Patient Barriers to Discontinuing Long-Acting Reversible Contraception.

OBJECTIVES: To describe how frequently a national sample of patients with experience discontinuing or desiring discontinuation of long-acting reversible contraception (LARC) experienced barriers to discontinuation. METHODS: We conducted an online survey of individuals ages 18 to 50 in the United States who had previously used and discontinued or attempted to discontinue LARC. We recruited respondents using the Amazon platform MTurk. Respondents provided demographic information and answered questions regarding their experience discontinuing LARC, including reasons removal was deferred or denied. We analyzed frequency of types of barriers encountered and compared these by demographic factors. RESULTS: Of the 376 surveys analyzed, 99 (26%) described experiencing at least one barrier to removal. Barriers were disproportionately reported by those who had public health insurance, a history of abortion, and a history of birth compared to those who did not report barriers to removal. They also more frequently identified as Latinx, Asian, or Middle Eastern. Most barriers were provider-driven and potentially modifiable. CONCLUSIONS FOR PRACTICE: Barriers to LARC discontinuation are common and may be provider- or systems-driven. Providers should be mindful of biases in their counseling and practices to avoid contributing to these barriers.

A qualitative study of perspectives on research participation among individuals who recently experienced an abortion in Hawai'i.

OBJECTIVES: The United States Code of Federal Regulations mandates extra protections for research involving pregnant participants seeking abortions. This study aims to understand the perspectives of abortion patients regarding recruitment, decision-making, and participation in research. STUDY DESIGN: We recruited adults in Hawai'i who reported at least one induced abortion in the previous 6 months. Recruitment strategies included online advertisements and flyers posted in reproductive health clinics. We conducted in-person, semistructured interviews exploring research preferences. The authors collaboratively reviewed the resulting transcripts and created a code dictionary. We reviewed, organized, condensed, and diagrammed the resulting data to identify dominant themes. RESULTS: Between February and November 2019, we interviewed 25 participants aged 18-41 years who had medication (n = 14) or procedural (n = 11) abortions. Interviews ranged from 32 to 77 minutes (mean = 48 minutes). Four themes emerged: (1) people having abortions are capable of making informed decisions about research participation, (2) abortion-related stigma influences research decision-making, (3) people having abortions prefer to learn about study opportunities early and through participant-driven recruitment methods, and (4) the ideal role of the abortion provider in research is unclear. CONCLUSIONS: Abortion patients in this study want to be informed of research opportunities and feel capable of deciding about participation in research studies. Current federally mandated protections and common research practices could be revisited and revised to better reflect these preferences. IMPLICATIONS: Revision of federal regulations and optimization of recruitment methods may allow researchers to improve the research experience for patients having an abortion.

Oxytocin and Hypotension During Dilation and Evacuation Procedures at 18-24 Weeks Gestation.

Oxytocin is a neurohormone that is routinely administered to patients during dilation and evacuation procedures (D&E) to control bleeding despite minimal evidence in support of this common practice. In this study, the authors sought to evaluate patients with hypotension after receiving oxytocin during D&E procedures. The secondary data from a double-blind, randomized, placebo-controlled trial involving 112 patients who underwent a D&E at 18-24 weeks gestation and prophylactically received an intravenous bolus of either 30 units of oxytocin in 500 mL of normal saline or 500 mL of saline alone at the start of the procedure were analyzed. Anesthesia providers measured blood pressure before, at the time of, and after study medication administration in 5-minute increments until the end of the procedure. No differences in demographic characteristics or mean blood pressure between the 2 groups were observed. The proportion of hypotensive patients was not statistically different at 5 minutes following fluid bolus (oxytocin 25% versus placebo 13%, P=.09). The proportion of hypotensive patients was similar by 10 minutes (oxytocin 20% versus placebo 16%, P=.62). A sample size of 112 provided the ability to detect a 23% difference in the proportion of patients who experienced hypotension (2-sided 95% CI, power of 80%). These findings suggest that oxytocin may have a transient hypotensive effect.

Linking Public Health and Public Safety Data on Co-occurring Disorders Among Adults in Hawaii's Criminal Justice System.

