The intrauterine device, pelvic inflammatory disease, and infertility: the confusion between hypothesis and knowledge.

An earlier editorial made many false claims against the IUD and women. In many cases, the author extrapolated experience from the Dalkon Shield to today's IUDs. He even said the modern contraception has not reduced fertility, but data from at least 7 developing countries clearly refute that statement. Moreover he claims that the most female ambition is motherhood. Thus he blamed women for high fertility rates without acknowledging that women in developing countries have little control over fertility. Husbands determine when and how often to have intercourse and whether to use contraceptives or not. Women do not always have access to contraceptives. The author boldly stated that the IUD poses a threat to future fertility because it causes pelvic infections. The real threat is intercourse by which upper genital tract infections are transmitted. It is these sexually transmitted diseases that cause pelvic infections. The studies the author quoted have been found to have considerable bias and/or methodologic flaws. Some studies used as the comparison group women using contraceptive which lower the pelvic infection risk. Contemporary studies find no increased risk of infertility in copper and hormone IUD users, but instead show increased risk for multiple sex partners. Some studies do indicate an increased risk shortly after insertion which is due to insertion instrumentation used. The author even claimed that a Swedish study concluded that IUDs promote pelvic infection in patients with gonorrhea and chlamydia. But the Swedish study found no difference in pelvic infection risk between IUD and non-IUD, nonhormonal contraceptive users. Based on hundreds of millions of woman-years of worldwide experience, WHO claims modern copper and hormone releasing IUDs, when used as directed, may be the most effective and reliable reversible contraceptive method. This editorial based on flawed conclusions and misinformation does an injustice to the IUD and to women.     

Otoacoustic emissions as a screening test for hearing impairment in children

Transient evoked otoacoustic emissions (TEOAEs) are low amplitude sound waves produced by the healthy cochlea. They can be recorded with a microphone in the external ear. TEOAEs are abolished by hearing losses of 30 dB or more. The feasibility of using TEOAEs as a screening test for hearing loss in children was studied. TEOAE recordings were attempted in 56 children attending an audiology clinic. Recordings were possible from both ears in 52 children; of these 104 ears, 32 had hearing deficits of 30 dB or more. Hearing status was compared with the results of six TEOAE screening criteria. All criteria had a sensitivity of 1.00. Four standard TEOAE criteria yielded specificities of 0.46-0.58. Two new criteria derived from analysis of limited frequencies from the TEOAE waveform gave specificities of 0.76 and 0.82. It can be concluded that, when appropriate pass/fail criteria are employed, TEOAEs are a feasible screening test in children.     

The Fremantle Lead Study

Objective: To ascertain blood lead levels in a sample of preschool children from Fremantle, Western Australia, and to correlate these with possible risk factors.
Methodology The study was a cross-sectional prevalence survey of 120 children from day-care centres and 44 hospital inpatients. Blood lead and ferritin levels were determined and a risk factor questionnaire was completed by parents.
Results Of the 164 children 25.6% had lead levels above the NH&MRC goal (<10μg/dL). Nine of 133 (6.7%) had ferritin levels below 10 μg/L suggesting iron deficiency. Excessive blood lead concentrations as defined by the NH&MRC (>9μg/dL) related to: child's presence during house renovation (OR 3.35, P = 0.007, 95% Cl 1.39-8.81); Aboriginality (OR 6.4, P = 0.008, 95% Cl 1.6-24.9), and, in the 9-24 month age group, inversely to distance between home and a road carrying >7000 vehicles/day (r-0.56, P = 0.009, n = 24).
Conclusions A group of Fremantle children with unacceptably high blood lead levels has been identified. Renovation of older housing and Aboriginality are important risk factors.     

Systemic lupus erythematosus and reproductive function: a case-control study

Systemic lupus erythematosus characteristically afflicts women of reproductive age, yet the explanation for this feature is unknown. This hospital-based, case-control study of 109 incident cases of systemic lupus erythematosus and 109 randomly selected controls was conducted to search for risk factors related to reproduction. Women who were 34 years of age and younger had a crude risk of systemic lupus erythematosus 3.6 times that of older women, and women who were of minority races had a crude risk 4.8 times that of white women (P less than 0.001). Prior hysterectomy or tubal sterilization had a significant protective effect (odds ratio, 0.55; 95% confidence interval, 0.31 to 0.99). Endometriosis was associated with a twofold increased risk of systemic lupus erythematosus, although this was not statistically significant. The latter two findings are consistent with the hypothesis that retrograde menstruation may be an inciting factor for systemic lupus erythematosus in susceptible women.     

