An investigation into the microflora of heroin.

In 2000, an unusual increase of morbidity and mortality among illegal injecting drug users in the UK and Ireland was reported and Clostridium novyi was identified as the likely source of the serious infection, although infections due to C. botulinum and Bacillus cereus were also reported. Because heroin was a possibile source of infection, this study investigated the microflora of heroin samples seized in England during 2000 and 2002. Two methods were developed for the examination of the microflora of heroin. The first consisted of suspension of the drug in maximum recovery diluent (MRD) which was inoculated directly into Clostridium Botulinum Isolation Cooked Meat Broth (CBI). The second method rendered the heroin soluble in citric acid, concentrated particulate material (and bacterial cells) by filtration and removed heroin residues by washing with citric acid and phosphate-buffered saline before placing the filter in CBI broth. Duplicate CBI broths from both methods were incubated without heating and after heating at 60 degrees C for 30 min. Subcultures were made after incubation for 7 and 14 days on to eight different solid media. The methods were evaluated with heroin samples spiked with either C. botulinum or C. novyi spore suspensions; recovery of 10 spores in the original sample was demonstrated. Fifty-eight heroin samples were tested by citric acid solubilisation and 34 by the MRD suspension technique. Fifteen different gram-positive species of four genera were recognised. No fungi were isolated. Aerobic endospore-forming bacteria (Bacillus spp. and Paenibacillus macerans) were the predominant microflora isolated and at least one species was isolated from each sample. B. cereus was the most common species and was isolated from 95% of all samples, with B. licheniformis isolated from 40%. Between one and five samples yielded cultures of B. coagulans, B. laterosporus, B. pumilus, B. subtilis and P. macerans. Staphylococcus spp. were isolated from 23 (40%) samples; S. warneri and S. epidermidis were the most common and were cultured from 13 (22%) and 6 (10%) samples respectively. One or two samples yielded cultures of S. aureus, S. capitis and S. haemolyticus. The remainder of the flora detected comprised two samples contaminated with C. perfringens and two samples with either C. sordellii or C. tertium. Multiple bacterial species were isolated from 43 (74%) samples, a single species from the remaining 15. In 13 samples B. cereus alone was isolated, in one B. subtilis alone and in one sample B. pumilus alone. C. botulinum and C. novyi were not isolated from any of the heroin samples. Recommendations for the optimal examination of the microflora of heroin are given.

Trends in induced abortion in England and Wales.

Analysis of routinely published abortion and fertility data for England and Wales between 1968 and 1980 shows that the age-specific abortion rates increased from 1968 until about 1973 when the rates peaked for all ages; rates then declined until 1977 but have subsequently returned to higher levels. Two factors are implicated: (1) the recent changes are related to parallel changes in the fertility rate; but (2) there is also a tendency for recent cohorts of women to resort to abortion more readily. These relationships are derived from analyses of fertility rates and abortion ratios, the proportion of conceptions that result in abortions. The results are discussed in terms of attitudes and practices related to birth control.

Provision of induced abortion in Wessex Health Region: unmet need and feasibility of compensatory day care.

A study of routinely collected data showed that in 1975 only 42% of Wessex abortion patients obtained a National Health Service operation in their own region. Within this average the range for own district National Health Service operations was from 8.7% (Central Hampshire) to 68% (South West Hampshire) when known paybed operations had been excluded. Most of the remaining patients obtained private operations outside the region and of these about 50% obtained an operation at the British Pregnancy Advisory Service Clinic (BPAS) at Brighton.A survey of Wessex women obtaining induced abortions at BPAS, Brighton, found that 85% of a sample of patients interviewed would have been willing to have a National Health Service operation locally but it had not been available. Only 24% of these women had been referred by way of a formal and accepted path, and had obtained their operation before ten weeks gestation, a suggested maximum for day-care provision.It this proportion is representative of Wessex patients obtaining operations outside the region, the numbers of patients involved in 1975 would have been 643 and the feasibility of a day surgical unit specially providing for this number would be questionable.It is suggested that by reducing delays in the referral process and accepting patients by nontraditional referral paths at least a further 21% of the patients would have qualified for day care. On the basis of this estimate a Regional Day Abortion Unit is probably a practicable proposition.

The after-care of abortion patients.

