Patient and pharmacist perspectives on pharmacist-prescribed contraception: A systematic review.

OBJECTIVE: Increasingly, states authorize pharmacists to prescribe hormonal contraception to patients without a prescription from another healthcare provider. The purpose of this review is to investigate pharmacist and patient perspectives on pharmacist-prescribed contraception in the United States. STUDY DESIGN: We searched Medline, Embase, PsycInfo, CINAHL, Scopus, and the Cochrane Library from inception through July 10, 2019. We included qualitative and mixed-methods studies, quantitative surveys, observational studies, and randomized trials in the United States. Risk of bias was assessed using tools for quantitative and qualitative studies. RESULTS: Fifteen studies met inclusion criteria, including studies on pharmacists and student pharmacists (n = 9), patients (n = 5), and both (n = 1). Study samples ranged from local to national. Studies had moderate to high risk of bias, primarily due to low response rates and lack of validated instruments. Most pharmacists (57-96%) across four studies were interested in participating in pharmacist-prescribed contraception services. Among patients, 63-97% across three studies supported pharmacist-prescribed contraception, and 38-68% across four studies intended to participate in these services. At least half of pharmacists across four studies felt comfortable prescribing contraception, though pharmacists identified additional training needs. Pharmacists and patients identified several reasons for interest in pharmacist-prescribed contraception services, including increasing patient access, reducing unintended pregnancies, and offering professional development for pharmacists. They also identified barriers, including payment, time and resource constraints, liability, and patient health concerns. CONCLUSIONS: Most pharmacists and patients across 15 studies were interested in expanded access to contraception through pharmacist-prescribed contraception. Findings on facilitators and barriers may inform implementation efforts. IMPLICATIONS: Pharmacist-prescribed contraception is a strategy to expand patient access to contraception. Reducing barriers to implementation could improve participation among pharmacists and patients.

Factors associated with provision of depot medroxyprogesterone acetate to adolescents by US health care providers.

OBJECTIVE: Identify factors associated with healthcare providers' frequency of depot medroxyprogesterone acetate (DMPA) provision to adolescents. STUDY DESIGN: We analyzed data from surveys mailed to a nationally representative sample of public-sector providers and office-based physicians (n=1984). We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with frequent DMPA provision to adolescents in the past year. RESULTS: Although most providers (>95%) considered DMPA safe for adolescents, fewer reported frequent provision (89% of public-sector providers; 64% of office-based physicians). Among public-sector providers, factors associated with lower odds of frequent provision included working in settings without Title X funding (aOR 0.44, 95% CI 0.30-0.64), reporting primary care as their primary clinical focus versus reproductive or adolescent health (aOR 0.42, 95% CI 0.28-0.61), and providing fewer patients with family planning services. Among office-based physicians, factors associated with lower odds of frequent provision included specializing in obstetrics/gynecology (aOR 0.50, 95% CI 0.27-0.91) and family medicine (aOR 0.21, 95% CI 0.09-0.47) versus adolescent medicine, completing training ≥15 versus <5 years ago (aOR 0.27, 95% CI 0.09-0.83), and reporting that 0-24% of patients pay with Medicaid or other government healthcare assistance versus ≥50% (aOR 0.23, 95% CI 0.09-0.61). The reason most commonly reported by providers for infrequent DMPA provision was patient preference for another method. CONCLUSIONS: While most providers reported frequently providing DMPA to adolescents, training on evidence-based recommendations for contraception, focused on subgroups of providers with lower odds of frequent DMPA provision, may increase adolescents' access to contraception. IMPLICATIONS: Although >95% of providers considered depot medroxyprogesterone (DMPA) a safe contraceptive for adolescents, only 89% of public-sector providers and 64% of office-based physicians reported frequently providing DMPA to adolescents. Provider training on evidence-based recommendations for contraception counseling and provision may increase adolescents' access to DMPA and all methods of contraception.

