Electronic patient record systems and the general practitioner: an evaluation study.

We studied how well electronic patient record (EPR) systems meet the needs of general practitioners (GPs) and other health-care professionals for specific information. GPs in eight health centres in the South-Ostrobothnia region of Finland were invited to participate. They used three types of EPR system. They were asked to access EPRs to obtain 20 types of information for patients receiving anticoagulant treatment. In total 2,389 patient cases were studied. All of the information requested was available for 73% of the cases (range 55-93%). There was a significant difference between the type of EPR system and the percentage of patients for whom information was available through the EPR. However, further analysis showed that differences in performance between EPR systems probably reflected differences in the way EPRs were used by different organizations. Great care should be taken in attempts to rank EPR systems based on their performance.

Direct intraperitoneal or intrauterine insemination and superovulation in infertility treatment: a randomized study.

Direct intraperitoneal or intrauterine insemination in combination with superovulation was used randomly as the treatment of infertility that was unexplained or due to male subfertility or mild endometriosis in 124 couples during 326 cycles. The pregnancy rate per couple was 24% in the direct intraperitoneal insemination group and 31% in the IUI group. The difference was not significant. The pregnancy rates with both treatments were significantly higher than those seen during the 326 control cycles of the same couples (1.1% and 0.6%).

Measurements of salivary progesterone throughout the menstrual cycle in women suffering from unexplained infertility reveal high frequency of luteal phase defects.

Forty-five women suffering from unexplained infertility collected saliva for progesterone (P) measurements every morning during 1 to 3 complete cycles. A total of 27 cycles analyzed were unstimulated, 19 were stimulated by clomiphene citrate (CC), and 7 with CC, human menopausal gonadotropin (hMG), and human chorionic gonadotropin (hCG). Compared with reference profiles of salivary P from 27 normal cycles, the length and magnitude of P secretion were significantly lower in the infertility group. Luteal P concentrations were normalized during CC stimulation and significantly elevated during the CC-hMG-hCG stimulation. The other abnormalities found in the salivary P profiles of these patients included preovulatory P peaks, interruption of P secretion during luteal phase, and high P level at the beginning of menstruation. The results suggest that patients with prolonged unexplained infertility represent a heterogenous population with common luteal phase defects. The disturbance is effectively corrected with treatments stimulating gonadotropin secretion.

Contraception with levonorgestrel-releasing subdermal capsules, Norplant, after pregnancy termination.

Six Silastic levonorgestrel-releasing capsules, Norplant, were introduced subcutaneously into the ventral aspect of the left forearm or upper arm of thirty-eight patients immediately after first trimester pregnancy termination. In the control group, a Nova-T device was inserted immediately after pregnancy termination in thirty patients. Clinical examination was performed after three, six and twelve months of use. The continuation of the Norplant at one year was 91.7 per cent and that of the Nova-T 73.9 per cent. No pregnancies occurred during the study period of one year. Hemoglobin concentrations and the diastolic blood pressures of the Norplant users increased significantly. Dysmenorrhea and menstrual flow increased in the IUD group. Menstrual disturbances were the main side effects in the Norplant group during the first five months of use.

Intracervical release of levonorgestrel for contraception.

Twenty-one women used a levonorgestrel-releasing intracervical contraceptive device, which was designed to release 20 microgram/ay. The devices were inserted after cessation of menstrual bleeding. Patterns of bleeding and clinical performance wer evaluated and plasma concentrations of levonorgestrel, estradiol and progesterone in selected subjects were measured by radioimmunoassay. The results of the initial 90-day treatment are presented. Levonorgestrel was detected in peripheral plasma by 30 minutes after insertion of the device. Considerable variation of plasma levonorgestrel concentrations was observed between subjects, but within each subject, the plasma level of levonorgestrel was very stable with time. Of 24 cycles monitored by blood sampling, 19 were ovulatory. One subject did not ovulate at all. During the first 30-day period of treatment, frequent intermenstrual bleeding or spotting periods occurred. Two spontaneous expulsions occurred 9 and 22 days after insertion. Both of these subjects were nulligravidas. Side-effects were few and no pregnancies occurred during the study period.

