Evaluation and management of abnormal uterine bleeding

Abnormal uterine bleeding (AUB) is one of the commonest complaints of women in reproductive age and non-gravid state that brings them to the attention of the primary care doctor or the gynaecologist. Anovulation without any medical illness or pelvic pathology seems to be the common cause. Bleeding due to a wide variation in pathology both inside and outside the reproductive tract can be termed as anovulatory bleeding. Therefore, it is mandatory to elicit a focused menstrual history and appropriate evaluation followed by a pelvic examination. This includes a vaginal speculum examination to differentiate anovulatory bleeding from other causes of bleeding. In contrast, Heavy menstrual bleeding (HMB) is referred to as an ovulatory bleeding exceeding 8 days duration and is often caused by uterine fibroids or adenomyosis, a copper IUD or coagulation disorders. PALM-COEIN classification is a system designed by the Federation Internationale de Gynaecologie et d'Obstetrique to define the precise underlying causes of AUB. Aetiology of AUB can be classified as the following acronym "PALM-COEIN": Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic and Not yet classified. AUB describes a range of symptoms, such as HMB, intermenstrual bleeding (IMB) and a combination of both heavy and prolonged menstrual bleeding (MB). Dysfunctional uterine bleeding (DUB) and menorrhagia are now better described as AUB. Newborn girls sometimes spot for a few days after birth, due to placental oestrogenic stimulation of the endometrium in utero.

Reconsideration of planned vaginal breech delivery in selected cases

INTRODUCTION

The debate surrounding the management of term breech presentation (BP) has resulted in the presence of a multitude of guidelines, reviews, and directives. The vaginal delivery of a breech baby requires sound obstetric skills since approximately 3-4% of babies at term are breech presentations. BP is the commonest of all malpresentations. However, expertise required to deliver breech babies vaginally has virtually disappeared. There is no convincing evidence that Caesarean Section (CS) is better than assisted vaginal delivery when conducted in appropriate settings, with experienced obstetricians and strict prevailing protocols. Unfortunately, planned vaginal breech delivery (VBD) is becoming an uncommon event. This has led to fewer opportunities for obstetric residents to master the skills of vaginal birth of breech presentations.

MATERIALS AND METHODS

The BP has always been a challenge for obstetricians, due to special skills required to deliver the breech safely. In addition, the immediate perinatal outcome, in terms of APGAR scores and acid-base status of the breech babies is of great concern. Thus, in 2000, in order to provide more evidence-based data, the Term Breech Trial (TBT) was published which compared the outcome of VBD with planned CS. In their 2003 Clinical Guideline, the National Institute for Health and Clinical Excellence (NICE) recommended external cephalic version (ECV) for breech presentation at 36 weeks of gestation a ns elective CS if the procedure is declined or failed. The first edition, Green-top Guidelines by the Royal College of Obstetricians and Gynaecologists (RCOG) regarding the breech delivery was first published in 1999 and revised in 2001, 2006 (Nos. 20a and 20b) and March 2017. In 2020, the Guideline Committee meeting decided on a further revision and deferred the decision for further 3 years (2023). The aim of this Guideline is to aid decision making regarding the route of delivery and choice of various techniques used during delivery. In March 2005, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) issued a formal statement concerning breech delivery at term. Through their Committee on Obstetric Practice, the American College of Obstetricians and Gynecologists (ACOG) issued a Committee Opinion paper on "Mode of term singleton breech delivery" in 2006.

RESULTS

Almost immediately, the medical community all over the world embraced the conclusions of the trial highlighting the superiority of outcomes in planned CS compared to VBD in terms of maternal, neonatal mortality and morbidity. Clinicians, in consultation with their patients, must make the final decisions regarding mode of breech delivery in the light of the updated clinical guidelines and committee opinions for a rational choice for the mode of delivery.

CONCLUSION

There is a place for planned VBD, the prerequisites are: strict case selection, operator skills and vigilant intrapartum monitoring. Provision of basic skills training by utilizing birthing pelvic models and mannikins, hands-on practice of External Cephalic Version (ECV) in clinical settings, may result in larger reduction in the risk of CS.

