Male contraception: narrative review of ongoing research.

BACKGROUND: Since the release of the combined oral contraceptive pill in 1960, women have shouldered the burden of contraception and family planning. Over 60 years later, this is still the case as the only practical, effective contraceptive options available to men are condoms and vasectomy. However, there are now a variety of promising hormonal and non-hormonal male contraceptive options being studied. The purpose of this narrative review is to provide clinicians and laypeople with focused, up-to-date descriptions of novel strategies and targets for male contraception. We include a cautiously optimistic discussion of benefits and potential drawbacks, highlighting several methods in preclinical and clinical stages of development. RESULTS: As of June 2023, two hormonal male contraceptive methods are undergoing phase II clinical trials for safety and efficacy. A large-scale, international phase IIb trial investigating efficacy of transdermal segesterone acetate (Nestorone) plus testosterone gel has enrolled over 460 couples with completion estimated for late 2024. A second hormonal method, dimethandrolone undecanoate, is in two clinical trials focusing on safety, pharmacodynamics, suppression of spermatogenesis and hormones; the first of these two is estimated for completion in December 2024. There are also several non-hormonal methods with strong potential in preclinical stages of development. CONCLUSIONS: There exist several hurdles to novel male contraception. Therapeutic development takes decades of time, meticulous work, and financial investment, but with so many strong candidates it is our hope that there will soon be several safe, effective, and reversible contraceptive options available to male patients.

RéSUMé: CONTEXTE: Depuis la sortie de la pilule contraceptive orale combinée en 1960, les femmes ont assumé le fardeau de la contraception et de la planification familiale. Plus de 60 ans plus tard, c'est toujours le cas, car les seules options contraceptives pratiques et efficaces disponibles pour les hommes sont les préservatifs et la vasectomie. Cependant, il existe maintenant une variété d'options contraceptives masculines hormonales et non hormonales prometteuses qui sont à l'étude. Le but de cette revue narrative est de fournir aux cliniciens et aux profanes des descriptions ciblées et à jour de nouvelles stratégies et cibles pour la contraception masculine. Nous incluons une discussion prudemment optimiste sur les avantages et les inconvénients potentiels, en soulignant plusieurs méthodes aux stades précliniques et cliniques du développement. RéSULTATS: En juin 2023, deux méthodes contraceptives masculines hormonales faisaient l'objet d'essais cliniques de phase II pour leur innocuité et leur efficacité. Un essai international de phase IIb à grande échelle, portant sur l'efficacité de l'acétate de ségestérone transdermique (Nestorone) et du gel de testostérone, a recruté plus de 460 couples et devrait être achevé pour la fin de 2024. Une seconde méthode hormonale, l'undécanoate de diméthandrolone, fait l'objet de deux essais cliniques axés sur l'innocuité, la pharmacodynamique, la suppression de la spermatogenèse et des hormones; le premier de ces deux essais devrait être achevé en décembre 2024. Il existe également plusieurs méthodes non hormonales à fort potentiel aux stades précliniques de développement. CONCLUSIONS: Il existe plusieurs obstacles à la nouvelle contraception masculine. Le développement thérapeutique nécessite des décennies de temps, un travail méticuleux et un investissement financier ; mais avec autant de candidats solides, nous espérons qu'il y aura bientôt plusieurs options contraceptives sûres, efficaces et réversibles, disponibles pour les hommes.

Burnout Among South Dakota-Licensed Physicians.

INTRODUCTION: Physician well-being is a topic of increasing attention nationwide. In collaboration with the South Dakota Board of Osteopathic and Medical Examiners and the South Dakota State Medical Association, we undertook an anonymous, web-based survey of all licensed physicians to assess the current baseline level of physician burnout. METHODS: The survey consisted of demographic questions and a single, validated burnout question that correlates with the lengthier Maslach Burnout Index. A link to take the survey was emailed to all licensees by the Board, and a single reminder email and link was sent two weeks later. The collector was open for 4 weeks from date of the initial invitation. Both quantitative and qualitative analyses were performed on the responses. RESULTS: There were 612 responses (10%). Overall 33.0% of responses were positive for burnout. Comparing subgroups divided by average work hours, practice size, community size, geographic location within the state, employment status, and specialty type, only those practicing primarily telemedicine demonstrated statistically significant lower prevalence of burnout (17%). Qualitative analysis identified themes that both increased risk and offered protection against burnout, including sense of control, availability of resources, relationships, and meaning in work. CONCLUSION: Burnout among physicians licensed by South Dakota is prevalent, though lower than the rate reported in most studies of physicians nationally. Apart from practicing primarily telemedicine, there was no correlation between burnout and practice characteristics, but provoking and palliating factors across practice types were identified that may offer potential areas for intervention to improve wellness.