PIP: One of a systematic series of studies into the provision of induced abortion in the Wessex Health Authority Region provided information about the use of lay and professional services after abortion. Information from this study forms the basis of this discussion. The study sample consisted of each patient having a National Health Service induced abortion in the Southampton Health District during an 8-week period. During this time, 118 patients had an induced abortion, and 102 consented to postabortion followup (87%). There were 3 principal sources of followup data: followup interview; followup data from general practitioners; and hospital and social work record search. Questionnaires were completed for 64 (63%) of the 102 patients who had been willing to be seen for a followup interview. 94 (91%) of the 103 general practitioners involved completed their questionnaires; no data were available for 8 of their patients. Of the 64 patients, 23 had discussed the induced abortion with other patients, and 13 of these patients had found this helpful. In general, the medical and nursing staff were found to have been helpful or very helpful; only 6 patients felt that the staff had been unhelpful. A majority of the patients indicated that they had no preference as to the sex of the physicians whom they had consulted. 61 of the patients (95%) had discussed their abortion with somebody by the time of the followup interview, usually with friends (17%), family doctors (17%), boyfriends (14%), mothers (12%), or husbands (9%). 70% of all discussions (128 out of 182) had been at least some help. The most helpful discussions had been those with husbands, boyfriends, and girlfriends. Of the 86 patients for whom general practitioner data were available, 80 (93%) had consulted their doctor since the abortion. The majority of these consultations concerned matters not directly related to the abortion. Of the 102 patients for whom a record search was possible, 20 had had a gynecological outpatient appointment in the 8 months following their abortion. Among the 16 patients who attended and whose consultations were not of a routine nature, 6 had physical problems related to abortion. Of the 10 patients consulting nongynecological specialists, only 2 had problems related to their abortion. Of the 103 patients who consented to followup, 3 had seen a hospital social worker and 3 had seen a community social worker within 8 months of their abortion for persistent psychiatric disturbance after their abortions. At the time of followup, 53 (83%) of the patients for whom a questionnaire was completed claimed to be using some form of contraception.^ieng

Components of delay amongst women obtaining termination of pregnancy.

PIP: A study of factors involved in delay among a group of 308 Wessex women obtaining induced abortions in one of 2 abortion centers, both outside the Wessex Health District. The most striking finding was that only 47% of women aged 17-18 years obtained their abortion before 12 weeks of gestation, compared with more than 70% of women in other age groups. Women aged 17-19 accounted for 19% of legal abortions in England and Wales during 1977. If the Eessex data are applicable nationally, 53% of these patients were having 2nd trimester abortions, with the increased risk that this implies for their health and future childbearing. In addition, the fact that 75% of women suspect that they are pregnant and 41% decide to have an abortion by 6 weeks from their last menstrual period suggests that access to outpatient menstrual regulation services would cause a revolution in abortion practices. The case is stated for the development of adequate sex education, birth control and early abortion services oriented toward late teenagers.^ieng

Patterns of discussion and decision-making amongst abortion patients.

PIP: Discussion and decision making among 308 of 338 Wessex women who obtained an induced abortion at one of 2 centers are studied. The most important discussants were found to be family doctors, boy and girl friends, husbands, mothers, and pregnancy counselors. In the majority of key discussions the patient had been able to discuss the pregnancy fully, had a sympathetic reception and met a discussant who was favorable to her having an abortion. However, younger patients were less likely to have such an experience and were later at arriving at their abortion decision and were more prone to uncertainty. It is argued that alternative counseling and referral systems should be developed for younger patients with unplanned pregnancies who may request abortion.^ieng

The psychosocial outcome of induced abortion.

The psycho-social outcome of induced abortion was assessed in 64 women after eight weeks and in 86 women after eight months. Three groups were identified. About 5 per cent had enduring, severe psychiatric disturbance following abortion. Women especially at risk were those with a previous psychiatric or abnormal obstetric history or with physical grounds for abortion and those expressing ambivalence towards abortion. Short-lived disturbances affected about half of all abortion patients. These symptoms included initial guilt and regrets and sensitivity to the comments of people around them which relate to abortion. The third group of women experienced no adverse sequelae. It is suggested that an awareness of the risk factors should lead to the instigation of more adequate counselling and support for those women who need it.

