Effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate on endometrial bleeding

OBJECTIVE

To evaluate vaginal bleeding profiles with lower doses of conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA) as continuous combined therapy.

DESIGN

The Women's Health, Osteoporosis, Progestin, Estrogen (Women's HOPE) study, a randomized, double-blind, placebo-controlled trial.

SETTING

Study centers across the United States.

PATIENT(S)

Two thousand six hundred seventy-three healthy, postmenopausal women.

INTERVENTION(S)

Women received CEE, 0.625 mg/d; CEE, 0.625 mg/d, plus MPA 2.5 mg/d; CEE, 0.45 mg/d; CEE, 0.45 mg/d, plus MPA, 2.5 mg/d; CEE 0.45 mg/d, plus MPA, 1.5 mg/d; CEE, 0.3 mg/d; CEE, 0.3 mg/d, plus MPA, 1.5 mg/d; or placebo for 1 year.

MAIN OUTCOME MEASURE(S)

Bleeding data were analyzed in efficacy-evaluable and intention-to-treat populations.

RESULT(S)

Cumulative amenorrhea and no bleeding rates were higher with lower doses of CEE/MPA than with CEE 0.625/MPA 2.5. A linear trend between time since menopause and cumulative amenorrhea was observed (P<.05) in all CEE/MPA groups except the CEE 0.45/MPA 1.5 group. The proportion of patients who experienced no bleeding in cycle 1 was 89%, 82%, and 80% in the CEE 0.3/MPA 1.5, CEE 0.45/MPA 1.5, and CEE 0.45/MPA 2.5 groups, respectively. These values were significantly greater than the incidence of no bleeding in the CEE 0.625/MPA 2.5 group (P<.05).

CONCLUSION(S)

Lower-dose regimens of CEE and MPA produce higher rates of amenorrhea and no bleeding compared with CEE 0.625/MPA 2.5 and may be appropriate for newly menopausal patients.

Polycystic ovary syndrome. A diagnostic challenge

Polycystic ovary syndrome remains a diagnostic challenge because there is no single defining test. The clinical presentation must dictate the extent of the work-up. The typical PCOS patient has a history of irregular menses and appears hirsute. Demonstration of ovulatory dysfunction and hyperandrogenism can also be made by appropriate hormonal measurements. An ultrasound showing multiple small ovarian follicles can support a diagnosis of PCOS in the patient for whom the clinical diagnosis has been made. Other causes of hyperandrogenism and ovulatory dysfunction should be excluded.

Voice processing abilities in children with autism, children with specific language impairments, and young typically developing children

It is well established that people with autism have impaired face processing, but much less is known about voice processing in autism. Four experiments were therefore carried out to assess (1) familiar voice-face and sound-object matching; (2) familiar voice recognition; (3) unfamiliar voice discrimination; and (4) vocal affect naming and vocal-facial affect matching. In Experiments 1 and 2 language-matched children with specific language impairment (SLI) were the controls. In Experiments 3 and 4 language-matched children with SLI and young mainstream children were the controls. The results were unexpected: the children with autism were not impaired relative to controls on Experiments 1, 2 and 3, and were superior to the children with SLI on both parts of Experiment 4, although impaired on affect matching relative to the mainstream children. These results are interpreted in terms of an unexpected impairment of voice processing in the children with SLI associated partly, but not wholly, with an impairment of cross-modal processing. Performance on the experimental tasks was not associated with verbal or nonverbal ability in either of the clinical groups. The implications of these findings for understanding autism and SLI are discussed.

Relationships between symbolic play, functional play, verbal and non-verbal ability in young children

It is well established that certain aspects of play in young children are related to their emerging linguistic skills. The present study examined the relationships between functional play, symbolic play, non-verbal ability, and expressive and receptive language in normally developing children aged between 1 and 6 years using standardized assessment procedures, including a recently developed Test of Pretend Play (ToPP). When effects of chronological age were partialled out, symbolic play remained significantly correlated with both expressive and receptive language, but not with functional play or non-verbal ability; and functional play was only correlated significantly with expressive language. It is concluded that ToPP will provide practitioners with a useful way of assessing symbolic ability in children between the ages of 1 and 6 years, and will contribute to the assessment and diagnosis of a number of communication difficulties, and have implications for intervention.