Contraception with subdermal ST-1435 capsules: side-effects, endocrine profiles and liver function related to different lengths of capsules.

One Silastic capsule of 15 mm, 20 mm or 30 mm length was inserted subcutaneously into the ventral aspect of the left forearm or upper arm of 28 healthy women during menstrual bleeding or not later than on the seventh day of the menstrual cycle. A new capsule of the same length was inserted after six months and both capsules were removed twelve months after the first insertion. Side-effects, including changes in body weight, blood pressure, menstrual bleeding and liver function test results, were registered. Blood samples were taken from selected subjects twice a week during the 1st, 2nd, 3rd, 6th, 7th and 12th month of use. Plasma concentrations of ST-1435 were measured by radioimmunoassay and the effects of treatment on pituitary and ovarian function were determined by assaying plasma concentrations of LH, FSH, estradiol and progesterone. There were no differences in hormonal side-effects between subjects who had a 30 mm capsule or subjects who had 20 mm or 15 mm capsules, but subjects who had 20 or 15 mm capsules had significantly longer bleeding or spotting periods in comparison with subjects who had a 30 mm capsule. There were no changes in blood pressure, body weight or liver function test results in comparison with pre-insertion values. The plasma level of ST-1435 was not significantly higher during the use of 30 mm capsules than during the use of 20 or 15 mm capsules. During the use of the shorter ST-1435 capsules, plasma estradiol elevation and slightly suppressed FSH were seen, while the use of longer capsules resulted in a slight suppression of LH. Progesterone concentrations during monitored cycles indicated anovulation. No pregnancies occurred during the study period of one year. The continuation rate at one year was 71% in the 30 mm capsule group and 57% in the 20 and 15 mm capsule groups taken together.

Immediate postabortal contraception with Norplant: levonorgestrel, gonadotropin, estradiol, and progesterone levels over two postabortal months and return of fertility after removal of Norplant capsules.

Six Silastic levonorgestrel-releasing capsules, Norplant, were introduced subcutaneously into the ventral aspect of the left forearm or upper arm of thirteen patients immediately after first trimester pregnancy termination. Blood samples were taken twice a week over two months after abortion and from one subject over one month after removal of Norplant capsules. Plasma concentrations of levonorgestrel were measured by radioimmunoassay and the effects of treatment on pituitary and ovarian function were determined by assaying plasma concentrations of LH, FSH, estradiol and progesterone. If removal of Norplant capsules took place because of planning pregnancy, the subjects were asked to inform us if they had become pregnant. During the first month after abortion the mean levonorgestrel concentration (489 pg/ml) was statistically significantly higher than during the second month (237 pg/ml). The mean estradiol values fell to prefollicular levels within four days, remaining a little suppressed. The mean progesterone concentrations were below 2 ng/ml three days after abortion. Three subjects had a transient increase in plasma progesterone concentrations nine days after abortion. Thereafter no ovulatory progesterone concentrations were seen. The LH concentrations ranged within normal values of the follicular phase and FSH values were just beneath the lower limit of follicular phase FSH values, apart from a few peaks, indicating mild suppression. After removal of Norplant capsules, progesterone concentrations increased to ovulatory levels fifteen days after removal. The Norplant capsules were removed from two subjects because of planning pregnancy and they delivered healthy babies 9.5 and 12.5 months after removal.

Pharmacokinetic observations on ST-1435 administered subcutaneously and intravaginally.

Plasma levels of ST-1435 were determined by radioimmunoassay in 36 women and three men during treatment with subdermal capsules releasing ST-1435. The total lengths of the capsules used were 180 mm, 90 mm, 30 mm, 15 mm and 7.5 mm. A linear correlation between the mean plasma concentrations of ST-1435 and capsule length was found during the treatment period studied. However, great interindividual variation in plasma levels of ST-1435 between study subjects having similar capsules was observed. In comparison with the mean plasma concentrations in the initial months, only less than half of these plasma concentrations of ST-1435 were measured after six months of treatment, which indicates a short lifetime for this contraceptive system. In two women the disappearance of ST-1435 from the circulation was studied by measuring ST-1435 concentrations in the plasma after removal of a contraceptive vaginal ring (CVR) releasing ST-1435. Triphasic disappearance curves of ST-1435 were found, with half-lives 0.7-1.0 h, 3.1-4.0 h, and 10.7.3-11.8 h.

