Global health workforce strategies to address the COVID-19 pandemic: Learning lessons for the future

COVID-19 put unprecedented strain on the health and care workforce (HCWF). Yet, it also brought the HCWF to the forefront of the policy agenda and revealed many innovative solutions that can be built upon to overcome persistent workforce challenges. In this perspective, which draws on a Policy Brief prepared for the WHO Fifth Global Forum on Human Resources for Health, we present findings from a scoping review of global emergency workforce strategies implemented during the pandemic and consider what we can learn from them for the long-term sustainability of the HCWF. Our review shows that strategies to strengthen HCWF capacity during COVID-19 fell into three categories: (1) surging supply of health and care workers (HCWs); (2) optimizing the use of the workforce in terms of setting, skills and roles; and (3) providing HCWs with support and protection. While some initiatives were only short-term strategies, others have potential to be continued. COVID-19 demonstrated that changes to scope-of-practice and the introduction of team-based roles are possible and central to an effective, sustainable workforce. Additionally, the use of technology and digital tools increased rapidly during COVID-19 and can be built on to enhance access and efficiency. The pandemic also highlighted the importance of prioritizing the security, safety, and physical and mental health of workers, implementing measures that are gender and equity-focused, and ensuring the centrality of the worker perspective in efforts to improve HCWF retention. Flexibility of regulatory, financial, technical measures and quality assurance was critical in facilitating the implementation of HCWF strategies and needs to be continued. The lessons learned from COVID-19 can help countries strengthen the HCWF, health systems, and the health and well-being of all, now and in the future.

The launch of the EU Health Emergency Preparedness and Response Authority (HERA): Improving global pandemic preparedness?

The crowded global health landscape has been joined by the European Union Health Emergency Preparedness and Response Authority (HERA). HERA will assume four broad areas of responsibility: horizon scanning for major health threats; research and development; support for capacity to manufacture drugs, vaccines, and equipment; and procuring and stockpiling key medical countermeasures. In this Health Reform Monitor article, we outline the reform process and describe HERA's structure and responsibilities, explore issues that arise from the creation of this new organisation, and suggest options for collaboration with existing bodies in Europe and beyond. The COVID-19 pandemic and other infectious disease outbreaks have shown the need to treat health as a cross-border issue, and there is now a broad consensus that greater direction and coordination at the European level is needed. This ambition has been matched with a considerable increase in EU funding to tackle cross-border health threats, and HERA can be used to deploy this funding in an effective manner. Yet this is contingent upon clearly defining its role and responsibilities vis-à-vis existing agencies to reduce redundancies.

Efficacy and toxicity of weekly paclitaxel, carboplatin, and cetuximab as induction chemotherapy or in cases of metastases or relapse for head and neck cancer with a focus on elderly or frail patients

BACKGROUND

Paclitaxel, carboplatin, and cetuximab (PCC) has shown promise as induction chemotherapy and in patients with metastatic/recurrent head and neck cancer (HNC). Given its tolerability, the regimen is used in frail and elderly patients.

METHODS

Software generated the cohort of adult patients with HNC treated with PCC in 2014-2019. Modified RECIST response rate (RR), progression-free survival (PFS), and overall survival (OS) were calculated for the metastatic/recurrent group, and successful induction rate and RR for the induction group. These were also calculated in the elderly/frail subset (EF): age ≥75, performance status ≥2, albumin <3.5.

RESULTS

Fifty-two percent of patients experienced ≥grade 3 toxicities. For metastatic/recurrent disease (N = 58), RR was 22%, mean PFS was 7.1 months. Mean OS was 15.2 months. In the induction cohort (N = 22), 86% reached their endpoint. The RR was 64%. There were no significant differences for EF.

CONCLUSIONS

PCC is well-tolerated with good induction success rate and reasonable PFS/OS in metastatic/recurrent disease.

Social Determinants of Disparities in Mortality Outcomes in Congenital Heart Disease: A Systematic Review and Meta-Analysis

Background

Social determinants of health (SDoH) affect congenital heart disease (CHD) mortality across all forms and age groups. We sought to evaluate risk of mortality from specific SDoH stratified across CHD to guide interventions to alleviate this risk.

Methods

We searched electronic databases between January 1980 and June 2019 and included studies that evaluated occurrence of CHD deaths and SDoH in English articles. Meta-analysis was performed if SDoH data were available in &gt;3 studies. We included race/ethnicity, deprivation, insurance status, maternal age, maternal education, single/multiple pregnancy, hospital volume, and geographic location of patients as SDoH. Data were pooled using random-effects model and outcome was reported as odds ratio (OR) with 95% confidence interval (CI).

Results

Of 17,716 citations reviewed, 65 met inclusion criteria. Sixty-three were observational retrospective studies and two prospective. Of 546,981 patients, 34,080 died. Black patients with non-critical CHD in the first year of life (Odds Ratio 1.62 [95% confidence interval 1.47–1.79], I2 = 7.1%), with critical CHD as neonates (OR 1.27 [CI 1.05-1.55], I2 = 0%) and in the first year (OR 1.68, [1.45-1.95], I2 = 0.3%) had increased mortality. Deprived patients, multiple pregnancies, patients born to mothers &lt;18 years and with education &lt;12 years, and patients on public insurance with critical CHD have greater likelihood of death after the neonatal period.