Tranexamic Acid in the Prevention and Treatment of Postpartum Hemorrhage: A Review.

Postpartum hemorrhage (PPH) continues to be one of the leading causes of maternal morbidity and mortality worldwide. The four main causes of PPH are uterine atony, lacerations, retained placenta, and bleeding diathesis. In the patient with PPH, immediate evaluation is needed to diagnose and treat the underlying cause of hemorrhage. Uterotonic agents such as oxytocin remain first line for prevention and treatment of uterine atony. Studies have evaluated the antifibrinolytic tranexamic acid (TXA) as an adjunctive therapy in the prevention and treatment of PPH. TXA has been shown to reduce blood loss, bleeding-associated mortality, and transfusion rates in a variety of clinical settings and thus may serve a role in treating PPH. Current studies have demonstrated that TXA is an effective treatment option with limited risk of adverse events in appropriately selected patients; however, additional studies are needed to further clarify the role of TXA in the prevention of PPH.

Isthmoceles: A Growing Concern.

An isthmocele is described as a pouch-like defect in the uterus with a thin roof formed by inadequate healing of the smooth muscle of the anterior uterine wall at the site of a hysterotomy. With increased rates of deliveries by cesarean section, isthmoceles are becoming a more common cause of gynecologic and obstetric complications. Gynecologic issues include pelvic pain, postmenstrual bleeding, and reduced fertility or infertility. Therefore, it is important that providers consider these defects in their differential diagnosis as their presentation can mimic other gynecologic conditions, such as endometriosis. Fortunately, many effective treatment options are available, such as conservative hormonal treatment or surgical repair by laparoscopic, hysteroscopic, or transvaginal methods.

COVID-19 Vaccine Hesitancy in Rural Midwestern Infertility Patients: A Cross-Sectional Survey.

BACKGROUND: Pregnant patients with COVID-19 experience higher rates of maternal mortality, pregnancy loss, and other severe comorbidities. Despite these well-characterized risks, this group displayed a high level of vaccine hesitancy that contributed to their slow acceptance of the COVID-19 vaccinations and greater maternal mortality during the pandemic. The rural Midwest was no exception to this unfortunate trend, so here we sought to determine attitudes, beliefs, and perceptions in these women and their partners associated with vaccine hesitancy to better address uncertainties and improve vaccination rates. METHODS: We used a cross-sectional survey of rural Midwestern infertility patients. Study population included both women and men, ranging from 21 to 53 years old. We evaluated vaccination status, hesitancy or refusal for COVID-19 vaccination, sociodemographic factors, sources and types of medical information, employer vaccination requirements, and specific attitudes, beliefs, and perceptions towards vaccines using questions guided by the Health Belief Model. RESULTS: We surveyed 390 Midwestern patients with pre-existing clinic appointments who were being evaluated for infertility and/or trying to conceive. Vaccine-hesitant patients held significant concerns of rushed vaccine development, safety, and benefits not outweighing potential risks. Patients were significantly more likely to obtain the vaccine if it was recommended by their physician. They were also more likely to receive the vaccine if they were given written resources or if required by their employer. CONCLUSIONS: Survey results identified specific concerns and strategies that may be used to address vaccine hesitancy in this at-risk population. Addressing vaccine hesitancy may improve vaccination rates and in turn reduce maternal mortality and morbidity, particularly in rural populations.

Effects of alcohol use on sperm chromatin structure, a retrospective analysis.