Pituitary and ovarian function and clinical performance during the use of a levonorgestrel-releasing intracervical contraceptive device.

A levonorgestrel-releasing intracervical device (ICD) was inserted postmenstrually to twenty-one voluntary women. Eight subjects gave blood samples twice a week during the initial three months of use of the ICD and during the seventh and twelfth months of use. Clinical performance was studied; plasma concentrations of levonorgestrel were measured by radioimmunoassay and the effects of the treatment on pituitary and ovarian function were determined by assaying plasma concentrations of LH, FSH, estradiol and progesterone. The results of the first year are presented. Dysmenorrhea, menstrual flow and the number of days of bleeding decreased during the first treatment year. Three spontaneous expulsions occurred; two at the very beginning of the treatment and one after six months of use. Side-effects were few. The plasma level of levonorgestrel remained fairly constant during the observation time of 12 months. Thirty-one of the 36 cycles were ovulatory as judged by plasma progesterone elevations. No pregnancies occurred during the study period of one year.

Intracervical release of ST-1435 for contraception.

Seven women used an ST-1435-releasing intracervical contraceptive device (ST-ICD), inserted immediately after the cessation of menstrual bleeding. Patterns of bleeding and clinical performance were evaluated and plasma concentrations of ST-1435, estradiol, progesterone and gonadotropins were measured by radioimmunoassays. The results of ten months of treatment are presented. There were no uniform patterns of bleeding. No hormonal side-effects were registered. The plasma concentration of ST-1435 reached 100 pg/ml within two hours after insertion of an ST-ICD. No ovulations occurred during the initial three months of treatment. A rapid decline in the plasma concentrations of ST-1435 was observed; during the tenth month the concentration of ST-1435 was under the sensitivity of the radioimmunoassay of ST-1435. Hence, the release of ST-1435 from Silastic was too rapid for long-acting contraceptive purposes.

A short luteal phase in cycles stimulated with clomiphene and human menopausal gonadotropin for in vitro fertilization.

Of 70 cycles stimulated with clomiphene and human menopausal gonadotropin (hMG) for an in vitro fertilization-embryo transfer (IVF-ET) program, a short luteal phase of 11 days or less was found in 18. In this group the mean estradiol and progesterone levels were elevated in the early luteal phase. Despite the elevated initial values, progesterone levels fell rapidly at the mid luteal phase as a sign of premature luteolysis. The mean total amount of gonadotropin administered and the mean number of follicles punctured and of oocytes recovered did not show any significant difference between the groups of normal and short luteal phases. The present findings support the theory that hyperestrogenism in the early luteal phase may initiate the premature luteolysis observed in clomiphene-menopausal gonadotropin-stimulated cycles.

Bond strength of fibre-reinforced composite to the metal surface.

The aim of this study was to measure push-out bond strength of gold alloy and pure titanium bars to dimethacrylate polymer-glass fibre composite. Metal bars were either left untreated, or sandblasted with 110 microm grain size aluminium oxide, pyrolytically silica-coated (Silicoater, Heraeus Kulzer) and silanized, tribochemically silica-coated, silanized (Rocatec, 3M-ESPE) and heat treated (100 degrees C/10 min), or tribochemically silica-coated and left unsilanized. Light-polymerizable opaque was applied on the metal surface and unidirectional glass fibres with Bis-GMA-PMMA monomer-polymer gel matrix was placed in contact to the bars and polymerized. Push-out test was performed for dry specimens and for those thermocycled (12.000 x55-5 degrees C). For titanium and gold alloy silica-coatings with the silane treatments resulted in the highest bond strengths. Values for titanium were somewhat higher than those for gold alloy. Silica-coating without silane treatment gave lower bond strengths but higher than that obtained with aluminium oxide sandblasting. The control specimens showed the lowest bond strength values. anova showed differences between the groups (P < 0.0001) whereas no significant differences between dry and thermocycled specimens were found. The results suggest that pyrolytical silica-coating with silane application resulted in highest bond strengths of dimethacrylate based fibre-reinforced composite to pure titanium and gold alloy.

