Implicit Assessment of Non-Suicidal Self-Injury: Group Differences in Temporal Stability of the Self-Injury Implicit Association Test (SI-IAT)

OBJECTIVE

We examine differences on the Self-Injury Implicit Association Test (SI-IAT) by history of non-suicidal self-injury (NSSI), in a test-retest design, to examine short-term temporal stability of SI-IAT scores.

METHOD

Treatment-seeking participants (N = 113; 58% female; 89% White; Mage = 30.57) completed the SI-IAT and self-report measures at two time points (MTimeframe = 3.8 days).

RESULTS

Data suggested NSSI (51% of the sample endorsed lifetime NSSI) was related to Time 1 (T1) identity and attitude, and affected stability of scores. T1 and T2 SI-IAT identity and attitude were more strongly related for participants with NSSI history. NSSI characteristics (recency; number of methods) affected stability.

CONCLUSIONS

The short-term test-retest reliability of the SI-IAT is strong among those with NSSI history from T1 to T2. However, the SI-IATs use with participants without a history of NSSI was not supported beyond its established ability to differentiate between groups by NSSI history. This test may provide clinically-relevant assessment among those with a history of NSSI.

Facteurs associés à la létalité chez les patients hospitalisés pour le VIH avancé

CONTEXT

A unit supported by Médecins Sans Frontières (MSF) cares for patients with advanced HIV at Donka National Hospital, Conakry, Guinea.

OBJECTIVE

To determine the factors associated with the occurrence of death in patients hospitalised in the unit between 2017 and 2021.

DESIGN

This was a retrospective analysis of routine data from patients hospitalised with advanced HIV.

RESULTS

A total of 3,718 patients were included, with a median age of 40 years (IQR 33-51), of whom 2,241 (60.3%) were women. The mean mortality rate was 33.6% (n = 1,240), down from 40% in 2017 to 29% in 2021, but this was not statistically significant. The period most at risk of death was the first 25 days of hospitalisation. Among these patients, TB (43.8%) and toxoplasmosis (11.4%) were the most frequent diagnoses. After multivariate analysis using Cox regression, the factors associated with death were age 25-49 years (adjusted hazard ratio [aHR] 1.60; P = 0.002) or ≥50 years (aHR 1.80; P < 0.001), the presence of respiratory (aHR 1.23; P = 0.001) or abdominal symptoms (aHR 1.26; P < 0.001) and readmission (aHR 0.54; P < 0.001).

CONCLUSION

Patients aged 25-49 years or older, or those presenting with respiratory or abdominal signs require increased surveillance, as they are at the greatest risk of dying from the disease, especially during the first 25 days of hospitalisation.

Does the unified protocol really change neuroticism? Results from a randomized trial

BACKGROUND

Neuroticism is associated with the onset and maintenance of a number of mental health conditions, as well as a number of deleterious outcomes (e.g. physical health problems, higher divorce rates, lost productivity, and increased treatment seeking); thus, the consideration of whether this trait can be addressed in treatment is warranted. To date, outcome research has yielded mixed results regarding neuroticism's responsiveness to treatment, perhaps due to the fact that study interventions are typically designed to target disorder symptoms rather than neuroticism itself. The purpose of the current study was to explore whether a course of treatment with the unified protocol (UP), a transdiagnostic intervention that was explicitly developed to target neuroticism, results in greater reductions in neuroticism compared to gold-standard, symptom focused cognitive behavioral therapy (CBT) protocols and a waitlist (WL) control condition.

METHOD

Patients with principal anxiety disorders (N = 223) were included in this study. They completed a validated self-report measure of neuroticism, as well as clinician-rated measures of psychological symptoms.

RESULTS

At week 16, participants in the UP condition exhibited significantly lower levels of neuroticism than participants in the symptom-focused CBT (t(218) = -2.17, p = 0.03, d = -0.32) and WL conditions(t(207) = -2.33, p = 0.02, d = -0.43), and these group differences remained after controlling for simultaneous fluctuations in depression and anxiety symptoms.

CONCLUSIONS

Treatment effects on neuroticism may be most robust when this trait is explicitly targeted.

An exploratory mixed methods approach to implicit and explicit identification with non-suicidal self-injury

BACKGROUND AND OBJECTIVES

Identification with non-suicidal self-injury (NSSI) is uniquely related to NSSI behavior and predicts future NSSI. This exploratory, mixed methods study used implicit and explicit approaches to further understanding of NSSI identity.