BACKGROUND: The evaluation of the infertile couple is often complex as multiple factors in both the male and female can contribute, including social history. Previous studies have displayed that male ethanol consumption can disturb sperm motility, nuclear maturity, and deoxyribonucleic acid (DNA) integrity. The main purpose of this study is to evaluate the effects of male alcohol use on sperm chromatin structure analysis (SCSA®). This study was a retrospective chart review of 209 couples that presented to a midsize infertility clinic in the Midwest and had a semen analysis and SCSA® performed. Data extracted from the electronic medical record included demographics, tobacco use, alcohol use, occupational exposures, semen analysis results, and SCSA® results (DNA Fragmentation index (DFI) and High DNA stainability (HDS)). Statistical analysis was performed on this data set to determine significance with a p-level of 0.05, with the primary input being level of alcohol use and primary outcome being the SCSA® parameters. RESULTS: Overall, 11% of the cohort had heavy alcohol use (> 10 drinks/week), 27% moderate (3-10/week), 34% rare (0.5- < 3/week), and 28% none. 36% of the cohort had HDS > 10% (a marker of immature sperm chromatin). Level of alcohol use was not significantly associated with HDS > 10% or DFI. Heavier alcohol use was significantly associated with lower sperm count (p = 0.042). Increasing age was significantly associated with increasing DNA Fragmentation Index (p = 0.006), increased sperm count (p = 0.002), and lower semen volume (p = 0.022). Exposure to heat at work was significantly associated with lower semen volume (p = 0.042). Tobacco use was associated with lower sperm motility (p < 0.0001) and lower sperm count (p = 0.002). CONCLUSIONS: There was not a significant association between the level of alcohol use and the High DNA Stainability or DNA Fragmentation Index of sperm. Increasing age was associated with semen parameters as expected, heat exposure was associated with lower semen volume, and tobacco use was associated with lower sperm motility and density. Further studies could investigate alcohol use and reactive oxidative species in sperm.

RéSUMé: CONTEXTE: L'évaluation du couple infertile est souvent complexe car de multiples facteurs chez l'homme et la femme peuvent y contribuer, y compris l'histoire sociale. Des études antérieures ont montré que la consommation masculine d'éthanol pouvait altérer la mobilité des spermatozoïdes, la maturité nucléaire et l'intégrité de l'acide désoxyribonucléique (ADN). L'objectif principal de cette étude était d'évaluer les effets de la consommation d'alcool chez les hommes sur l'analyse de la structure de la chromatine des spermatozoïdes (SCSA®). Cette étude consistait en un examen rétrospectif des dossiers de 209 couples qui se sont présentés à une clinique d'infertilité de taille moyenne dans le Midwest et ont subi une analyse du sperme et un SCSA®. Les données extraites du dossier médical électronique comprenaient les données démographiques, le tabagisme, la consommation d'alcool, les expositions professionnelles, les résultats de l'analyse du sperme et les résultats du SCSA® (DFI et HDS). L'analyse statistique effectuée sur cet ensemble de données, pour déterminer la signification avec un niveau p de 0,05, a utilisé comme intrant principal le niveau de consommation d'alcool, le critère de jugement principal étant les paramètres du SCSA®. RéSULTATS: Dans l'ensemble, 11% de la cohorte avait une forte consommation d'alcool (> 10 verres / semaine), 27% modérée (3­10/semaine), 34% rare (0,5 à < 3/semaine) et 28% aucune. 36% de la cohorte avait HDS > 10%. Le niveau de consommation d'alcool n'était pas significativement associé à un HDS > 10% ou au DFI. Une consommation d'alcool plus importante était significativement associée à une diminution du nombre de spermatozoïdes (p = 0,042). L'augmentation de l'âge était significativement associée à une augmentation de l'indice de fragmentation de l'ADN (p = 0,006), à une augmentation du nombre de spermatozoïdes (p = 0,002) et à une diminution du volume séminal (p = 0,022). L'exposition à la chaleur au travail était significativement associée à un volume séminal plus faible (p = 0,042). La consommation de tabac était associée à une mobilité plus faible des spermatozoïdes (p < 0,0001) et à une numération plus faible des spermatozoïdes (p = 0,002). CONCLUSIONS: Il n'y avait pas d'association significative entre le niveau de consommation d'alcool et la stabilité élevée de l'ADN ou l'indice de fragmentation de l'ADN des spermatozoïdes. L'augmentation de l'âge était associée aux paramètres du sperme comme attendu, l'exposition à la chaleur à un volume de sperme plus faible, et la consommation de tabac à une mobilité et une numération plus faibles des spermatozoïdes. Des études à venir pourraient explorer les relations entre consommation d'alcool et espèces oxydatives réactives dans le sperme.

