The effects of losartan or angiotensin II receptor antagonists on cartilage: a systematic review.

OBJECTIVE: The aim of this study is to analyze the latest evidence on the effects of losartan or Ang II receptor antagonists on cartilage repair, with a focus on their clinical relevance. DESIGN: The PubMed, Embase, and Cochrane Library databases were searched up to November 12th 2021 to evaluate the effects of losartan or Ang II receptor antagonists on cartilage repair in in vitro studies and in vivo animal studies. Study design, sample characteristics, treatment type, duration, and outcomes were analyzed. The risk of bias and the quality of the eligible studies were assessed using the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE) risk of bias assessment tool and Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies (CAMARADES). RESULTS: A total of 12 studies were included in this systematic review. Of the 12 eligible studies, two studies were in vitro human studies, three studies were in vitro animal studies, one study was an in vitro human and animal study, and six studies were in vivo animal studies. The risk bias and quality assessments were predominantly classified as moderate. Since meta-analysis was difficult due to differences in treatment type, dosage, route of administration, and method of outcome assessment among the eligible studies, qualitative evaluation was conducted for each study. CONCLUSIONS: Both in vitro and in vivo studies provide evidence to demonstrate beneficial effects of Ang II receptor antagonists on osteoarthritis and cartilage defect models across animal species.

Cystic fibrosis foundation position paper: Redefining the CF care model.

Specialized care is provided to people with cystic fibrosis (pwCF) by interdisciplinary teams nested within the CF Foundation's accredited care center network. This network allows for standardization of the care model, implementation of clinical care guidelines, efficient communication, and outcomes reporting. Recent developments have impacted this care model. Increased access to CFTR modulator therapies has improved overall health for many, although not all pwCF. The COVID-19 pandemic resulted in a rapid adoption of telemedicine and remote monitoring to ensure continuity of CF care. A collaboration of care providers, pwCF, and parent caregivers reevaluated key aspects of the current care model and considered potential modifications based on a widening range of needs. Available evidence was used to evaluate components of routine clinical practice and identify potential adaptations to care. The review included identification of patient characteristics warranting intensive monitoring, while embracing patient-centric care, and emphasizing the integration of telemedicine and at-home health technologies. Despite the changing landscape, the importance of the relationship between pwCF, their support system, and the care team was confirmed as a timeless and foundational aspect of the care model. Shared decision making, partnership, and coproduced care plans between pwCF and their CF care teams guide the best adaptations of the care model to support individual priorities and wellbeing. As health care advances and pwCF age, further research is needed to understand the impact of the care model on long-term health outcomes and to identify best practices that support pwCF to live longer healthier lives.

Levonorgestrel implants (Norplant II) for male contraception clinical trials: combination with transdermal and injectable testosterone.