METHODS

Participants included 15 treatment-seeking adults (60% female, 87% Caucasian) with lifetime NSSI. Participant age ranged from 19 to 38 years (M = 25.33, SD = 6.10). Implicit tasks were completed at two time points in a test-retest design, followed by a qualitative interview.

RESULTS

Qualitative data suggest that explicit NSSI identity is relevant to some individuals with NSSI history. Mixed methods analyses indicate that individuals who explicitly identify with NSSI have stronger implicit NSSI identities than those who do not, and report more methods of NSSI on average.

LIMITATIONS

Results are novel, although exploratory in nature due to the sample size, and may not be generalizable to non-clinical samples or individuals currently engaging in NSSI.

CONCLUSIONS

Individuals with stronger explicit identity evidence higher implicit identity scores, suggesting a potential higher risk profile for future NSSI. This study offers further support for the value of including both implicit and explicit assessment of NSSI identity in risk assessment.

From Urges to Action: Negative Urgency and Nonsuicidal Self-Injury in an Acute Transdiagnostic Sample

Urgency-rash action during strong emotion-is a robust correlate of nonsuicidal self-injury (NSSI). This study tested whether urgency is associated with time between NSSI urges and NSSI, and sought to replicate the finding that urgency is associated with NSSI history. Participants attending a partial hospitalization program (N = 669) completed self-report measures of urgency, NSSI history and latency, and psychiatric symptoms. Consistent with previous research in clinical samples, rates of lifetime engagement in NSSI were high. Using logistic regression to predict short vs. long latency between urges and NSSI, no significant relationship emerged between negative urgency and latency to self-injure. Negative urgency more than doubled the likelihood of NSSI history (p < .001, OR = 2.39). In addition, exploratory analyses revealed several links between NSSI latency and negative urgency. Results confirm that urgency is robustly related to NSSI, yet also suggest that more research is needed to understand how urgency relates to the parameters of NSSI within those who self-injure. Use of retrospective self-report measures may limit the ability to test links between urgency and latency of NSSI.

Efficacy of the Unified Protocol for transdiagnostic treatment of comorbid psychopathology accompanying emotional disorders compared to treatments targeting single disorders

OBJECTIVE

This study aimed to examine whether the Unified Protocol (UP), a transdiagnostic cognitive-behavioral therapy for emotional disorders (i.e., anxiety, mood, and related disorders), is efficacious in the treatment of co-occurring emotional disorders compared to established single disorder protocols (SDPs) that target specific disorders (e.g., panic disorder).

METHOD

Participants included 179 adults seeking outpatient psychotherapy. Participant age ranged from 18 to 66 years, with an average of 30.66 years (SD = 10.77). The sample was 55% female and mostly Caucasian (83%). Diagnostic assessments were completed with the Anxiety Disorder Interview Schedule (ADIS), and disorder-specific, clinician-rated measures for the comorbid diagnoses of interest.

RESULTS

In both treatment conditions, participants' mean number of diagnoses dropped significantly from baseline to posttreatment, and baseline to 12-month follow-up. Additionally, large effects were observed for changes in comorbid generalized anxiety (ESSG: UP = -1.72; SDP = -1.98), social anxiety (ESSG: UP = -1.33, -0.86; SDP = -1.60, -1.54), and depression (ESSG: UP = -0.83; SDP = -0.84). Significant differences were not observed in between-group comparisons.

CONCLUSIONS

Results suggest that both the UP and SDPs are efficacious in reducing symptoms of comorbid emotional disorders. The clinical, practical, and cost-effective advantages of transdiagnostic CBT are discussed.

Missed opportunities for earlier diagnosis of rifampicin-resistant tuberculosis despite access to Xpert® MTB/RIF

OBJECTIVE

To assess the proportion of rifampicin-resistant tuberculosis (RR-TB) patients with potential earlier RR-TB diagnoses in Khayelitsha, South Africa.

DESIGN

We conducted a retrospective analysis among RR-TB patients diagnosed from 2012 to 2014. Patients were considered to have missed opportunities for earlier diagnosis if 1) they were incorrectly screened according to the Western Cape diagnostic algorithm; 2) the first specimen was not tested using Xpert® MTB/RIF; 3) no specimen was ever tested; or 4) the initial Xpert test showed a negative result, but no subsequent specimen was sent for follow-up testing in human immunodeficiency virus-positive patients.