Conclusion

This systematic review and meta-analysis found that Black patients with CHD are particularly vulnerable for mortality. Numerous SDoH that affect mortality were identified for specific time points in CHD course that may guide interventions, future research and policy.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019139466&amp;ID=CRD42019139466], identifier [CRD42019139466].

Drawing light from the pandemic: Rethinking strategies for health policy and beyond

The COVID-19 pandemic is a catastrophe. It was also preventable. The potential impacts of a novel pathogen were foreseen and for decades scientists and commentators around the world warned of the threat. Most governments and global institutions failed to heed the warnings or to pay enough attention to risks emerging at the interface of human, animal, and environmental health. We were not ready for COVID-19, and people, economies, and governments around the world have suffered as a result. We must learn from these experiences now and implement transformational changes so that we can prevent future crises, and if and when emergencies do emerge, we can respond in more timely, robust and equitable ways, and minimize immediate and longer-term impacts.

In 2020–21 the Pan-European Commission on Health and Sustainable Development assessed the challenges posed by COVID-19 in the WHO European region and the lessons from the response. The Commissioners have addressed health in its entirety, analyzing the interactions between health and sustainable development and considering how other policy priorities can contribute to achieving both. The Commission's final report makes a series of policy recommendations that are evidence-informed and above all actionable. Adopting them would achieve seven key objectives and help build truly sustainable health systems and fairer societies.

Global consumption of prescription opioid analgesics between 2009-2019: a country-level observational study

BACKGROUND

Opioid analgesics play a key role in pain management but providing access while mitigating risk of misuse and dependence remains a challenge. Tracking global consumption of all opioids over time can help identify emerging patterns and drivers of use.

METHODS

Prescription opioid analgesic consumption was estimated for 76 countries between 2009 and 2019 using IQVIA MIDAS data. We reported country-level consumption trends in morphine milligram equivalents (MMEs), assessed differences in consumption between high-income (HICs), upper-middle income (UMICs), and low- and lower-middle income countries (LMICs), and identified country-level socioeconomic drivers of consumption using fixed-effects panel regression models.

FINDINGS

Global opioid consumption rate declined from 216·3 to 151·5 morphine milligram equivalents per 1,000 inhabitants per day (MID) between 2009 and 2019, with consumption declines in the US and Germany. Overall, consumption rates increased in HICs by a median 36·6 MID (IQR, -7·5 -124·5) with substantial heterogeneity between countries. Median consumption rates were lower in UMICs (23·6 MID) and LMICs (8·3 MID) compared to HICs (345·1 MID) and increased by median 10·4 and 3·7 MID from 2009-2019, respectively. Consumption rates were associated with income (coefficient 18·84, 95% confidence interval 3·8-33·9) and trade (13·59, 1·3-25·8) in UMICs, and physician density (1·95, 1·2-2·7) in LMICs. Tramadol consumption rate increased in the study period and accounted for a relatively large proportion of total opioid volume consumed across all country-income groups.

INTERPRETATION

Substantial heterogeneity in global opioid consumption patterns reflect the challenges involved with providing adequate access to opioid treatment while avoiding potential misuse.

COVID-19 vaccine mandate for healthcare workers in the United States: a social justice policy

INTRODUCTION

Vaccination is the most effective strategy to mitigating COVID-19 and restoring societal function. As the pandemic evolves with no certainty of a herd immunity threshold, universal vaccination of at-risk populations is desirable. However, vaccine hesitancy threatens the return to normalcy, and healthcare workers (HCWs) must embrace their ambassadorial role of shoring up vaccine confidence. Unfortunately, voluntary vaccination has been suboptimal among HCWs in the United States, a priority group for whom immunization is essential for maintaining health system capacity and the safety of high-risk patients in their care. Consequently, some health systems have implemented mandates to improve compliance.

AREAS COVERED

This article discusses the ethical and practical considerations of mandatory COVID-19 vaccination policies for HCWs utilizing some components of the World Health Organization's framework and the unique context of a pandemic with evolving infection dynamics.

EXPERT OPINION

COVID-19 vaccine mandates for universal immunization of HCWs raise ethical and practical debates about their appropriateness, especially when the vaccines are pending full approval in most jurisdictions. Given the superiority of the vaccines to safety and testing protocols and their favorable safety profile, we encourage health systems to adopt vaccination mandates through participatory processes that address the concerns of stakeholders.