Drug interactions between rifamycin antibiotics and hormonal contraception: a systematic review.

BACKGROUND: Rifamycin antibiotics are commonly used for treatment of tuberculosis, but may reduce the effectiveness of hormonal contraception (HC). OBJECTIVES: To determine whether interactions between rifamycins and HC result in decreased effectiveness or increased toxicity of either therapy. SEARCH STRATEGY: We searched MEDLINE, Embase, Cochrane and clinicaltrials.gov through May 2017. SELECTION CRITERIA: We included trials, cohort, and case-control studies addressing pregnancy rates, pharmacodynamics or pharmacokinetic (PK) outcomes when HC and rifamycins were administered together versus apart. Of 7291 original records identified, 11 met inclusion criteria after independent review by two authors. DATA COLLECTION AND ANALYSIS: Two authors independently abstracted study details and assessed study quality using the United States Preventive Services Task Force grading system. Findings are reported descriptively. MAIN RESULTS: Studies only addressed combined oral contraceptives (COCs) and none reported pregnancy rates. Quality ranged from good to poor. Rifampin increased the frequency of ovulation in two of four studies, and reduced estrogen and/or progestin exposure in five studies. Rifabutin led to smaller PK changes than rifampin in two studies. In one study each, rifaximin and rifalazil did not alter hormone PK. CONCLUSIONS: No studies evaluated pregnancy risk or non-oral HCs. PK and ovulation outcomes support a clinically concerning drug interaction between COCs and rifampin, and to a lesser extent rifabutin. Data are limited for other rifamycins. TWEETABLE ABSTRACT: Rifampin and rifabutin reduce systemic exposure of oral contraceptives, but no studies have evaluated pregnancy risk.

Maternal obesity and risk of cesarean delivery: a meta-analysis.

Despite numerous studies reporting an increased risk of cesarean delivery among overweight or obese compared with normal weight women, the magnitude of the association remains uncertain. Therefore, we conducted a meta-analysis of the current literature to provide a quantitative estimate of this association. We identified studies from three sources: (i) a PubMed search of relevant articles published between January 1980 and September 2005; (ii) reference lists of publications selected from the search; and (iii) reference lists of review articles published between 2000 and 2005. We included cohort designed studies that reported obesity measures reflecting pregnancy body mass, had a normal weight comparison group, and presented data allowing a quantitative measurement of risk. We used a Bayesian random effects model to perform the meta-analysis and meta-regression. Thirty-three studies were included. The unadjusted odd ratios of a cesarean delivery were 1.46 [95% confidence interval (CI): 1.34-1.60], 2.05 (95% CI: 1.86-2.27) and 2.89 (95% CI: 2.28-3.79) among overweight, obese and severely obese women, respectively, compared with normal weight pregnant women. The meta-regression found no evidence that these estimates were affected by selected study characteristics. Our findings provide a quantitative estimate of the risk of cesarean delivery associated with high maternal body mass.

Pregnancy intention and its relationship to birth and maternal outcomes.

OBJECTIVE: To examine whether there are associations between pregnancy intention (intended, unwanted, mistimed, or ambivalent) and negative birth and maternal outcomes: low birth weight (less than 2,500 g), preterm delivery (fewer than 37 weeks), small for gestational age, premature labor, hypertension, and other maternal outcomes. METHODS: We analyzed data from the population-based Pregnancy Risk Assessment Monitoring System, including 87,087 women who gave birth between 1996 and 1999 in 18 states. Information on pregnancy outcomes was derived from birth certificate data and a self-administered questionnaire completed postpartum. We employed SUDAAN (RTI International, Research Triangle Park, NC) for univariable and logistical regression analyses. RESULTS: In analyses controlling for demographic and behavioral factors, women with unwanted pregnancies had an increased likelihood of preterm delivery (adjusted odds ratio [OR] 1.16, 95% confidence interval [CI] 1.01-1.33) and premature rupture of membranes (adjusted OR 1.37, 95% CI 1.01-1.85) compared with women with intended pregnancies. Women who were ambivalent toward their pregnancies had increased odds of delivering a low birth weight infant (adjusted OR 1.15, 95% CI 1.02-1.29); in contrast, women with mistimed pregnancies had a lower likelihood (adjusted OR 0.92, 95% CI 0.86-0.97). CONCLUSION: Pregnancy intention, specifically unwanted and ambivalent, may be an indicator of increased risk for some poor birth and maternal outcomes and should be considered in interventions aimed at improving the health of the mother and child. LEVEL OF EVIDENCE: III.

