Clomiphene citrate as a new modality in management of vaginal bleeding with depomedroxyprogesterone acetate (DMPA): A randomized controlled trial

BACKGROUND

Depo-medroxyprogesterone acetate (DMPA) functions as a contraceptive method by inhibiting the secretion of gonadotropins, which prevents follicular maturation and ovulation, as well as thinning of the endometrium leading to unscheduled vaginal bleeding and subsequent discontinuation of DMPA. Our study aimed to evaluate the efficacy and safety of clomiphene citrate (CC) in stopping bleeding among DMPA users.

MATERIALS AND METHODS

We randomly assigned 200 DMPA users using a computer-generated random numbers table in a 1:1 ratio to one of two groups; the study group, which received CC at a dose of 50 mg twice daily for five days (n = 100), and the control group, which received a placebo for five days (n = 100). Our primary outcome measure was the onset and duration of bleeding cessation. Secondary outcomes included endometrial thickness, recurrence of vaginal bleeding, and any reported side effects associated with CC use.

RESULTS

Clomiphene citrate significantly resulted in early cessation of vaginal bleeding in 83 % of the patients, which continued for three months of follow-up. In addition, the recurrence of vaginal bleeding was significantly reduced in the CC group compared to the control group (11 % vs. 67 %; p < 0.001). Endometrial thickness was significantly greater in the CC group than in the control group (p < 0.001). Breast tenderness was more frequently reported in the study group, with no difference in dyspareunia between the two groups.

CONCLUSIONS

Clomiphene citrate is effective in controlling bleeding among DMPA users. Further studies are encouraged to confirm our findings.

Effects of letrozole alone or in combination with gonadotropins on ovulation induction and clinical pregnancy in women with polycystic ovarian syndrome: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To compare letrozole in combination with gonadotropins versus letrozole monotherapy in ovulation induction and clinical pregnancy among infertile women with polycystic ovarian syndrome (PCOS).

METHODS

Several databases were searched for available clinical trials from inception until March 2023. We selected randomized controlled trials (RCTs) that compared sequential letrozole/gonadotropin versus letrozole alone among infertile women who met the Rotterdam criteria for PCOS. RevMan software was used to perform our meta-analysis. Our primary outcomes were ovulation and clinical pregnancy rates. Our secondary outcomes were endometrial thickness, number of mature follicles (diameter ≥ 18 mm), and incidence of miscarriage and ovarian hyperstimulation syndrome (OHSS).

RESULTS

Six RCTs were retrieved with a total number of 723 patients. The ovulation and clinical pregnancy rates were significantly higher among the letrozole/gonadotropin group versus the letrozole monotherapy group (p < 0.001). In addition, there were significant improvements in endometrial thickness and number of mature follicles in the letrozole/gonadotropin group. There were no significant differences between the two groups regarding incidence of miscarriage and ovarian hyperstimulation syndrome.

CONCLUSION

Letrozole in combination with gonadotropin is superior to letrozole alone in improving ovulation induction and clinical pregnancy among PCOS patients. More trials are required to confirm our findings.

Does Ultrasound Guidance Provide Pain Relief During Intrauterine Contraceptive Device Insertion? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate ultrasound guidance effect in pain relief during intrauterine device (IUD) insertion.

METHODS

Four different databases were searched from inception till June 2022. We selected randomized controlled trials (RCTs) that compared transabdominal ultrasound guidance versus traditional non-guided IUD insertion among women undergoing IUD placement for contraception. We used Revman software during performing our meta-analysis. Our primary outcome was the pain score during IUD insertion as evaluated by the Visual Analog Scale (VAS). Our secondary outcomes were the procedure insertion time, satisfaction, and incidences of complications and misplaced IUDs.

RESULTS

Seven RCTs were retrieved with a total number of 1267 patients. There was a significant reduction in the VAS pain score during IUD insertion among the ultrasound-guided group (MD = -1.91, 95% CI [-3.08, -0.73], P = .001). The procedure insertion time was significantly shorter within the ultrasound guidance group compared with the control group (MD = -1.35, 95% CI [-1.81, -0.88], P < .001). Moreover, more women were significantly satisfied with the procedure among the ultrasound-guided group (P < .001). In addition, ultrasound-guided IUD insertion was linked to significant decline in incidences of complications and misplaced IUDs.