Self-deprecation and estimates of body size in women

The subject of body image in women has received considerable attention particularly with concern about its relationship to behaviours such as dieting. This study investigated the reported tendency of women to see thinness as desirable and to perceive themselves as fatter than others do. This tendency is inconsistent with the general findings on self-enhancement that show that people (including women) generally overestimate the extent to which they possess desirable characteristics. Thus, the purpose of this study was to investigate whether the tendency for women to report themselves as fatter than others perceive them is part of a general tendency to deprecate themselves on socially desirable qualities or whether this deprecation is restricted to body size. To investigate this, 29 female undergraduates in psychology participated in a study comparing own and others' perceptions of body size, attractiveness, sexiness, intelligence, and friendliness. Compared with the ratings of them given by others, women tended to make self-enhancing judgements of their attractiveness, sexiness, intelligence, and friendliness. This was not found for body size, however, for which self-ratings tended to be the same as those made by others. The failure to find self-enhancing judgements of body size is discussed in terms of the relatively unvarying standards presented to women concerning ideal body size compared to the more subjective standards used to evaluate other qualities.

Protein status of infants with phenylketonuria undergoing nutrition management

OBJECTIVES

The objectives of this study were to determine if Phenex-1, amino-acid modified medical food with iron maintained normal indices of protein status in infants with phenylketonuria (PKU) and to investigate factors that influence plasma amino acid concentrations.

METHODS

A study was conducted for six months in 35 infants with classical PKU diagnosed in the neonatal period. Diet diaries and plasma amino acid concentrations were obtained monthly. Blood for analysis of plasma albumin, blood urea nitrogen (BUN), retinol binding protein (RBP) and transthyretin was obtained at one, three and six months of study.

RESULTS

Mean (+/-SEM) total daily intake of medical food and nutrients was 79+/-4 g; 17.3+/-0.6 g protein, 660+/-18 kcal, 255+/-10 mg phenylalanine (Phe), and 1423+/-56 mg tyrosine (Tyr). Mean concentrations of plasma amino acids, except cystine (during entire study), glycine (first month) and Phe were in the normal range. Mean concentrations of plasma Phe were in the treatment range (120 to 360 micromol/L). Plasma concentrations of arginine, methionine, Phe, tryptophan, Tyr, and valine were positively correlated with intakes at various months of study. Concentrations of aspartic and glutamic acids, Phe, and Tyr were positively correlated and 17 amino acids were negatively correlated with the interval between feeding and blood draw. At six months of study, concentration of plasma albumin was 4.1+/-0.1 g/dL, RBP was 3.74+/-0.2 mg/dL, transthyretin was 17.9+/-0.9 mg/dL, and urea nitrogen was 11.9+/-0.5 mg/dL.

CONCLUSION

During study, all mean plasma indices of protein status were in normal reference ranges. Phenex-1 supports normal mean plasma amino acid, albumin, RBP, transthyretin, and BUN concentrations when fed in adequate amounts.

Survey of genetic screening for oocyte donors

OBJECTIVE

To describe current screening practices of oocyte donation programs in the Society for Assisted Reproductive Technologies (SART).

DESIGN

Descriptive data from a mailed questionnaire.

SETTING

Academic medical center.

PARTICIPANT(S)

In vitro fertilization programs in SART.

INTERVENTION(S)

Survey mailed to IVF programs in the SART registry.

MAIN OUTCOME MEASURE(S)

Current practices, opinions, and genetic criteria for oocyte donor selection.

RESULT(S)

Results from 159 of 229 (69%) eligible oocyte donation programs are described. Most centers (70%) completed fewer than 25 cycles and used both anonymous and directed donors. There was considerable variability in limits on numbers of cycles or births allowed per donor, with many centers having no limits. As well, the use of well-established screening tests for genetic disorders, such as sickle cell anemia and cystic fibrosis, varied considerably. Consultation with a geneticist was possible at most (89%) centers and specifically mentioned by some centers as a means to help make decisions.

