Single embryo transfer for all?

Historically to maintain live birth rates for women undergoing in vitro fertilisation (IVF), multiple embryos were transferred. Improvements in technology have meant a move to selective single embryo transfer (SET). Do we now have enough confidence in SET to make it mandatory?

Dropout rate and cumulative birth outcomes in couples undergoing in vitro fertilization within a funded and actively managed system of care in New Zealand.

OBJECTIVE: To determine the dropout rate between the first and second in vitro fertilization (IVF) cycles in a controlled population derived from a funded and actively managed system of care in New Zealand, including the reason for dropout and associated cumulative live birth rate. DESIGN: Retrospective cohort. SETTING: Multicenter IVF practice. PATIENT(S): Couples qualifying for publicly funded IVF treatment under New Zealand's Clinical Priority Assessment Criteria. Couples (n = 974) started treatment between July 2011 and June 2013, used their own gametes, and were eligible for up to 2 IVF packages of funded care (including the transfer of surplus embryos). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): IVF dropout rate, reason for dropout, and cumulative live birth rate. RESULT(S): A low IVF dropout rate between the first and second IVF cycle was reported within this controlled IVF population, with 10% of couples discontinuing treatment for reasons related to stress. The cumulative live birth rate in this "low dropout" population was 59% at the end of treatment, ranging from 72% (≤30 years) to 42% (38-39 years) according to female age. Most patients who discontinued for stress had a good prognosis, and a third of patients still had embryos in cryostorage. Only 30% of those who discontinued used the funded counseling services. CONCLUSION(S): A low dropout rate (10%) can be achieved within an actively managed IVF population. This was lower than previously reported, suggesting that prognosis, cost, and treatment management are the significant causes of dropout within the general IVF population. Couples with many embryos also require psychological support because of treatment fatigue or repeated transfers.

Tensions in the parent and adult child relationship: Links to solidarity and ambivalence.

Tensions are normative in the parent and adult child relationship, but there is little research on the topics that cause the most tension or whether tensions are associated with overall relationship quality. In this study, adult sons and daughters, age 22 to 49, and their mothers and fathers (N = 158 families, 474 individuals) reported the intensity of different tension topics and relationship quality (solidarity and ambivalence) with one another. Tensions varied between and within families by generation, gender, and age of offspring. Compared to tensions regarding individual issues, tensions regarding the relationship were associated with lower affective solidarity and greater ambivalence. Findings are consistent with the developmental schism hypothesis, which indicates that parent-child tensions are common and are the result of discrepancies in developmental needs that vary by generation, gender, and age.

Increasing compliance with a clinical practice guideline for fetal fibronectin testing and the management of threatened preterm labour: A quality improvement project.

OBJECTIVE: To increase adherence to a local hospital clinical practice guideline for the use of fetal fibronectin testing in women presenting with symptoms of threatened preterm labour. STUDY DESIGN: A quality improvement project using a multi-faceted implementation strategy. SETTING: National Women's Health, Auckland City Hospital; a tertiary referral maternity unit in Auckland, New Zealand. POPULATION: All obstetricians, junior obstetric doctors and hospital employed midwives. METHODS: A pre-education audit and survey, compulsory interactive educational intervention with audit feedback and provision of reminders followed by a post-education audit and survey one year later. MAIN OUTCOME MEASURES: Number of fetal fibronectin tests performed, proportion of tests performed meeting clinical criteria for testing and proportion of results managed according to hospital guideline. RESULTS: There was a 25% increase in the number of tests performed with an increase in the proportion that met clinical criteria for testing, 76% (31/41)-93% (51/55) (OR 4.1, 95% CI 1.2-14.2). Adherence to guidelines for clinical management according to fFN results changed over time, 80% (33/41)-95% (52/55) (OR 4.2, 95% CI 1.04-17.0). Clinician knowledge on some (but not all) indications for fFN testing improved. Education and reminders did not improve understanding of clinical scenarios that may result in a false positive fFN test. CONCLUSIONS: A multi-faceted approach of audit and clinician feedback, interactive education and reminders supports the implementation of a clinical practice guideline for the use of fFN as a preterm birth prediction test for women presenting with symptoms of threatened preterm labour.

