The Scottish national LifeCurve™ survey: costs of functional decline, opportunities to achieve early intervention to support well-being in later life, and meaningfulness of the LifeCurve™.

OBJECTIVES: The aim of the Scottish AHP LifeCurve™ survey was to gather a snapshot of where people are on their LifeCurve™ when receiving allied health professions (AHP) services and to understand the cost consequence of intervening 'late' in the ageing trajectory. The objectives were to promote discussion around preventing functional decline, support innovation in service delivery, and facilitate broader engagement with individuals, communities, and wider environments for improving health and well-being in later life. In addition, subsequent learning could help address the increasing resource gap between the demand and capacity across health and social care. STUDY DESIGN: The survey was paper-based in the form of a printed booklet, which contained the 15 activities of daily living (ADL) and instrumental ADL (IADL) which comprise the LifeCurve™ with additional lifestyle questions and information about the member of staff and service the participant was seen in, including their Community Health Index (CHI) number. The survey questions and booklet layout were tested over a five-month period with AHPs and people receiving AHP services. Liaison with national health literacy colleagues and lead speech and language therapists ensured that the survey material was accessible to a wide range of people. In addition, the survey could be made available in alternative formats, on request. METHODS: Agreement to undertake the national survey was obtained in November 2016 by all AHP directors and associate directors who appointed communication support leads in their area who would support implementation at all stages at a local level. All materials relating to the survey were published on a dedicated area of a community of practice to support awareness and training during the preimplementation phase. AHPs working in adult services were asked to complete a survey with a minimum of two people they would 'typically' see in their service during a two-week period in May 2017, with the exclusion of people who were too unwell to participate, children and young people under 16 years, and adults with incapacity and without a guardianship arrangement in place. Approval was gained from the Public Benefit Privacy Panel to link the survey data to participants' health service usage using their CHI number. Completed forms were returned to the University of Strathclyde for entry into an encrypted electronic database using a double data entry process and were allocated a unique identifier. The unique identifier and CHI numbers were sent to Information Services Division (ISD), and then, the CHI numbers were deleted from the encrypted database. ISD sent the linked health data to the Scottish Government Analytical Services Division, which thus produced a full encrypted and anonymised database. RESULTS: The data explain what stages on the LifeCurve™ AHPs are intervening, and the matched data provide associated healthcare costs at each stage. Due to poor or missing data in the AHP/Service section, only 60% (n = 8261) of the total completed surveys were able to be matched with health service usage records. These data show that whilst AHPs are seeing people at each of the 15 ADL/IADL stages on the LifeCurve™, interventions fell into three groups where 25% of people where seen at the 'precurve' stage, 13% of people at 'mid-curve' (stage number five), and 39% of people at 'late-curve' (stages 10 to 13). The healthcare cost usage of these participants increased the further along the LifeCurve™ a person moves, with an average annual cost of £2700 at 'precurve' rising to £12,330 at 'late-curve' in 2016-2017. The results indicate that different services and professions are represented at each of these three points. So, for example, as might be expected, outpatient (especially musculoskeletal) services were seen more often at the 'precurve' stage, and in-patient and community rehabilitation, services were seen more often at the 'late-curve' stages; diagnostic radiographers and orthoptists saw people at the 'early-curve' stages, dieticians and podiatrists saw people at the 'mid-curve' stage, whilst physiotherapists, speech and language therapists, and occupational therapists saw people at the 'late-curve' stages. Data analysis showed this pattern is different for people receiving mental health services and, so, their data were removed and will be analysed and reported separately. CONCLUSIONS: It is clear from the results that healthcare costs increased as participants moved down LifeCurve™ stages, that is, as their levels of functional decline increase. It is also clear that AHPs are intervening late in a person's functional decline with associated limitations on changing their ageing trajectory. The cost consequence of this is significant - moving someone from 'late- to mid-curve' could save £3200 per person per annum. However, those AHPs typically associated with reabling approaches and rehabilitation, which have greatest potential to change ageing trajectories, were not represented at the 'mid-curve' stage (e.g., physiotherapists, occupational therapists). Therefore, we must find places to have conversations with people to inform them that functional decline is malleable and not inevitable purely by virtue of chronological age and provide education and support to prevent or reverse functional decline and collaborate around strategic planning and commissioning to offer different options that support an optimum LifeCurve™.

A purpose-built dynamometer to objectively measure static and dynamic knee torque.