Efficacy and toxicity of weekly paclitaxel, carboplatin, and cetuximab as induction chemotherapy or in cases of metastases or relapse for head and neck cancer in elderly or frail patients

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Background: Standard of care treatments for locally advanced and metastatic head and neck squamous cell carcinoma (HNSCC) are not well tolerated, particularly in elderly or frail patients. One combination that has been studied in recent years is paclitaxel, carboplatin and cetuximab (PCC). Studies have shown this regimen yields promising results when used as an induction chemotherapy for locally advanced disease. PCC has also been studied in patients with metastatic or recurrent incurable disease, and has shown good response with tolerable toxicity rates, but there is a relative dearth of evidence surrounding its use. Methods: This retrospective observational study utilized EMR data analysis software to generate the cohort of adult patients that received PCC for HNSCC in 2014-2019 as well as demographic data. Chart review was used to gather details about the patients’ tumors and clinical course. Modified RECIST response rates (MRRR), progression free survival (PFS) and overall survival (OS) were the primary end points calculated for the metastatic/recurrent group, and percentage of successful inductions (e.g., patients went on to definitive treatment, avoided surgery) and MRRR were used for the induction group. Results: There were 80 patients in the cohort. The average age was 65 (range 33-84) and the patients were 81% male. The most common tumor site was the tongue (25 patients), followed by tonsil (15), oropharynx (9), and larynx (7). 13 patients had p16 positive disease. Most patients had Stage IVA (36 patients), followed by IVB (20), and IVC (15); the remainder had stage III or below or unknown stage. The most common reasons patients did not receive cisplatin were performance status (13 patients), hearing loss (11), concern for nephrotoxicity (6) and age (5). 97.5% of patients experienced at least one adverse effect. The most common adverse effect was dermatologic (69%), followed by hematologic (51%), fatigue (41%) and gastrointestinal symptoms (41%). 53 patients (66%) experienced at least one dose interruption due to adverse effects. 11 patients (14%) stopped treatment due to toxicities. 58 patients received PCC for metastatic or recurrent disease. They had received a median of 1 line of systemic treatment prior; 72% had prior radiation, and 26% had prior salvage surgery. The MRRR was 22% (5 patients with complete response, 8 partial response, 15 stable, 27 progression). There was a 7.0 month mean PFS, and 17.3 month mean OS. Of the 22 patients who received PCC as induction, 86% (19) successfully reached their induction endpoint. The MRRR was 64% (8 patients with complete response, 6 partial response). Conclusions: PCC is a relatively well-tolerated combination with a very good induction success rate. More research is needed around alternate options for frail and elderly patients with HNSCC.

Medical Student Personality Traits and Clinical Grades in the Internal Medicine Clerkship

BACKGROUND

Third year clerkship grades include subjective evaluations. The purpose of this study is to identify if personality traits and self-esteem predispose students to better clerkship performance.

METHODS

Third-year medical students completed the OCEAN Five Factor Model Personality Test and Rosenberg Self-Esteem Scale. Clerkship grades were matched to survey results. Chi-squared and linear regression analyses assessed the correlation between students' clerkship grades, personality traits, and self-esteem.

RESULTS

There was no association between OCEAN personality domains and any component of clerkship grade. In secondary post hoc analysis, students who are "deep thinking" (OR 2.97, 95% CI 1.26-7.01, p = 0.01), "sophisticated" (OR 2.70, 95% CI 1.12-6.50, p = 0.03), and "outgoing" (OR 2.45, 95% CI 1.02-5.89, p = 0.04) were significantly more likely to get an overall clerkship grade of Honors. "Deep thinking" (OR 3.44, 95% CI 1.47-8.04, p = 0.004) and "efficient" (OR 2.87, 95% CI 1.12-7.36, p = 0.03) students scored better on shelf exams, while "shy" students scored worse (OR 0.30, 95% CI 0.13-0.69, p = 0.004); "aloof" students received worse clinical scores (OR 0.57, 95% CI 0.37-0.89, p = 0.03), and "rude" (OR 5.08, 95% CI 1.03-24.94, p = 0.03) and "sophisticated" (OR 2.47, 95% CI 1.02-6.00, p = 0.04) students received higher preceptor scores. There was no correlation between self-esteem and clerkship grades.

CONCLUSION

Students with certain personality traits may be predisposed to success during clerkships. Medical educators should be cognizant of biases favoring certain personalities and help students maximize success by recognizing their strengths and identifying gaps.

COVID-19 vaccine challenges: What have we learned so far and what remains to be done?

Developing and distributing a safe and effective SARS-CoV-2 (COVID-19) vaccine has garnered immense global interest. Less than a year after COVID-19 was declared a pandemic, several vaccine candidates had received emergency use authorization across a range of countries. Despite this scientific breakthrough, the journey from vaccine discovery to global herd immunity against COVID-19 continues to present significant policy challenges that require a collaborative, global response. We offer a framework for understanding remaining and new policy challenges for successful global vaccine campaigns against COVID-19 as well as potential solutions to address them. Decision-makers must be aware of these challenges and strategize solutions that can be implemented at scale. These include challenges around maintaining R&D incentives, running clinical trials, authorizations, post-market surveillance, manufacturing and supply, global dissemination, allocation, uptake, and clinical system adaption. Alongside these challenges, financial and ethical concerns must also be addressed.