EPHect - the Endometriosis Phenome (and Biobanking) Harmonisation Project - may be very helpful for clinicians and the women they are treating.

This article acts as a summary of the recently published papers by the World Endometriosis Research Foundation aiming to set up the Endometriosis Phenome and Biobanking Harmonisation Project.  The objective of this project is to standardise recording of patient history and characteristics, recording of surgical procedure and extent of disease as well as collection, processing and storage of specimens and consequently create a reliable resource for research into endometriosis.

Eligibility For And Enrollment In Medicare Part D Medication Therapy Management Programs Varies By Plan Sponsor.

Medicare Part D prescription drug plans must offer medication therapy management to beneficiaries with multiple chronic conditions and high drug expenditures. However, plan sponsors have considerable latitude in setting eligibility criteria. Newly available data indicate that enrollment rates in medication therapy management among stand-alone prescription drug plans and Medicare Advantage drug plans averaged only 10 percent in 2012. The enrollment variation across plan sponsors-from less than 0.2 percent to more than 57.0 percent-was associated with the restrictiveness of their eligibility criteria. For example, enrollment was 16.4 percent in plans requiring two chronic conditions versus 9.2 percent in plans requiring three, and 12.7 percent in plans requiring the use of any Part D drug versus 4.4 percent in plans requiring the use of drugs in specific classes. This variation represents inequities in access to medication therapy management across plans and results in missed opportunities for interventions that might improve therapeutic outcomes and reduce spending. The new Part D Enhanced Medication Therapy Management model of the Centers for Medicare and Medicaid Services has the potential to significantly increase the impact of medication therapy management by aligning financial incentives with improvements in medication use and encouraging innovation.

Update on the pharmacist shortage: national and state data through 2003.

PURPOSE: Aggregate Demand Index (ADI) survey results were used to describe the severity of the pharmacist shortage at the national and state levels and by practice site and impact on the U.S. population. METHODS: Time-series analysis was used to characterize national and state trends in the ADI from September 1999 through September 2003. The time trends for the distribution of ratings and the demand index by practice site were also examined. Historical data about retail prescriptions filled and related growth rates were compiled and compared. ADI survey results were also compared with data from other surveys. RESULTS: Over time, ADI data demonstrated a continuing national pharmacist shortage, as the ability to fill pharmacist vacancies was rated at least moderately difficult. A very slight downward trend in severity (slope = -0.008) was observed. Other survey series had similar findings. States with the most severe shortage levels tended to have large populations, while those with the lowest levels tended to have smaller populations. More states improved than worsened the severity of their shortage, with 30 states maintaining the same ADI rating. Although there was a high correlation between the retail prescription growth rate and the ADI (r = 0.84), there was a much greater decrease in prescription growth (73%) than ADI levels (6.5%). CONCLUSION: There was a sustained unmet demand for pharmacists throughout the United States from September 1999 through September 2003. More states moved toward having an adequate supply of pharmacists than toward having a more severe shortage of pharmacists, but the national ADI suggests that the system remains stressed.

Increased Use Of Prescription Drugs Reduces Medical Costs In Medicaid Populations.

We used data on more than 1.5 million Medicaid enrollees to examine the impact of changes in prescription drug use on medical costs. For three distinct groups of enrollees, we estimated the effects of aggregate prescription drug use-and, more specifically, the use of medications to treat eight chronic noncommunicable diseases-on total nondrug, inpatient, outpatient, and other Medicaid spending. We found that a 1 percent increase in overall prescription drug use was associated with decreases in total nondrug Medicaid costs by 0.108 percent for blind or disabled adults, 0.167 percent for other adults, and 0.041 percent for children. Reductions in combined inpatient and outpatient spending from increased drug utilization in Medicaid were similar to an estimate for Medicare by the Congressional Budget Office. Moving forward, policy makers evaluating proposed changes that alter medication use among the nearly seventy million Medicaid recipients should consider the net effects on program spending to ensure that scarce federal and state health care dollars are allocated efficiently.

