Advanced Prescription of Emergency Contraceptive Pills Among Adolescents and Young Adults.

OBJECTIVE: To examine healthcare providers' adherence to professional recommendations for advanced prescription of emergency contraceptive pills (ECPs). METHODS: We conducted a retrospective chart review of 432 visits by 282 unique nonpregnant women 14 to 25 years of age seen at an obstetrics and gynecology teaching clinic to determine the percentage of visits during which advanced prescriptions of ECPs were provided when indicated. A logistic regression model, which accounted for nonindependent observations through generalized estimating equations, was used to identify factors associated with the provision of ECP advanced prescriptions. RESULTS: Approximately one-fifth of eligible visits (19.9%) and eligible patients (19.1%) had documentation of an ECP advanced prescription when indicated. Healthcare providers in this clinical setting were more likely to prescribe ECPs to adolescents and women whose primary contraceptive methods were associated with higher failure rates in typical use, such as condoms. Compared with women aged 20 to 25 years, the adjusted odds ratio of receiving an advanced prescription for ECPs was 5.94 (95% confidence interval [CI] 2.85-12.41) for adolescents. Compared with users of depot medroxyprogesterone acetate, the adjusted odds ratio was 4.25 (95% CI 1.62-11.15) for condom users, and 3.90 (95% CI 1.54-9.86) for users of other short-term hormonal contraceptives. CONCLUSIONS: Despite clear professional recommendations for ECP advanced prescriptions for all women at risk for unintended pregnancy, a substantial gap exists between this standard of care and routine clinical service provision in an obstetrics and gynecology teaching clinic.

Early events in the cellular formation of proparathyroid hormone.

Early events in the cellular synthesis and subsequent transfer into membrane-limited compartments of pre-proparathyroid hormone (pre-proPTH) and proparathyroid hormone (proPTH) were investigated by electrophoretic analyses of newly synthesized proteins in subcellular fractions of parthyroid gland slices pulse-labeled for 0.5-5 min with [(35)S] methionine. During these short times of incubation, both pre-proPTH and proPTH were confined to the microsomal fraction. Labeled pre-proPTH and proPTH were detected in a 30-s interval between 0.5 and 1.0 min of incubation. The radioactivity in proPTH became relatively constant between 3 and 5 min, whereas the radioactivity in ProPTH increased markedly over this period. When corrected for the known content of methionine in the prohormone and the prohormone, we found four times as much radiolabeled prohormone as prehormone between 0.5 and 1.0 min of synthesis. Sequestration of labeled prohomrone into endoplasmic reticulum compartments was shown by treatment of the microsomal fraction with chymotrypsin and trypsin, which resulted in the degradation of the prehormone but not of the prohormones. Approximately 50 percent of pre-prohormone and 25 percent of prohormone were released from the microsomes by their extraction with 1.0 M KCl, whereas 80-90 percent of both was released by treatment with Triton X-100. These results in intact cells support the signal hypothesis proposed by Blobel and his co-workers in studies utilizing cell-free systems, inasmuch as the results indicate transfer of prohormone into the cisternal space of the rough endoplasmic reticulum concomitant with the growth of the nascent polypeptide chain. Appearance of membrane-sequestered proPTH takes place without entry of pre-proPTH into the cisternal space, suggesting that proteolytic removal of the leader peptide occurs during transfer of the polypeptide through the lipid bilayer. Further evidence in support of this process is that pre-proPTH is only partly extracted from the microsomes by treatment with 1.0 M KCl, suggesting that a substantial fraction of the nascent pre-proPTH is integrally inserted into the membranes before it is cleaved to form proPTH.

Calcitonin messenger RNA encodes multiple polypeptides in a single precursor.

Recombinant DNA techniques were used to analyze the structure of the messenger RNA encoding a precursor of calcitonin, a small calcium-regulating hormone of 32 amino acids. Analyses of the nucleotide sequences of cloned complementary DNA's comprising the entire coding sequence of the messenger RNA revealed that calcitonin is flanked at both its amino and carboxyl termini by peptide extensions linked to the hormone by short sequences of basic amino acids. The location of glycine next to the carboxyl terminal prolinamide of calcitonin is consistent with indications that glycine is required for the enzymatic amidation of proline to the prolinamide. During cellular biosynthesis, calcitonin arises from a large precursor protein by cleavages at both amino and carboxyl terminal residues of the hormone. These findings raise questions concerning the regulation of these cleavages and the potential biological functions of the precursor extensions derived from these cleavages.

