A qualitative study of barriers to postpartum sterilization and women's attitudes toward unfulfilled sterilization requests

BACKGROUND: This longitudinal, qualitative study explores barriers to postpartum sterilization from the perspective of low-income minority women. We examine women's feelings and attitudes regarding a canceled or postponed procedure over time. STUDY DESIGN: We conducted structured, in-depth baseline interviews with 34 postpartum women with unfulfilled sterilization requests in a university hospital setting. Follow-up phone interviews were conducted at 6 weeks and 6 months postpartum. RESULTS: Reasons for unfulfilled sterilization requests included last-minute misgivings, maternal medical complications, lack of a valid Medicaid consent form, fear of the procedure and provider influence. Sense of autonomy regarding sterilization decision making and ability to obtain interval sterilization or initiate and/or successfully use reversible contraception influenced subsequent attitudes regarding an unfulfilled request. CONCLUSIONS: Sterilization counseling should include comprehensive information regarding the surgical procedure and associated risks and the development of a backup contraceptive plan, with particular emphasis on increasing contraceptive self-efficacy and autonomy in sterilization decision making.     

透明质酸修饰纳米胶束用于靶向肿瘤治疗及药物释放行为的研究进展

透明质酸(HA)是一种具有良好生物相容性、生物可降解性的天然线性多糖,通过细胞表面分化簇44(CD44)受体靶向肿瘤。其作为抗肿瘤药物传递载体广泛应用于肿瘤治疗领域,已成为肿瘤靶向给药系统研究的热点。CD44是透明质酸高亲和性的受体,因其在肿瘤细胞过表达,可以作为肿瘤标志物或靶向受体。许多肿瘤都表现出CD44受体的过度表达,如乳腺癌、结肠直肠癌、肝癌和胰腺癌等。CD44配体通过与纳米药物载体结合,可以提高纳米载体对肿瘤细胞的亲和力。HA结构中因含有CD44配体具备有效的肿瘤靶向效应而闻名,通过HA-CD44受体介导的内吞作用途径可以增强肿瘤细胞的摄取。本文对HA纳米胶束在临床肿瘤治疗中的进展以及其药物释放行为进行了综述,并表明HA的纳米胶束在肿瘤治疗中的巨大潜力。体内外研究表明,基于HA的纳米胶束是药物和基因特异性靶向肿瘤的传递方式,在临床肿瘤治疗中具有良好的应用前景。     

Mitral or aortic regurgitation: quantification of regurgitant volumes with cine MR imaging

A new, rapid magnetic resonance (MR) imaging method, cine MR imaging, was used to determine the regurgitant fraction (RF) in patients with left-sided regurgitant lesions. Right and left ventricular stroke volumes were determined with cine MR imaging and a modified Simpson formula in ten healthy volunteers and 23 patients known to have either predominant mitral (n = 17) or aortic (n = 6) regurgitation. RFs evaluated at cine MR imaging were compared in healthy persons and patients with mild, moderate, or severe regurgitation demonstrated at angiography (n = 10) and Doppler echocardiography (n = 13). Cine MR imaging depicted regurgitant blood flow in all 29 regurgitant lesions in 23 patients as areas of low signal intensity within the regurgitant chamber. The RF was 4% +/- 7% in healthy subjects and 12% +/- 12% in those with mild, 35% +/- 14% in those with moderate, and 63% +/- 5% in those with severe regurgitation. The RFs determined by two observers were similar.     

Physicians' perspectives on the uncertainties and implications of chromosomal microarray testing of children and families

Chromosomal microarray analysis (CMA) has improved the diagnostic rate of genomic disorders in pediatric populations, but can produce uncertain and unexpected findings. This article explores clinicians' perspectives and identifies challenges in effectively interpreting results and communicating with families about CMA. Responses to an online survey were obtained from 40 clinicians who had ordered CMA. Content included practice characteristics and perceptions, and queries about a hypothetical case involving uncertain and incidental findings. Data were analyzed using nonparametric statistical tests. Clinicians' comfort levels differed significantly for explaining uncertain, abnormal, and normal CMA results, with lowest levels for uncertain results. Despite clinical guidelines recommending informed consent, many clinicians did not consider it pertinent to discuss the potential for CMA to reveal information concerning biological parentage or predisposition to late‐onset disease, in a hypothetical case. Many non‐genetics professionals ordering CMA did not feel equipped to interpret the results for patients, and articulated needs for education and access to genetics professionals. This exploratory study highlights key challenges in the practice of genomic medicine, and identifies needs for education, disseminated practice guidelines, and access to genetics professionals, especially when dealing with uncertain or unexpected findings.     

Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy

Objective

Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers.

Study Design

We constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively.

Results

With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved.

Conclusion

A revised Medicaid sterilization policy could potentially honor women’s reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds.

Implication

Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year.     

Knowledge,attitudes & barriers to condom use among female sex workers and truck drivers in Uganda: a mixed-methods study

Background

There is limited documentation on knowledge, attitudes and barriers to condom use among female sex workers (FSWs) and truck drivers (truckers).

Objective

To explore knowledge, attitudes and barriers to condom use among FSWs and truckers operating along major transport corridors in Uganda

Methods

Structured questionnaires were administered to explore FSWs'' and truckers'' knowledge of and attitudes towards condom use among 259 FSWs and 261 truckers. Qualitative data were collected on barriers to condom use using focus group discussions. Quantitative data were analyzed using SPSS while qualitative data were audio-recorded, transcribed and thematically analyzed.

Results

Condom knowledge was high with 97% of FSWs and 95% of truckers agreeing with the statement, “using condoms properly and consistently reduces risk of HIV infection”. Attitudes towards condom use were generally favorable with 91% of FSWs and 82% of truckers agreeing with the statement, “condom use is the best method of HIV prevention”. Qualitative findings show that poverty, refusal to use condoms by male partners, alcohol use before sex and beliefs that condoms ‘kill the mood for sex’ remain key barriers to consistent condom use.

Conclusions

Consistent condom use among FSWs and truckers is still hampered by economic and relationship factors.     

Do instructions for over-the-counter pre-coital female contraceptives promote “perfect use”?

Background

This study was conducted to estimate the readability and related features of English-language over-the-counter (OTC) pre-coital female contraceptive (PFC) instructions.

Study Design

We identified and purchased all currently available OTC PFCs (n=8), including Encare (Contraceptive Gel® and Insert®), F.C. Female Condom®, Ortho Options® (Conceptrol,® Delfen® and Gyncol II Jelly®), Today Sponge® and VCF Vaginal Film®. Reading grade level was calculated using the Simple Measure of Gobbledygook. Text point size was measured and total number of graphics was tallied. Graphic dimensions were also measured. We also assessed OTC PFC instructions on four main criteria — derived from the “User-Friendliness Tool (UFT)” — including layout features, graphic characteristics, presence of a clear message and presentation of manageable information.

Results

Reading level ranged from 8th to 12th grade (mean±SD=10.0±1.2). Mean page length was 24.4±7.0 cm (9.6±2.76 in.), while average page width was 20.3±13.8 cm (7.99±5.43 in.). Average text point size was 7.9±2.3 (range=6-12). Illustrations, predominantly line drawings, were used throughout (range=3-11), and most were similar in size to a matchbox. None of the “How to Use” sections scored high in all criteria on the UFT.

Conclusions

“How to Use” sections of OTC PFC instructions should be revised to be easier to read and more user friendly. Ideally, the gap between “typical” and “perfect” contraceptive efficacy could potentially be narrowed if instructions were developed that the large majority of women could easily understand.