Competition between translation initiation factor eIF5 and its mimic protein 5MP determines non-AUG initiation rate genome-wide

In the human genome, translation initiation from non-AUG codons plays an important role in various gene regulation programs. However, mechanisms regulating the non-AUG initiation rate remain poorly understood. Here, we show that the non-AUG initiation rate is nearly consistent under a fixed nucleotide context in various human and insect cells. Yet, it ranges from <1% to nearly 100% compared to AUG translation, depending on surrounding sequences, including Kozak, and possibly additional nucleotide contexts. Mechanistically, this range of non-AUG initiation is controlled in part, by the eIF5-mimic protein (5MP). 5MP represses non-AUG translation by competing with eIF5 for the Met-tRNAi-binding factor eIF2. Consistently, eIF5 increases, whereas 5MP decreases translation of NAT1/EIF4G2/DAP5, whose sole start codon is GUG. By modulating eIF5 and 5MP1 expression in combination with ribosome profiling we identified a handful of previously unknown non-AUG initiation sites, some of which serve as the exclusive start codons. If the initiation rate for these codons is low, then an AUG-initiated downstream ORF prevents the generation of shorter, AUG-initiated isoforms. We propose that the homeostasis of the non-AUG translatome is maintained through balanced expression of eIF5 and 5MP.

eIF1A residues implicated in cancer stabilize translation preinitiation complexes and favor suboptimal initiation sites in yeast

The translation pre-initiation complex (PIC) scans the mRNA for an AUG codon in favorable context, and AUG recognition stabilizes a closed PIC conformation. The unstructured N-terminal tail (NTT) of yeast eIF1A deploys five basic residues to contact tRNA_i, mRNA, or 18S rRNA exclusively in the closed state. Interestingly, EIF1AX mutations altering the human eIF1A NTT are associated with uveal melanoma (UM). We found that substituting all five basic residues, and seven UM-associated substitutions, in yeast eIF1A suppresses initiation at near-cognate UUG codons and AUGs in poor context. Ribosome profiling of NTT substitution R13P reveals heightened discrimination against unfavorable AUG context genome-wide. Both R13P and K16D substitutions destabilize the closed complex at UUG codons in reconstituted PICs. Thus, electrostatic interactions involving the eIF1A NTT stabilize the closed conformation and promote utilization of suboptimal start codons. We predict UM-associated mutations alter human gene expression by increasing discrimination against poor initiation sites.

Conformational changes in the P site and mRNA entry channel evoked by AUG recognition in yeast translation preinitiation complexes

The translation preinitiation complex (PIC) is thought to assume an open conformation when scanning the mRNA leader, with AUG recognition evoking a closed conformation and more stable P site interaction of Met-tRNA_i; however, physical evidence is lacking that AUG recognition constrains interaction of mRNA with the 40S binding cleft. We compared patterns of hydroxyl radical cleavage of rRNA by Fe(II)-BABE tethered to unique sites in eIF1A in yeast PICs reconstituted with mRNA harboring an AUG or near-cognate (AUC) start codon. rRNA residues in the P site display reduced cleavage in AUG versus AUC PICs; and enhanced cleavage in the AUC complexes was diminished by mutations of scanning enhancer elements of eIF1A that increase near-cognate recognition in vivo. This suggests that accessibility of these rRNA residues is reduced by accommodation of Met-tRNA_i in the P site (P_IN state) and by their interactions with the anticodon stem of Met-tRNA_i. Our cleavage data also provide evidence that AUG recognition evokes dissociation of eIF1 from its 40S binding site, ejection of the eIF1A-CTT from the P-site and rearrangement to a closed conformation of the entry channel with reduced mobility of mRNA.

β-Hairpin loop of eukaryotic initiation factor 1 (eIF1) mediates 40 S ribosome binding to regulate initiator tRNA(Met) recruitment and accuracy of AUG selection in vivo

Recognition of the translation initiation codon is thought to require dissociation of eIF1 from the 40 S ribosomal subunit, enabling irreversible GTP hydrolysis (Pi release) by the eIF2·GTP·Met-tRNAi ternary complex (TC), rearrangement of the 40 S subunit to a closed conformation incompatible with scanning, and stable binding of Met-tRNAi to the P site. The crystal structure of a Tetrahymena 40 S·eIF1 complex revealed several basic amino acids in eIF1 contacting 18 S rRNA, and we tested the prediction that their counterparts in yeast eIF1 are required to prevent premature eIF1 dissociation from scanning ribosomes at non-AUG triplets. Supporting this idea, substituting Lys-60 in helix α1, or either Lys-37 or Arg-33 in β-hairpin loop-1, impairs binding of yeast eIF1 to 40 S·eIF1A complexes in vitro, and it confers increased initiation at UUG codons (Sui(-) phenotype) or lethality, in a manner suppressed by overexpressing the mutant proteins or by an eIF1A mutation (17-21) known to impede eIF1 dissociation in vitro. The eIF1 Sui(-) mutations also derepress translation of GCN4 mRNA, indicating impaired ternary complex loading, and this Gcd(-) phenotype is likewise suppressed by eIF1 overexpression or the 17-21 mutation. These findings indicate that direct contacts of eIF1 with 18 S rRNA seen in the Tetrahymena 40 S·eIF1 complex are crucial in yeast to stabilize the open conformation of the 40 S subunit and are required for rapid TC loading and ribosomal scanning and to impede rearrangement to the closed complex at non-AUG codons. Finally, we implicate the unstructured N-terminal tail of eIF1 in blocking rearrangement to the closed conformation in the scanning preinitiation complex.