This paper reports the development of a purpose-built knee dynamometer (PBKD) to evaluate passive range of motion (ROM) and isometric muscle strength measurements of the knee. The PBKD uses a TorqSense rotary torque transducer and objectively measures isometric knee muscle strength in a valid and reliable manner and passive resistance to motion through range. The device and all associated instrumentation underwent dynamic and static calibration to ensure consistent and accurate measurements were obtained in terms of knee joint angular position, passive torque measures, and isometric torque measures. Eleven healthy male participants performed a knee flexion and extension task designed to evaluate knee function. The validation of the PBKD entailed measuring the consistency of measurement and accuracy of measurement. Accuracy of the PBKD was determined by comparing peak isometric muscle strength measurements against a KIN-COM machine. No significant differences were observed both passively and isometrically between cycles and between trials. This device can have widespread applications within the rehabilitation and clinical environment and could be used as a functional outcome measuring tool to distinguish pathological from non-pathological knees. The presented preliminary results indicate that reliable and accurate measurements of knee ROM and muscle strength can be obtained.

The Past and Future of Clinical Biomechanics: Time to deliver on the legacy of pioneers such as Professor John P. Paul (1927-2013).

This editorial pays tribute to the work of Professor John P. Paul and his team at the University of Strathclyde in the 1960s and '70s, and subsequently by the Strathclyde Rehabilitation Engineering Group, as featured in the journal Medical Engineering & Physics. It also includes a consideration of the nature of full biomechanical analysis of movement and how it can be mathematically modelled and physically recorded, the different approaches taken by Paul's and Winter's groups, respectively, and what a full biomechanical model should include in the future. The article also attempts to signpost the reader to future developments in the field, and how the techniques pioneered by Paul in the 1960s may influence Clinical Biomechanics and Rehabilitation in the years to come.

Between-day repeatability of knee kinematics during functional tasks recorded using flexible electrogoniometry.

The objective of this study was to assess the between-day repeatability of knee kinematics during activities of daily living recorded by electrogoniometry. One rater assessed the peak knee angles and knee excursion of 15 subjects during 13 activities twice with an average of 22 days (range 5-31) between the two assessments. The 15 subjects included four patients one year after total knee replacement (TKR) surgery, five patients before TKR surgery and six age-matched controls. Intra-class correlation coefficients and Bland and Altman coefficient of repeatability were derived to analyse the results. Only the most affected leg of the patients and the right leg of the controls were used for analysis. Different measures of repeatability showed different results. Intra-class correlation coefficients were higher than 0.75 for peak values of all functions except sitting down and rising from a standard chair. However, coefficients of repeatability ranged from 5.6 degrees for the loading response in level walking to 39.8 degrees for stepping out of a bath. Both of these values are higher than clinically significant changes seen after total knee surgery. It was concluded that for a single assessment on individual patients, the functional knee motion as performed in this study did not have sufficient repeatability. However, if the measurements are used to assess the average changes before and after surgery in a group of patients, the assessment of knee motion during activities such as level walking, and slope and stair ascending and descending were found to be sufficiently repeatable.

Gait stability in response to platform, belt, and sensory perturbations in young and older adults.

Perturbation-based gait assessment has been used to quantify gait stability in older adults. However, knowledge on which perturbation type is most suitable to identify poor gait stability is lacking. We evaluated the effects of ipsi- and contra-lateral sway, belt acceleration and deceleration, and visual and auditory perturbations on medio-lateral (ML) and anterior-posterior (AP) margins of stability (MoS) in young and older adults. We aimed to evaluate (1) which perturbation type disturbed the gait pattern substantially, (2) how participants recovered, and (3) whether recovery responses could discriminate between young and older adults. Nine young (25.1 ± 3.4 years) and nine older (70.1 ± 7.6 years) adults walked on the CAREN Extended (Motek BV, The Netherlands). The perturbation effect was quantified by deviation in MoS over six post-perturbation steps compared to baseline walking. Contra-lateral sway and deceleration perturbations resulted in the largest ML (1.9-4 times larger than other types) and AP (1.6-5.6 times larger than other types) perturbation effects, respectively. After both perturbation types, participants increased MoS by taking wider, shorter, and faster steps. No differences between young and older adults were found. We suggest to evaluate the potential of using contra-lateral sway and deceleration perturbations for fall risk identification by including both healthy and frail older adults. Graphical abstract Margins of stability during steady state (left) and perturbed (right) gait to quantify reactive gait stability in response to various perturbation types in young and older adults.