12 Lessons learned from the management of the coronavirus pandemic

The Coronavirus SARS-CoV-2 has spread rapidly since the first cases hit Wuhan, China at the end of 2019, and has now landed in almost every part of the world. By mid-February 2020, China, South Korea, Singapore, Taiwan, and - to some extent - Japan began to contain and control the spread of the virus, while conversely, cases increased rapidly in Europe and the United States. In response to the pandemic, many countries have had to introduce drastic legally mandated lockdowns to enforce physical separation, which are ravaging economies worldwide. Although it will be many months or even years before the final verdict can be reached, we believe that it is already possible to identify 12 key lessons that we can learn from to reduce the tremendous economic and social costs of this pandemic and which can inform responses to future crises. These include lessons around the importance of transparency, solidarity, coordination, decisiveness, clarity, accountability and more.

The Search for Consumers of Web-Based Raw DNA Interpretation Services: Using Social Media to Target Hard-to-Reach Populations

Background

In recent years, there has been a proliferation of third-party Web-based services available to consumers to interpret raw DNA from direct-to-consumer genetic testing companies. Little is known about who uses these services and the downstream health implications. Identifying this hard-to-reach population of consumers for research raised questions about the most effective recruitment methods to undertake. Past studies have found that Web-based social media survey distribution can be cost-effective for targeting hard-to-reach populations, yet comparative efficacy information across platforms is limited.

Objective

The aim of this study was to identify the most effective Web-based strategies to identify and recruit the target population of direct-to-consumer genetic testing users who also made use of third-party interpretation services to analyze their raw genetic data. Web-based survey recruitment methods varying by social media platform and advertising method were compared in terms of cost-effectiveness and demographics of survey respondents.

Methods

A total of 5 Web-based survey distribution conditions were examined: 4 paid advertising services and 1 unpaid service. For the paid services, a 2x2 quasi-experimental design compared social media platforms (Facebook vs Twitter) and advertising tracking metrics (by click vs by conversion). The fifth unpaid comparison method consisted of study postings on the social media platform, Reddit, without any paid advertising. Links to identical Web-based versions of the study questionnaire were posted for 10 to 14 days for each of the distribution conditions, which allowed tracking the number of respondents that entered and completed the questionnaire by distribution condition.

Results

In total, 438 individuals were recruited to the study through all conditions. A nearly equivalent number of participants were recruited from paid campaigns on Facebook (n=159) and Twitter (n=167), with a smaller sample recruited on Reddit (n=112). Significantly more participants were recruited through conversion-tracking (n=222) than through click-tracking campaigns (n=104; Z=6.5, P<.001). Response rates were found to be partially driven by organic sharing of recruitment materials among social media users. Conversion tracking was more cost-effective than click tracking across paid social media platforms. Significant differences in terms of gender and age distributions were noted between the platforms and between the tracking metrics.

Conclusions

Web-based recruitment methods were effective at recruiting participants from a hard-to-reach population in a short time frame. There were significant differences in the effectiveness of various paid advertising techniques. Recruitment through Web-based communities also appeared to perform adequately, yet it may be limited by the number of users accessible in open community groups. Future research should evaluate the impact of organic sharing of recruitment materials because this appeared to play a substantial role in the observed effectiveness of different methods.

One-year survival following early revascularization for cardiogenic shock

CONTEXT

Cardiogenic shock (CS) is the leading cause of death for patients hospitalized with acute myocardial infarction (AMI).

OBJECTIVE

To assess the effect of early revascularization (ERV) on 1-year survival for patients with AMI complicated by CS.

DESIGN

The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) Trial, an unblinded, randomized controlled trial from April 1993 through November 1998.

SETTING

Thirty-six referral centers with angioplasty and cardiac surgery facilities.

PATIENTS

Three hundred two patients with AMI and CS due to predominant left ventricular failure who met specified clinical and hemodynamic criteria.

INTERVENTIONS

Patients were randomly assigned to an initial medical stabilization (IMS; n = 150) group, which included thrombolysis (63% of patients), intra-aortic balloon counterpulsation (86%), and subsequent revascularization (25%), or to an ERV group (n = 152), which mandated revascularization within 6 hours of randomization and included angioplasty (55%) and coronary artery bypass graft surgery (38%).

MAIN OUTCOME MEASURES

All-cause mortality and functional status at 1 year, compared between the ERV and IMS groups.

RESULTS

One-year survival was 46.7% for patients in the ERV group compared with 33.6% in the IMS group (absolute difference in survival, 13.2%; 95% confidence interval [CI], 2.2%-24.1%; P<.03; relative risk for death, 0.72; 95% CI, 0.54-0.95). Of the 10 prespecified subgroup analyses, only age (<75 vs >/= 75 years) interacted significantly (P<.03) with treatment in that treatment benefit was apparent only for patients younger than 75 years (51.6% survival in ERV group vs 33.3% in IMS group). Eighty-three percent of 1-year survivors (85% of ERV group and 80% of IMS group) were in New York Heart Association class I or II.

CONCLUSIONS

For patients with AMI complicated by CS, ERV resulted in improved 1-year survival. We recommend rapid transfer of patients with AMI complicated by CS, particularly those younger than 75 years, to medical centers capable of providing early angiography and revascularization procedures.