Unraveling Internal Structures of Highly Luminescent PbSe Nanocrystallites Using Variable-Energy Synchrotron Radiation Photoelectron Spectroscopy

The internal structure of PbSe nanocrystals was deduced using synchrotron X-ray photoemission spectroscopy for three different sizes of nanocrystals. The photoemission data revealed the layered structure of PbSe nanocrystals with the crystalline PbSe core surrounded by a nonstoichiometric Pb(1-x)Se shell, finally passivated by a capping agent in the outermost layer. A detailed analysis of the experimental data yielded quantitative information on the thickness of three different layers, which is unavailable through any other technique; moreover, the overall sizes of the nanocrystals probed by transmission electron microscopy were in agreement with the corresponding quantity obtained in the present experiment. The present results provide a plausible explanation for the strong variation in the photoluminescence intensity with size observed for these nanocrystals.

Optical and magnetic properties of manganese-doped zinc sulfide nanoclusters

We report the synthesis of fixed-size ZnS nanoclusters approximately 24 A in diameter with varying manganese concentrations. Various samples of Zn1-x MnxS, with x = 0, 0.02, 0.055, 0.09, and 0.13, have been prepared and characterized using X-ray diffraction, energy-dispersive analysis of X-rays, UV absorption, fluorescence emission and excitation, electron paramagnetic resonance (EPR), and magnetic susceptibility measurements. The manganese ions are found to substitute Zn randomly without giving rise to any clustering of Mn sites, as seen from EPR and magnetic susceptibility results. Our studies reveal that the band gap of the doped nanoclusters passes through a maximum as the manganese concentration is varied. Also, we observe orange emission from Mn2+ ions in the doped ZnS nanoclusters, apart from the blue emission characteristic of the ZnS defect states. The relative intensity of the orange emission compared with the blue varies with the manganese concentration in a nonmonotonic way. The inverse of susceptibility temperature plots can be plotted onto a universal curve by simple multiplicative constants, thus showing that the magnetic interactions between Mn2+ ions are weak.

Blue emission from cysteine ester passivated cadmium sulfide nanoclusters

A one-pot synthesis is reported of water-soluble cadmium sulfide nanoclusters capped with cysteine ester, with an average size of 2.0 nm and fluorescing in the blue region, establishing the possibility of using these as fluorescent biological probes.

Rural school nurses' asthma education needs

School nurses play an important role in identifying children with asthma and providing care during school hours. Educational programs designed to improve nurses' asthma knowledge and practices have concentrated on urban settings. The purpose of this investigation was to determine asthma-related practices and educational needs of rural school nurses. A survey about asthma was mailed to school nurses in all counties of the state of Maryland and in Washington, D.C. Responses were compared between rural Maryland counties and counties from the remainder of Maryland and Washington, D.C. The survey addressed attitudes and beliefs, function and roles, medication administration, and educational needs about asthma. We found that rural nurses used peak flow meters less often to assess and monitor asthma, requested fewer referrals for asthma, had fewer interactions with health room assistants, and had reduced access to asthma educational resources. Also, they provided less asthma education in the schools than other school nurses. These results suggest a need for comprehensive asthma educational programs in rural areas that are based on national guidelines, and that address the unique needs of rural school nurses. These programs should also emphasize the need for open communication between rural school nurses, health room assistants, primary care providers, and parents/caregivers.

The American College of Nurse-Midwives' Domestic Violence Education Project: evaluation and results

From October 1994 through September 1998, the American College of Nurse Midwives conducted a nationwide Domestic Violence Education Project. The project aimed to encourage universal screening for domestic violence among all women being seen for care. A four-pronged set of objectives was used, including policy, basic education, continuing education, and advocacy/activism. A description of the project and the results of the project evaluation, including replicable features, are presented. Process and outcome evaluations were performed using both quantitative and qualitative data. Surveys, interviews, and site visits formed the basis for the evaluation of the policy reform, education program, and advocacy components. Pretests and posttests of training participants formed the basis of the evaluation of the continuing education component. All project objectives were met. Policy reform occurred as expected. Changes were noted in education programs in both didactic content and clinical exposure. Changes in clinical behavior as assessed by the pretests and posttests look promising, although numbers of respondents at 12 and 24 months after training are small. Participants reported an increase in advocacy and activism. The Domestic Violence Education Project seems to be a successful and somewhat replicable model for changing attitudes about a health topic (among providers) with possible implications for clinical practice.