CONCLUSION(S)

Most programs follow recommendations made by the American Society of Reproductive Medicine (ASRM) for screening of gamete donors, but a significant percentage does not use well-established testing. The widespread availability of genetic consultation should promote responsible screening practices.

The transition to managed care: experiences of planned parenthood patients

A review of the findings from a 1996 survey of women visiting a Planned Parenthood clinic reveals that some members of managed care organizations (MCOs) may not be receiving appropriate preventive services and information from their primary care providers. This article details the results of a survey of 115 women who attended a Planned Parenthood of New York City clinic for reproductive health services. Based on these survey findings, the authors provide recommendations for MCOs and traditional providers of reproductive health to improve service delivery.

Nutrient intake and growth of infants with phenylketonuria undergoing therapy

BACKGROUND

Because of reports of poor growth, a study was conducted for 6 months in 35 infants with classic phenylketonuria diagnosed during the neonatal period who were fed Phenex-1 Amino Acid Modified Medical Food With Iron (Ross Products Division, Columbus, OH, U.S.A.).as their primary protein source.

METHODS

Diet diaries and anthropometric measures were obtained monthly as part of a larger study in which nutrition status was evaluated.

RESULTS

In 6-month-old infants, mean percentiles for crown-heel length (59.14+/-4.31 SEM), head circumference (63.88+/-4.50) and weight (71.51+/-4.25) were normal. Mean (+/- SEM) daily intake of medical food was 79+/-4 g; protein and energy intakes were 17.3+/-0.6 g and 2772+/-75.6 kJ (660+/-18 kcal). Mean daily phenylalanine and tyrosine intakes per kilogram of body weight were 40+/-1 mg and 219+/-9 mg. Intakes of protein, energy, and tyrosine were positively correlated with crown-heel length, head circumference, and weight at 3 months of study. Overall plasma phenylalanine and tyrosine concentrations during the 6-month study were 297+/-41 micromol/l and 58+/-5 micromol/l, respectively. Neither plasma phenylalanine nor tyrosine concentration was correlated with growth.

CONCLUSION

Phenex-1 supports normal growth when fed in adequate amounts. These data support those of the Medical Research Council Working Party on Phenylketonuria for 3 g/kg per day of amino acids from medical food.

The evolving role of submucosal injectables for treating internal sphincteric deficiency

Each of the previously mentioned materials can be used in procedures performed on an outpatient basis using sedation and local anesthesia. Teflon usually requires general anesthesia. None of these materials, however, should be used in acute conditions involving cystitis, urolithiasis, or infection. Table 4 summarizes the postoperative care after a bulking agent injection. There are obvious advantages to using injectable materials for ISD, one of which is that the outpatient procedure is usually done under local anesthesia. It does not have the risks inherent in open surgical procedures like slings or artificial sphincters, and it causes minimal increase of urethral resistance to detrusor-generated micturition force. Such procedures are obviously easier and faster to perform with less cost and rapid recovery followed by a return to regular activity within 48 hours. In conclusion, injection therapy for urinary incontinence is appropriate, but the most effective substance has probably not yet been determined.

Familiar face and voice matching and recognition in children with autism

Relatively able children with autism were compared with age- and language-matched controls on assessments of (1) familiar voice-face identity matching, (2) familiar face recognition, and (3) familiar voice recognition. The faces and voices of individuals at the children's schools were used as stimuli. The experimental group were impaired relative to the controls on all three tasks. Face recognition and voice recognition correlated significantly with voice-face identity matching, but not with each other, suggesting that the recognition impairments jointly cause the matching impairment. Neither chronological age nor verbal mental age were consistently related to the recognition and matching impairments.

Can young people with autism refer to knowledge states? Evidence from their understanding of "know" and "guess"

A number of studies have reported that most individuals with autism have difficulty in attributing mental states. The primary aim of the present study was to compare the ability of children with autism to refer to knowledge states with that of mainstream school children and children with Down's syndrome. The second aim was to investigate the role of verbal mental age in referring to knowledge states. The third aim was to compare the ease with which the children referred to their own mental state and to that of others. The results suggest that some individuals with autism are able to attribute knowledge to themselves and others but that they need to have higher verbal skills than is necessary in normal individuals. The level of language skill predicted the performance of the individuals with autism, but not that of the children in the other groups. There was no good evidence that referring to one's own mental states was easier than referring to another person's, a finding which supports representational theory rather than the simulationist position.