Embolization of uterine leiomyomata: current concepts in management

Transcatheter bilateral uterine artery embolization is a relatively new, but fast increasing modality being offered as an alternative to surgery for the treatment of symptomatic uterine fibroids (myomata). Since its introduction in 1995, it is estimated that over 5000 procedures have been performed, despite little objective evidence of its efficacy in comparison with more traditional surgical procedures, e.g. hysterectomy, abdominal or laparoscopic myomectomy or hysteroscopic procedures. The enthusiastic uptake of uterine artery embolization is partly due to the fact that it can be performed as a day case, and is a means of avoiding surgery especially hysterectomy. However, the procedure is not without significant risks, and these are becoming clearer as more procedures are being reported. This review examines the procedure, its use and purported efficacy and discusses its complications and potential hazards.

Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?

OBJECTIVES

We wished to assess the profile and outcomes of patients with ventricular septal rupture (VSR) in the setting of cardiogenic shock (CS) complicating acute myocardial infarction (MI).

BACKGROUND

Cardiogenic shock is often seen with VSR complicating acute MI. Despite surgical therapy, mortality in such patients is high.

METHODS

We analyzed 939 patients enrolled in the SHOCK Trial Registry of CS in acute infarction, comparing 55 patients whose shock was associated with VSR with 884 patients who had predominant left ventricular failure.

RESULTS

Rupture occurred a median 16 h after infarction. Patients with VSR tended to be older (p = 0.053), were more often female (p = 0.002) and less often had previous infarction (p < 0.001), diabetes mellitus (p = 0.015) or smoking history (p = 0.033). They also underwent right-heart catheterization, intra-aortic balloon pumping and bypass surgery significantly more often. Although patients with rupture had less severe coronary disease, their in-hospital mortality was higher (87% vs. 61%, p < 0.001). Surgical repair was performed in 31 patients with rupture (21 had concomitant bypass surgery); 6 (19%) survived. Of the 24 patients managed medically, only 1 survived.

CONCLUSIONS

There is a high in-hospital mortality rate when CS develops as a result of VSR. Ventricular septal rupture may occur early after infarction, and women and the elderly may be more susceptible. Although the prognosis is poor, surgery remains the best therapeutic option in this setting.

Coronary flow reserve of nonischemic heart failure

Coronary flow reserve (CFR) provides essential information about the coronary microvascular bed in the absence of narrowing of epicardial coronary arteries. Experimental and human data suggest chronic heart failure is associated with a reduction of CFR in the absence of coronary artery disease. Dipyridamole, papaverine, or adenosine administration intravenously or intracoronary achieve maximal vasodilation of coronary arteries in human studies, however, systemic administration of vasodilator (dipyridamole) resulted in conflicting effects on systemic blood pressure. Various mechanisms including the nitric oxide pathway, neurohumoral alterations, and microvascular spasm among others, may contribute to the decrease in CFR in nonischemic heart failure. Notably, there is no study which describes the correlation between subjective symptoms of heart failure and the severity of the decrease in CFR. Further investigation of this area may be beneficial in determining the appropriate level of exercise training for heart failure patients and understanding mechanisms of the progression of heart failure. (c)1999 by CHF, Inc.

New ECG changes associated with a tension pneumothorax: a case report

This case report reveals new ECG changes associated with a left tension pneumothorax, specifically, PR-segment elevation in the inferior leads and reciprocal PR-segment depression in the aVR lead. A mechanism of atrial injury and/or ischemia is proposed as the cause, and the ECG changes associated with a left tension pneumothorax are briefly reviewed.

Cellular and subcellular sites for noradrenergic action in the monkey dorsolateral prefrontal cortex as revealed by the immunocytochemical localization of noradrenergic receptors and axons

A series of electron microscopic immunocytochemical studies was performed to analyze subcellular sites for noradrenergic modulation in monkey prefrontal cortex. One out of 12 noradrenergic varicosities, identified by dopamine beta-hydroxylase immunocytochemistry within single ultrathin sections, forms morphologically identifiable junctions with small dendrites and spines. Accordingly, alpha2-adrenergic receptors, almost all of which are of the A-subtype, that occur in spines are localized discretely over postsynaptic membranes. alpha2-Adrenergic receptors are also found at sites along axons, dendritic shafts and astrocytic processes lacking morphologically identifiable synaptic junctions, suggesting that these receptors are activated by volume transmission. In particular, axonal alpha2-adrenergic receptors occur mostly at pre-terminal regions, suggesting that axo-axonic interactions may mediate reduction of neurotransmitter release at sites other than axo-spinous junctions by closing voltage-dependent calcium channels. These results indicate that noradrenergic modulation of prefrontal cortex involves synaptic interactions at spines of pyramidal neurons and nonsynaptic volume transmission to glia, dendritic shafts and axons.

Folic acid and prevention of neural tube defects: a study of Canadian mothers of infants with spina bifida

OBJECTIVES

To determine the diffusion of information about preventing neural tube defects (NTDs) through folic acid consumption by examining whether mothers of Canadian children born with spina bifida, who had become pregnant at least a year after evidence of the preventive effect of folic acid had been published, had taken sufficient amounts of folic acid in the periconceptional period and were aware of this important new information.