RESULTS

Among 543 patients, 386 (71%) were diagnosed with Xpert and 112 (21%) had had at least one presentation at a health care facility within the 6 months before the presentation at which RR-TB was diagnosed. Overall, 95/543 (18%) patients were screened incorrectly at some point: 48 at diagnostic presentation only, 38 at previous presentation only, and 9 at both previous and diagnostic presentations.

CONCLUSIONS

These data show that a significant proportion of RR-TB patients might have been diagnosed earlier, and suggest that case detection could be improved if diagnostic algorithms were followed more closely. Further training and monitoring is required to ensure the greatest benefit from universal Xpert implementation.

Objective cosmetic and anatomical outcomes at adolescence of feminising surgery for ambiguous genitalia done in childhood

There are few, if any data on the long-term outcome of feminising genital surgery for children with ambiguous genitalia. We present a retrospective study of cosmetic and anatomical outcomes in 44 adolescent patients who had ambiguous genitalia in childhood and underwent feminising genital surgery. Cosmetic result was judged as poor in 18 (41%) of these patients. 43 (98%) of 44 needed further treatment to the genitalia for cosmesis, tampon use, or intercourse. 23 (89%) of 26 of genitoplasties planned as one-stage procedures required further major surgery. This information must be available to parents and clinicians planning such surgery. Cosmetic genital surgery in infancy needs to be reassessed in the light of these results.

A map of interactions between the proteins of a retrotransposon

The yeast two-hybrid system and in vitro binding assays were used to characterize 54 potential interactions between the proteins of Tf1, an LTR-retrotransposon found in Schizosaccharomyces pombe. The Tf1 integrase (IN) protein was found to interact strongly with itself and not with other control proteins. In addition, the IN core domain interacted strongly with itself and full-length IN. Interestingly, the two-hybrid analysis detected an interaction between the RNase H domain of reverse transcriptase and IN. The biological implications of these interactions are discussed.

What are the effects of anonymity and secrecy on the welfare of the child in gamete donation?

A perennial concern when using donated gametes in infertility treatment is the effect on the child and his/her family of the traditional anonymity of the donor, and of the secrecy of the procedure. As all involved, from potential parents to carers, wish to maximize the 'welfare of the child' born of gamete donation, conflicting attitudes, sometimes translated into diverging legislations in Europe, are analysed. In the face of the lack of evidence on the consequences of secrecy or openness, it is concluded that future parents are best placed to decide on this matter for the potential children.

Ovarian tissue cryopreservation for patients

For patients about to receive chemotherapy, radiotherapy or to undergo a surgical procedure, loss or impairment of fertility is a major issue. For males, sperm banking is a standard accepted procedure to circumvent loss or damage to spermatozoa and this has been undertaken in this unit since 1975 (Steele et al., 1995). For women there is no established procedure for gamete storage. Embryo preservation is not an option for single women or even for those in a stable relationship, as treatment would have to be delayed while ovarian stimulation and oocyte retrieval took place. With the general shortage of donor oocytes, the possibility of maturing primordial follicles from fetal ovaries has become a subject for debate (HFEA 1995: Recent deliberations). In animals, the use of frozen ovarian tissue has been encouraging with a report of a live birth in lamb after orthotopic transplantation (Gosden et al., 1995). Media attention to the future prospect for freezing ovarian tissue has meant that pressure from patients is likely to increase either for information or as requests to freeze the ovarian tissue which could irretrievably be lost as a result of surgery and/or treatment. In the absence of well defined procedures and technologies, should women be given the chance to preserve ovarian tissue prior to receiving intensive chemotherapy or radiotherapy?