PIP: The psychosocial outcome of induced abortion was assessed in 64 women after 8 weeks and in 86 women after 8 months. 3 groups were identified. About 5% had enduring, severe psychiatric disturbance following abortion. Women especially at risk were those with a previous psychiatric or abnormal obstetric history or with physical grounds for abortion and those expressing ambivalence towards abortion. Short-lived disturbances affected about half of all abortion patients. These symptoms included initial guilt and regrets and sensitivity to the comments of people around them which relate to abortion. The third group of women experienced no adverse sequelae. It is suggested that an awareness of the risk factors should lead to the instigation of more adequate counselling and support for those women who need it.

Characteristics of special groups of abortion patients from one health district.

PIP: 4 special groups of women resident and obtaining abortions in 1 British health district are described: women under 16 years and over 35, those undergoing a 2nd or 3rd abortion, and those obtaining operations later than 20 weeks gestation. These women rarely obtain adequate contraceptive advice and services, particularly when oral contraception has not proved to be suitable for them. It appears that some general practitioners do not offer a comprehensive family planning service and that this can result in women resorting to unreliable methods of birth control despite their demonstrated willingness to use contraception. Among the very young, though most have received teaching about contraception, few appear to use any method; the confusion over age consent may be contributing to the failure of adults to make adequate provision for this group. The women over 35 seemed to have little contact with family planning advice. There was a disturbing failure to meet the demand for sterilization until an unwanted pregnancy had occurred. Patients undergoing a 2nd or 3rd abortion were frequently found to have contraceptive problems; there was no evidence that they were irresponsible as a group. A description of 2 patients obtaining operations after 20 weeks gestation illustrates the complexities of the late abortion issue. It is suggested that restrictive legislation cannot hope to contain the determination which may accompany the decision to seek abortion.^ieng

Suicide by burning as an epidemic phenomenon: an analysis of 82 deaths and inquests in England and Wales in 1978-9.

An epidemic of suicide by burning in England and Wales occurred during the one-year period October 1978 to October 1979, following a widely publicized political suicide. For the 82 cases, death certificates were obtained and coroners' inquest reports sought. The victims were predominantly young single men or older married women; both groups had strong psychiatric histories; and there were no suicides which had political overtones, apart from the index case. Compared with suicides by this method in the past, a higher proportion of victims were born in the UK. It is proposed that a code of practice for the reporting of suicides by the media is required.

Post-coital contraception.

PIP: 137,000 British women chose to have an abortion in 1981 and about 25% were teenagers. A recent estimate noted that 10% of unintended pregnancies could have been avoided if postcoital contraception had been obtainable. The availability of postcoital contraception is limited and few doctors have much knowledge of or interest in this contraceptive method. 2 questions that arise are why have doctors been so slow to adopt this effective method of birth control and what are the chances of its availability in the National Health Service (NHS) improving. Postcoital contraception is a comparatively new and until recently unpublicized fertility control method, and there was little knowledge of it among the general population or the medical profession. Doctors' ignorance and reluctance to provide the method may have been due in part to the fact that the pharmaceutical firms have been hesitant to recommend oral contraceptive (OC) pills for this use. There is no specially packaged product, and it is necessary for a patient to be given 4 pills from a 21-pill pack. This has meant that the method has not been advertized, as most new methods would be, in the medical magazines. Hopefully, this lack of knowledge has been rectified by the Family Planning Association. As part of its campaign to launch the method, it has sent details to all general practitioners. Attitudes to postcoital contraception are important, and clearly there are strong parallels with the abortion issues and legal and moral undercurrents as well. Many doctors might have been put off providing postcoital contraception by the experience of the 2 clinics (BPAS in Sheffield and the Caithorpe Nursing Home in Birmingham) which had been reported by Life, an antiabortion pressure group, to the Director of Public Prosecutions under the Offences Against the Persons Act 1863. But on May 10, 1983 the Attorney General announced that the provisionof postcoital contraception is not a criminal offense. This statement may not be sufficient for those extremely cautious general practitioners or those with moral objections who believe that postcoital contraception is really abortion. Some doctors may feel that insufficient research has been done on the effects of postcoital contraception on women. Some general practitioners may have been slow to take up the service because they were unsure of payment, but it is now clear that they can prescribe it as partof their contraceptive services to women under the NHS for which a fee is payable. Swift access to a clinical service able to offer appropriate counseling and prescription of a postcoital method is mandatory for postcoital contraception to have an impact, but a 1983 telephone survey in May 1983 found a wide variation in its availability.^ieng