Adherence to dual-method contraceptive use

BACKGROUND

Patient characteristics associated with adherence to dual-method contraceptive use are not known.

STUDY DESIGN

Project PROTECT was a 24-month-long randomized trial designed to promote the use of dual methods of contraception using an individualized computer-based intervention or enhanced standard care counseling intervention. We analyzed 463 women with follow-up data and examined sustained dual-method use (reported at 2+ interviews).

RESULTS

While 32% initiated dual-method contraceptive use, only 9% reported sustained use. Education increased (RR(adj)=4.42; 95% confidence interval [CI] 1.19-16.42), substance abuse decreased (adjusted relative risk [RR(adj)]=0.49; 95% CI 0.24-0.97), no contraceptive use at baseline decreased (RR(adj)=0.32; 95% CI 0.11-0.92) and contraceptive stage of change increased (RR(adj)=5.04; 95% CI 1.09-23.4) adherence to dual-method use.

CONCLUSION

To effectively prevent sexually transmitted diseases and unplanned pregnancies, dual-method use must be consistent and sustained. Future interventions to promote dual-method use should focus on high-risk groups and additional dual-method combinations (e.g., barrier plus intrauterine devices or implants).

Screening for infectious diseases in pregnant, foreign-born women from multiple global areas

OBJECTIVE

To describe and compare infectious diseases commonly screened for during pregnancy among pregnant immigrant women from multiple global regions.

STUDY DESIGN

We retrospectively reviewed the charts of all women born outside the United States who delivered at Vanderbilt University Medical Center during 2003-2006. These women were identified through the birth certificate applications for their children. The primary outcomes were prevalence of positive tests for tuberculosis, HIV, hepatitis B, gonorrhea and Chlamydia, rubella immunity and syphilis.

RESULTS

During the years 2003-2006, 1,767 immigrant women gave birth at Vanderbilt University Medical Center. The women were from Africa (17%), Asia (25%), Europe (11%), Latin America (26%), Middle East (18%), North America (2%) and Oceana (1%). There were no statistically significant differences in prevalence among immigrant groups for positive purified protein derivatives (PPDs), rubella titers, rapid plasma reagin (syphilis) and gonorrhea. Significantly more women from Asia and Africa had positive hepatitis B surface antigen. Asian women were less likely than other immigrant groups to be positive for HIV. Significant differences were also noted among groups for Chlamydia. Screening rates differed by immigrant groups and were related to mode of testing.

CONCLUSION

Our data reinforce the importance of screening for diseases for which vaccinations are available, especially for hepatitis B and rubella. The data also show the importance of following up positive PPDs, particularly among pregnant immigrant women. Screening differences among groups may exist, and further research is needed to examine causal factors.

Treatment of overactive bladder in women

OBJECTIVES

The Vanderbilt Evidence-based Practice Center systematically reviewed evidence on treatment of overactive bladder (OAB), urge urinary incontinence, and related symptoms. We focused on prevalence and incidence, treatment outcomes, comparisons of treatments, modifiers of outcomes, and costs.

DATA

We searched PubMed, MEDLINE, EMBASE, and CINAHL.

REVIEW METHODS

We included studies published in English from January 1966 to October 2008. We excluded studies with fewer than 50 participants, fewer than 75 percent women, or lack of relevance to OAB. Of 232 included publications, 20 were good quality, 145 were fair, and 67 poor. We calculated weighted averages of outcome effects and conducted a mixed-effects meta-analysis to investigate outcomes of pharmacologic treatments across studies.

RESULTS

OAB affects more than 10 to 15 percent of adult women, with 5 to 10 percent experiencing urge urinary incontinence (UUI) monthly or more often. Six available medications are effective in short term studies: estimates from meta-analysis models suggest extended release forms (taken once a day) reduce UUI by 1.78 (95 percent confidence interval (CI): 1.61, 1.94) episodes per day, and voids by 2.24 (95 percent CI: 2.03, 2.46) per day. Immediate release forms (taken twice or more a day) reduce UUI by 1.46 (95 percent CI: 1.28, 1.64), and voids by 2.17 (95 percent CI: 1.81, 2.54). As context, placebo reduces UUI episodes by 1.08 (95 percent CI: 0.86, 1.30), and voids by 1.48 (95 percent CI: 1.19, 1.71) per day. No one drug was definitively superior to others, including comparison of newer more selective agents to older antimuscarinics. Current evidence is insufficient to guide choice of other therapies including sacral neuromodulation, instillation of oxybutynin, and injections of botulinum toxin. Acupuncture was the sole complementary and alternative medicine treatment, among reflexology and hypnosis, with early evidence of benefit. The strength of the evidence is insufficient to fully inform choice of these treatments. Select behavioral interventions were associated with symptom improvements comparable to medications. Limited evidence suggests no clear benefit from adding behavioral interventions at the time of initiation of pharmacologic treatment.

CONCLUSIONS

OAB and associated symptoms are common. Treatment effects are modest. Quality of life and treatment satisfaction measures suggest such improvements can be important to women. The amount of high quality literature available is meager for helping guide women's choices. Gaps include weak or absent data about long-term followup, poorly characterized and potentially concerning harms, information about best choices to minimize side effects, and study of how combinations of approaches may best be used. This is problematic since the condition is chronic and a single treatment modality is unlikely to fully resolve symptoms for most women.

Vesicovaginal fistula following a transobturator midurethral sling procedure

Synthetic mid-urethral slings are currently the most common surgical procedure performed for the treatment of female stress urinary incontinence. The transobturator mid-urethral sling technique was originally described in 2001 and has since become widely accepted due to its high rate of success and low complication rate. Although complications remain infrequent, when they do occur, there is potential for significant patient morbidity. We report a case of a vesicovaginal fistula following a transobturator mid-urethral sling procedure and describe successful reconstruction with transvaginal sling excision, fistula closure, and placement of an autologous pubovaginal sling.