Bone mineral density testing, and bisphosphonate and oestrogen prescribing associated with depot medroxyprogesterone acetate utilization-The impact of the boxed warning.

WHAT IS KNOWN AND OBJECTIVE: Depot medroxyprogesterone acetate (DMPA) prevents follicular maturation and ovulation, resulting in oestrogen deficiency. Oestrogen deficiency is particularly concerning as it is associated with decreases in bone mineral density (BMD) or bone mass. Widespread use of concurrent oestrogen or bisphosphonates with DMPA has been observed in a previous single-centre US study. The authors also reported that more than half of obstetrician-gynaecologists ordered BMD testing solely due to DMPA. The small sample size of the survey, potential for volunteer bias and recall bias limit the utility of this study. Given the study limitations, we sought to examine the trends of concurrent bone mineral density (BMD) testing, and bisphosphonate (BPA) and oral oestrogen-only (EST) prescribing during depot medroxyprogesterone (DMPA) use in a large administrative database. METHODS: From IMS Health LifeLink™ database (2001-2013), we identified DMPA and combined hormonal contraceptive (CHC) users as women with no contraceptive claim 6 months before and after the defined episode. We examined concurrent use as the proportion of BPA or EST claims and concurrent therapy days during contraception use. We also determined the proportion of users who had a concurrent BMD test by calendar year. RESULTS: We identified 203 477 DMPA episodes associated with 600 BPA and 7060 EST claims and 1 297 806 CHC episodes associated with 2792 BPA and 145 600 EST claims. Most concurrent BPA use overlapped with 10% or less of the DMPA episode, whereas most concurrent BPA use overlapped with >90%-100% of CHC episode. No difference was noted with concurrent EST use. Concurrent BMD testing was higher among DMPA users (0.68%) compared to CHC users (0.11%). Across calendar year, BMD testing peaked in 2004 and declined steadily to the baseline. Most DMPA concurrent BPA (69.3%) users had a BMD test. CONCLUSION: Our findings indicate the absence of BST or EST use solely due to DMPA initiation and present alternative explanations. Published research and publicity leading to the final implementation of the boxed warning in 2004 may explain observed trends for BMD testing. The majority of patients who had a BMD test ordered were also receiving bisphosphonates, suggesting high-risk fracture status or appropriate monitoring.

A clinical research integration special program (CRISP) for young women with primary ovarian insufficiency.

Large-scale medical sequencing provides a focal point around which to reorganize health care and health care research. Mobile health (mHealth) is also currently undergoing explosive growth and could be another innovation that will change the face of future health care. We are employing primary ovarian insufficiency (POI) as a model rare condition to explore the intersection of these potentials. As both sequencing capabilities and our ability to intepret this information improve, sequencing for medical purposes will play an increasing role in health care beyond basic research: it will help guide the delivery of care to patients. POI is a serious chronic disorder and syndrome characterized by hypergonadotrophic hypogonadism before the age of 40 years and most commonly presents with amenorrhea. It may have adverse health effects that become fully evident years after the initial diagnosis. The condition is most commonly viewed as one of infertility, however, it may also be associated with adverse long-term outcomes related to inadequate bone mineral density, increased risk of cardiovascular disease, adrenal insufficiency, hypothyroidism and, if pregnancy ensues, having a child with Fragile X Syndrome. There may also be adverse outcomes related to increased rates of anxiety and depression. POI is also a rare disease, and accordingly, presents special challenges. Too often advances in research are not effectively integrated into community care at the point of service for those with rare diseases. There is a need to connect community health providers in real time with investigators who have the requisite knowledge and expertise to help manage the rare disease and to conduct ongoing research. Here we review the pathophysiology and management of POI and propose the development of an international Clinical Research Integration Special Program (CRISP) for the condition.

Clinical and histopathological study of mass in ear: a study of fifty cases.

Study of mass in ear was undertaken with the aim that clinical diagnosis was in most but not all cases consistent with the histo-pathological diagnosis. Therefore incisional or excisional biopsy with histo-pathological study is a must in all types of small masses in ear. A study of 50 patients, attending Ear, Nose and Throat department, was done and specimen collected from them and subjected to histopathological examination. These masses were further classified as inflammatory, benign and malignant lesions and the frequency of their occurrence in saurashtra region (Jamnagar, GUJARAT), their age and sex distribution were observed. Most common lesion was found to be inflammatory Polyps (20), followed by Cholesteatomas (12) and chronic non-specific inflammations (7), Abscess (1). In malignant lesions Squamous cell carcinoma (7) was the commonest followed by Embryonal rhabdomyosarcoma (1) and in benign lesion, Carcinoid tumor (1) and Nevus (1) were diagnosed on histo-pathological examination. Right side masses were more common than left side; males were more affected than females. Adolescents/children more affected than adults for benign lesions while reverse was true for malignant lesions.

Insulinoma induced hypoglycaemia in a Jamaican patient.

Herein reported is the case of a young woman who had hyperinsulinaemic hypoglycaemia which was biochemically consistent with an insulinoma. Initial imaging was negative and definitive treatment was delayed until repeat imaging localized the tumour several years later. This case demonstrates the importance of clinical judgment and biochemical testing in the diagnosis of insulinoma despite negative imaging.

Insulinoma induced hypoglycaemia in a Jamaican patient / Hipoglicemia inducida por insulinoma en un paciente de Jamaica

Herein reported is the case of a young woman who had hyperinsulinaemic hypoglycaemia which was biochemically consistent with an insulinoma. Initial imaging was negative and definitive treatment was delayed until repeat imaging localized the tumour several years later. This case demonstrates the importance of clinical judgment and biochemical testing in the diagnosis of insulinoma despite negative imaging.

Aquí se reporta el caso de una joven que presentó hipoglicemia hiperinsulinémica, bioquímicamente concordante con un insulinoma. La imagen inicial fue negativa y el tratamiento fue retardado hasta que mediante la repetición de la técnica de imaginología años más tarde localizó el tumor. Este caso demuestra la importancia de juicio clínico y las pruebas bioquímicas en el diagnóstico del insulinoma, especialmente frente a la obtención de una imagen negativa.