Promotion of Long-Acting Reversible Contraception Among Adolescents and Young Adults.

INTRODUCTION: Intrauterine devices and contraceptive implants are recommended as first-line contraceptives by health care professional societies. However, uptake among US women lags substantially behind other developed countries. Little information is available on the extent to which clinicians document discussion about long-acting reversible contraception (LARC) in this patient population. We sought to determine the frequency with which clinicians document LARC discussion with eligible women aged 14 to 25 years in a training clinic and evaluate factors associated with LARC discussion and uptake. METHODS: We conducted a retrospective chart review of all visits of nonpregnant women aged 14 to 25 years seen at an obstetrics and gynecology resident physician clinic during a calendar year. A logistic regression model was used to assess demographic factors associated with LARC education and uptake. RESULTS: Among 450 visits by eligible patients, LARC discussion was documented during 47.8% (215/450) of visits. Among visits with documentation of LARC counseling, 45.6% (98/215) had documentation of a LARC placement plan. Among patients who decided to initiate LARC, 40.8% (40/98) had a device placed at the same visit. LARC placement was documented during 8.9% (40/450) of visits. Clinicians documented LARC counseling for women aged 14 to 19 years more frequently than for women aged 20 to 25 years. Compared with women who did not use any method of contraception, clinicians documented LARC counseling less frequently for women who used short-term hormonal contraception. DISCUSSION: Clinicians in a training clinic did not document LARC counseling for more than half of eligible patients. Every clinical visit is an opportunity to assess risk of unintended pregnancy and ensure that contraceptive needs are addressed.

Physician Adherence to Sexually Transmitted Infection Screening Guidelines in an OB/GYN Teaching Clinic in Hawai'i.

Rates of chlamydia (CT) and gonorrhea (GC) have risen for the first time in the United States since 2006. Certain population groups are disproportionately affected by these sexually transmitted infections (STIs) as well as HIV. The Centers for Disease Control and Prevention (CDC) and professional societies have published screening guidelines for these STIs for women under the age of 25. We aimed to quantify physician adherence to GC/CT and HIV screening guidelines and to determine demographic factors associated with GC/CT and HIV screening recommendations among women 14-25 years old in Honolulu, Hawai'i. We conducted a retrospective chart review of all visits to an OB/GYN teaching clinic in 2014 to determine rates of STI screening recommendations and evaluate differences in screening recommendations by demographic factors such as patient age, race, insurance type, visit type, and visit number during the study period. Electronic medical records of 726 visits by 446 patients were reviewed. Among visits by patients with indications for screening, 71.0% and 21.6% received screening recommendations for GC/CT and HIV, respectively. Age group, race, and visit type were significantly associated with receiving screening recommendations. A lack of appropriate documentation regarding the assessment of risk factors for GC/CT and HIV screening was observed. Emphasis should be placed on more thorough ascertainment and documentation of patients' risk factors for STI acquisition to determine screening needs at each clinical visit based on professional guidelines, as substantial public health benefits may be gained through the identification and prompt treatment of GC/CT and HIV infections.

The use of Tc-99m MDP bone scanning in the study of vascularized bone implants: concise communication.

The extent to which the nutrient artery alone is capable of maintaining bone growth in the immature animal was studied by excision and reimplantation of the upper tibia in two groups of puppies. In one group the reimplant was totally devascularized, and in a second group attempts were made to preserve the nutrient vessels to the reimplant. Technetium-99m methylene diphosphonate (Tc-99m MDP) was used to assess the effectiveness with which the nutrient circulation was maintained. With one exception the Tc-99m MDP scans proved to be reliable in indicating the potential for continued growth after reimplantation. It was found that the nutrient artery alone is capable of maintaining longitudinal bone growth in metaphyseal reimplants in immature animals. Complete devascularization results in cessation of growth. The Tc-99m MDP bone scan should prove of critical importance in the assessment of free vascularized transplants of immature bone.

Utility of two-dimensional echocardiography in suspected ascending aortic dissection.