Discovery of N-[2-[2-[[3-methoxy-4-(5-oxazolyl)phenyl]amino]-5-oxazolyl]phenyl]-N-methyl-4- morpholineacetamide as a novel and potent inhibitor of inosine monophosphate dehydrogenase with excellent in vivo activity.

Inosine monophosphate dehydrogenase (IMPDH) is a key enzyme that is involved in the de novo synthesis of purine nucleotides. Novel 2-aminooxazoles were synthesized and tested for inhibition of IMPDH catalytic activity. Multiple analogues based on this chemotype were found to inhibit IMPDH with low nanomolar potency. One of the analogues (compound 23) showed excellent in vivo activity in the inhibition of antibody production in mice and in the adjuvant induced arthritis model in rats.

Increasing Medicare part D enrollment in medication therapy management could improve health and lower costs.

Targeting efforts to improve medication adherence, especially among people with high health needs, can improve health and lower health care spending. To this end, Medicare requires that insurance plans that provide prescription drug (Part D) coverage offer specialized medication therapy management services to optimize medication use for enrollees with high drug costs, multiple chronic diseases, and multiple covered drugs. We analyzed a large random sample of Part D enrollees with diabetes, heart failure, and chronic obstructive pulmonary disease, to see whether poor adherence to recommended drugs was associated with higher Medicare costs. We found that beneficiaries with poor adherence had higher costs, ranging from $49 to $840 per month for patients with diabetes, for example. However, such beneficiaries were not uniformly more likely than others to be eligible for medication therapy management services. Aligning medication therapy management eligibility with a metric such as potentially preventable future costs holds promise for both improving the quality of care and reducing spending.

College student knowledge and attitudes toward emergency contraception.

BACKGROUND: This study explored male and female college students' knowledge of and attitudes toward emergency contraception pills (ECPs). STUDY DESIGN: A survey of 692 undergraduate college students (338 male and 358 female) was conducted at a mid-size university in northwest Pennsylvania during the Spring 2008 semester. RESULTS: Eighty-three percent of the participants had experienced sexual intercourse, and 52% of them had feared a pregnancy at least once. Only 17% of the participants indicated prior use of ECP. Seventy-four percent of the students had heard of emergency contraception (EC); however, less than one-third knew the prescription status, common side effects or mechanisms of ECP. Only 16% of the participants knew that ECP was available at their college health center. Fifty percent of the students reported that they would feel comfortable using ECP, and 58% felt that ECP should be available without a prescription. CONCLUSIONS: College students' knowledge level about EC is poor. There is a clear need for ECP as a pregnancy prevention method among college students and for better education about it.

Emergency contraceptive pill (ECP) use and experiences at college health centers in the mid-Atlantic United States: changes since ECP went over-the-counter.

OBJECTIVE: To investigate the availability of emergency contraceptive pills (ECPs) at college health centers since ECP went over-the-counter (OTC) in 2006. Related issues, such as distribution procedure, existence of a written protocol, personnel involved, contraindications, follow-up procedures, methods of advertising, and staff attitudes, were examined. PARTICIPANTS: The sample included 135 college and university health centers in the mid-Atlantic region of the United States. METHODS: Data were collected via telephone survey with the use of a 42-item survey instrument. RESULTS: Forty-three percent of schools reported distributing ECPs, for an average of 10.6 years. Major changes in ECP distribution and usage since ECP went OTC related primarily to protocol in ECP distribution, advertising for ECP services, and ECP accessibility to university students. CONCLUSIONS: College health centers are responding to the OTC status of ECP in a number of ways, primarily relating to their distribution procedures and advertising techniques.