Recent studies demonstrate that combinations of androgens and progestagens are highly effective in the suppression of spermatogenesis in normal volunteers. To test whether progestagen and androgen delivery systems designed to produce steady serum levels will be as effective as other androgen plus progestagen combinations, we compared Norplant II and testosterone (T) transdermal patch to T patch alone on the suppression of spermatogenesis in normal men. Thirty-nine healthy male volunteers (age, 20-45 yr) were randomly assigned to one of two groups. Group 1 (n = 19) received two transdermal T patches daily (Testoderm TTS, each patch designed to deliver about 5 mg/d T) alone, and group 2 (n = 20) received combined Norplant II [Jadelle, four capsules delivering approximately 160 microg/d levonorgestrel (LNG)] plus T patch. Neither of these regimens were very effective, with suppression of spermatogenesis to severe oligozoospermia occurring in less than 60% of subjects. We then expanded the study to include two more groups to determine whether T patch or Norplant II was the main factor causing the inadequate suppression of spermatogenesis. Another 29 subjects were randomized to one of two groups. Group 3 (n = 15) received oral LNG (125 microg/d) plus T patch, and group 4 (n = 14) received Norplant II plus T enanthate (TE) injection (100 mg/wk i.m.). After a pretreatment phase of 4 wk, all subjects received treatment for 24 wk, followed by a recovery period of 12-24 wk. Steady-state serum LNG levels (800-1200 pmol/liter) were achieved from wk 3-24 after Norplant II insertion and decreased rapidly after the removal of the implants at wk 24. Trough serum LNG levels after oral LNG administration were at a comparable range (940-1300 pmol/liter). Azoospermia was achieved in 24%, 35%, 33%, and 93%, and severe oligozoospermia (<1 x 10(6)/ml) developed in 24%, 60%, 42%, and 100% of the subjects in groups 1, 2, 3, and 4, respectively, during treatment phase. All subjects in the Norplant II plus TE groups had persistent sperm concentrations less than 3 x 10(6)/ml from wk 12 until the end of treatment. Concomitant with the marked suppression of spermatogenesis in the Norplant II plus TE group, serum FSH and LH levels were most decreased in this group compared with all other groups. In the T patch-only group, serum SHBG was not suppressed, and total serum T was higher than baseline levels. In the other three groups administered progestagens, serum SHBGs were significantly suppressed, and serum total T remained similar to baseline levels. Serum free T levels were not changed in any group. Except for a suppression of serum high-density lipoprotein cholesterol, there was no significant change in weight, hematocrit, clinical chemistry, or prostate-specific antigen levels in any of the treatment groups. Although more efficacious than T patch alone, Norplant II or oral LNG plus T patch was not as effective in suppressing spermatogenesis to severe oligo- or azoospermia as in previous reports using oral LNG plus TE. This relative lesser efficacy occurred despite the achievement of serum LNG levels by Norplant II that were equivalent to those reported after administration of oral LNG. Substituting the transdermal T delivery system with TE injections resulted in very effective suppression of sperm output. The difference in spermatogenesis suppression of these combined regimens is likely due to less T delivered by the transdermal patch compared with the TE weekly injections. We conclude that Norplant II implants plus TE 100 mg/wk were very efficient in suppressing spermatogenesis to a level acceptable for contraceptive efficacy. This study demonstrates that the dose or route of administration of androgens is critical for sperm suppression in combined androgen-progestagen regimens for hormonal male contraception.

Dynamic urethral pressure profilometry pressure transmission ratio: what do the numbers really mean?

Sixty-three women with genuine stress urinary incontinence were evaluated urodynamically both before and after modified Burch colposuspension to determine the association between pressure transmission ratio and leakage of urine during dynamic urethral pressure profile and the effect of surgery on pressure transmission ratio. Preoperatively, there was no difference in pressure transmission ratios between urethral pressure profiles associated with leakage of urine and those without urine leakage. Postoperatively, there were differences in pressure transmission ratios between leak and nonleak profiles in the sitting full and supine positions (P less than .001). We could not determine a threshold pressure transmission ratio that was more characteristically associated with leakage of urine. Finally, preoperative pressure transmission ratios were not associated with surgical success, but the higher the postoperative pressure transmission ratio, the more likely the surgery was to be successful (P = .023). In addition, the greater the difference between preoperative and postoperative pressure transmission ratios, the more likely was a cure (P = .011). The pressure transmission ratio may not be helpful in discriminating leak from nonleak dynamic urethral pressure profiles, and there may not be a threshold pressure transmission ratio below which patients characteristically leak urine. However, comparison of preoperative and postoperative pressure transmission ratios is helpful in determining the adequacy of surgical correction of the anatomical defect associated with genuine stress incontinence.

Attenuation of protection with repeated cromolyn dosing before exercise challenge in subjects with asthma.