The effectiveness of the comprehensive coping strategy program on clinical outcomes in breast cancer autologous bone marrow transplantation

Patients with breast cancer who undergo autologous bone marrow/peripheral blood stem cell transplantation (ABMT) cope not only with a life-threatening medical treatment, but also with multiple, interrelated symptoms including pain, fatigue, psychological distress, and nausea. The purpose of this study was to determine, in a randomized controlled clinical trial, whether a comprehensive coping strategy program (CCSP) was effective in significantly reducing pain, fatigue, psychological distress, and nausea in patients with breast cancer who underwent ABMT. The CCSP was composed of preparatory information, cognitive restructuring, and relaxation with guided imagery. Randomization placed 52 patients in the CCSP treatment group and 58 patients in the control group. The CCSP was found to be effective in significantly reducing nausea as well as nausea combined with fatigue 7 days after the ABMT when the side effects of treatment were most severe. These results are important given the high incidence of nausea and fatigue in the ABMT population. The CCSP-treated group experienced mild anxiety as compared with the control group who reported moderate anxiety. The greatest effectiveness of CCSP may correspond to the time of the greatest morbidity for patients with breast cancer who have undergone ABM.

Effects of physical activity on preterm birth

The authors conducted a cohort study of low income women to determine the effect of physical activity on the risk of preterm birth. Women were sampled prenatally from four clinic sites and were scheduled for delivery at the University of Maryland Medical Systems (UMMS). Women who delivered infants at UMMS but who had received no prenatal care were also eligible. Preterm delivery was defined as a delivery prior to 37 completed weeks gestation. After adjusting for confounders, the odds of preterm delivery were increased for women who climbed stairs > or = 10 times per day (odds ratio (OR) = 1.60, 95% confidence interval 1.05-2.46) and for women who engaged in purposive walking > or = 4 days per week (OR = 2.10, 95% CI 1.38-3.20). Leisure-time exercise (> or = 60 days in the first and second trimesters combined) had a protective effect on preterm delivery (OR = 0.51, 95% CI 0.27-0.95). Television viewing had a U-shaped relation with preterm delivery (ORs (95% CI): < 15 hours, 2.09 (1.21-3.61); 29-42 hours, 1.50 (0.84-2.67); > 42 hours, 3.05 (1.75-5.40)). While the results support current recommendations regarding leisure-time activities, activities of daily living appear to increase risk of preterm delivery among low income women. These findings and those for television watching warrant further investigation.

Consumer experiences and provider perceptions of the quality of primary care: implications for managed care

BACKGROUND

The purpose of this study was to determine the extent to which consumer and provider reports of primary care differ according to particular characteristics of the primary care setting.

METHODS

A random sample of consumers was surveyed by telephone in a defined geographic area of Washington, DC, to determine their experiences with care provided to a randomly chosen child. The primary care provider of each respondent was sent a parallel survey. Scores were obtained for each of two subdomains in the four cardinal primary care domains (first contact, longitudinality, comprehensiveness, and coordination) and for three related domains (family centeredness, community orientation, and cultural competence). Differences between settings that did or did not impose limitations on autonomy for referrals and between fee-for-service and capitated settings were ascertained.

RESULTS

Both consumers and their providers in settings characterized by high degrees of limitation on physician autonomy or by capitation reported better first-contact accessibility and a greater range of services available than did consumers in settings with low degrees of limitation, or by fee-for-service reimbursements to physicians. Consumers but not providers reported better family centeredness in these settings. Most other differences favored these settings as well, but these were not consistently statistically significant for both providers and consumers in both types of settings.

CONCLUSIONS

The quality of primary care services in different settings can be ascertained by using an instrument with demonstrated reliability and convergent validity. Although certain types of settings, in the particular geographic area studied, appear to perform better in several key aspects of the primary care, replication of the study in other areas would be useful judging the performance of the newer types of settings to be superior to more conventional care for general populations.