An electromyographical study to investigate the effects of patellar taping on the vastus medialis/vastus lateralis ratio in asymptomatic participants.

It is commonly theorised that patellofemoral pain syndrome (PFPS) is caused by maltracking due to vastus medialis (VM) weakness relative to the vastus lateralis (VL). Despite this being a controversial theory, patellar taping is a commonly used technique that purports to correct this muscle imbalance by increasing the VM/VL ratio. The effects of different forms of taping on vasti muscle activity are still not known. The objective of this study was to investigate the effects of three different types of patellar taping on the VM/VL ratio in asymptomatic university students. Each participant performed a set of four single-legged squats under four separate taping conditions: A) medial, B) lateral, C) neutral, and D) no-tape. The condition sequence was randomised. The main outcome measure was the normalised VM/VL ratio, assessed by using surface electromyography. Secondary outcome measures were the normalised EMG activity of the VM and the VL. A convenience sample of 24 (17 females) students (22 +/- 10 years, M +/- SD) completed this study. The lateral taping condition produced small but significantly greater VM/VL ratios than the medial (p = 0.007) and neutral (p = 0.007) but not the no-tape (p = 0.123) condition. There were no significant differences between the medial, neutral, and no-tape conditions. These results question whether patellar taping can impart a clinically significant effect on the VM/VL ratio. The results of this study cannot be directly extrapolated to a patient population, and further research in the PFPS population is required before clinical recommendations can be made.

The effect of total knee arthroplasty on joint movement during functional activities and joint range of motion with particular regard to higher flexion users.

PURPOSE: To evaluate active and functional knee excursion of patients before and after total knee arthroplasty (TKA) and to determine whether TKA restores quality of life related to functional activities of daily living. METHODS: Electrogoniometry was used to measure the functional movement of the knee during 11 activities of daily living in 50 patients who underwent TKA. These data were compared with the patient's active range of motion and quality-of-life scores. RESULTS: A cut-off point existed between loss and gain in flexion at between 90 and 95 degrees of preoperative active flexion. Two thirds of patients had preoperative flexion of more than 90 degrees, 83% of them had reduced flexion postoperatively. The remaining one third had preoperative flexion of 90 degrees or less, 85% of them had improved flexion postoperatively. A similar pattern of loss and gain occurred for functional movement of the knee. Reduced functional range was associated with significantly reduced physical quality of life compared with age-matched healthy subjects. CONCLUSION: Although TKA offers excellent pain relief and contributes to the overall well-being of the patient, these results suggest that it also leads to a reduced range of active and functional motion in the majority of patients. This is associated with a lower-than-normal physical quality of life. The design of implants and rehabilitation programmes should be reconsidered so that better range of motion and quality of life can be achieved for patients.

The use of colposcopy in assessing vaginal irritation in research.

Since the early 1990s, colposcopy of the vagina and cervix has been used in the development of vaginal products in order to detect epithelial changes that may increase the likelihood of HIV or acquisition of other sexually transmitted diseases. As part of a continued effort to examine and define the role of colposcopy in a research setting, the Contraceptive Research and Development Program (CONRAD) and the International Working Group on Microbicides (IWGM), in association with the United Nations Program for AIDS (UNAIDS) sponsored a conference entitled, 'The Use of Colposcopy in Assessing Vaginal Irritation in Research', held in Washington, DC in January 1999. This is a report of that conference. The World Health Organization's colposcopy procedure and nomenclature, published in 1995, were reviewed and changes were recommended. The revised procedure involves colposcopic examination of the external genitalia, naked eye examination of the cervix, fornices, and vaginal walls, followed by lavage and colposcopic examination of those areas, and sampling as appropriate for microscopic examination. Revised nomenclature replaces the terms used for findings with descriptions of what is actually seen. Digital video imaging and testing for inflammatory markers may be adjuncts to colposcopy and should be further studied. Other areas requiring additional research include the natural history of colposcopic changes, factors other than product use that may affect colposcopic findings, the clinical significance of findings, and the procedure which best assesses these findings.

The effects of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine on presynaptic dopamine uptake sites in the mouse striatum.