The value of 2-dimensional echocardiography (2-D echo) in patients with suspected ascending aortic dissection was assessed. During a 5.5-year period, 56 consecutive patients underwent bedside 2-D echo for unexplained chest pain possibly due to ascending aortic dissection. Patients with obvious aortic dissection who proceeded directly to aortography were excluded and in all 56 study cases, 2-D echo was the initial diagnostic test. Using standard criteria, 2-D echo correctly identified all 13 patients with ascending aortic dissection. There were 5 false-positive study results and 38 true-negative results, yielding a sensitivity of 100%, specificity of 88% and overall diagnostic accuracy of 91%. In the group of 13 patients with confirmed ascending aortic dissection, 2-D echo identified 4 with pericardial fluid, and 3 of these patients (75%) died within 24 hours. In comparison, 7 patients in the group of 43 without confirmed dissection had pericardial fluid by 2-D echo and only 1 died (p less than 0.001). Finally, in the group of 38 patients with true-negative results, 2-D echo provided useful information in 16 (42%) that assisted or was essential in establishing an alternative diagnosis. However, 5 patients in this group had type III dissection and in none was it identified by 2-D echo. Thus, our data indicate that 2-D echo represents a reliable noninvasive method for rapidly diagnosing ascending aortic dissection at the bedside; offers important prognostic information which is directly related to the presence of pericardial fluid, and provides useful additional information which assists or establishes an alternative diagnosis when ascending aortic dissection is absent.(ABSTRACT TRUNCATED AT 250 WORDS)

Mucous plugging simulating pulmonary embolism in patients with quadriplegia.

Two quadriplegic patients suddenly lost consciousness and were found to have an elevated alveolar-arteriolar oxygen gradient. Their chest x-ray films were normal. Perfusion scintiscans of their lungs showed large areas with markedly reduced or absent perfusion. Ventilation scintiscans demonstrated absent or decreased ventilation to the hypoperfused areas, suggesting mucous plugging. In quadriplegic subjects who have an ineffective cough, acute mucous plugging can produce the sudden onset of hypoxia with essentially normal chest x-ray films, thus mimicking acute pulmonary embolism.

Metabolism of amino- and carboxyl-sequence immunoreactive parathyroid hormone in the bovine: evidence for peripheral cleavage of hormone.

Radioimmunoassays that detect specifically peptide sequences within either the biologically active amino region (N-assay) or inactive carboxyl region (C-assay) of parathyroid hormone (PTH) were used to evaluate the metabolism of PTH during and after infusion and injection of homogeneous (containing less than 0.1% hormonal fragments) intact bovine PTH (bPTH) into calves. During continuous infusions of hormone, when constant blood levels of immunoreactive PTH were reached, a dissociation between the concentrations of amino versus carboxyl immunoreactivity was observed; concentrations of hormone measured by the C-assay rose to a level of approximately three times higher than that measured by the N-assay. Analysis by gel filtration of immunoreactive PTH in plasma samples from calves after injection of hormone showed the rapid disappearance of intact hormone (N- and C-assays) and the appearance of a large fragment detected by the C-assay but not by the N-assay. The hormonal fragment lacked antigenic determinants within the amino peptide sequence required for biologic activity. No additional fragments of PTH were detected by gel filtration using the N- and C-assays. No detectable conversion of intact PTH to hormonal fragments occurred during incubation in vitro in bovine serum. The results are consistent with the concept that PTH is metabolized after entry into the circulation at peripheral sites located outside the vascular space, resulting in the rapid disappearance from blood of intact hormone and the appearance of a biologically inactive hormonal fragment(s). These studies done in calves agree with earlier studies done in dogs and man and point to the existence in mammals of common pathways for the peripheral metabolism of PTH.

The radiology of chest trauma.

This paper deals with chest trauma, both blunt and penetrative. The emphasis is on the significance of various manifestations of trauma and the indications for further radiologic study.

Magnetic resonance imaging of injury to the lateral ankle ligaments.