DESIGN

Validated food-frequency questionnaire to assess folate intake.

SETTING

The Hospital for Sick Children in Toronto between Jan. 4 and Aug. 16, 1994.

PARTICIPANTS

Thirty mothers whose infants were being treated for spina bifida.

MAIN OUTCOME MEASURES

The mothers' mean folate intake and knowledge about the protective effect of folic acid; demographic and health information.

RESULTS

The mothers' mean folate intake was 0.182 mg/d (standard deviation 0.076 mg/d, range 0.02 to 0.53 mg/d), less than half the protective dose. Only 4 (13%) of the mothers had been aware of the relation between nutritional folate and NTDs when they conceived, but even they did not supplement their diets with sufficient folic acid. The medical data showed that, in addition to the failure of primary prevention of NTDs, secondary prevention through diagnostic tests during pregnancy were also inadequate.

CONCLUSIONS

Our study, one of the first to be conducted after the role of folate in preventing NTDs was confirmed, reveals that, in one of the most advanced countries in the world, this new information has had no effect on patients' folate intake. Unless food is fortified with folate, the estimated 400 to 800 annual cases of NTDs in Canada will not be prevented.

Prevalence of fetal exposure to cocaine in Toronto, 1990-1991

There has been an increasing use of cocaine in North America among women of reproductive age. The potential effects of cocaine on the fetus have raised serious concerns about the health of large numbers of children exposed in utero to the drug. Using neonatal hair and urine tests for benzoylegconine (BE), we quantified the incidence of fetal exposure to cocaine among 600 babies born in 3 nurseries in Toronto from 1990-91. A total of 37 babies (6.25%) tested positive for cocaine exposure by either hair test, urine test, or both. The hair test detected 33 cases and failed to identify 4 babies who had low urine concentrations of BE. The urine test failed to identify 76% of the cases. In downtown Toronto, the overall rate of fetal exposure to cocaine was 12.5% (25/200), significantly higher than in the 2 suburban nurseries (3%; 12/400). Babies are born with hair which has grown during the last trimester of pregnancy; hence, our analysis identifies women who have used cocaine long after they became aware of pregnancy. Our figures translate to more than 5,000 babies annually in the greater Toronto area who are cared for postnatally by mothers regularly using cocaine. Because history and urine testing during delivery fail to identify the majority of these cases, most of these children are not likely to receive the appropriate medical and social services and follow-up.

A method for simultaneous measurement of cocaine and nicotine in neonatal hair

Maternal exposure to drugs and chemicals is increasingly being recognized as adversely affecting the developing fetus. To date, a very large number of fetuses have been exposed in utero to cocaine and cigarette smoke. Neonatal hair as a biological marker for fetal exposure in cocaine and nicotine has emerged as an excellent tool in correlating in utero exposure and outcome. However, a limiting factor is the sparsity of neonatal hair. We report on the first method that allows determination of both cocaine and nicotine as well as their metabolites in the same hair samples.

Maternal and neonatal characteristics following exposure to cocaine in Toronto

We prospectively ascertained gestational cocaine use by neonatal urine and hair tests in 600 mother infant pairs in 3 nurseries in Toronto. The 37 (6.25%) babies who tested positive for cocaine and their mothers were compared to the 563 nonexposed with regard to pregnancy outcome and neonatal complications. Mothers using cocaine were not different in their ages, racial distribution, and obstetric history from those nonexposed. Cocaine-using women had significantly higher risk for vaginal bleeding (16% vs 6%, P < 0.05), hepatitis B carrier state (8% vs 0.8%, P < 0.005), and perhaps more urinary tract infections (8% vs 2.5%, P = 0.08). Cocaine-using mothers were significantly more likely to smoke cigarettes (29% vs 10%, P < 0.001). Infants exposed to cocaine in utero were of lower birth weight (3162 +/- 645 [SD] g vs 3391 +/- 573, P < 0.05) and birth length (49.9 +/- 2.9 cm vs 51.1 +/- 3.1 cm, P < 0.05). Further stratification of babies exposed to cocaine by maternal cigarette smoking suggests that cigarette smoking accounted for most of this variability [birth weight of babies exposed to cocaine and cigarettes 2899 +/- 7.50 g (and 50% of them weighed less than 2500 g), vs 3423 +/- 612 (and only 8% less than 2500 g) in those exposed to cocaine only (P < 0.05)]. Babies exposed to cocaine in utero were significantly more likely to need initial medical support or resuscitation (52% vs 30%, P < 0.05). We conclude that gestational exposure to cocaine, ascertained by a sensitive biologic marker, is associated with substantial perinatal risks.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcervical cannulation of the fallopian tube for the management of ectopic pregnancy: prospective multicenter study

OBJECTIVE

To determine the efficacy of transcervical tubal cannulation and intraluminal methotrexate injection for the management of tubal ectopic pregnancy (EP).

DESIGN

Prospective multicenter study of 33 patients with tubal pregnancies.