CONCLUSION

Ultrasound guidance can be used as a modified technique during IUD insertion as it decreases pain, procedure time, and rates of complications and misplaced IUDs with better patient satisfaction.

The acceptability of using IUDs among Egyptian nulliparous women: a cross-sectional study

Background

Although intrauterine contraceptive device is highly effective, safe, long term and reversible method of contraception, the general population and physicians refuse. IUDs for nulliparous women due to persistent rumors about its side effects and complications. The aim of this study was to assess the acceptability of IUD use in nulliparous women by both women and health care providers in Egypt.

Methods

Five hundred thirty nulliparous women and 200 physicians were interviewed in 10 family planning clinics in Suez and Minia cities – Egypt. The knowledge and attitudes of women and health care providers towards IUD use in nulliparous women were assessed through a well designed questionnaire over 2 years. Those women who accepted using IUD were then followed up for 6 months.

Results

Most of nulliparous women sought for contraception reported a negative impression of IUD method (96.2%). 82.5% of physicians had the same attitude. The reasons for refusing IUD among nulliparous women are fear of side effects including infection (52.8%), and bleeding (37.7%).Also, fear of subsequent infertility 51.9% of women. Regarding the providers, increased pelvic inflammatory disease (PID) represented the highest percentage (70%) for non acceptability, followed by difficult insertion (52.5%). Ninety women who accepted use IUD were followed up 6 months later, 94.4% were still using the method and77.8% were happy with the results.

Conclusion

The main barriers that hinder the use of IUD in nulliparous women are the women insufficient knowledge and attitude of their physicians. Good client counseling. Good training for physician to improve their experience would help increase the use of such effective and safe method.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Wound complications and treatment of the infected implantable cardioverter defibrillator generator

Since 1980, the automatic implantable cardioverter defibrillator (ICD) has evolved as effective therapy for prevention of sudden cardiac death following documented sustained ventricular tachycardia or fibrillation. During a 5-year period, 412 ICD devices were implanted at the University of Michigan Hospitals with a wound complication rate of 4.1%. In this group, there were 13 infections, 3 erosions of the generator pocket, and 1 wound hematoma. Of the 16 patients with infection or erosion, 12 patients were treated with a rectus abdominis muscle flap closure and 4 with ICD generator removal. In 83% (n = 12) of the muscle flap patients, the wound healed uneventfully. Preoperative chest CT scanning was found to be helpful in identifying probable infection of the epicardial leads. In these cases, all hardware had to be removed to achieve resolution of the infection. We concluded that rectus abdominis muscle flaps were helpful in salvaging infected or exposed ICD generators in the absence of infected epicardial leads.

The stress response in skin: the role of neutrophil products in preconditioning

In this study we tested the hypothesis that neutrophil products are present in ischemic skin flaps and that they are abolished with preconditioning of the skin. Random back flaps were created on rats, and the sequential appearance of neutrophil products and tissue oxidants was measured in the skin flaps. These flaps had predictable skin necrosis (4.7 +/- 0.8 cm) in the distal ends, while preconditioned flaps had no skin necrosis. Neutrophil products were assayed by both histomorphometrics and myeloperoxidase assays. Lipid peroxidation products were measured to assess tissue oxidant production. These data demonstrate that there is an increase in myeloperoxidase activity in skin flaps that is statistically significantly greater in the distal ends of the flaps at 24 hours (p < 0.05). The lipid peroxidation products were statistically significantly elevated at 48 hours in the distal ends (p < 0.05). Preconditioning the skin as a bipedicled skin flap for 7 days and then dividing the distal attachment abolished neutrophil products and tissue oxidant activity in the skin flaps (p < 0.05). These data suggest that neutrophil products and oxidant production are increased in ischemic skin and that preconditioning of the flap markedly attenuates this response.

Mycosis fungoides cells in sputum. A case report

Atypical lymphoid cells were identified in the sputum of a patient known to have mycosis fungoides. Although the lungs are the second most common organ to be affected when there is extracutaneous dissemination of mycosis fungoides, this is the first report of pulmonary involvement diagnosed by the cytologic identification of "mycosis cells" in the sputum.