Implementation of Recommendations for Long-Acting Contraception Among Women Aged 13 to 18 Years in Primary Care

ObjectiveClinical specialty societies recommend long-acting reversible contraceptives (LARCs) as first-line contraception for adolescent women. We evaluated whether a combined educational and process improvement intervention enhanced LARC placement in primary care within an integrated health care system.MethodsThe intervention included journal clubs, live continuing education, point-of-care guidelines, and new patient materials. We conducted a retrospective cohort study across 3 time periods: baseline (January 2013?September 2015), early implementation (October 2015–March 2016), and full implementation (April 2016–June 2017). The primary outcome was the proportion of LARCs placed by primary care clinicians among women aged 13 to 18 years compared with gynecology clinicians.ResultsKaiser Foundation Health Plan of Colorado cared for approximately 20,000 women aged 13 to 18 years in each calendar quarter between 2013 and 2017. Overall, LARC placement increased from 7.0 per 1000 members per quarter at baseline to 13.0 per 1000 during the full intervention. Primary care clinicians placed 6.2% of all LARCs in 2013, increasing to 32.1% by 2017 (P < .001), including 45.5% of contraceptive implants. Clinicians who attended educational sessions were more likely to adopt LARCs than those who did not (17.9% vs 6.4% respectively, P = .009). Neither overall LARC placement rates (relative risk, 1.9; 95% confidence interval, 0.7?5.6) nor contraceptive implant rates (relative risk, 3.0; 95% confidence interval, 0.9?9.8) increased significantly in clinicians who attended educational activities.ConclusionsThis multimodal intervention was associated with increased LARC placement for adolescent women in primary care. The combination of education and process improvement is a promising strategy to promote clinician behavior change.     

Is intrauterine insemination a viable treatment option for women over 43 years old? An analysis by ovarian stimulation protocol and sperm source

PurposeThe aim of this study was to determine how female age at the end of the reproductive spectrum effects success of natural cycle intrauterine insemination (IUI) or IUI in combination with ovarian stimulation.MethodsWe performed a retrospective cohort study of women 43 years of age and older at the time of IUI in a single academic fertility center between January 2011 and March 2018. Primary outcomes were both pregnancies and live births per cycle of IUI. Data are presented as percentage or mean ± SD. Fisher exact and chi-squared analyses were performed.ResultsThere were 9334 IUI cycles conducted during the study period. Of these cycles, 325 IUIs (3.5%) were for women aged 43 years and over at the time of insemination (43.6 ± 0.8, range 43 to 47 years). Analysis of these 325 IUI cycles revealed 5 biochemical pregnancies (1.5%) and only 1 live birth (0.3%). The pregnancy rate did not differ between IUIs using donor sperm (N = 1/49, 2.0%) compared to IUIs with partner sperm (N = 4/276, 1.4%). The pregnancy rate did not differ between IUIs with gonadotropins (N = 2/211, 0.9%), clomiphene or letrozole (N = 2/78, 2.6%), or natural cycle (N = 1/36, 2.8%).ConclusionsThe use of intrauterine inseminations in women 43 years of age and older is an ineffective treatment strategy. This is irrespective of the use of ovarian stimulation or donor sperm. Costly gonadotropin injections did not increase the chance of pregnancy nor did oral medication when compared to natural cycle IUIs.     

Innate defense mechanisms against HSV-1 infection in the target tissues,skin and brain

Herpes simplex virus type 1 (HSV-1) initiates productive infection in mucocutaneous tissues to cause cold sores and establishes latent infection in the trigeminal ganglia. Under certain circumstances, HSV-1 may cause encephalitis. Here, we compared host innate defenses against HSV-1 in the two clinically relevant tissues, skin and brain, using a unique ex vivo system of organ culture. Upon HSV-1 infection and spread, apoptosis induction was observed in the skin, but not in brain tissues. While the two tissues elicited interferon (IFN-β) response upon HSV1 infection, IFN induction was more robust in the skin compared to the brain. Moreover, antiviral response to exogenous IFNβ treatment was much stronger in the skin compared to brain tissues. This observation was not related to the availability of the IFN receptor on cells’ surface. Taken together, our study demonstrates differential innate antiviral responses to HSV-1 infection that may be exploited in future development of selective and tissue-specific anti-viral treatments.     