Preventing Unintended Pregnancies: A Review of Long-Acting Reversible Contraception.

With increasing uncertainty surrounding female reproductive rights, patient education about contraceptive options is of paramount importance. Although traditional oral contraceptive pills (OCP) are often used to prevent pregnancy, they require precise, daily effort and have continual monetary maintenance costs for patients. Long-acting reversible contraceptives (LARCs) - intrauterine devices and the contraceptive implant - are effective and reliable alternatives to OCPs that are gaining popularity in the U.S. These contraceptive options do not require continual patient maintenance and are overall cost-effective. Physicians should be well versed in what contraceptive options are available for their patients and comfortable providing education and recommendations. This analysis will cover what LARCs are on the U.S. market, risks and benefits of each, as well as the CDC's medical eligibility criteria.

Snowed In: A Case Report on the Utilization of Ultrasound in the Diagnosis of Fractures.

The standard convention for diagnosing bone fractures is through radiography. However, radiography can miss fractures depending on the type of injury or if human error is present. This may be due to improper patient positioning leading to superimposing bones being captured in the image, obscuring pathology. As of late, ultrasound has been gaining traction in terms of its utilization for diagnosing fractures, which radiography can miss at times. Here we present a case of a 59-year-old female who was diagnosed using ultrasound with an acute fracture that was initially missed on X-ray. We present a case of a 59-year-old female with a past medical history significant for osteoporosis who presented to an outpatient clinic for evaluation of acute left forearm pain. She reported sustaining a mechanical fall forward to the ground three weeks before bracing herself with her forearms, immediately developing left upper extremity pain lateralized to the forearm. Upon initial evaluation, forearm radiographs were obtained and showed no evidence of acute fractures. She then underwent a diagnostic ultrasound that showed an obvious fracture of the proximal radius, distal to the radial head. Upon reviewing initial radiograph films, it was evident that the proximal ulna was superimposed over the radius fracture as a proper neutral anteroposterior view of the forearm was not taken. The patient then underwent a computed tomography (CT) scan of her left upper extremity, which confirmed the presence of a healing fracture. We present a case in which ultrasound is an excellent adjunct when a fracture cannot be identified on plain film radiography. Its utilization should be well-known and considered more often in the outpatient setting.

Vitamin D levels and human sperm DNA fragmentation: a prospective, cohort study.

BACKGROUND: Intracytoplasmic sperm injection (ICSI) has revolutionized the treatment of couples with male factor infertility but results remain suboptimal and suggest the need for further investigation into the molecular biology of spermatozoa. Vitamin D has been implicated in spermatogenesis and sperm function. Hypovitaminosis D has been associated with abnormal testicular function, including elevated sperm DNA fragmentation in a murine model. This study's objective was to evaluate if there is a correlation between Vitamin D sufficiency and human spermatozoa DNA fragmentation index % (DFI%) in infertile couples. RESULTS: A prospective cohort study using a consecutive, convenience sample of subjects with infertility. The primary endpoint was the effect of Vitamin D sufficiency on human spermatozoa DFI%, and secondary outcomes included Vitamin D's effect on moderate DFI%, high DFI%, High DNA stainability % (HDS%), sperm density (million/mL), sperm total motility (% total) and sperm strict morphology (% total). Of the 111 participating, 9 were excluded, leaving 102subjects. The subjects were stratified by vitamin D levels: deficient (< 20 ng/mL; n = 24), insufficient (20-30 ng/mL; n = 43),, and sufficient (> 30 ng/mL; n = 35). There were no statistical difference between the categories of serum vitamin D levels and sperm DFI% as well as the secondary outcomes. An increased BMI was associated with low serum vitamin D levels (p = 0.0012). CONCLUSION: Vitamin D deficiency was not associated with sperm DFI% or routine sperm parameters. Previous animal and human studies have demonstrated conflicting results between sperm parameters and Vitamin D levels. Redundant pathways in Vitamin D and calcium homeostasis in the human male reproductive tract may maintain essential reproductive processes during Vitamin D insufficiency or deficiency. TRIAL REGISTRATION: Trial Registration Number: MOD00002311 (ClinicalTrials.gov).