The effects of the specific dopaminergic neurotoxin, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), were studied on the kinetics of [3H]mazindol binding to striatal membranes of C57 black mice. This radioligand was used to label dopamine uptake sites and when administered in vivo, MPTP caused an irreversible, non-competitive inhibition of mazindol binding, consistent with damage to dopaminergic terminals. This effect was abolished by pretreatment with pargyline, a MAOB inhibitor, suggesting that oxidation of MPTP to the pyridinium moiety, MPP+, is a necessary step for toxicity when mazindol binding is used as an end point. In keeping with these findings, pretreatment of mice with mazindol protected against the dopamine-depleting effects of MPTP in vivo. This data suggests that MPTP exerts its toxic effects via MPP+ which is concentrated intraneuronally via the dopamine uptake system. During this process the neurotoxin irreversibly inactivates the dopamine uptake sites.

Regional and temporal effects of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine on dopamine uptake sites in mouse brain.

When the regional effects of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) on brain dopamine uptake sites in C57 Black mice were studied using [3H]mazindol autoradiography, marked regional differences in effect were seen: the mesolimbic system was less affected than the nigrostriatal tract and within each system the effect was more severe in the terminal fields of the striatum than in the cells of origin. Within the striatum itself there was inhomogeneity of effect, with relative sparing of the dorsomedial aspect compared to the remainder. Complete recovery of [3H]mazindol binding to striatal membranes occurred over 12 months, while dopamine levels recovered more slowly. This supports the concept that MPTP has a highly selective effect within dopaminergic systems and that the initial effect is more pronounced on distal terminals compared to cell bodies. The possibility that recovery of mazindol binding with time may be associated with terminal regrowth needs to be investigated further.

Assessment of menstrual blood loss in Belgian users of the frameless copper-releasing IUD with copper surface area of 200 mm2 and users of a copper-levonorgestrel-releasing intrauterine system.

OBJECTIVE: This study was conducted to evaluate the effect of a miniaturized frameless copper IUD (GyneFix 200 small) and a copper-levonorgestrel (GynePlant) intrauterine system (IUS) on the amount of menstrual blood loss (MBL). METHODS: In 60 Belgian women using GyneFix 200 and 21 using GynePlant, MBL was assessed with the visual assessment technique. RESULTS: MBL scores in GyneFix 200 users did not change from baseline during the mean observation period of 31 months. In GynePlant users, mean MBL scores decreased by at least 50% in all but one user. CONCLUSION: The impact of copper IUDs on MBL can be minimized by reducing the surface area of the foreign body. Reduction of MBL, without causing amenorrhea, can be obtained by adding levonorgestrel.

Assessment of menstrual blood loss in women with ideopathic menorrhagia using the frameless levonorgestrel-releasing intrauterine system.

OBJECTIVE: This study was conducted to evaluate the effect of a "low-dose" levonorgestrel (LNG)-releasing intrauterine system (IUS) on the amount of menstrual blood loss (MBL) in women with ideopathic menorrhagia. METHODS: Menstrual blood loss was assessed with the visual assessment technique in 12 Belgian FibroPlant-LNG users with menorrhagia. In addition, ferritin levels were measured. RESULTS: The median MBL, evaluated by the visual scoring technique, decreased by more than 90%. The ferritin levels increased significantly during treatment with the levonorgestrel system. CONCLUSION: This study confirms previous MBL studies conducted with the FibroPlant-LNG IUS demonstrating the efficacy of the LNG-IUS to significantly reduce the amount of MBL in women with menorrhagia. The strong endometrial suppression is the principal mechanism explaining the effect on MBL. The therapeutic effect of this contraceptive method is highly desirable, particularly in women with heavy bleeding or anemia, as other treatment modalities are less effective, more costly, more invasive or inaccessible. The simple design characteristics and anchoring system account for minimizing the occurrence of complaints of pain and expulsion.

A comparative study of the effect of the Progestasert TM and Gravigard IUDs on dysmenorrhoea.

Data obtained from questionnaires on the occurrence of dysmenorrhoea in women using IUDs inserted randomly (146 of them Progestasert and 149 Copper 7) are analyzed. In both groups a reduction in the intensity of menstrual cramps was observed over 12 months of use. Although these reductions are significant in each group, they are slightly higher in Progestasert users. However, on comparing the reduction tendencies of both groups, the difference between them is not significant. No significant differences become apparent either when comparing premenstrual and intermenstrual camps. The usefulness of simple questionnaires directed at detecting the nature of pain in currently used family planning forms for IUD users is discussed.