ECD kidney transplantation outcomes are improved when matching donors to recipients using a novel creatinine clearance match ratio (CCMR)

Improved outcomes have been associated with various methods of size matching between expanded criteria (ECD) donors and recipients. A novel method for improved functional based matching was developed utilizing manipulation of Cockcroft‐Gault estimated creatinine clearances for donor and recipient. We hypothesized that optimal clearance‐based matches would have superior outcomes for both immediate graft function and long‐term graft survival. For the analysis, recipients of ECD kidneys in the Scientific Registry of Transplant Recipients (SRTR) transplanted between October 1, 1987 and August 31, 2011 were included. Univariate and multivariate analyses predicted the hazard ratio of graft failure and the odds ratio of requiring dialysis within the first week. A total of 25,640 ECD kidney transplants were analyzed. On multivariate analysis, higher creatinine clearance match ratio (CCMR) was associated with increased graft failure and odds of requiring dialysis within the first week (comparing highest ratio quintile versus lowest ratio quintile: HR 1.43, p < 0.001; OR 2.08, p < 0.001). This study suggests that ECD kidneys have improved outcomes when the recipient/donor CCMR is optimized.     

Straddle Injuries in Female Children and Adolescents: 10-year Accident and Management Analysis

Objective

To analyze unintentional straddle injuries in girls with regards to epidemiology, etiology and injury management.

Methods

The hospital database was retrospectively reviewed (1999–2009) for female patients managed for genital trauma. Patients were evaluated based on age, causative factors, type of injury, area of genitals affected, management and outcomes.

Results

Straddle injuries were documented in 91 girls with age ranging from 1 to 15 y (mean?=?6.3 y; median?=?6.1 y). The causes of injuries were falls at home (n?=?31) or outdoors (n?=?27), and sport activities (swimming pool n?=?11, skating n?=?11, bicycle n?=?9 and scooter n?=?2). Most of the injuries were lacerations. Injuries involved major labia (n?=?56), minor labia (n?=?45) and introitus vaginae (n?=?15). Twelve children received outpatient treatment. Inspection under anesthesia was performed in 79 patients, with 76 requiring sutures. While hematuria was observed in 18 patients, cystoscopy did not reveal lesions in the urethra or bladder. Associated injuries were femur fracture (n?=?1), lower extremity lacerations (n?=?4) and anal lesions (n?=?2). Follow-up investigations were uneventful; however one patient developed a secondary abscess and another secondary hyperplasia of the labia minor.

Conclusions

Falls and sports are major causes of straddle injuries with a peak at the age of six years. Lacerations are the most common injuries and often require surgical management. Urinary tract injuries and other associated injuries are relatively uncommon in girls with straddle injuries.     

Dental predictors of high caries increment in children.

A comprehensive set of dental variables was investigated to find the "best" combination of predictors for high caries increment in 7/8-year-old and 10/11-year-old children. Four populations with widely different caries prevalence were studied. Logistic regression analysis supplied multiple-input models by stepwise selection of predictors. A "low number of sound primary molars" was the best and most consistent predictor of high caries increment. The second best predictors were "high numbers of pre-cavity lesions on permanent first molars" (discolored pits and fissures in the younger age group and white spots on the smooth parts of buccolingual surfaces in the older age group). Inclusion of radiological variables did not substantially increase the quality of prediction. For practical application, models with various multiple inputs selected by stepwise procedures were compared with "fixed" three-input models. These three-input models resulted in predictive quality nearly equal to those of the multiple models. Traditional one-input models, containing DMFT or dmft, were inferior to the three-input models, particularly in the older age class. The lower the caries prevalence of the source data, the better was the prediction. As a summary measure characterizing the predictive performance of a model, we used the index "area under the receiver operating characteristic curve" A. For the 1984 data and the three-input models, the area was approximately 80%, and for the 1972 data, the area was 65-70%.