Molecular cytogenetic analysis of five newly established cervical cancer cell lines using G banding and fluorescence in situ hybridization

Cervical tumors nearly all have complex karyotypes and more precise cytogenetic information is required to establish whether specific rearrangements occur, and if they are related to the type of HPV infection found. The karyotypes of five recently established cervical cancer cell lines, three from squamous cell carcinomas (two HPV 16 +ve and one HPV 18 +ve), one from an adenocarcinoma (HPV -ve), and one from an adenosquamous carcinoma (HPV 16 +ve), have been analysed using fluorescence in situ hybridization (FISH), with 23 chromosome specific paints, YACs and cosmids as probes, in addition to conventional G banding, in order to identify markers and clarify the breakpoints. Chromosomes 1 and 3 were rearranged in all cell lines. Breakpoints in the squamous lines were all in 3q. but in different regions. Small metacentrics involving chromosome 5 were a del(5q) in one line, and a t(X;5) in another, rather than i(5p). The region 6q21 was involved in three cases and chromosome 9 was rearranged in four. An i(8q) was found in three squamous carcinoma cell lines. Structural changes of 11q were found only in two cases, but a marker 11 representing amplification in the 11q14-22 region was duplicated in the adenosquamous line.

Effect of smoking cessation on cervical lesion size

BACKGROUND

Cigarette smoking has been postulated as a cofactor in the aetiology of cervical cancer, but a causal role is difficult to establish because of potential confounding by sexual behaviour. We have investigated the effect of cessation or reduction of cigarette smoking on the course of minor-grade cervical lesions.

METHODS

In this intervention study 82 women volunteers with minor-grade lesions on colposcopy (cervical intraepithelial neoplasia grade 1 or less) attempted to give up smoking for 6 months. Smoking histories were taken at 3-monthly clinic visits and verified by measurement of salivary cotinine concentrations. At each clinic visit, a photograph of the cervix was taken; the image was digitised and computer-aided image analysis was used to assess lesion size, by investigators unaware of smoking status.

FINDINGS

Of the 82 women, 17 stopped smoking completely for at least 6 months and 11 others reduced their smoking consumption by more than 75%. Of these 28 women, 23 (82%) showed a reduction in lesion size of at least 20% or 4 mm2 compared with 13 (28%) of the 47 non-quitters (odds ratio 12.0 [95% Cl 3.9-32.7]). The remaining seven women had unconfirmed smoking histories. There was a significant correlation between the extent of smoking reduction and the change in lesion size (chi2 for trend=31.55, p<0.0001). Adjustment for social class, method of contraception, and stage of menstrual cycle did not affect the results.

INTERPRETATION

Our findings support a link between smoking and cervical disease and suggest that smoking cessation could have a beneficial effect on early cervical abnormalities.

The potential for improved abdominal procedures and approaches for tubal occlusion

Methods of sterilization by the abdominal route are reviewed. There are wide variations in practice which reflect experience, training and resources in different countries. Clip sterilization comes nearest to fulfilling the criteria of a satisfactory method, whether performed by laparoscopy or minilaparotomy. The development of the Cambridge clip seems to offer the prospect of a significant improvement in reliability and safe application while microlaparoscopy and a smaller clip would facilitate the use of local anesthesia and decrease morbidity.

In-vitro cervical mucus-sperm penetration tests and outcome of infertility treatments in couples with repeatedly negative post-coital tests

The results of in-vitro cervical mucus-sperm penetration tests and cross-hostility tests in 178 couples with repeatedly negative post-coital tests were recorded. Using a protocol of three cycles with intra-uterine inseminations (IUI) followed by three cycles with ovulation induction + IUI, the association between the cause of infertility, results of the in-vitro tests and the outcome of infertility treatment was investigated. We found that repeatedly negative post-coital tests are a good indicator of a cervical mucus-sperm penetration problem. The cross-hostility test clearly differentiates the abnormal factor in this interaction, and a good performance of the donors' spermatozoa in the cervical mucus correlates with increased pregnancy rate. In male factor infertility, failure of the husbands' spermatozoa to penetrate cervical mucus was not indicative of a deficient fertilization potential in vivo. In these patients a serious attempt should therefore be made to reverse the infertility by treatment with IUI or ovulation induction + IUI before attempting assisted reproduction. Women with polycystic ovaries and repeatedly negative post-coital tests should be investigated for sperm receptivity of the cervical mucus. Low receptivity of the cervical mucus may imply that endometrial receptivity and oocyte quality are also low. Ovulation induction and not IUI alone should therefore be used as the preferred mode of treatment to improve pregnancy rate.