RéSUMé: CONTEXTE: L'injection intracytoplasmique de spermatozoïdes (ICSI) a révolutionné le traitement des couples avec infertilité masculine, mais les résultats restent sous-optimaux et suggèrent la nécessité d'aller plus loin dans l'étude de la biologie moléculaire des spermatozoïdes. La vitamine D a été impliquée dans la spermatogenèse et les fonctions des spermatozoïdes. Dans un modèle murin, l'hypovitaminose D a été associée à une fonction testiculaire anormale, y compris une fragmentation élevée de l'ADN des spermatozoïdes. L'objectif de cette étude était d'évaluer s'il existait une corrélation entre un taux suffisant en vitamine D et l'indice de fragmentation de l'ADN (DFI) des spermatozoïdes humains chez les couples infertiles. RéSULTATS: Une étude de cohorte prospective utilisant un échantillon consécutif et approprié de sujets atteints d'infertilité. Le critère d'évaluation principal était l'effet d'un taux suffisant en vitamine D sur le DFI des spermatozoïdes humains; et les critères de jugement secondaires comprenaient l'effet de la vitamine D sur un DFI modéré, un DFI élevé, un taux élevé de coloration de l'ADN (HDS), le nombre des spermatozoïdes (millions/mL), la motilité totale des spermatozoïdes et sur la morphologie stricte des spermatozoïdes. Sur les 111 participants, 9 ont été exclus, laissant 102 sujets. Les sujets ont été stratifiés par niveau de vitamine D : déficient (<20 ng/mL ; n= 24), insuffisant (20-30 ng/mL ; n=43) et suffisant (>30 ng/mL ; n=35). Il n'y a eu aucune différence statistique entre les catégories de taux sériques de vitamine D et le pourcentage de DFI de spermatozoïdes ainsi qu'avec les critères de jugement secondaires. Une augmentation de l'indice de masse corporelle était associée à de faibles taux sériques de vitamine D (p = 0,0012). CONCLUSION: La carence en vitamine D n'est pas associée au pourcentage l'indice de fragmentation de l'ADN de spermatozoïdes ou aux paramètres de routine des spermatozoïdes. Des études antérieures chez les animaux et les humains ont montré des résultats contradictoires entre les paramètres des spermatozoïdes et les niveaux de vitamine D. Les voies redondantes dans l'homéostasie de la vitamine D et du calcium dans l'appareil reproducteur masculin humain peuvent maintenir les processus essentiels à la reproduction lors d'insuffisance ou de carence en vitamine D. MOTS-CLéS: Test de structure de la chromatine des spermatozoïdes, fragmentation de l'ADN des spermatozoïdes, vitamine D, infertilité masculine, hypovitaminose D.

Developing a Rapid Response Single IRB Model for Conducting Research During a Public Health Emergency.

Research is foundational for evidence-based management of patients. Clinical research, however, takes time to plan, conduct, and disseminate-a luxury that is rarely available during a public health emergency. The University of Nebraska Medical Center (UNMC) developed a single institutional review board (IRB), with a vision to establish a rapid review resource for a network focused on clinical research of emerging pathogens in the United States. A core aspect of successful initiation of research during a pandemic or epidemic is the ability to operationalize an approach for rapid ethical review of human subject research and conduct those reviews at multiple sites-without losing any of the substantive aspects of ethics review. This process must be cultivated in anticipation of a public health emergency. US guidance for operationalizing IRB review for multisite research in a public health emergency is not well studied and processes are not well established. UNMC sought to address operational gaps and identify the unique procedural needs of rapid response single IRB (RR-sIRB) review of multisite research by conducting a series of preparedness exercises to develop and test the RR-sIRB model. For decades, emergency responder, healthcare, and public health organizations have conducted emergency preparedness exercises to test requirements for emergency response. In this article, we describe 2 types of simulation exercises conducted by UNMC: workshops and tabletops. This effort represents a unique use of emergency preparedness exercises to develop, refine, and test rapid review functions for an sIRB and to validate readiness of regulatory research processes. Such processes are crucial for conducting rapid, ethical, and sound clinical research in public health emergencies.

Pancreas Transplantation for Type 2 Diabetes: A Systematic Review, Critical Gaps in the Literature, and a Path Forward.