Time course of spontaneous in vitro sperm acrosome reaction

The acrosome reaction (AR) is an exocytotic process essential for sperm penetration of the zona pellucida and binding to the oocyte (DeJonge, 1994). Evaluation of in vitro AR can suggest fertility potential. The purpose of this study was to determine AR as a function of time after removal of sperm from the seminal fluid using a novel test, the Acrobeads test (Fertility Technologies, Natick, Massachusetts), which uses paramagnetic beads coated with MH61, a monoclonal antibody that binds to acrosome-reacted sperm. Specimens were acquired from known fertile donors (n = 9) and in vitro fertilization (IVF) patients (n = 8) with no apparent male factor on the day of the IVF and processed by a minipercoll wash at 30 minutes after ejaculation. An aliquot of washed sperm was then divided into two portions. The first was placed with the Acrobeads (according to the manufacturer's instructions) and assessed for bead binding after 6 and 24 hours with the beads. The second aliquot of washed sperm was held at room temperature for 24 hours, then exposed to the beads, with bead binding assessed at 6 and 24 hours later (30 and 48 hours after washing). The Acrobeads score was determined by assessing the binding of MH61 beads in each of four replicates with a resulting score of 1 (lowest) to 4 (highest). The mean (+/-SD) motility was 62.0% (7.5) at 6 hours, 52.3% (6.4) at 24 hours, 55.9% (10.4) at 30 hours, and 54.7% (8.4) at 48 hours after removal from the seminal fluid. At 6 hours after washing and exposure to the beads, the score was 0.077 (0.27) with a range of 0-1; one donor specimen gave a score of 1, while all others had a score of 0. At 24 hours postremoval from the semen, donor and patient sperm were positive for the test, with a mean score of 3.6 (0.65). The mean fertilization rate for the IVF patients was 64.4% (range 33-90). When sperm were held for 24 hours prior to the test, there was little or no bead binding 6 hours later (score of 0.46 +/- 0.77) and at 24 hours later (48 hours after washing) (mean score of 0.25 +/- 0.45). These data suggest that completion of the acrosome reaction occurs by 24 hours after removal of the sperm from the seminal fluid. Since the MH61 beads bind to specific residues on the inner acrosomal membrane, these data also suggest that following the acrosome reaction at 24 hours with removal of the outer acrosomal contents and acrosomal matrix, the inner acrosomal membrane may be modified in some way that does not allow MH61 beads to bind to the sperm.

Influenza among hospitalized adults with leukemia

Influenza is one of the most important respiratory diseases of mankind, yet scant data exist concerning the frequency and clinical course of influenza in severely immunocompromised adults. From October 1993 to September 1994, we cultured the respiratory secretions of all adults with leukemia who were hospitalized with an acute respiratory illness at The University of Texas M.D. Anderson Cancer Center in Houston. During a 9-week period from 29 November 1993 to 29 January 1994, influenza virus type A (H3N2) was isolated from 15 (33%) of these 45 hospitalized adults. Twelve (80%) of the cases of influenza were associated with pneumonia, and four patients (33%) with pneumonia died. Patients who died tended to have received chemotherapy more recently and to be more myelosuppressed. Autopsy examination in two cases revealed histopathologic changes consistent with viral pneumonia. During community outbreaks, influenza is a frequent cause of serious respiratory disease in hospitalized adults with leukemia. Effective prophylactic and therapeutic regimens need to be defined for immunocompromised patients.

Effect of transvaginal stimulation in the treatment of detrusor instability

INTRODUCTION

Early research on implantable electrodes for transvaginal stimulation had high rates of complications and mechanical failures. Today's nonimplantable devices are safe for short-term or long-term use. This study evaluated an intermittent short-term transvaginal stimulation program for treatment of bladder overactivity.

METHODS

Fifteen women who ranged in age from 22 to 96 years and had bladder instability were enrolled into this noncontrolled, open, clinical evaluation program. Six to 10 biweekly office sessions were followed by use of a home unit twice daily for approximately 6 weeks.