To better understand the behavioral health treatment needs of adults involved in the criminal justice system and to improve the continuum of services provided to this vulnerable population, Hawaii initiated a data linkage project that connects substance use and mental health data from the state Department of Public Safety with behavioral health treatment data from the state Department of Health for the State of Hawaii. Specifically, this linkage project begins to examine behavioral health treatment levels recommended by the criminal justice system and Hawaii State Hospital inpatient psychiatric admissions. We provide a preliminary summary on individuals who were both involved in the criminal justice system and received court-ordered inpatient psychiatric treatment and outline data governance procedures, future directions, and practice recommendations.

Fetal tissue donation for research at the time of abortion: A qualitative study of individuals who experienced an abortion in Hawaii in 2018-19.

OBJECTIVES: This qualitative study explores how individuals recently experiencing abortions feel about donating fetal tissue for research. In addition, we sought to identify motivating or discouraging factors that influence decision making for these individuals. STUDY DESIGN: We recruited individuals living in Hawaii who reported undergoing an abortion in the previous 6 months for one-on-one semi-structured interviews as part of a broader study investigating views on peri-abortion research practices and protections. We devoted approximately 15 minutes of each 1-hour interview to discussing the donation of aborted fetal tissue for research. We double coded transcribed interviews and identified themes related to fetal tissue donation. RESULTS: We interviewed 25 respondents and identified 4 themes. (1) Individuals viewed fetal tissue donation as an opportunity to help others. (2) Respondents preferred for aborted fetal tissue to be used rather than discarded. (3) Respondents viewed the fetal tissue to be an extension of themselves, so informed consent is critical. (4) Information found online promotes mistrust of fetal tissue handling. CONCLUSIONS: Individuals who have had an abortion are open to fetal tissue donation for research purposes. Pre-abortion counseling could be improved by clarifying the process of fetal tissue handling and, when available, discussing options for fetal tissue donation. IMPLICATIONS: Informed pregnant individuals who have had an abortion appear to be supportive of fetal tissue research and their views can differ from the concerns of ethicists, politicians, and scientists. The perspective of the individuals donating fetal tissue should be included in future discussions of fetal tissue research.

Intranasal fentanyl for first-trimester uterine aspiration pain: A randomized controlled trial.

OBJECTIVE: To evaluate whether administration of intranasal fentanyl reduces reported pain during first-trimester uterine aspiration. STUDY DESIGN: We conducted a multicenter, randomized, double-blind, placebo-controlled trial of patients with pregnancies less than or equal to 14 weeks gestation seeking uterine aspiration for induced abortion, early pregnancy loss, or failed medication abortion. We randomized participants 1:1 to either intranasal fentanyl 100 mcg or intranasal placebo. All participants received ibuprofen and a standardized paracervical block. The primary outcome was pain indicated at the time of uterine aspiration on a 100 mm visual analog scale (VAS). We designed the study to detect a 15 mm difference in mean pain scores, which required 53 people in each arm for a total of 106 participants. Secondary outcomes included postprocedure pain and patient satisfaction with pain control. RESULTS: From March 2017 through June 2018, we screened 355 people for eligibility and enrolled 107 participants. Those who received intranasal fentanyl reported similar uterine aspiration pain to participants who received placebo (58.4 ± 28.0 fentanyl vs 58.6 ± 24.5 placebo, p = 0.97). Participants who received intranasal fentanyl also reported similar postprocedure pain scores compared to participants who received placebo (19.1 ± 19.4 fentanyl vs 17.2 ± 19 placebo, p = 0.63), and were equally satisfied with procedure pain control (66.8 ± 31.2 fentanyl vs 63.3 ± 29.2 placebo, p = 0.57). CONCLUSION: Intranasal fentanyl did not decrease reported pain with first-trimester uterine aspiration, nor did it decrease postprocedure pain compared to placebo. As an adjunct to ibuprofen and paracervical block, intranasal fentanyl did not improve patient satisfaction with pain control. IMPLICATIONS: Intranasal fentanyl does not reduce reported pain with first-trimester uterine aspiration, however abortion-seeking patients are amenable to receiving intranasal medications for pain management.

The experience of pain in real-time during medication abortion.