SETTING

Four university-based gynecology and radiology departments in three different countries: France, England, and Germany.

PATIENTS

Thirty-three patients who presented with a clinical diagnosis of EP.

INTERVENTIONS

Patients underwent transcervical tubal cannulation under fluoroscopic or ultrasound control and local injection of methotrexate (up to 50 mg).

MAIN OUTCOME MEASURES

We evaluate the feasibility of transcervical tubal cannulation for the management of tubal pregnancy.

RESULTS

Two patients elected to withdraw from the protocol. In the remaining 31 patients there was complete resolution of the EP in 27 (87%). Surgery was performed in 4 patients. Seventeen patients, 14 of whom desired pregnancies, were available for follow-up to assess the return of reproductive potential. Seven of 7 patients who subsequently underwent hysterosalpingography had patency of the affected tube. Five patients later had an intrauterine pregnancy. One patient had an early miscarriage, two have given birth, and two singleton pregnancies are still ongoing. The remaining patients are symptom free.

CONCLUSIONS

This study demonstrates that transcervical tubal catheterization in patients with tubal pregnancies is feasible and can be performed without anesthesia or analgesia in most cases. Intraluminal methotrexate per se is capable of causing regression of the EP. This approach offers a new alternative for the treatment of selected patients with tubal EP.

Hair analysis of cocaine: differentiation between systemic exposure and external contamination

Cocaine has been shown to accumulate in hair of admitted users. Before using this test to verify cocaine use, however, it is crucial to differentiate between systemic exposure and external contamination from being in contact with crack smoke. In the present studies, the authors document that pyrolysis of crack results in hair accumulation of cocaine, but not its benzoylecgonine metabolite, whereas after admitted cocaine use both species are detectable in hair. External contamination with crack smoke is washable, whereas systemic exposure is not. The authors suggest these two criteria to distinguish systemic exposure from external contamination.

Impaired endothelium-mediated vasodilation in the peripheral vasculature of patients with congestive heart failure

Impaired endothelial-dependent vasodilation has been demonstrated in two animal models of congestive heart failure and in the coronary circulation of patients with idiopathic dilated cardiomyopathy. To determine whether this impairment contributes to the abnormal peripheral vasomotor tone in patients with congestive heart failure, the local vascular response to intraarterial infusions of graded concentrations (10(-8) M to 10(-5) M) of acetylcholine (an endothelial-dependent vasodilator) and nitroglycerin (a direct-acting vasodilator) was studied in the superficial femoral artery of 19 patients with congestive heart failure (New York Heart Association classes I to IV) and 6 age-matched normal control subjects. The local vascular response was determined from the arterial blood flow velocity pattern obtained by transcutaneous Doppler ultrasonography. Acetylcholine, 10(-5) M, induced a pattern characteristic of vasodilation in all six normal subjects; mean blood flow velocity for the group significantly increased from 11.9 +/- 2.7 to 44.8 +/- 20.9 cm/s (p less than 0.05). In contrast, the same dose of acetylcholine induced a blood flow velocity pattern characteristic of vasodilation in only 4 of the 19 patients with congestive heart failure. Group mean blood flow velocity did not change significantly. Nitroglycerin, 10(-7) M, induced vasodilation in all 6 normal subjects but in only 1 of 19 patients. Nitroglycerin, 10(-5) M, was administered to 10 patients; all 10 demonstrated a pattern characteristic of vasodilation. Thus, acetylcholine-mediated endothelial-dependent vasodilation appears to be impaired in the peripheral vasculature of patients with congestive heart failure. Both endothelial dysfunction and abnormal vascular smooth muscle responsiveness may contribute to abnormal peripheral vasomotor tone.

Accumulation of cocaine in maternal and fetal hair; the dose response curve

Cocaine and its major metabolites are incorporated into hair during the growth of the shaft and stay there for the whole life of the hair. Cocaine crosses the placenta and its metabolites for example Benzoylecgonine (BZ), have been found in neonatal urine, meconium and hair. In order to utilize hair measurements of cocaine as a biological marker of systemic exposure, we conducted both animal and human investigations on the dose response characteristics of this phenomenon. Our data suggest that both maternal and fetal accumulation of cocaine and its metabolite follow a linear pattern within the clinically used doses. Similarly, a good correlation was observed in animals between maternal dose and fetal hair accumulation.

Liver abnormality in ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a potentially fatal condition associated with the therapeutic induction of ovulation in infertility. Liver function abnormality has been previously reported in four patients, one of whom had ultrastructural abnormalities on liver biopsy. This paper describes a patient presenting with severe OHSS 16 days after ovulation had been induced. Liver function abnormality was apparent 11 days later, with a sustained rise in alkaline phosphatase and aspartate aminotransferase (AST) which lasted up to 2 months. A liver biopsy performed during the second month of her protracted hospital admission showed marked zonal fatty change (acinar zone 1) and associated inflammation, with mitochondrial crystalline inclusions and rough endoplasmic reticulum dilatation on electron microscopy. This report discusses the clinical features and possible aetiological factors.