PIP: A study was conducted at the Family Planning Centre of the Hospital Jose Joaquin Aguirre, Chile, involving 146 patients who had a Progestasert TM IUD inserted and 149 patients who had a Copper 7 IUD, Gravigard TM, inserted to determine the occurrence of dysmenorrhea. All patients completed questionnaires concerning habitual pelvic or genital pain prior to IUD insertion as well as at 1, 3, 6, and 12 months after insertion. Results indicated a reduction in menstrual cramps over 12 months of use. The Progestasert TM group showed a slightly higher reduction of menstrual cramps than Copper 7 users; however, the reductions are not significant. There were no significant differences between premenstrual and intermenstrual cramps. With the use of a questionnaire and the subjective condition of pain, it is difficult to ascertain whether the IUD produced any change in menstrual cramps or whether the reduction of pain originated in the patients; therefore, the technique of questioning the occurrence of pain may not be reliable enough.

Quantitative menstrual and intermenstrual blood loss in women using Lippes Loop and Copper T intrauterine devices.

PIP: 127 women were studied during 3 consecutive menstrual cycles preceding, and 6 non-consecutive menstrual cycles during the 1st year following insertion of either Lippes Loop C or Copper T. Both (MBL) menstrual blood loss and (IMBL) intermenstrual blood loss were quantified during these cycles. When postinsertion MBL was averaged and compared to mean preinsertion MBL, the Lippes Loop and Copper T devices increased the volume of menstrual bleeding by 99 and 42% respectively. In spite of this, mean hemoglobin levels did not change significantly during the period of study. Quantifiable MBL was experienced primarily during the 1st cycle postinsertion. The incidence was 90% in women inserted with the Lippes Loop C and 48% in those women inserted with the Copper T during this cycle. The volume of IMBL was extremely variable among the women studied (0.7 - 398 ml). In several cases the volume nearly equalled or even exceeded the MBL of the 1st cycle. Incidence of IMBL fell to 6.5% and 5.0% in the 2nd postinsertion cycle for women with loops and copper devices, respectively. Thereafter the incidence was neglibible. This marked decrease in incidence was not due to closures for bleeding. Less than 10% of the total blood loss experienced during the 1st year postinsertion was the result of IMBL and following the 1st postinsertion cycle, it contributed less than 2% of the total blood loss. The conclusion is that IMBL, while contributory to IUD discontinuation rates, does not contribute significantly to total blood loss and thus to iron loss following IUD insertion.^ieng

Effect of prior pregnancy and combined oral contraceptives on baseline menstrual blood loss and bleeding response to intrauterine devices.

No effect of pregnancy was found on baseline menstrual blood loss (MBL) in women within one year of parturition or abortion. The increased bleeding response of women to intrauterine devices (IUDs) was found to be independent of pregnancy status during the year preceding IUD sertion. Women pregnant within a year of insertion had no different MBL than those pregnant more than a year prior to insertion. MBL quantified in subjects within three months of discontinuing combined oral contraceptives (OCs) was significantly lower than in prior non-OC users. Furthermore, MBL was significantly reduced in the former group during the first three menses following IUD insertion. At the sixth and twelfth menses post-insertion, MBL was still lower in prior OC users, but the difference between users and non-users was less and no longer statistically significant.

PIP: The effects of pregnancy and oral contraceptive (OC) use within 1 year of IUD insertion were studied on both preinsertion and postinsertion menstrual blood loss. Of 88 starting subjects, 36 (41%) had not used OCs for the previous 15 months or longer, and had had a pregnancy termination more than (n=21) or less than (n=15) l year of study (nonusers). 52 patients had used OCs (combined-type) for 3 months-13 years before study; they discontinued OCs from 38-88 days before IUD insertion (users). No effect of pregnancy was found on baseline menstrual blood loss in women within 1 year of parturition or abortion. Increased bleeding was found in all women after IUD insertion was independent of pregnancy status; women pregnant within 1 year of insertion had no different menstrual blood loss than those pregnant more than 1 year of prior. The OC user group had significantly lower menstrual blood losstthan prior non-users. Menstrual blood loss was significantly reduced in the OC user group during the 1st 3 menstrual flows after IUD insertion. Though still lower at the 6th and 12th months postinsertion, the difference was no longer statistically significant for either.

Menstrual blood loss and body iron stores in Brazilian women.