Though cromolyn sodium exhibits tachyphylaxis in laboratory models of allergy, this pattern has not been identified in clinical use or in human asthma provocation models. We looked for it using a treadmill exercise challenge scheme that had previously confirmed cromolyn's protective effect. Twelve exercise-sensitive asthmatic volunteers received in random order, 12 20-mg cromolyn inhalations, 12 placebo inhalations, and 11 placebo inhalations with a final 20-mg dose of cromolyn. Each regimen was given over a three-day period, with the final dose administered 30 minutes before exercise. Subjects' respiratory functions were measured before and repeatedly after exercise with body plethysmography and peak flow rates. Beginning six minutes after the end of exercise, parameters measured after single-dose cromolyn and placebo administration differed in all endpoints at most of the measurement intervals. Results with 12-dose cromolyn pretreatment were significantly different from those seen with placebo only at 40 minutes after exercise, whereas single- and multiple-dose cromolyn results differed at 20 and 30 minutes. Cromolyn accelerated recovery from exercise-induced falls in lung function; this effect was attenuated with multiple dosing. These results are consistent with development of tachyphylaxis.

Intrauterine device practice guidelines: medical conditions.

PIP: Contraception selection poses special challenges to women with pre-existing medical problems and clinicians often lack the knowledge to counsel these women. The IUD represents an excellent option for many US women with medical problems. Because IUDs have no direct systemic effects other than increasing circulating immunoglobulins and possibly copper ions, they are unlikely to affect a woman's underlying disease process or to interact with medications used in disease treatment. Currently available IUDs may be appropriate for women with cardiovascular disease, diabetes mellitus with vascular disease, hematologic disorders, neurologic conditions, and psychiatric disorders. Other candidates for IUD use include women with a history of breast cancer or other hormone-sensitive cancers, active liver disease, hypertriglyceridemia, a sensitivity to hormonal contraception, and smokers over 40 years old. IUDs are contraindicated in women with diseases that increase their vulnerability to infection (e.g., AIDS, leukemia, and intravenous drug abuse), diseases or medications that produce profuse uterine bleeding, and conditions that distort the uterine cavity. Given the deleterious impact of unintended pregnancy on the clinical course of many diseases, information on contraception for women with pre-existing medical conditions should be more broadly disseminated among clinicians.^ieng

Neutralizing pH of lidocaine reduces pain during Norplant system insertion procedure.

The acidity of lidocaine used as a local anesthetic during the insertion of Norplant System capsules can cause patient discomfort. Buffering lidocaine with sodium bicarbonate significantly reduced pain scores reported by 46 women who participated in this randomized, double-blind study. Derived from a pain scale of 1 to 10, the mean difference in reported pain scores with and without buffering was 1.17 (P = 0.0098) with women using themselves as controls, for an average reduction in pain of 29%. Because this added step minimized patient discomfort, it might make the Norplant System a more attractive option for women apprehensive about insertion pain.

PIP: At the Harbor-UCLA Medical Center in Torrance, California, 46 consecutive women, 17-34 years old, seeking the contraceptive implant Norplant were randomly assigned to either the group that first received three infiltrations of lidocaine buffered with 7.4% sodium bicarbonate (pH 6) followed by 2% unbuffered lidocaine (pH 7.27) or the group that received these medications in reverse order. Researchers aimed to determine whether the addition of sodium bicarbonate to the lidocaine solution would affect the discomfort/pain when providers inserted the Norplant System. 36 of the women were Hispanic. Vaginal childbirth was the worst pain most women (32) had experienced in the past. 30 of the 46 women experienced less pain with the buffered solution than with the unbuffered solution. On the pain scale of 1 (no pain) to 10 (worst pain in their lives), the pain score fell by 1.17 points (29%) with the buffered solution (p = 0.0098). These results suggest that, if providers used buffered lidocaine, women who were apprehensive about insertion pain might be more likely to accept the Norplant system for contraception.

Evaluation of prostate-specific antigen as a quantifiable indicator of condom failure in clinical trials.