Ectopic pregnancy after luteal phase initiation of gonadotropin-releasing hormone analog before in vitro fertilization

Three patients had an undetected pregnancy when they commenced a GnRH-a on the 21st day of their cycle before ovulation stimulation for IVF. Two of the three pregnancies were later diagnosed as ectopic gestations. Based on this and previous case reports in the literature, it is suggested that luteal phase administration of GnRH-a may predispose to EPs, particularly in patients with damaged tubes, by reducing tubal motility secondary to a transient increase in circulating P concentrations.

Burning mouth symptoms, Part II: A clinical review

Part I of this series presented a review of the literature on Burning Mouth Symptoms (BMS) focusing on its prevalence, its symptoms, and proposed local etiologic factors associated with the condition. Part II will focus on the possible systemic and psychological etiologic factors in order to provide the dental clinician with a perspective on the alternative factors that may cause BMS.

Burning mouth symptoms: a clinical review, Part I

The multiple etiologies proposed in the literature for burning mouth symptoms (BMS) make definitive clinical diagnosis and treatment difficult. Proposed etiologies can be divided into local systemic, and psychogenic factors. Part I of this two-part article provides a review of the BMS literature focusing on local etiological factors and possible approaches to their treatment.

Embryo quality and uterine receptivity in in-vitro fertilization cycles with or without agonists of gonadotrophin-releasing hormone

The proportion of abnormal oocytes or embryos per recovered oocyte in in-vitro fertilization (IVF) cycles had no influence on the occurrence of pregnancy following the transfer of normal embryo(s) derived from oocytes capable of fertilization. There were more implantations per transferred embryo in stimulated IVF cycles using long-acting buserelin (30.0%) compared with short-acting decapeptyl (17.3%) or no gonadotrophin-releasing hormone agonist (GnRHa, 15.2%) treatments. However, the chances of implantation per embryo transferred being in excess of one in patients who became pregnant tended to be higher in non-GnRHa (23.5%) compared to buserelin- (16.4%) or decapeptyl- (13.3%) treated IVF cycles. Moreover, frozen--thawed embryos had a higher implantation rate (P less than 0.05) when originating from IVF cycles without GnRHa (11.7%) compared to GnRHa-treated cycles (buserelin, 4.3%; decapeptyl, 5.9%). It can be concluded that GnRHa associated with gonadotrophins produced embryos of a poorer aptitude for development than stimulation treatments without GnRHa. The clinical efficacy of GnRHa in IVF--ET cycles could be the result of an improved uterine receptivity to the transferred embryos.

Influence of different stimulation treatments on oocyte characteristics and in-vitro fertilizing ability

A retrospective analysis was performed in order to compare the number and quality of oocytes recovered in in-vitro fertilization cycles according to different protocols for ovarian stimulation. Treatments including a gonadotrophin-releasing hormone agonist (GnRHa), either decapeptyl or buserelin, were associated with the recovery of more oocytes (6.0-7.2%) than treatments without GnRHa (3.7-4.8%). However, the mean number of normal embryos per patient yielding oocyte(s) was comparable between cycles stimulated with or without GnRHa (2.4-2.7), except in those cycles programmed with norethisterone and gonadotrophins (1.7). There was no difference in the rates of immature or atretic oocytes between stimulation treatments. Following clomiphene and human menopausal gonadotrophin treatment there was a lower rate of fractured zona oocytes, higher rates of fertilization and normal growth of fertilized eggs than after any other treatment. The proportion of normal embryos per recovered oocyte was inversely related to the degree of ovarian response in most of the stimulation treatments. Most of the abnormal embryos contained more than two pronuclei in cycles without GnRHa administration and exhibited polynucleated blastomeres in cycles treated with buserelin or decapeptyl. In conclusion, the use of GnRHa and gonadotrophins for ovarian stimulation increased the mean number of recovered oocytes, but did not increase the mean number of embryos able to develop.

Comparison between flare up and down regulation effects of luteinizing hormone-releasing hormone agonists in an in vitro fertilization program

Luteinizing hormone-releasing hormone (LH-RH) agonists are being increasingly used in ovulation stimulation protocols in IVF programs. The results of two methods of utilization of LH-RH agonists are compared. In the long protocol, gonadotropin stimulation was commenced only after a preliminary period of pituitary desensitization with LH-RH agonist. In the short protocol, exogenous gonadotropins were administered shortly after the start of LH-RH agonist therapy, benefiting from the gonadotropin flare up effect. One hundred eighty-six patients were equally divided between the two treatments. There was no difference in the ovarian response on the day of human chorionic gonadotropin (hCG) or the number of mature oocytes recovered. The cleavage rate of mature oocytes was higher in the short protocol (70% versus 56% P less than 0.01). The ongoing pregnancy rate per treatment cycle was similar in both groups (18% in the long protocol and 16% in the short protocol). Analysis of the luteal phases revealed a trend for higher progesterone values in the long protocol although this was only significant on the 2nd day following oocyte retrieval. As the clinical results were similar, other factors should be taken into account when deciding therapy. These include patient convenience, cost, and side effects. Other schedules of ovulation stimulation with LH-RH agonists are discussed.