A revised structure for the disialosyl globo-series gangliosides of human erythrocytes and chicken skeletal muscle

Disialosyl globo-series gangliosides have previously been isolated from chicken skeletal muscle (E. L. Hogan, R. D. Happel, and J.-L. Chien (1982) Adv. Exp. Med. Biol. 152, 273-278; S. Dasgupta, J.-L. Chien, E. L. Hogan, and H. van Halbeek (1991) J. Lipid Res. 32, 499-506) and human erythrocytes (S. K. Kundu, B. E. Samuelsson, I. Pascher, and D. Marcus (1983) J. Biol. Chem. 258, 13857-13866). In both cases, the structure of this ganglioside was proposed to be NeuAc alpha 2-->3(NeuAc alpha 2-->6)Gal beta 1-->3GalNAc beta 1-->3Gal alpha 1-->Gal alpha 1-->4Gal beta 1-->1Cer (V3NeuAcV6NeuAcGb5Cer). We have reinvestigated the human erythrocyte antigen and now propose an alternative structure differing in the location of the NeuAc alpha 2-->6 residue: NeuAc alpha 2-->3Gal beta 1-->3 (NeuAc alpha 2-->6)GalNAc beta 1-->3Gal alpha 1-->4Gal beta 1-->4Glc beta 1-->1 Cer (V3NeuAcIV6NeuAcGb5Cer). This novel structure is supported by results of 1H-NMR spectroscopy, negative ion fast atom bombardment mass spectrometry, and methylation linkage analysis with capillary gas chromatography--mass spectrometry in both electron impact and chemical ionization modes. Furthermore, based on new results from negative ion fast atom bombardment mass spectrometry and linkage analysis, we propose that the chicken skeletal muscle antigen also has this revised structure, differing only in ceramide composition. The terminal tetrasaccharide of these gangliosides is identical to that of GD1 alpha, NeuAc alpha 2-->3Gal beta 1-->3(NeuAc alpha 2-->6)GalNAc beta 1-->4Gal beta 1-->4Glc beta 1-->1 Cer(IV3NeuAcIII6NeuAcGg4Cer), previously identified in a rat ascites hepatoma cell line (T. Taki, Y. Hirabayashi, H. Ishikawa, S. Ando, K. Kon, Y. Tanaka, and M. Matsumoto (1986) J. Biol. Chem. 261, 3075-3078) and a murine lymphoma cell line with low metastatic potential (K. Murayama, S. B. Levery, V. Schirrmacher, and S. Hakomori (1986) Cancer Res. 46, 1395-1402), although they appear to be immunologically distinct.

Stage-specific glycosphingolipids from amastigote forms of Leishmania (L.) amazonensis. Immunogenicity and role in parasite binding and invasion of macrophages

Neutral glycosphingolipids (GSLs) from amastigote forms of Leishmania (L.) amazonensis were isolated, and their structures and biological properties were characterized. Based on various immunochemical methods, these GSLs were shown to be expressed at certain stages of amastigote development. GSLs were extracted and purified from amastigotes of hamster foot lesions by established procedures. Three mouse monoclonal antibodies (MoAbs) specific for carbohydrate epitopes of these GSLs were established, and their inhibition of parasite binding and macrophage invasion was analyzed. MoAb ST-3 inhibited 80% of macrophage invasion by amastigotes and 60% of that by promastigotes. Since GSLs reacting with MoAb ST-3 were found in amastigotes but not in promastigotes, ST-3 reactivity with promastigotes presumably depends on an epitope present on an unidentified promastigote glycoconjugate. MoAbs ST-4 and ST-5 inhibited 60-80% of macrophage invasion by amastigotes but were not effective in preventing macrophage invasion by promastigotes. Fab fragments of ST-3 inhibited invasion of cultured mouse macrophages by amastigotes (80%) or promastigotes (60%). The GSL with the simplest structure recognized by these MoAbs was isolated and characterized (by negative ion fast atom bombardment-mass spectrometry, gas chromatography-mass spectrometry of the permethylated compound, degradation with exoglycosidases, and 1H NMR) as the novel globoseries structure Gal beta 1-->3Gal alpha 1-->4Gal beta 1-->4Glc beta 1-->Cer, which has beta 1-->3Gal in place of the beta 1-->3GalNAc of globoside. The ceramide contains a 16:0 fatty acid and d18:1 sphingosine as the long chain base. The MoAbs also reacted with a series of GSLs from amastigote forms of L. amazonensis, with longer carbohydrate chains, probably containing identical end groups Gal beta 1-->3Gal alpha 1-->R. Expression of surface GSLs may render amastigote forms more effective than promastigotes in binding and invading host macrophages, thus enhancing the infectious process.