Ovulation induction increases serum levels of insulin-like growth factor binding protein 1.

The effect of ovulation induction on serum insulin-like growth factor binding protein 1 (IGFBP-1) level in relation to sex hormone binding globulin (SHBG) levels was evaluated. Serum samples were collected 8 to 12 days after ovulation from 26 women undergoing ovulation induction with clomiphene citrate (CC), and from 58 women treated with CC in combination with human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG). In addition, serum samples were obtained from 63 spontaneously ovulating women and from 12 women during an anovulatory cycle. Luteal phase serum IGFBP-1 levels were 4.22 +/- 2.95 micrograms/L (P less than .05) in the CC group and 7.31 +/- 6.13 micrograms/L (P less than .001) in the CC/hMG/hCG group as compared to unstimulated ovulatory cycles (2.64 +/- 2.52 micrograms/L). No significant difference in IGFBP-1 levels was seen between spontaneously ovulatory and anovulatory cycles. The serum IGFBP-1 levels correlated positively to SHBG levels (r = .52, P less than .001). The data show that ovulation induction increases serum IGFBP-1 levels in parallel to SHBG levels, indicating that ovarian stimulation, which results in increased steroid hormone production, also induces changes in other factors known to modulate steroid hormone actions.

Anticoagulant treatment in primary health care in Finland.

OBJECTIVE: To establish the prevalence of anticoagulant (AC) treatment, the indications, and the quality of care in primary health care. DESIGN: A cross-sectional study, in which patients on AC treatment were identified from laboratory records. The main and second indications for AC treatment and the last value of the AC-test were taken from medical records. SETTING: Eight Finnish health centres with a total population of 182091 inhabitants. RESULTS: A total of 1255 patients on AC treatment were identified, 48% of them men. The mean age was 68.9 years. The age-adjusted prevalence of AC treatment was 0.65%. The commonest main indication was atrial fibrillation (38%). It was the main or second indication in 591 patients (age-adjusted prevalence 0.30%). The next commonest main indication was deep vein thrombosis (15%), followed by pulmonary embolism (8%). A total of 274 (22%) patients were anticoagulated for cerebral circulatory disturbances. 86% of the latest prothrombin time values fell within recommended ranges. CONCLUSION: The prevalence of AC treatment in Finland seems to be high. The proportion of patients with atrial fibrillation is high, differing from the results in other countries. The monitoring of AC-treatment as the general practitioner's responsibility functions well. The quality of care is good, even in older age groups.

Anticoagulant treatment of patients with atrial fibrillation in primary health care.

OBJECTIVE: To determine the prevalence of anticoagulant (AC) treatment of patients with atrial fibrillation in primary health care. To identify complications in the same patients during 1 year. DESIGN: Cross-sectional study and 1-year follow-up. SETTING: Seven health centres with a total population of 164093. SUBJECTS: Five hundred and twenty-two anticoagulated patients with atrial fibrillation. RESULTS: The age-adjusted prevalence of AC treated patients with atrial fibrillation was 0.30%. Of the 522 patients, 240 were men, mean age 69.6 years; and 282 women, mean age 75.1 years. At the beginning of the study 85% and after 1 year 81% of the latest prothrombin time values were within recommended range. After 1 year 414 out of the 522 patients continued AC treatment. During the 1-year follow-up 62 patients had minor or major complications. Eleven patients (2.1%) had to discontinue AC treatment because of complications. Prothrombin tests were mainly taken at 3-4 week intervals. CONCLUSION: High quality AC treatment is possible in the hands of general practitioners.