Steroidal contraceptives: effect on bone fractures in women.

BACKGROUND: Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. However, osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally. OBJECTIVES: To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women SEARCH STRATEGY: We searched MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for studies of fracture or bone health and hormonal contraceptives. We wrote to investigators to find additional trials. SELECTION CRITERIA: Randomized controlled trials were considered if they examined fractures, bone mineral density (BMD), or bone turnover in women with hormonal contraceptive use prior to menopause. Studies were excluded if hormones were provided for treatment of a specific condition rather than for contraception. Interventions could include comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive. Interventions could also include the provision of a supplement versus a placebo. DATA COLLECTION AND ANALYSIS: We assessed for inclusion all titles and abstracts identified through the literature searches with no language limitation. The weighted mean difference (WMD) was computed with 95% confidence interval (CI) using a fixed-effect model. MAIN RESULTS: No trial had fracture as an outcome. Combination contraceptives did not appear to affect bone health. Of progestin-only methods, depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density, while results were inconsistent for implants. The two placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo. AUTHORS' CONCLUSIONS: Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Due to different interventions, no trials could be combined for meta-analysis. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.

Improving surveillance for maternal and perinatal health in 2 districts of rural Tanzania.

OBJECTIVES: As part of a community-based reproductive health project in rural Tanzania, a maternal and perinatal health care surveillance system was established to monitor pregnancy outcomes. This report presents preliminary results. METHODS: Village health workers were trained to collect data during health education visits to pregnant and postpartum women. Maternal and fetal or infant survival or deaths were tracked on a community monitoring board. RESULTS: Among 904 pregnancies, the fetoneonatal mortality rate was 69.4 deaths per 1000 live births and fetal deaths; 4 maternal deaths occurred. Intrapartum and early neonatal deaths of infants with birthweights of 1500 g or greater represented a large proportion of deaths. CONCLUSIONS: These preliminary results will be used to prioritize project interventions, including increasing access to skilled delivery care.

Strategy for systematic assembly of large RNA and DNA genomes: transmissible gastroenteritis virus model.

A systematic method was developed to assemble functional full-length genomes of large RNA and DNA viruses. Coronaviruses contain the largest single-stranded positive-polarity RNA genome in nature. The approximately 30-kb genome, coupled with regions of genomic instability, has hindered the development of a full-length infectious cDNA construct. We have assembled a full-length infectious construct of transmissible gastroenteritis virus (TGEV), an important pathogen in swine. Using a novel approach, six adjoining cDNA subclones that span the entire TGEV genome were isolated. Each clone was engineered with unique flanking interconnecting junctions which determine a precise systematic assembly with only the adjacent cDNA subclones, resulting in an intact TGEV cDNA construct of approximately 28.5 kb in length. Transcripts derived from the full-length TGEV construct were infectious, and progeny virions were serially passaged in permissive host cells. Viral antigen production and subgenomic mRNA synthesis were evident during infection and throughout passage. Plaque-purified virus derived from the infectious construct replicated efficiently and displayed similar plaque morphology in permissive host cells. Host range phenotypes of the molecularly cloned and wild-type viruses were similar in cells of swine and feline origin. The recombinant viruses were sequenced across the unique interconnecting junctions, conclusively demonstrating the marker mutations and restriction sites that were engineered into the component clones. Full-length infectious constructs of TGEV will permit the precise genetic modification of the coronavirus genome. The method that we have designed to generate an infectious cDNA construct of TGEV could theoretically be used to precisely reconstruct microbial or eukaryotic genomes approaching several million base pairs in length.