Pancreas transplantation in patients with type 2 diabetes (T2D) remains relatively uncommon compared with pancreas transplantation in patients with type 1 diabetes (T1D); however, several studies have suggested similar outcomes between T2D and T1D, and the practice has become increasingly common. Despite this growing interest in pancreas transplantation in T2D, no study has systematically summarized the data to date. We systematically reviewed the literature on pancreas transplantation in T2D patients including patient and graft survival, glycemic control outcomes, and comparisons with outcomes in T2D kidney transplant alone and T1D pancreas transplant recipients. We searched biomedical databases from January 1, 2000, to January 14, 2021, and screened 3314 records, of which 22 full texts and 17 published abstracts met inclusion criteria. Full-text studies were predominantly single center (73%), whereas the remaining most often studied the Organ Procurement and Transplantation Network database. Methodological quality was mixed with frequent concern for selection bias and concern for inconsistent definitions of both T2D and pancreas graft survival across studies. Overall, studies generally reported favorable patient survival, graft survival, and glycemic control outcomes for pancreas transplantation in T2D and expressed a need to better characterize the T2D patients who would benefit most from pancreas transplantation. We suggest guidance for future studies, with the aim of supporting the safe and evidence-based treatment of end-stage T2D and judicious use of scarce resources.

Nonalcoholic Fatty Liver Disease in Women with Polycystic Ovarian Syndrome: A Narrative Review.

Polycystic ovarian syndrome (PCOS) has been estimated to affect 10-15 percent of women in the U.S. Emerging research has found higher rates of nonalcoholic fatty liver disease (NAFLD) among PCOS individuals. While the mechanism continues to be poorly understood the aim of this review is to convey the most recent knowledge regarding the pathogenesis, diagnosis, and treatments for NAFLD in PCOS patients. Elements of insulin resistance, hyperandrogenism, obesity, and chronic inflammation are culprits in the pathogenesis of NAFLD in these patients therefore early liver screening and diagnosis is essential. Although liver biopsy remains the gold standard, advances in imaging modalities show accurate diagnosis and some can even assess the risk of progression to cirrhotic states. Apart from lifestyle modifications resulting in weight loss, other treatments with bariatric surgery, thiazolidinediones, angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin-receptor blockers (ARBs), and vitamin E show promising results.

Relationship between body mass index and malignancy rates of MRI-guided breast biopsies: impact of clinicodemographic factors.

PURPOSE: To determine the positive predictive value (PPV) of magnetic resonance imaging (MRI)-guided breast biopsy stratified by body mass index (BMI). Secondary endpoints include evaluation of indications for breast MRI and identification of factors associated with malignant biopsy. METHODS: We retrospectively analyzed results of MRI-guided breast biopsies in a consecutive cohort of women at a single institution between 2014 and 2019. The PPV was compared between BMI subgroups and the overall group by the one-sample z-test. Factors associated with malignant biopsy were analyzed using multivariate regression analysis. RESULTS: Among 427 MRI-guided breast biopsies, the PPV was significantly higher in patients with a BMI ≥ 35 compared to BMI < 35 (38.6% versus 24.5%, p = 0.043). This remained true in the 180 biopsies from high-risk screening studies, but there was no difference in PPV by BMI in the 205 biopsies performed to evaluate extent of known disease. Among this cohort who underwent MRI-guided breast biopsy, the underlying indication for MRI was less likely to be high-risk screening in those with a higher BMI or Black or Hispanic race (p = 0.015 and p < 0.001, respectively). For high-risk screening studies, only BMI ≥ 35 was associated with malignant biopsies (OR 37.5, p = 0.003). For evaluation of extent of disease studies, only increased lesion size was a significant predictor of malignant result (OR 1.01, p = 0.04). CONCLUSIONS: Among women who underwent MRI-guided breast biopsy, elevated BMI was associated with increased PPV and malignant biopsies. Patients with a higher BMI or Black or Hispanic race who had MRI-guided biopsy were less likely to be undergoing high-risk screening and more likely to have breast MRI to evaluate extent of known disease.

A Case of Uterine Arteriovenous Malformation Treated With Uterine Artery Embolization.

Uterine arteriovenous malformation (AVM) is a rare condition that is potentially life-threatening. There are limited published reports on this condition. This is a case report of a 25-year-old woman who presented with a symptomatic AVM. We review the differential diagnoses, evaluation, and treatment options. Conservative treatment with interventional radiology can be considered in select women who desire fertility preservation.