Perceptions of social transgressions in adulthood.

People may react differently when individuals of different ages commit a social faux pas. Younger (22 to 35 years old) and older (65 to 77 years old) participants read vignettes where age of characters committing social transgressions varied (young vs. old). Participants rated whether the offended person would respond with engagement, confrontational, and avoidant behaviors and how much people would blame or forgive the transgressor. Multilevel models revealed endorsement of avoidant behaviors with older transgressors, confrontational behaviors with younger transgressors, and engagement behaviors with both. Levels of blame and forgiveness mediated this association, with less blame and greater forgiveness of older adults. Discussion focuses on the social input model and why adults may regulate reactions to interpersonal problems with older adults.

Changes in Medicaid prescription volume and use in the wake of Medicare Part D implementation.

Implementation of the Medicare drug benefit resulted in a major shift of prescription drug spending from Medicaid to Medicare. Data indicate that Medicaid programs experienced substantial changes in the volume and types of prescriptions used by enrollees. Medicaid prescription volume and total payments to pharmacies dropped by almost 50 percent in 2006. Generic dispensing rates increased 4.6 percentage points nationally. The mix of drug classifications also shifted, reflecting the younger makeup of the population that remains eligible for Medicaid prescription drug benefits. Still, patterns of use reflect the major mental and physical health needs of Medicaid enrollees.

A murine model of cigarette smoke-induced pulmonary inflammation using intranasally administered smoke-conditioned medium.

To date, few animal models of chronic obstructive pulmonary disease (COPD) exist that are ideal for the evaluation of pathophysiology, as they typically require many months of cigarette smoke exposure in inhalation facilities. Here we show that pulmonary inflammation and some of the inflammatory hallmarks of COPD can be induced in mice by cigarette smoke-conditioned media (CS) administered by the intranasal route. Balb/c mice were challenged with CS for up to 40 days. At the end of smoke treatment, mice were sacrificed and bronchoalveolar lavage (BAL) fluid collected. Total cell counts and cell differentials were performed. Enzyme-linked immunosorbent assays (ELISAs) for KC and tumor necrosis factor alpha (TNF-alpha) were performed on BAL fluid. Lungs and nasal cavities were examined histologically. Intranasal CS treatment significantly increased BAL neutrophils, lymphocytes, KC, TNF-alpha, and mucin. Changes in pulmonary reactivity to methacholine were also observed in mice challenged with CS for 40 days. The model described above demonstrates that within 1 to 8 weeks of intranasal instillation of CS, mice develop pulmonary inflammation and cellular lung changes that are characteristic of human COPD and therefore may be a good short-term in vivo model that can be utilized to monitor intervention strategies targeted for COPD.

Analysis of pharmacist and pharmacist-extender workforce in 1998--2000: assessing predictors and differences across states.

OBJECTIVE: To examine the impact of supply and demand factors on filled positions for pharmacists and pharmacist extenders (pharmacist technicians and aides) and assess differences across states through analysis of state-level pharmacist labor market data. DESIGN: Cross-sectional analysis. SETTING: United States. PARTICIPANTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: State-level counts of filled pharmacist and pharmacist-extender positions, wages, and various available demographic, health, policy, and other factors related to the pharmacist labor market. RESULTS: Across states, the total population and the number of community pharmacy prescriptions were very accurate predictors (R2 = 0.99) of the number of pharmacist and pharmacist-extender positions, and all other variables were insignificant after these two variables were controlled for. Pharmacists and pharmacist-extenders were positively correlated, and the ratio of the two was not related to observable policy-related variables. Outlying states, in terms of simple pharmacist-to-population ratios, were difficult to categorize. CONCLUSION: Future changes in prescriptions are likely to affect the pharmacist and pharmacist-extender labor markets. Across states, pharmacists and extenders relate as complements rather than substitutes. The number of pharmacist graduates and state-level regulations regarding technician-to-pharmacist ratios appears to have a small effect on filled positions across states.