Thymic function after hematopoietic stem-cell transplantation for the treatment of severe combined immunodeficiency.

BACKGROUND: Immune function can be restored in infants with severe combined immunodeficiency by transplantation of unfractionated bone marrow from HLA-identical donors or T-cell-depleted marrow stem cells from haploidentical donors, with whom there is a single haplotype mismatch, without the need for chemotherapy before transplantation or prophylaxis against graft-versus-host disease. The role of the thymus in this process is unknown. METHODS: We analyzed the phenotypes of circulating T cells and the proliferative responses of peripheral-blood mononuclear cells to phytohemagglutinin in 83 patients with severe combined immunodeficiency who received allogeneic marrow transplants without T-cell ablation from related donors over an 18-year period. We also tested for the presence of episomes of T-cell antigen receptors (extrachromosomal DNA circles formed during intrathymic T-cell development) to assess thymus-dependent T-cell reconstitution. RESULTS: Before and early after transplantation, the numbers of circulating T cells were low, with a predominance of mature CD45RO+ T cells (primarily resulting from the transplacental transfer of maternal cells); T-cell antigen-receptor episomes were undetectable in peripheral-blood mononuclear cells. In 73 of the infants, thymus-derived T cells expressing CD45RA and T-cell antigen-receptor episomes were detected within three to six weeks after transplantation. The mean (+/-SD) value for thymus-dependent T-cell antigen-receptor episomes peaked (at 7311+/-8652 per microgram of peripheral-blood mononuclear-cell DNA) 1 to 2 years after transplantation and declined to low levels (less than 100 episomes per microgram of DNA) within 14 years, as compared with a gradual decline from birth to the age of about 80 years in normal subjects. CONCLUSIONS: The vestigial thymus in infants with severe combined immunodeficiency is functional and can produce enough T cells after bone marrow transplantation to provide normal immune function.

Exposure to phenoxy herbicides and the risk of spontaneous abortion.

The Ontario Farm Family Health Study was designed to assess retrospectively the potential adverse effects of exposure to pesticides on pregnancy. Information on the health and life style of approximately 2,000 farm couples, as well as a history of use of pesticides on the farm, was collected by questionnaire. This analysis focuses on pre- and postconception exposure to phenoxy herbicides and the risk of spontaneous abortion using the complete (to date) pregnancy history for each woman. Preconception exposure (from 3 months before conception to the month of conception) was weakly associated with the risk of spontaneous abortion at <20 weeks' gestation [adjusted odds ratio (OR) = 1.1; 95% confidence interval (CI) = 0.6-1.9]. When the analyses were restricted to spontaneous abortions of <12 weeks, the risk was more than doubled (adjusted OR = 2.5; 95% CI = 1.0-6.4), but the results were sensitive to the cutpoint used. If the husband did not normally wear protective equipment during application, the crude OR for early spontaneous abortions was 5.0 (95% CI = 0.7-36.2). Exposure to phenoxy herbicides during the first trimester was generally not associated with increased risk of spontaneous abortion. The results suggest a possible role of preconception (possibly paternal) exposures to phenoxy herbicides in the risk of early spontaneous abortions.

Violence in the emergency department.

Violence in the emergency department is a frequently encountered problem that is often not promptly or adequately addressed. This article outlines the epidemiology of violence in the emergency department, including patients at greatest risk for aggressive behavior. The necessary steps to identify and approach these patients and recommended methods for sedation and restraint are discussed.

The effect of pesticide exposure on time to pregnancy.