A world-wide survey on kidney transplantation practices in breast cancer survivors: The need for new management guidelines.

Kidney transplantation reduces mortality in patients with end stage renal disease (ESRD). Decisions about performing kidney transplantation in the setting of a prior cancer are challenging, as cancer recurrence in the setting of immunosuppression can result in poor outcomes. For cancer of the breast, rapid advances in molecular characterization have allowed improved prognostication, which is not reflected in current guidelines. We developed a 19-question survey to determine transplant surgeons' knowledge, practice, and attitudes regarding guidelines for kidney transplantation in women with breast cancer. Of the 129 respondents from 32 states and 14 countries, 74.8% felt that current guidelines are inadequate. Surgeons outside the United States (US) were more likely to consider transplantation in a breast cancer patient without a waiting period (p = .017). Within the US, 29.2% of surgeons in the Western region would consider transplantation without a waiting period, versus 3.6% of surgeons in the East (p = .004). Encouragingly, 90.4% of providers surveyed would consider eliminating wait-times for women with a low risk of cancer recurrence based on the accurate prediction of molecular assays. These findings support the need for new guidelines incorporating individualized recurrence risk to improve care of ESRD patients with breast cancer.

The Female Athlete Triad - What it is and Why it is Important in Primary Care.

The female athlete triad (FAT) is a disorder involving greater energy expenditure than energy consumption leading to 1) low energy availability (EA) with or without disordered eating 2) menstrual irregularities or amenorrhea and 3) low bone mineral density. Consequences of FAT include osteoporosis, stress fractures, increased cardiovascular risk, infertility, and negative psychological effects. The key risk factor for FAT is inadequate caloric intake when compared to the amount and intensity of exercise. All female athletes should be screened at least annually at pre-participation physicals or with signs of disordered eating, weight loss, abnormal growth or development, menstrual dysfunction, recent injuries, decreased athletic performance, or mood changes. Presence of one of the components of the triad necessitates further investigation. Treatment involves a multidisciplinary approach with increased energy intake and decreased exercise intensity being the primary goal of treatment. Understanding FAT is important for preventative medicine, as some consequences, such as infertility and loss of bone mineral density may not be reversible.

Complementary and Alternative Treatments for Postpartum Depression.

Complementary and alternative treatments are commonly requested as treatment options for depression. This article provides a review of evidence for complementary and alternative therapies (doula support, saffron, yoga, aromatherapy, placentophagy, mindfulness, probiotics and wake therapy) in the treatment of postpartum depression. The included studies, mainly randomized control trials, focus on the efficacy of these interventions as compared to standard pharmacotherapy and or no treatment.

Menstrual Migraines: Diagnosis, Evidence, and Treatment.

"Menstrual" or "catamenial" migraine (MM) is separated into two categories in the International Classification of Headache Disorders pure menstrual migraine and menstrually-related migraine. Pure menstrual migraine is defined as a migraine occurring exclusively on day 1 ± 2 of menstruation in at least two out of three menstrual cycles and at no other time in the cycle. Menstrually-related migraine is defined as the same but may occur at other times in the menstrual cycle, not just around menstruation. The withdrawal of estrogen has been correlated with the onset of MM, providing an opportunity for specific treatment with hormone therapies. Traditionally, MM has been treated with nonspecific treatments such as abortive and prophylactic non-steroidal anti-inflammatory drugs and triptans. While this is first line, evidence suggests that nonspecific treatments can be used in combination with specific hormone treatments. The hormone treatment recommended is either continuous combined hormonal contraceptives (CHCs) with no placebo pills or using just two days of placebo pills to avoid the estrogen withdrawal trigger. Although MM with aura is uncommon, when referring to using CHCs for MM with aura, the U.S. Medical Eligibility Criteria for Contraceptive Use 2016 categorizes MM with aura as "A condition that represents an unacceptable health risk if the contraceptive method is used." Therefore, the current recommendation is not to use CHCs with a history of menstrual migraine with aura, especially when other risk factors such as smoking are present. Other treatments such as GnRH agonists, selective estrogen receptor modulators, and bilateral oophorectomy have limited evidence.