RESULTS

Results were based on patients' voiding diaries. All 15 completed the study, and 73% were satisfied with the results. On pretrial urodynamic examination nine patients had sensory urgency, and six patients had involuntary contractions. All tolerated therapy without side effects. Two women had slight vaginal discomfort because of vaginal narrowing. Urinary frequency, urgency, and nocturia were significantly decreased. Seven women reported 75% or more improvement; four women reported 50% to 75% improvement. Three women required a second office treatment series.

DISCUSSION

The results of this study support findings of previous researchers, although the follow-up time frame of the study was short. Most of these patients (N = 11 of 15) wished to continue transvaginal stimulation. When three women discontinued home treatments, symptoms recurred in 1 to 3 months. The exact cause is unclear, but scar tissue as a result of previous pelvic operations may have contributed to the problem. The second course of treatment had positive results. Intermittent therapy in these cases is recommended. Transvaginal stimulation should be considered for treatment for urinary incontinence because the device is easily used and adjusted by the patient, patients may be very compliant, and results are satisfactory and at least similar to those attained with drug therapy.

Management of an outbreak of tuberculosis in a small community

OBJECTIVE

To investigate an outbreak of tuberculosis, determine the number of active cases and infections, and examine efforts to control the spread of disease.

SETTING

A small town in Maine, in which no cases of tuberculosis had been reported in the previous 3 years.

DESIGN

Epidemiologic investigation of an outbreak of tuberculosis infection and disease.

MEASUREMENTS

A patient with an active case of tuberculosis was defined as a resident of the town or the surrounding area or an employee of the local shipyard who had a culture of sputum or tissue that was positive for Mycobacterium tuberculosis between June 1989 and May 1992. A case of tuberculous infection was defined as a positive tuberculin skin test result in a person with no previous positive test result.

RESULTS

21 active cases of tuberculosis occurred among shipyard workers and persons residing in the affected community between 1989 and 1992. One patient was the source of the outbreak; 8 months lapsed between the onset of this patient's illness and appropriate diagnosis and treatment. The M. tuberculosis strains isolated from this patient and from six other patients belonged to phage type I, auxiliary 14. All isolates were susceptible to drug treatment. Of 9898 persons who were tested, 697 (7%) were newly infected. Because isoniazid prophylaxis was not routinely offered to infected persons older than 35 years of age, only 341 (49%) infected persons completed isoniazid prophylaxis.

CONCLUSIONS

Many secondary cases of tuberculosis occurred throughout this small Maine community because of delayed diagnosis and treatment of the source patient, delayed outbreak investigation, and failure to promote isoniazid prophylaxis to all persons infected during the outbreak. Aggressive efforts to identify persons with new infection are of limited value in controlling tuberculosis unless they are accompanied by an equally aggressive use of isoniazid prophylaxis.

A prospective comparison of Synthetic Serum Substitute and human serum albumin in culture for in vitro fertilization-embryo transfer

OBJECTIVE

To compare the efficacy of a globulin-containing protein source, Synthetic Serum Substitute (Irvine Scientific, Santa Ana, CA) and human serum albumin (HSA) in the early culture of human oocytes and embryos.

DESIGN

Oocytes from 31 consecutive IVF cycles were assigned alternately to dishes containing human tubal fluid (HTF) and either Synthetic Serum Substitute or HSA as the protein source. Each semen sample was split for processing in Synthetic Serum Substitute or HSA. Sperm processed in Synthetic Serum Substitute was added to oocytes cultured in Synthetic Serum Substitute, and sperm processed in HSA was added to oocytes cultured in HSA. After determination of fertilization, zygotes were placed in HTF containing the same protein supplement. Before transfer, the embryos were graded morphologically.

MAIN OUTCOME MEASURES

Occurrence of normal fertilization and embryo quality as assessed by morphological grading.

RESULTS

There was no significant difference in the occurrence of fertilization or in embryo morphological quality between oocytes cultured in Synthetic Serum Substitute as compared with HSA.

CONCLUSIONS

The use of a globulin-containing protein source in culture for IVF-ET did not improve the fertilization rate or embryo quality. Our design did not allow for demonstration of an effect on pregnancy rate.