The ability of condoms to retain all elements of semen during intercourse has been assessed by postcoital visual inspection and in vitro permeability studies. Yet, these observations may not be sufficiently precise or realistic. This pilot study evaluated prostate-specific antigen (PSA) as a semen marker of inapparent failure of the condom barrier under conditions of actual use. Twelve couples collected samples from the vagina and surfaces of the condom using sterile cotton swabs. We obtained precoital and postcoital samples for 24 acts of unprotected intercourse, 54 acts of intercourse using intact condoms, and 40 acts of intercourse using condoms that had been deliberately punctured. We used electrophoresis to determine the amount of PSA present in the samples. PSA was detected in 100% (24/24) of vaginal samples collected immediately after unprotected intercourse and in none of the vaginal samples collected more than 24 h after intercourse (0/90). PSA was also present in 98% (83/85) of the samples collected from the inside of the condom that had failed during intercourse. Excluding uses where the condom failed during intercourse, PSA was detected in 2% (1/47) of the postcoital vaginal samples collected after use of intact condoms and in 41% (14/34) of the samples collected after use of condoms with known 1-mm punctures. We conclude that PSA shows great promise as a semen biomarker in clinical trials of barrier methods. We recommend that future studies further investigate the ability of this biomarker to identify condom failures and quantify the extent of semen exposure associated with various types of condom failures.

PIP: The ability of condoms to retain all elements of semen during intercourse has been assessed by postcoital visual inspection and in vitro permeability studies. Yet, these observations may not be sufficiently precise or realistic. This pilot study evaluated prostate-specific antigen (PSA) as a semen marker of inapparent failure of the condom barrier under conditions of actual use. 12 couples collected samples from the vagina and surfaces of the condom using sterile cotton swabs. The authors obtained precoital and postcoital samples for 24 acts of unprotected intercourse, 54 acts of intercourse using intact condoms, and 40 acts of intercourse using condoms that had been deliberately punctured. They used electrophoresis to determine the amount of PSA present in the samples. PSA was detected in 100% (24/24) of vaginal samples collected immediately after unprotected intercourse and in none of the vaginal samples collected more than 24 hours after intercourse (0/90). PSA was also present in 98% (83/85) of the samples collected from the inside of the condom that had failed during intercourse. Excluding uses where the condom failed during intercourse, PSA was detected in 2% (1/47) of the postcoital vaginal samples collected after use of intact condoms and in 41% (14/34) of the samples collected after use of condoms with known 1-mm punctures. The authors conclude that PSA shows great promise as a semen biomarker in clinical trials of barrier methods. They recommend that future studies further investigate the ability of this biomarker to identify condom failures and quantify the extent of semen exposure associated with various types of condom failures.

The intrauterine contraceptive device.

The intrinsic appeal of the convenience and effectiveness of the IUD has increased interest in these devices in the United States in recent years. Understanding the uniqueness of the Dalkon Shield experience and applying the lessons learned about appropriate candidate selection should continue to reduce any lingering liability concerns. One lawsuit has been filed against the copper IUD in the 12 years that it has been available in the United States. If legislation requiring insurance coverage for IUDs and other prescription contraceptive agents continues to be passed by more states, the use of IUDs will continue to grow. The introduction of new IUDs with different side-effect profiles will expand the number of US women who can and will be interested in using this method of birth control.

Counseling issues and management of side effects for women using depot medroxyprogesterone acetate contraception.

Patients satisfaction is crucial to maximizing long-term utilization and efficacy of any contraceptive method. Satisfaction is enhanced when appropriate preutilization counseling is offered and when side effects are successfully managed. This article provides a conceptual model for patient counseling, highlights the significant points that should be included in counseling patients about depot medroxyprogesterone acetate (DMPA) and offers clinical suggestions to help evaluate and treat the more common side effects associated with DMPA use.

