescent pregnancies.

Intranasal administration of RA 27/3 rubella virus vaccine. A clinical trial in young adults

Of the vaccines and inoculation routes studied for the prevention of rubella, only the RA27/3 vaccine, administered intranasally, has the ability to stimulate a humoral antibody pattern very similar to that evoked by wild rubella infection. Because information about intranasal (IN) vaccination has only been obtained using the RA 27/3 vaccine manufactured in Europe, we conducted a trial of IN vaccination among young adults using Meruvax II which is manufactured in the USA. Of 597 family planning clinic patients screened in 1980-1981, 71 (11.9%) were susceptible to rubella; forty-one subjects were randomly assigned to receive IN or subcutaneous (SC) vaccine. All 20 SC vaccinees, but only 8/21 (38%) IN vaccinees, were successfully immunized. We conclude that standard doses of commercially available RA 27/3 vaccine are insufficient for IN immunization against rubella. Additional study of the dose-response relationship is needed if IN vaccination is to be recommended.

Complications of female sterilization: immediate and delayed

Surgical sterilization in women has changed dramatically over the past 20 years. The development of laparoscopy and minilaparotomy have made the procedure readily available even in developing countries. In the United States, changing social values and changes in hospital regulations have done as much as technology to account for the tremendous increases in the number of women undergoing sterilization. Improved sterilization procedures have resulted in lower costs for sterilization and lowered morbidity and mortality rates. Hysterectomy for sterilization alone carries unacceptable morbidity and mortality rates. Originally, laparoscopic techniques utilized unipolar cautery. However, bowel burns, a rare but serious complication, were reported, and this led to newer techniques. These techniques, using bands, clips, and bipolar cautery, have gained increasing popularity and have eliminated many of the serious complications of female sterilization. Historically, there has been concern that tubal sterilization by any method produces, in significant numbers of patients, the subsequent gynecologic and psychologic problems called "post-tubal ligation syndrome." A review of earlier literature indicates that many of these studies have serious methodologic problems, including recall bias, inappropriate control groups, failure to elicit prior history of gynecologic or psychologic problems, and failure to account for the use of oral contraceptives or IUDs. More recent large prospective epidemiologic studies that have controlled for prior gynecologic problems and contraceptive usage have failed to show increased incidence of gynecologic sequelae in large numbers of women. However, there are some data to support the concept that in certain individuals, sterilization may result in disruption of ovarian blood or nerve supply, producing gynecologic sequelae. Additional data from these ongoing large-scale studies and others should help to elucidate this problem in the future. Pregnancy after sterilization (even excluding pregnancies present at the time of the procedure) is more common the first year after the procedure with the risk decreasing in subsequent years.(ABSTRACT TRUNCATED AT 400 WORDS)

Mild cervical dysplasia. Experience in a family planning clinic

To evaluate mild cervical dysplasia, the results of Papanicolaou smears were reviewed for a six-month period in an inner-city family planning program. Papanicolaou smear evidence of mild dysplasia was consistent with the biopsy diagnosis in most cases. A single Papanicolaou smear is not a reliable indication of condylomata, nor is a single normal Papanicolaou smear in this setting completely reassuring. Persistent mild dysplasia is an indicator of high risk for cervical dysplasia and cervical infection. Aggressive initial cervical surgery is not indicated, but close follow-up is required.

Physiologic and psychologic profiles in a survey of women runners

The purpose of the present study is to report physiologic and psychologic factors in a survey of women runners. Psychologic factors were used in an investigation of differences in perceived emotional distress within a group of women runners. The psychologic information was compared with the results of two groups of infertility patients and a group of fertile control subjects. Among the physiologic factors, there was a significant difference in the mean weight and the height/weight ratio between amenorrheic and regularly cycling runners (P less than 0.001) and amenorrheic runners and runners with irregular cycles (P less than 0.01). The psychologic data showed no difference between runners and fertile control subjects. When runners were divided according to menstrual intervals or miles run per week, there were differences in perceived emotional distress.

Self-reports of emotional distress in a sample of urban black high school students

Emotional distress as assessed by the self-report Hopkins Symptom Checklist (HSCL) was examined in a sample of 607 urban black high school students aged 15–18. These adolescents reported high distress primarily about feelings of disadvantage, volatile anger, interpersonal sensitivity and loneliness. Females were significantly more likely than males to indicate emotional distress, although several of the leading distress items were endorsed equally by both groups. Male and female scores across the HSCL factors differed in degree rather than form. The great majority of these adolescents didnotreport significant emotional distress. These data provide a base from a non-clinical sample for comparison with other adolescent groups where emotional distress may play a role.

Never-pregnant adolescents and family planning programs: contraception, continuation, and pregnancy risk

Four hundred urban Black teenagers enrolling in a family planning program before pregnancies occurred were followed for one year to assess factors influencing continuation of contraceptive use. Over half the follow-up respondents claimed to always use contraception. Program discontinuers were less likely to use contraception, but nearly half had no sex activity when contacted at follow-up. Sex frequency reported in the sample was low. Background factors of age, grade, and household were associated with contraceptive use and with pregnancy. Girls who had pregnancies were significantly more likely to live in a single-parent household, to have sex more frequently, and to have stated at enrollment that they wanted their first child before age 20. A majority of the sample, nearly all of whom obtained oral contraception, did not know at the one year follow-up how to use any alternative methods for preventing conception, hence many would again be at risk of pregnancy when sex activity resumed.