Effects of age, gravidity and male infertility status on cumulative conception rates following artificial insemination with cryopreserved donor semen: analysis of 2998 cycles of treatment in one centre over 10 years

The effects of age, gravidity and male infertility status on cumulative conception rates after donor insemination were investigated in an analysis of 2998 treatment cycles undertaken on 443 patients. It was found that the cumulative conception rates after 3, 6 and 12 cycles of treatment were 21, 40 and 62% respectively for patients < 30 years of age compared with 17, 26 and 44% for those aged > or = 30 years (P = 0.008). There was also a significant difference (P < 0.001) in results depending on course of treatment and the cumulative conception rates were 19% after 3 cycles, 33% after 6 cycles and 54% after 12 cycles of treatment in the first course of treatment compared with 40, 67 and 79% respectively in those who returned for subsequent courses of treatment after having achieved a donor insemination pregnancy in the first treatment course. Gravidity and male infertility status (azoospermia or oligozoospermia/asthenozoospermia) did not significantly affect the cumulative conception rates.

Quantitative determination of acid-labile DNA in cervical intraepithelial neoplasia

Using a modified Feulgen hydrolysis procedure and integrating microdensitometry, the acid-labile nuclear DNA in exfoliated cervical epithelial cells was quantified in a range of histologically confirmed cervical intraepithelial neoplasia (CIN), invasive cancer, and normal controls. The mean relative optical densities obtained for each sample group showed an increase from normal epithelium, through CIN grades, to invasive cancer. Although there was some overlap between groups, the difference in the overall mean values between the adjacent groups was statistically significant. The sensitivity of the test was 87.1% with a specificity of 99.2% and a predictive value of 99.5%, with no false negatives in the severe dysplasia and cancer groups. Quantitative data allows the threshold value to be altered to vary the sensitivity and specificity according to prevailing requirements. This suggests the possibility of using quantitative acid-labile DNA measurements to improve existing screening for cervical precancer.

Outcome of pregnancy in underweight women after spontaneous and induced ovulation

Low maternal weight before pregnancy and poor weight gain during pregnancy are known to result in an increased prevalence of low birthweight infants. Low body weight is also an important cause of amenorrhoea. The hypothesis that amenorrhoeic underweight women who become pregnant after induction of ovulation are more at risk of delivering low birthweight infants than underweight women who ovulate spontaneously was investigated. Forty one pregnant women in whom ovulation had been induced and 1212 in whom ovulation was spontaneous were studied. Women ovulating spontaneously whose weight was normal and who showed good weight gain during pregnancy (greater than 450 g a week) had the lowest incidence (6%) of babies who were small for gestational age. Underweight women (body mass index less than 19.1) who ovulated spontaneously had a threefold increased risk of delivering babies who were small for gestational age (18%). Overall, the women in whom ovulation had been induced had an even higher risk of babies who were small for dates (25%), and the risk was greatest (54%) in those who were underweight. The outcome of pregnancy is related to weight before conception, which in many cases reflects nutritional state; lack of spontaneous ovulation indicates an increased risk of producing a small for dates infant. The most suitable treatment for infertility secondary to weight related amenorrhoea is therefore dietary rather than induction of ovulation.

Quantitative assessment of cervical neoplasia by hydrolysed DNA assay

A hydrolysed component of DNA was measured in cervical smears from 187 women. The results clearly distinguished patients with cervical intraepithelial neoplasia and invasive carcinoma from a control group. This method could be automated.

The natural history of cervical intraepithelial neoplasia as determined by cytology and colposcopic biopsy

The smears preceding the histologic diagnosis of cervical intraepithelial neoplasia (CIN 3) were examined in 100 consecutive cases from an intensively screened population. In 60 patients, negative cytology has been recorded prior to the development of dysplasia; in 27 this had occurred within two years of the histologic diagnosis. These findings suggest that the transition time from epithelial normality to CIN 3 may be shorter than has been generally assumed; therefore, the intensity and frequency of screening should be reviewed.