PIP: Because no contraceptive agent is perfect, patients must weigh the benefits and risks of the contraceptive method they decide to initiate and continue. Individual decision making and provider-client communication interact in complex ways to determine contraceptive behavior. Use of the contraceptive injectable depot medroxyprogesterone acetate (DMPA) should be preceded by counseling which individualizes its risks and benefits, answers all questions (asked and unasked), and develops a longterm plan to minimize side effects. Counseling should cover the contraceptive and noncontraceptive benefits of DMPA; specific side effects such as bleeding changes, weight changes, and fertility changes; the mechanisms of action; and ways to avoid acquiring sexually transmitted diseases. When evaluating and managing side effects, a differential diagnosis independent of DMPA must be considered first (especially for postcoital bleeding and headache). A pregnancy test should be offered in the first month of amenorrhea, after which no treatment is necessary. Ovulation resumption after use may be spontaneous or may be induced with menotropin therapy. Spotting and breakthrough bleeding may be handled by counseling or by a short course of high-dosage ibuprofen or of low-dose estrogen supplementation. Counseling may help women manage weight gain through caloric reduction and an increase in exercise. Acne which occurs soon after adoption of the method may be managed pharmacologically. Increased intake of dietary fiber and fluids may ameliorate the symptoms of abdominal bloating, and temporary nausea can be treated with antacids. Recent research has shown that depression does not increase with DMPA use, although the contraceptive is sometimes implicated in mood changes. Breast tenderness decreases with prolonged DMPA usage and can be managed with proper support garments and a reduction in other causative agents such as caffeine. Women who experience an increase in varicose veins should wear support hose and elevate their legs when possible. Women with symptoms of hypoestrogenic side effects should undergo a serum estradiol level test and appropriate replacement therapy. DMPA can be used immediately postpartum even in breast-feeding women. Women with amenorrhea should be tested for pregnancy before initiating DMPA or reinitiating use at an interval longer than 11-13 weeks. No adverse side effects have been found if pregnancy does occur.

Stress incontinence in women. Psychological status before and after treatment.

Sixty-three women with clinical and urodynamic evidence of stress incontinence were evaluated before and after incontinence surgery for symptoms of depression, nervousness, tension, sleep disturbances, decreased appetite, somatic weakness and headaches. Women treated successfully with surgery demonstrated a statistically significant improvement in their subjective psychologic status (P less than .05). Unsuccessful treatment, however, was not associated with a significant change in or deterioration of their symptoms. All the symptoms were evaluated individually to ascertain the specific effects of treatment. Sleep disturbances were significantly improved with successful treatment and worsened with unsuccessful treatment (P less than .05). Tension was significantly improved with successful therapy (P less than .05) but was unchanged if surgery was unsuccessful. Depression became worse with subjectively unsuccessful surgery. Headaches and appetite were not affected by the therapeutic outcome. Therapy can be instrumental in affecting the psychologic status of women with stress incontinence. If the psychologic disability continues after therapy and/or treatment is unsuccessful, a referral for psychologic evaluation should be considered.

Design of the advanced commode-shower chair for spinal cord-injured individuals.

The purpose of this development project was to design a new commode-shower chair that can be safely used by individuals with spinal cord injuries (SCI) and their caregivers. The need for this new design was consumer-driven. Patients and caregivers identified the following fatal flaws in the commode-shower chairs used in Spinal Cord Injury (SCI) centers: 1) risk for patient falls during transfers, propelling, and while leaning over for showering; 2) risk for pressure ulcers due to inadequate padding and seat positioning for lengthy bowel care regimes; 3) inadequate caregiver access to the perianal area of the patient to perform bowel care procedures; and, 4) wheel-related inability to properly position the chair directly over the toilet. The new, self-propelled chair addresses each of these concerns. Lockable, swing-away, pivoting armrests and improved, lever-activated brakes were designed to facilitate safe transfers. An innovative foot-lift was invented to facilitate washing of feet. Larger handrims were designed to aid in propulsion in wet environments. To prevent pressure ulcers, a chair frame and padding combination was designed to facilitate a seating position that optimally distributes body weight to prevent the development of pressure ulcers in the sacral and ischial areas. To address the common risk of heel ulcers, footrests, featuring edgeless, rounded heel cups, were designed. A new tubular chair frame, a new seat and smaller wheels were designed to enhance caregiver access and ensure proper chair positioning over the toilet. Following its successful clinical evaluation at the Milwaukee and Tampa VA Medical SCI Centers, the Advanced commode-shower chair is being patented by the Department of Veterans Affairs (VA). The VA has partnered with Everest & Jennings, to make this chair available commercially.