The Ontario Farm Family Health Study provided data for examination of the effects of pesticide exposure on time to pregnancy. In this retrospective cohort study of farm couples in Ontario, Canada, the farm operator, husband, and wife completed questionnaires during 1991-1992. We asked about pesticides used on the farm and pesticide activities of the husband and wife for each month of trying to conceive. After exclusions, 2,012 planned pregnancies remained for analysis. We used an analog of the Cox proportional hazards model to calculate conditional fecundability ratios (conditional on pregnancy). There was no strong or consistent pattern of associations of pesticide exposure with time to pregnancy. During exposure intervals in which women participated in pesticide activities (during most of which the men also participated), however, 6 of 13 pesticide exposure categories were associated with a decrease in fecundability (conditional fecundability ratio range = 0.51-0.80). For exposure intervals in which only the men participated in pesticide activities or in which neither men nor women participated in pesticide activities but pesticides had been used on the farm, conditional fecundability ratios ranged from 0.75 to 1.50, with no apparent consistency among pesticide classes, chemical families, or active ingredients.

Visits to emergency departments for gynecologic disorders in the United States, 1992-1994.

OBJECTIVE: To assess rates of visits to emergency departments for gynecologic disorders among women of reproductive age in the United States. METHODS: Data from the National Hospital Ambulatory Medical Care Survey for 1992-1994 were analyzed to determine rates of visits to emergency departments among women, ages 15-44 years. Average annual rates per 1000 women were calculated using age, race, and region-specific population estimates. Rate ratios were used to compare rates among subgroups. RESULTS: Approximately 1.4 million gynecologic visits were made to emergency departments annually, for an average annual rate of 24.3 visits per 1000 women, ages 15-44 years (95% confidence interval [CI] 22.0, 26.6). The most frequent diagnoses were pelvic inflammatory disease (average annual rate 5.8, 95% CI 5.0, 6.6), lower genital tract infections including sexually transmitted diseases (average annual rate 5.7, 95% CI 4.8, 6.6), and menstrual disorders (average annual rate 2.9, 95% CI 2.3, 3.5). Nearly half of all gynecologic visits resulted in diagnoses of genital tract infections. Younger women (ages 15-24 years) were 2.3 (95% CI 2.0, 2.6) times as likely as older women (ages 25-44 years), and black women were 3.6 (95% CI 2.9, 4.3) times as likely as white women, to visit emergency departments for gynecologic disorders. Rate ratios for genital tract infections were 10-20 times higher for younger black women than for older, white women. CONCLUSION: Almost half of gynecologic visits to emergency departments were related to genital tract infections, which largely are preventable.

Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecundability.

Data from the Ontario Farm Family Health Study were analyzed to determine whether smoking, caffeine, or alcohol use among men and women affect fecundability (the monthly probability of conception). In this retrospective cohort study of farm couples in Ontario, Canada, the farm operator, husband, and wife completed questionnaires during 1991-1992, yielding information on 2,607 planned pregnancies that had occurred over the previous 30 years. Fecundability ratios were calculated using an analog of the Cox proportional hazards model. Cigarette smoking among women and men was associated with decreased fecundability (fecundability ratio = 0.90, 95% confidence interval (CI) 0.82-0.98 and fecundability ratio = 0.88, 95% CI 0.81-0.95, respectively). Caffeine consumption of 100 mg or less versus more than 100 mg in women and men was not associated with fecundability (fecundability ratio = 0.98, 95% CI 0.91-1.07 and fecundability ratio = 1.05, 95% CI 0.97-1.14, respectively). Decreases were observed among women who were coffee drinkers (fecundability ratio = 0.92, 95% CI 0.84-1.00) and men who were heavy tea drinkers (fecundability ratio = 0.85, 95% CI 0.69-1.05), regardless of caffeine content. Alcohol use among women and men was not associated with fecundability. These data are consistent with previous studies of the adverse effect of tobacco on fecundability in female smokers and suggest an effect of smoking among males. Continued evaluation of coffee and tea is warranted to address constituents other than caffeine.