Traumatic flap displacement after LASIK

CASE REPORT: We present a case of traumatic displacement of corneal flap in the superior temporal quadrant 13 days after LASIK. The flap was repositioned after gentle irrigation of BSS, cleaned the interface and then drying the flap to verify its stability. In the next day the flap was adhered, clear cornea,smooth and visual acuity without correction was 1.00. DISCUSSION: We should try immediately to reposition the flap after traumatic displacement, as in this case.     

Prevention of cardiovascular disease in women: Role of the obstetrician-gynecologist

Cardiovascular disease poses a major threat to women's health. Obstetrician-gynecologists dominate the adult health care field in preventive services in the United States, and the scope of their preventive services should be broadened to encompass cardiovascular disease in women. Endogenous and exogenous risk factors jointly conyribute to a woman's cardiovascular risk profile; the risk of cardiovascular disease should be viewed as a multifactorial phenomenon with a continuous gradient of response. Three important risk factors—serum cholesterol, hypertension, and cigarette smoking—are amenable to change and should become a principal focus of women's health care. Although preventive medicine lacks the glamour and immediate rewards of obstetric and gynecologic interventions, the long-term benefits to the health of women are compelling.     

Auditory evoked potentials in patients with dementia of the Alzheimer type

Dementia of the Alzheimer type (DAT) disrupts the function of the central auditory nervous system as a result of temporal lobe pathology. Auditory brain stem response (ABR) and middle latency responses (MLR) were studied in a group of patients with DAT to determine whether a correlate of dementia existed in these electrophysiological potentials. Comparison of absolute and interwave latencies on ABR, and absolute latency and amplitude of the MLR in patients with DAT and normal aged controls showed no significant differences between groups for any measure. Further, no relationship with degree of dementia or temporal lobe involvement, as assessed through dichotic speech recognition studies, and auditory evoked potentials could be demonstrated. It was concluded that the temporal lobe atrophy and hypometabolism seen in DAT is not generally sufficient to disrupt the generating of ABR and MLR potentials; however, slow cortical and cognitive evoked potentials may be more sensitive to central auditory nervous system impairment in DAT.     

Fatal hemorrhage from legal abortion in the United States

Deaths from hemorrhage associated with legal induced abortion should not occur. Yet hemorrhage was the third most frequent cause of death from legal abortion in the United States between 1972 and 1979. This study was undertaken to document the scope of the problem, to identify risk factors for fatal hemorrhage and to recommend ways of preventing these deaths. Deaths were identified through the CDC's nationwide surveillance of deaths from abortions; information on numbers and characteristics of women having legal abortions was obtained from CDC and the Alan Guttmacher Institute. Twenty-four women died from hemorrhage after legal abortion in the United States from 1972 to 1979, for a death-to-case rate of 0.3 deaths per 100,000 abortions (95 per cent confidence interval 0.2 to 0.5). Women who died from hemorrhage were significantly older than those who died from other causes (27.6 versus 24.4 years; p less than 0.05). Documented uterine perforation or rupture was far more frequent among women who died from hemorrhage than those who died from other causes (71 versus 8 per cent; p less than 0.001). Women who sustained uterine perforation or rupture were over 1,000 times more likely to die from hemorrhage than those who did not. Deaths from hemorrhage can be eliminated by preventing uterine trauma during abortion and by rapidly diagnosing and treating hemorrhage if it occurs.     

Generation of allocation sequences in randomised trials: chance, not choice

The randomised controlled trial sets the gold standard of clinical research. However, randomisation persists as perhaps the least-understood aspect of a trial. Moreover, anything short of proper randomisation courts selection and confounding biases. Researchers should spurn all systematic, non-random methods of allocation. Trial participants should be assigned to comparison groups based on a random process. Simple (unrestricted) randomisation, analogous to repeated fair coin-tossing, is the most basic of sequence generation approaches. Furthermore, no other approach, irrespective of its complexity and sophistication, surpasses simple randomisation for prevention of bias. Investigators should, therefore, use this method more often than they do, and readers should expect and accept disparities in group sizes. Several other complicated restricted randomisation procedures limit the likelihood of undesirable sample size imbalances in the intervention groups. The most frequently used restricted sequence generation procedure is blocked randomisation. If this method is used, investigators should randomly vary the block sizes and use larger block sizes, particularly in an unblinded trial. Other restricted procedures, such as urn randomisation, combine beneficial attributes of simple and restricted randomisation by preserving most of the unpredictability while achieving some balance. The effectiveness of stratified randomisation depends on use of a restricted randomisation approach to balance the allocation sequences for each stratum. Generation of a proper randomisation sequence takes little time and effort but affords big rewards in scientific accuracy and credibility. Investigators should devote appropriate resources to the generation of properly randomised trials and reporting their methods clearly.