Patients' perspectives of a spinal cord injury unit.

The purpose of this study is to provide an ethnographic description of the subculture of a spinal cord injury (SCI) unit. The research method was qualitative, combining ethnographic interviews, participant observation, and document review. A 30 bed SCI facility on the west coast was selected as the setting for this ethnographic description. The developmental research sequence model (Spradley, 1980) and grounded theory (Glaser & Strauss, 1967) were used for data analysis. Findings indicate optimal rehabilitation is a creative and individualized process of reintegration. Reintegration prepares the individual for coping with physical limitations, architectural barriers, and societal prejudices while simultaneously making the person feel intact and valued. Successful reintegration promotes a "fit" between the newly injured spinal cord patient and the home environment. The patient learns to compensate for the physical limitations of the spinal cord injury in a manner that promotes safety, comfort, and personal worth. Successful reintegration assures the newly injured SCI patient returns to a viable occupation, feels physically attractive, participates in a rich, full social life, and maintains family ties. Four phases of reintegration emerged: buffering, transcending, toughening, and launching. Buffering is the nurturing and protective process of lessening, absorbing, or protecting the newly injured SCI patient against the shock of multiple ramifications of the injury and the indignities of being a patient; Transcending is the process of helping SCI patients recognize and rise above culturally imposed limitations and negative beliefs about people with disabilities. The "toughening up" process focuses on compensating for physical limitations, gaining independence, and maintaining social interactions without "using the disability." Launching is the process of (1) exposing rehabilitation patients to the real world, (2) exploring the range of options for living in the community, (3) promoting patient autonomy and decision making, and (4) facilitating the ejection of the patient from the rehabilitation program. The study is significant because it offers a new perspective for viewing a spinal cord injury unit. The proposed theoretical model explains patients' attitudes, beliefs, and behavior on SCI units. This model provides a framework for designing a prototype therapeutic milieu in SCI.

Comparison of seat pressures on three bowel care/shower chairs in spinal cord injury.

Pressure, positioning, and postural support are critical aspects in the design of a new bowel care/shower chair for persons with spinal cord injuries (SCI). The purpose of this evaluation was to evaluate seating pressures on three existing bowel care/shower chairs commonly used by persons with spinal cord injuries. A pressure mapping device, the Force Sensing Array, was used to measure seat pressure, position and postural support. Three seated subjects with spinal cord injuries were evaluated on each of the following three bowel care/shower chairs: Lumex, TRAUM-AID and E&J. The results of this evaluation will be briefly presented. This study is part of a larger study to design a bowel care/shower chair that uniquely meets the needs of persons with spinal cord injury.

RrgA is a pilus-associated adhesin in Streptococcus pneumoniae.

Adherence to host cells is important in microbial colonization of a mucosal surface, and Streptococcus pneumoniae adherence was significantly enhanced by expression of an extracellular pilus composed of three subunits, RrgA, RrgB and RrgC. We sought to determine which subunit(s) confers adherence. Bacteria deficient in RrgA are significantly less adherent than wild-type organisms, while overexpression of RrgA enhances adherence. Recombinant monomeric RrgA binds to respiratory cells, as does RrgC with less affinity, and pre-incubation of epithelial cells with RrgA reduces adherence of wild-type piliated pneumococci. Non-adherent RrgA-negative, RrgB- and RrgC-positive organisms produce pili, suggesting that pilus-mediated adherence is due to expression of RrgA, rather than the pilus backbone itself. In contrast, RrgA-positive strains with disrupted rrgB and rrgC genes exhibit wild-type adherence despite failure to produce pili by Western blot or immunoelectron microscopy. The density of bacteria colonizing the upper respiratory tract of mice inoculated with piliated RrgA-negative pneumococci was significantly less compared with wild-type; in contrast, non-piliated pneumococci expressing non-polymeric RrgA had similar numbers of bacteria in the nasopharynx as piliated wild-type bacteria. These data suggest that RrgA is central in pilus-mediated adherence and disease, even in the absence of polymeric pilus production.