Value of bromocriptine in unexplained primary infertility: a double-blind controlled trial

In a double-blind controlled study, 47 women with unexplained primary infertility were allocated at random to treatment with either bromocriptine 2.5 mg twice daily (24 patients) or placebo (23). Both groups showed a fall in serum prolactin concentrations but the reduction was much greater in the bromocriptine-treated group. Neither group showed a change in serum oestrogen or progesterone concentrations. Bromocriptine significantly reduced the duration of the follicular phase of the menstrual cycle but had no effect on the luteal phase. Five women conceived during treatment with placebo and seven during treatment with bromocriptine, but analysis of the cumulative conception rates showed no significant difference between the groups. The women who conceived were significantly younger and had a significantly shorter history of infertility than the women who did not conceive, but subtracting the number of years of infertility from age eliminated this difference. The results show that bromocriptine in the dose and duration of administration used in the trial is of no value in unexplained primary infertility.

Management of hyperprolactinaemic amenorrhoea

Results of treatment of 52 patients with amenorrhoea associated with hyperprolactinaemia are presented. All patients had a detailed radiological examination of the pituitary fossa, including lateral tomography in every patient and air encephalography in those in whom a pituitary tumour was suspected. There were 17 patients with untreated pituitary tumours, 5 patients with previously treated pituitary tumours and persisting hyperprolactinaemia, and 30 patients with normal pituitary radiology. Patients with pituitary tumours were treated either by transsphenoidal or transfrontal surgical extirpation of the tumour, followed, if necessary, by external irradiation and/or bromocriptine, Four patients were treated with external irradiation as primary therapy, and three patients who did not wish to conceive were treated with bromocriptine as primary therapy. Patients with normal radiological appearances were treated with bromocriptine as primary treatment. Ovulatory menstrual cycles developed in 42 patients and there were 19 pregnancies. Those ovulating but not conceiving had adequate nonendocrine factors to account for the disparity. Failure of response was seen in 10 patients and was due to inadequate fall of prolactin in response to surgery (2 patients), external irradiation (3 patients) and bromocriptine (1 patient), and gonadotrophin deficiency which developed after surgery in 3 patients but was present pre-operatively in 1. The relative merits of treatment by surgery, external irradiation and bromocriptine are discussed and a policy of treatment outlined.

Clinical and endocrine features of hyperprolactinaemic amenorrhoea

The clinical, radiological and endocrine findings in thirty-five women with hyperprolactinaemia and amenorrhoea are described. Twelve patients had radiological evidence of a pituitary tumour and six were tested after pituitary ablation. Seventeen patients with hyperprolactinaemia and normal pituitary X-rays were also studied. None was on any drug known to increase prolactin secretion and all patients were euthyroid when tested. Basal serum prolactin concentrations were high in the group with untreated pituitary tumours and in those with normal X-rays. The levels were variable in the post-ablation cases. The increase of prolactin after TRH was subnormal in all of the groups. Serum oestradiol concentrations were low in most patients and nineteen of twenty-one patients tested had no withdrawal bleeding after treatment with a progestogen. Mean serum gonadotrophin concentrations (basal and after LHRH) were normal in twenty-nine patients but subnormal in four post-ablative cases. Anovulatory responses to clomiphene were obtained in nineteen of twenty patients tested. Fifteen patients were treated with bromocriptine; twelve ovulated and eight became pregnant; two not responding had impaired LH and FSH production. Hyperprolactinaemic amenorrhoea is a common disorder with characteristic endocrine features. Galactorrhoea is unusual (30%). Treatment with bromocriptine lowers prolactin concentrations and rapidly repairs the reproductive defect.

Incidence and significance of hyperprolactinaemia in women with amenorrhea

Serum prolactin and gonadotrophin concentrations were measured by radioimmunoassay in 106 women with amenorrhoea. Prolactin was normal in those with weight related disorders, primary ovarian failure, those with a variety of systemic diseases and in those in whom amenorrhoea followed treatment with the oral contraceptive and in unexplained primary amenorrhoea. Gonadotrophin concentrations in the above patients were normal except in those with primary ovarian failure. Prolactin was elevated in eight of forty patients (20%) with functional secondary amenorrhoea and was greatly raised in all but one of the thirteen women in this series with pituitary tumours (five of whom were studied only after treatment). Only three patients in each of the last two groups had galactorrhoea. Gonadotrophin levels were normal or slightly raised in all of the hyperprolactinaemic patients apart from those studied after hypophysectomy. Four hyperprolactinaemic patients (three with pituitary tumours and one with functional amenorrhoea) who did not have galactorrhoea have been treated with bromocriptine. Prolactin secretion was reduced in all patients and, in the two with normal gonadotrophins, ovulatory menstruation was resumed. One became pregnant in the second ovulation cycle after starting treatment. We conclude that, despite the rarity of galactorrhoea, hyperprolactinaemia is common in patients with functional amenorrhoea and in those with pituitary tumours. Treatment with bromocriptine in patients with normal gonadotrophins restores ovulation when the infertility is due to prolactin excess.