Healthcare needs of HIV-infected persons in hospital, outpatient, home, and long-term care settings

In this descriptive study, healthcare needs reported by 386 HIV-infected persons from all risk categories and their primary nurses from four care settings (hospital, outpatient, long-term care, and home) are identified. Healthcare needs were classified into four domains of nursing practice using a conceptual framework from community health nursing--physiologic, psychosocial, health behaviors, environmental--and were assessed using the Healthcare Needs Scale for Patients with HIV/AIDS. Nurses' perceptions of major healthcare needs across all settings centered around decreased physical endurance, limited physical mobility, and sensory deficits. Patients' needs focused on financial issues. The results reflect the multidimensional nature of this infection and provide direction for clinical practice.

Mechanisms for maternal age differences in birth weight

The authors studied three hypothesized explanations for reduced birth weights of infants born to US adolescent mothers--social disadvantage, biologic immaturity, and unhealthy behaviors during pregnancy. A hierarchical regression analysis was pursued to evaluate these explanations using data from the National Longitudinal Study of Youth on 1,754 first births between 1979 and 1983 to women aged 14-25 years at the time of birth. The birth weights of infants of mothers aged 14-17, 18-19, and 20-23 years were 133, 54, and 88 g less than for infants of mothers aged 23-25. The regression results indicate that the reduced birth weights of infants born to young mothers, particularly women aged 14-17, were related to their disadvantaged social environment. When adjustment was made for poverty and minority status, there were no maternal age differences in birth weight. The reduced birth weights were not related to the young woman's health behaviors during pregnancy or her biologic characteristics. Ethnicity, poverty status, age at menarche, maternal height, net maternal weight gain, and smoking during pregnancy had an independent effect on birth weight in this sample of young women.

Young motherhood and infant hospitalization during the first year of life

We studied the relationship of young maternal age with infant hospitalization using data from the National Longitudinal Survey of Youth for 3,130 infants born between 1979 and 1983 to mothers aged 14-25 years. Data on the mothers were first collected in 1979 and yearly thereafter. Data on their children were collected starting in 1982. Logistic regressions of infant hospitalization rates were estimated for first and second and higher births. The odds of infant hospitalization during the first year of life increased with decreasing maternal age, even with adjustment for sociodemographic characteristics, preventive health-care practices, and newborn health status, factors hypothesized to explain the maternal age effect. The maternal age relationship with hospitalization differed by birth order; among second and higher births, the odds of hospitalization was increased only for infants of mothers aged 20-22 years. Male infants, infants with a first well-baby visit after the first month of life, with birth weights between 1501 and 2500 g, and with nursery stays longer than 1 week also had increased odds of hospitalization. Ethnicity, grandmother's education, poverty status, mother's school enrollment, and family composition were not related to the odds of hospitalization, nor was smoking during pregnancy when adjustment was made for birth weight and length of nursery stay.

Substance misuse and HIV/AIDS risks among delinquents: a prevention challenge

In the United States, there is growing concern that adolescents are at increasing risk for HIV-1 infection due to recreational substance use and sexual activity. Self-report questionnaires from a sample of 224 incarcerated delinquents quantified associations between drug use, sex, and other behaviors which risk HIV-1 infection. High rates of substance use and HIV-risking behaviors were found. Significant correlations between levels of substance use and both behavioral and attitudinal barriers to HIV/AIDS prevention programming were observed. This evidence and other subgroup differences in denial of vulnerability and in practice of preventive behaviors indicate the need for different approaches to prevention. An integrated HIV/AIDS and substance misuse prevention program is discussed as a viable alternative to the usual knowledge-enhancing programs.

Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers

This study introduced trained paraprofessionals, community health workers (CHWs), into the emergency department (ED) to supplement providers' routine efforts in high blood pressure (HBP) detection, treatment, and follow-up among high-risk black men. In a demonstration project over a 2-year period, CHWs provided (1) BP and pulse measurements, and educational counseling regarding HBP and cardiovascular risk factors; (2) telephone preappointment reminders to improve ED follow-up visit rates; and (3) recontact of patients failing to show for their ED follow-up visits to improve return rates even after missed BP appointments. Results of preappointment reminders by CHWs showed a 19% improvement in appointment keeping (P less than .001). With a sample of patients who had failed to return for a follow-up visit, CHW contact was also effective, showing an overall improvement rate of 7% (P less than .001). The results reported support the idea that individuals from the community, trained as paraprofessionals, can improve appointment keeping as well as be useful in assisting in screening and counseling for chronic conditions within the ED. These CHWs are seen as having the additional advantage of enhancing the integration of the ED, the community, and continuing care sites. The approaches used in this study should be applicable and may serve as a model for the approach to other chronic conditions experienced in urban high-risk communities.