Male pesticide exposure and pregnancy outcome.

Potential health effects of agricultural pesticide use include reproductive outcomes. For the Ontario Farm Family Health Study, the authors sampled Ontario farms from the 1986 Canadian Census of Agriculture, identified farm couples, and obtained questionnaire data concerning farm activities, reproductive health experience, and chemical applications. Male farm activities in the period from 3 months before conception through the month of conception were evaluated in relation to miscarriage, preterm delivery, and small-for-gestational-age births. Among the 1,898 couples with complete data (64% response), 3,984 eligible pregnancies were identified. Miscarriage was not associated with chemical activities overall but was increased in combination with reported use of thiocarbamates, carbaryl, and unclassified pesticides on the farm. Preterm delivery was also not strongly associated with farm chemical activities overall, except for mixing or applying yard herbicides (odds ratio = 2.1, 95% confidence interval 1.0-4.4). Combinations of activities with a variety of chemicals (atrazine, glyphosate, organophosphates, 4-[2,4-dichlorophenoxy] butyric acid, and insecticides) generated odds ratios of two or greater. No associations were found between farm chemicals and small-for-gestational-age births or altered sex ratio. Based on these data, despite limitations in exposure assessment, the authors encourage continued evaluation of male exposures, particularly in relation to miscarriage and preterm delivery.

Practical optoelectronic neural network realizations based on the fault tolerance of the backpropagation algorithm.

This paper describes how the fault tolerance of the backpropagation algorithm can be used to accommodate the realistic (nonideal) transfer characteristics of the optical communication links used, between neural layers, in optoelectronic neural networks. In particular the authors demonstrate that networks, utilizing MSM (metal-semiconductor-metal) photodiodes (PDs) and either LED (light emitting diode) or MQW (multiple quantum well) laser transmitters within these intraneural links, are capable of performing satisfactorily even in the presence of such nonideal device phenomena as: 60% optical crosstalk, 50% optoelectronic device variation, or a thresholded (I(th)=0.5*I(max)) laser output characteristic. Subsequent to this, the authors then show how it is possible to use this fault tolerance to simplify the neuron architecture, to the extent that it consists only of MSM PDs a current amplifier, and an MQW laser. The overall neuron transfer function is then a first-order approximation to the original sigmoidal function.

Weight and neuron output resolution requirements in optoelectronic neural networks.

We demonstrate that the resolution requirements of the optoelectronic devices used in the communication links of an analog multiperceptron neural network, trained with the standard backpropagation algorithm, can be simultaneously reduced to 8 bits (receiver) and 4 bits (transmitter), respectively, without any significant effect on the network's learning or generalization performances. In addition, we also show that a simple modification to the sigmoidal function, used within each neuron architecture, permits the resolution requirements of the optoelectronic receiver to be further reduced to 4 bits without any additional effect on network performance other than a reduction in learning rate. Both of these limited device resolution performances, however, can be achieved only provided that the weight-storage and the weight-updating procedures are maintained at 14 bits or greater.

The validity of the Rorschach for assessing cognitive and affective changes.

Exner's (1985) Rorschach norms of children 5 to 16 years old were used to test predictions based on developmental theory, previous cognitive studies, and Achenbach and Edelbrock's (1981) norms on behavior problems in children. In the cognitive realm, the Rorschach scores reflected the predicted increase in complexity, integration, and precision of thinking; richness of ideas; conformity to socially acceptable ways of thinking; and the concomitant decrease in unrealistic, egocentric ideas. In the affective realm, the Rorschach scores reflected the predicted decrease in uncontrolled expression of affect, increase in controlled expression of affect, and increase in inwardness. However, the Rorschach scores failed to reflect the predicted decrease in anxiety and increase in depression. Finally, there was no evidence of increased accuracy of perception.