Menstrual blood loss (MBL) studies are relevant for developing world women as this could be an important cause of anemia. Whenever a contraceptive method is to be used by such women, consideration should be given to the method which least affects the volume of MBL. In 309 women considered as clinically healthy, MBL, serum ferritin, serum iron and hemoglobin levels were measured: a mean MBL of 23 ml was found. Age, weight, height and previous oral contraceptive use did not affect MBL. Higher parity women may have higher MBL levels but their hematologic indices are not altered. While body iron stores (as judged by serum ferritin levels) are depleted in women who bleed more than 60 ml per cycle, clinical anemia may not be present until their blood loss exceeds 80 ml per menstruation. Brazilian women who lose more than 60 ml of menstrual blood associated with multiple pregnancies without adequate iron supplementation may have a depletion of their body iron stores.

Assessment of menstrual blood loss in Brazilian users of the frameless copper-releasing IUD with copper surface area of 330 mm2 and the frameless levonorgestrel-releasing intrauterine system.

OBJECTIVE: This study was conducted to evaluate the effect of two types of IUDs on the amount of menstrual blood loss (MBL): the frameless copper-releasing intrauterine device (IUD) with copper surface area of 330 mm2 (GyneFix; Contrel Research, Ghent, Belgium) and the frameless levonorgestrel (LNG)-releasing intrauterine system (IUS) releasing 14 microg per day (FibroPlant-LNG; Contrel Research). Heavy and abnormal MBL is the main reason for discontinuation of intrauterine devices. METHODS: In 20 Brazilian women using GyneFix 330 and 32 using FibroPlant-LNG, respectively, MBL was measured by the quantitative alkaline hematin technique. In addition, ferritin levels were measured in GyneFix 330 and FibroPlant-LNG users. RESULTS: MBL with GyneFix 330, measured over a 24-month period, increased but was less when compared with TCu380A. Ferritin levels with GyneFix 330 were not affected in contrast with TCu380A. In FibroPlant-LNG users, mean MBL decreased by about 90% and ferritin levels increased significantly. CONCLUSIONS: The authors confirm earlier reports that, especially for women with low body iron stores and heavy menstrual bleeding, there is an order of preference for IUD use to minimize MBL. The choice should first be a progestin-releasing IUS, then a copper IUD, which has the least effect on menstrual bleeding, such as the frameless GyneFix IUD.

Consequences of uterine blood loss caused by various intrauterine contraceptive devices in South American women. World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction.

Increased menstrual blood loss (MBL) associated with intrauterine device (IUD) use may precipitate or aggravate iron deficiency anaemia, adversely affecting the health of women particularly those from developing countries. Studies were conducted to define the association of MBL and iron status in South American women; to determine the level of MBL induced by IUD use which would result in iron depletion, the length of time for this depletion to occur and, comparing various IUDS, to determine if any currently tested IUDs are suited to long-term use in South American women. A total of 395 women received one of 5 types of IUDs in Santiago, Chile, and Juiz de Fora, Brazil: Lippes Loop, Multiload-250 and Multiload-375 were used in both centres; in Santiago some subjects received the Copper-7 or ProgestasertR devices and in Juiz de Fora, the TCu 200 and the T-Chloroquin IUDs were also tested. MBL and haemoglobin (HGB) were measured for 3 menstrual cycles before insertion, and following insertion, at one, two, four, six, nine, twelve, eighteen and twenty-four months in the majority of cases. Serum ferritin was measured before insertion and at intervals of six months. Mean values of MBL prior to IUD insertion in both centres varied from 21-30 ml. As with previous publications, the use of the Lippes Loop was associated with the greatest increase in MBL which was sustained throughout the 24 months of observation. Women who had one of the two types of Multiload devices inserted also had increased MBL and reduced ferritin for at least 12 months of use. TCu 200 and Copper-7 IUD users had an initial increase in MBL of 1 to 17 ml in the first six months of observation returning to normal levels beyond six months. Serum ferritin levels were lower for one year and then returned to admission values. ProgestasertR users confirmed previous reports of a reduction of 40-50% in MBL and an increase in serum ferritin. Few significant changes in haemoglobin (HGB) concentrations were found. Serum ferritin levels on admission ranged from 7.1 to 16.4 ng/ml in Santiago and from 15.8 to 23.2 ng/ml in Juiz de Fora. Many women were in a marginal state of iron balance as evidenced by lower serum ferritin values. Changes in serum ferritin were very closely related to those in MBL.(ABSTRACT TRUNCATED AT 400 WORDS)

Termination of very early pregnancy by RU 486--an antiprogestational compound.