The impact of contraceptive methods on the onset of symptomatic vulvovaginal candidiasis within the menstrual cycle.

OBJECTIVE: Vulvovaginal candidiasis is the second most common cause of vaginal discharge. Low-dose oral contraceptives are no longer thought to increase the absolute risk of episodic vulvovaginal candidiasis. This study investigates the possible impact that hormonal contraception may have on the timing of onset of symptoms within the menstrual cycle. STUDY DESIGN: In a retrospective chart review of reproductive-aged women seen at the Women's Health Care Clinic at Harbor-University of California, Los Angeles, Medical Center, data from the records of 448 symptomatic women who had 507 episodes of vulvovaginal candidiasis were extracted and analyzed for timing of onset of symptoms within the menstrual cycle. Diagnosis was based on symptoms, physical findings, and microscopy. Onset was divided into five physiologic ranges within an idealized 28-day menstrual cycle. Comparisons among groups were made with use of chi 2 and p < 0.05 thresholds for statistical significance. RESULTS: No differences were found in the onset of symptoms within the idealized menstrual cycle ranges between women using hormonal birth control methods and those using nonhormonal ones. The distribution was remarkably uniform throughout the cycle with the exception of the first few days (during menses). CONCLUSION: The timing of onset of symptoms of vulvovaginal candidiasis within a woman's menstrual cycle is not affected by her method of birth control.

PIP: 75% of US women have at least one episode of vulvovaginal candidiasis in their lives and an estimated US$600 million is spent each year on the diagnosis and treatment of this condition. To assess the possible impact of hormonal contraception on the timing of onset of symptoms within the menstrual cycle, a retrospective chart review was conducted of women treated for vulvovaginal candidiasis at the University of California, Los Angeles, Medical Center. A total of 448 women, with 507 symptomatic vulvovaginal candidiasis episodes, were included in the study. All had normal menstrual cycles (21-35 days). 231 of these women were using oral contraceptives containing 30-35 mg of ethinyl estradiol, 8 were using Depo-Provera, and 268 relied on nonhormonal methods. After adjustment for cycle length, analysis was restricted to five intervals in the idealized 28-day cycle: menses (days 1-5), follicular (days 6-11), periovulatory (days 12-17), luteal (days 18-24), and premenstrual (days 25-28). The distribution of onset of symptoms for users of hormonal methods did not differ significantly from that in users of nonhormonal methods. Moreover, there was no clear temporal grouping in the onset of symptoms within the menstrual cycle for any contraceptive group. Improved understanding of the dynamics of vulvovaginal candidiasis would facilitate the identification of strategies to reduce the risk factors and interrupt the transformation process before symptomatic infection develops.

Adolescent contraception.

PIP: By age 19, the average North American man has had sex with 5.11 people. Almost two thirds of high-school senior-aged women have had sex. While the rates of sexual activity among teens in the US are not substantially different from rates in other developed western countries, adolescent pregnancy rates in the US are several times higher than in most other countries. These high rates of adolescent pregnancy are partly due to the collective reluctance among adults in the US to discuss sexuality issues with adolescents and provide them with contraception. Effective communication is the key to providing contraception to teens. Studies have clearly shown that teens are interested in sexuality and would like to discuss the issue with their physicians. The author notes that any successful program to reduce unwanted pregnancies among teens will understand that teens are often concrete thinkers focused upon their physical appearance and dedicated to taking risks. Oral contraception, long-acting progestin methods, condoms, and other options are discussed. However, emergency contraception with birth control pills is the one most important contraceptive option which can be provided to teens. The approach has recently been approved by the FDA Advisory Board for both safety and efficacy. Recent studies, however, show that less than 10% of US clinicians informed their patients of the availability of emergency contraception. Information on providers of emergency contraception can be obtained by dialing Princeton University's Office of Population Research's toll-free emergency contraception hotline at (800) 584-9911.^ieng