Volatiles of exogenous origin from the human oral cavity

The volatiles found in the headspace above male and female saliva were examined by combined gas chromatography--mass spectrometry. This had led to the identification of a number of constituents of exogenous origin. The most likely source of these products are atmospheric and water pollutants as well as food stuffs and cosmetic products. Volatiles from saliva represent a potential medium for the detection of reproductive states as well as local and systemic diseases. Consequently, knowledge of compounds not arising from the body's metabolic process if important to prevent their identification as anomalous metabolites.

IUD use and unexplained vaginal bleeding

The Women's Health Study, a concurrent case-control study at 16 hospitals in 9 cities across the United States, examined the relationship between intrauterine contraceptive device (IUD) use and unexplained vaginal bleeding severe enough to require hospitalization. There were 545 eligible cases and 3453 controls. Analysis of all patients showed no association between IUD use and hospitalization for unexplained vaginal bleeding. When cases were analyzed separately with regard to prior episodes of vaginal bleeding, those patients with a history of vaginal bleeding had a decreased risk of hospitalization. Among cases, no significant differences between IUD users and nonusers were found in rates of anesthesia, blood transfusion, dilatation and curettage, or hysterectomy. The significant decreased risk between current IUD use (within 3 months before the study) and hospitalization for unexplained vaginal bleeding among women with a history of vaginal bleeding may reflect selective nonprescription for IUDs related to past episodes of vaginal bleeding.

Endocrine, cardiovascular, and psychological correlated of olfactory sensitivity changes during the human menstrual cycle

Signal detection measures olfactory sensitivity (d') and measures of blood pressure, heart rate, body temperature, nasal airflow, and respiration rate were repeatedly established within approximately 2.5-hr test sessions held every other day across 17 menstrual cycles of women not taking oral contraceptives, 6 menstrual cycles of women taking oral contraceptives, and 6 equivalent time periods of three men. In addition, radioimmunoassay-determined serum levels of luteinizing hormone, follicle stimulating hormone, estrone, estradiol, progesterone, and testosterone, as well as responses to the Moos Menstrual Distress Questionnaire (MDQ), were established daily or bidaily throughout the study periods. Peaks in olfactory sensitivity were noted during the second half of menses, midcycle, and midluteally in women taking and in women not taking oral contraceptives. The lack of correlation between the fluctuations in d' and the circulating hormone levels in the group using oral contraceptives suggests factors other than gonadal hormones were responsible for these changes. Significant fluctuations were also noted across the cycle phases of the normally cycling women for all the hormones examined, as well as for body temperature, nasal airflow, and the MDZ Water Retention and Pain Scales. In the oral contraceptive group, very small but statistically significant changes were observed across the cycle in body temperature and in circulating levels of luteinizing hormone and estrone. Interrelations between a number of the variables were noted both within and across the test periods in all three subject groups. The results are discussed in relation to fluctuations reported in a number of sensory systems during the menstrual cycle.

Adolescent contraceptive use: comparisons of male and female attitudes and information

Information and attitudes about contraception and pregnancy were assessed with a self-administered questionnaire in a sample of urban Black teenagers. Data were obtained from 607 male and female students in high school health classes and a demographically similar group of 123 never-pregnant teenage women in a family planning clinic who had not attended these classes. Males were less likely to recognize the risk of pregnancy, had less information about contraceptives, and fewer attitudes that supported contraceptive use than females who participated in the same shool health classes. More males than females indicated that school classes had been the main source of contraceptive information. Teenage women in the family planning clinic did not differ from the high school females in attitudes about contraceptives, but the school group had somewhat more contraceptive information. The female school group was more likely to have discussed contraception with parents, obtained more contraception information from their mothers, and discussed contraception more with male friends than the teenagers who requested contraceptives at the family planning clinic.

Emotional distress patterns among women having first or repeat abortions

Thirty-five percent of a sample of 413 women undergoing first-trimester abortions were repeating abortions. All patients rated their emotional symptoms on an SCL-90 scale and completed a brief demographic questionnaire. Preabortion and postabortion emotional distress factors and associated demographic characteristics were compared for women having first and those undergoing repeat abortions. Elevated distress levels were similar in both groups prior to abortion procedures, particularly depression, anxiety, and somatization. After abortion, repeat aborters continued to have significantly higher emotional distress scores in dimensions relating to interpersonal relationships. The variables that discriminated most between first and repeat abortion groups were number of living children, race, and phobic anxiety.

Alterations in the organic compounds of vaginal secretions caused by sexual arousal

The low-molecular weight organic constituents of human vaginal secretions from normally cycling subjects were analyzed both before and after sexual stimulation. Gas chromatography and combined gas chromatography-mass spectrometry were employed in the analyses of the secretions. Consistent increases were noted for a number of the lipid constituents of the secretions, suggesting that they are derived at least in part from the plasma and transude into the vaginal lumen during arousal. In addition, the increases in the concentrations of glycerol and stearic acid with respect to baseline levels were significant (P is equal to and less than 0.05). Compounds which are produced intravaginally appear to decrease in concentration during the arousal interval because of dilution by the transudate. No consistent qualitative changes were noted in the secretion.