To establish the value of magnetic resonance imaging in determining which patients with ankle sprains will benefit from surgical treatment, 1 uninjured volunteer and 15 patients with acute, subacute, and chronic injuries of the lateral ankle ligaments were imaged at 1.0 tesla using a fast imaging with steady-state precision three-dimensional technique and 1.5-mm slice thickness. A dedicated knee coil was used to hold the foot in a neutral or plantar-flexed position. In cases of acute, low-grade injuries, fraying of the anterior talofibular ligaments with intact calcaneofibular ligaments was observed in the presence of edema and hemorrhagic fluid. In cases of acute, high-grade sprains, the calcaneofibular ligament appeared wavy or was visualized only partially or not at all. Subacute injuries showed ligament disruption; chronic lesions, on occasion, showed atrophy of the calcaneofibular ligament but no edema or hemorrhagic fluid. These findings showed a good qualitative correlation with the results of graded stress radiography. Magnetic resonance imaging can definitely determine the ligaments involved in lateral ankle sprains and provide useful anatomic information in cases in which acute or reconstructive surgery is contemplated. However, the magnetic resonance imaging findings do not directly correlate with degree of instability and do not replace those of physical examination or routine radiographic studies.

The "mucous plug syndrome". A pulmonary embolism mimic.

Reported are ten instances of major bronchial obstruction by mucous plugs in eight patients during which the clinical features resembled pulmonary embolism. Perfusion lung studies showed significantly diminished perfusion of the involved portions of the lungs. The chest radiographs generally did not, however, reflect the severity of the airway obstruction and in some instances were completely normal. The ventilation studies indicated the extent and severity of the obstruction and matched with the perfusion scans. Pulmonary arteriograms were performed in three patients and gave direct evidence of focally diminished lung perfusion without embolism. The physiologic mechanisms underlying the condition are discussed.

The preauricular sulcus.

The preauricular sulcus of the iliac bone has been described by some as a characteristic of the female pelvis. The author investigated this possibility in a review of the pelvic radiographs of 100 men and 200 women. The results indicate that the preauricular sulcus is indeed a female characteristic which may be observed in approximately 25% of women.

Fibreoptic studies of the aortic valve in dogs.

The study describes a method for visualisation of the aortic valve in the intact animal using a non-obstructive endoscopic system. Clearing of blood from the field of vision is achieved by the rapid injection of saline during a period of asystole.

The radiographic findings in acute silicosis.

The radiological features of 4 cases of acute silicosis in sandblasters are described and correlated with the pathological findings. Alveolar involvement was more extensive than in chronic silicosis; in 2 cases an alveolar exudate similar to that found in alveolar proteinosis was present. The radiological changes in acute silicosis differ substantially from those in classical silicosis, mainly on the basis of the differing alveolar response.

Pneumocystis carinii infection of the lung: radiologic and pathologic correlation.

The incidence of Pneumocystis carinii infection of the lung was determined in 100 consecutive autopsies on patients with hematologic malignancies and in a control group of 50 patients with acute myocardial infarction and chronic obstructive pulmonary disease. Thirteen instances of infection were found in the study group and one instance in the control group. Of the 14 patients with P. carinii infection, five were classified as uncomplicated P. carinii pneumonia with typical host response and five had no evidence of any host response to the presence of the organisms. Four cases were impossible to assess because of complicating bacterial, viral, or fungal pneumonia. The five patients with the typical histologic response to the presence of P. carinii organisms all showed diffuse pulmonary densities on the chest radiographs in accordance with the classic descriptions of P. carinii pneumonia. The five without any evidence of host response to the presence of P. carinii organisms showed no evidence of parenchymal disease on chest radiographs. The finding of P. carinii organisms in the lung is not necessarily an indication of clinically significant disease and, from this study, it seems that chest radiography is of considerable importance in determining the significance of such infestation.

CT recognition of acute aortic dissection.

Twenty-six patients with suspected acute aortic dissection were investigated using computed tomography (CT) as the primary mode of investigation. The diagnosis was controlled by aortography or surgery or both. There were no false-positive or false-negative studies using CT. Aortography was performed on 19 of the 21 patients with aortic dissection and was positive in each instance. However, in two illustrated cases, CT indicated proximal or type A aortic dissection, whereas the corresponding aortograms indicated distal or type B aortic dissection. In two of the 21 acute aortic dissections, only CT was performed, and in both instances surgical confirmation was obtained. The results suggest that CT is at least as accurate as aortography in the diagnosis of acute aortic dissection.