Very early termination of pregnancy (menstrual extraction)

Very early termination of pregnancy was performed on 424 women in three London teaching hospitals. Altogether 90% of the women were no more than 14 days overdue, and 67% of these had histological evidence of pregnancy. The procedure differed little in technique or its acceptability to the patient from termination done later in the first trimester. The similar incidence of complications suggested that it is not an alternative to conventional contraception. The response of patients, general practitioners, and referral agencies, however, indicated that there is a definite need in the community for a very early termination service.

Amenorrhoea after discontinuing combined oestrogen-progestogen oral contraceptives

Out of 210 women seen at the Middlesex Hospital with secondary amenorrhoea the 63 who developed it after stopping oral contraceptives were fully investigated. Five had organic disease sufficient to account for the amenorrhoea (one had severe diabetes, one a pituitary tumour, and three premature ovarian failure); two patients had galactorrhoea (one of whom also had the pituitary tumour); two had anorexia nervosa.Of the 63 women 40 (63%) had suffered from amenorrhoea or prolonged or irregular menstrual cycles before taking the pill, and this suggested that combined oestrogen-progestogen oral contraceptives should be used with caution for women with irregular menstruation.Nineteen patients wished to become pregnant and 12 have so far done so after treatment with clomiphene or gonadotrophins.In another study 204 women recorded when their first menstrual cycle occurred after stopping the pill. Seventy-four had a cycle longer than five weeks but only five exceeded three months, and only one of the five had more than six months' amenorrhoea. These results confirm that the incidence of amenorrhoea after stopping oral contraceptives is low.

Localization of ethynyloestradiol in the reproductive tract of women

[4-14C]Ethynyloestradiol was administered to women at varying times before hysterectomy. At operation, samples of blood, adipose tissue and tissue from the reproductive tract were obtained. All tissues examined took up radioactivity, the concentration at 1 h varying from 0·22 to 0·4% of the dose per 100 g of tissue except for stroma and endometrium which showed high levels (0·68% and 0·60%, respectively). By 24 h the amount of radioactivity in the tissues had decreased markedly. Mean values for the amount of radioactivity present in total tissues at 1 h were: uterus, 0·9%; adipose tissue, 28·2%; blood, 8·8%. By 24 h these values had declined to 0·2%, 6·8% and 1·6%, respectively. In adipose tissue almost all the radioactivity was present in a freely extractable state whereas in myometrium and cervix about 20% of the radioactivity was in a conjugated form. In plasma, more than 80% of the metabolites were conjugated, mainly as sulphates. The major metabolite detected in the uterus was ethynyloestradiol itself and most of the radioactivity in the myometrium was associated with the nuclear fraction. In one pregnant subject studied, radioactivity crossed the placenta and small amounts of the dose were found in the foetus.

Metabolism of ethynyloestradiol in man

The metabolism of 17α-ethynyloestradiol was studied in one man and 16 women. After intravenous or oral administration, 22·6–46·9% of the dose was excreted in the urine over a 5-day period. Up to 36% of the urinary radioactivity may be present in the unconjugated form with a further 64% being extractable after enzymic hydrolysis. Sulphate conjugates formed only 11·4% of the urinary radioactivity. Semi-quantitation of these extracts showed ethynyloestradiol itself to be the major metabolite, accounting for 3·2–8·4% of the administered dose in the unconjugated fraction with a further 2·4–16·5% in the enzyme hydrolysed fraction. Up to 16·5% of the dose was therefore excreted unchanged, and metabolites less and more polar than ethynyloestradiol were also found. Excretion via the faeces accounted for up to 30% of the administered dose, with most of the extractable radioactivity being in the unconjugated form. Ethynyloestradiol accounted for up to 29·6% of faecal radioactivity. No significant amounts of radioactivity were detected in sweat collected from one subject 2 or 24 h after administration of the dose. Plasma levels of 3·32% and 1·72% of the administered dose per litre were found 1 and 24 h after administration. Metabolites in plasma were present mainly as sulphate conjugates.