RU 486, a new antiprogestational compound, was given to 37 women seeking termination of pregnancy and with amenorrhea of 42 days or less. One patient was found at the second follow-up visit to have an extrauterine pregnancy. The patients received either 25 mg, 50 mg or 100 mg RU 486 twice daily for four days. All patients attended three follow-up visits, one, two and five to six weeks after the start of therapy. The start, duration and amount of bleeding as well as plasma progesterone, beta-hCG and cortisol concentrations were determined for each treatment day and at the follow-up visits. All patients but three started to bleed during treatment. Frequency of complete abortion was 61% (22 out of 36 patients). In only three patients was the pregnancy unaffected by treatment. The clinical efficacy of the treatment was not dose-dependent. Most of the patients experienced only minor side effects in terms of mild uterine pain, nausea and vomiting. However, two patients suffered from heavy bleeding requiring blood transfusion and curettage. In the patients with complete abortion, beta-hCG values decreased significantly but not until the first follow-up visit. The plasma progesterone also decreased. The decrease appeared earlier with the higher daily dose of RU 486. Cortisol concentrations increased during treatment with all 3 dosage regimens but the levels remained within the normal range. It is concluded that treatment with RU 486 may provide a novel therapy for "menstrual regulation" but the efficacy of the treatment needs to be improved to compete with alternatives such as vacuum aspiration.

PIP: RU 486, a new antiprogestational compound, was given to 37 women seeking termination of pregnancy and with amenorrhea of 42 days or less. 1 patient was found at the 2nd follow-up visit to have an extrauterine pregnancy. The patients received either 25 mg, 50 mg, or 100 mg RU 486 twice daily for 4 days. All patients attended 3 follow-up visits, 1, 2, and 5-6 weeks after the start of therapy. The start, duration, and amount of bleeding as well as plasma progesterone, beta-human chorionic gonadotropin (hCG) and cortisol concentrations were determined for each treatment day and at follow-up visits. All but 3 patients started to bleed during treatment. Frequency of complete abortion was 61% (22 of 36 patients). In only 3 patients was the pregnancy unaffected by treatment. The clinical efficacy of the treatment was not dose-dependent. Most of the patients experienced only minor dise effects in terms of mild uterine pain, nausea, and vomiting. However, 2 patients suffered from heavy bleeding requiring blood transfusion and curettage. In patients with complete abortion, beta-hCG values decreased significantly but not until the 1ft follow-up visit. The plasma progesterone also decreased. This decrease appeared earlier with the higher daily dose of RU 486. Cortisol concentrations increased during treatment with all 3 dosage regimens but the levels remained within the normal range. It is concluded the treatment with RU 486 may provide a novel therapy for menstrual regulation but the efficacy of it needs to be improved to compete with such alternatives as vacuum aspiration.

Male infertility: risk factors in Mongolian men.

AIM: To determine the most common risk factors of male infertility in Mongolian men attending an infertility clinic. METHODS: A prospective, case-control study was conducted in which 430 men were enrolled. All the men had sought their first infertility evaluation between 1998-2002 in the State Research Center on Maternal Child Health, Ulaanbaatar, Mongolia. They were divided into two groups depending on the results of their semen analysis: 191 with abnormal semen and 239 with normal semen profile. Univariate and multivariate analyses were performed to determine any association between risk factors and semen abnormality. RESULTS: Logistic regression analysis demonstrated that the testicular volume, a history of sexually transmitted infections (STI), epididymitis and testicular damage all have statistically significant associations with semen abnormality, when controlled for multiple risk factors. Adjusted odds ratios of 3.4 for mumps orchitis, 2.3 for other orchitis and 3.9 for testicular injury were found. Gonorrhoea, the most commonly reported STIs in this study, gave an adjusted odds ratio of 1.0 for having one or more sperm abnormality. An adjusted odds ratio for subjects with a history of other STIs was 2.7. However, as a predictor of azoospermia, STIs had very high odds ratio, being 5.6 in patients with gonorrhoea and 7.6 in patients with other STIs. CONCLUSION: A history of pathology involving testicular damage appeared to have the strongest impact on male infertility in Mongolia. STIs have less impact on semen quality except when complicated by orchitis, epididymitis and vasal obstruction.