OBJECTIVE: We aimed to characterize the current pain experience of patients completing an evidence-based mifepristone-misoprostol medication abortion regimen using real-time pain scores. STUDY DESIGN: We collected real-time data on pain experienced by 54 women undergoing medication abortion using an evidence-based regimen of 200 mg mifepristone and 800 mcg buccal misoprostol. These women were enrolled in the placebo arm of a study on the effect of pregabalin for pain during medication abortion. All participants were dispensed ibuprofen and oxycodone/acetaminophen for analgesia. We assessed maximum pain experienced by participants on an 11-point numerical rating scale (NRS), duration of pain, and analgesic usage. Data was collected through electronic surveys sent via text message link at 6 specified points over 72 hours. RESULTS: Of the 54 women randomized to the placebo group, 2 were lost to follow-up. Participants experienced a mean maximum pain score of 5.5 ± 2.2. The mean time to maximum pain was 3.7 ± 2.4 hours after misoprostol. By hour 12 after misoprostol, 60.8% of participants reported no pain, which increased to 76.9% at 24 hours and 82.0% at 72 hours. Participants reported median ibuprofen usage of 2 800 mg tablets and median oxycodone/acetaminophen usage of one-half of a 5/325mg tablet. Approximately 12.0% of participants reported taking zero ibuprofen tablets, and 50.0% reported no opioid usage during the study period. CONCLUSIONS: Our real-time data collection demonstrated lower mean maximum experienced pain scores and shorter duration of pain than previously reported for medication abortion. Analgesic use was lower than previously described. IMPLICATIONS: This updated characterization of pain experienced during an evidence-based medication abortion regimen may allow for better pain-related counseling, tailoring of opioid prescription practices, and improvement in patient satisfaction.

"The Difference between Plan b and ella®? They're Basically the Same Thing": Results from a Mystery Client Study.

Pharmacy staff can serve an important role educating patients about emergency contraceptive pills (ECP), particularly ulipristal acetate (UPA), which requires a prescription. We conducted a secondary analysis of a previously completed mystery client study, assessing accuracy of information provided by pharmacy staffers to patients inquiring by telephone about filling a prescription for UPA. From the period December 2013 to July 2014, researchers used a mystery client methodology, contacting 198 retail pharmacies in Hawai'i. Researchers posed as patients or providers attempting to fill a prescription for UPA. During the course of the call, they asked about differences between UPA and levonorgestrel ECPs. Nearly half of all pharmacy staffers were unfamiliar with UPA. The majority of responses describing differences between the medications were incorrect or misleading, such as responses implying that UPA is an abortifacient. Lack of familiarity and incorrect information provided by pharmacy staffers may act as additional barriers in patient access to UPA. Health practitioners prescribing UPA should ensure patients receive evidence-based counseling at the time of prescription, while efforts should also be made to improve pharmacy staff familiarity with emergency contraceptive options.

Text message link to online survey: A new highly effective method of longitudinal data collection.

OBJECTIVES: To evaluate response rate to a text message link for an online survey as a method of data collection over the course of a medication abortion. STUDY DESIGN: This is a secondary analysis of a randomized, double-blind, placebo-controlled trial of 110 women initiating a medication abortion up to 70 days gestation. We sent a text message containing a link to an online survey collecting pain scores, analgesic use, and adverse effects at six time points over 72 h from time of misoprostol administration (0-, 2-, 6-, 12-, 24-, and 72-hours). Our primary outcome was the proportion of all text messages sent for which an online survey response was received. Secondary outcomes included the proportion of complete responses (all six surveys), responses received more than two hours after text prompt (defined as late), and differences in response rate by time of day. RESULTS: From June 2015 to October 2016, we screened 241 women, and 110 were randomized. We excluded three (1.2%) due to lack of a cellular phone with text capability, and three (2.7%) were lost to follow-up after enrollment. We received a response to 95.9% (633/660) of the delivered surveys, and 93.6% (103/110) of participants completed all six surveys. Over three-quarters of all responses were received within two hours of the requested time. Surveys sent before 08:00 were more likely to be returned late. CONCLUSIONS: In this population of women seeking medication abortion, text message link to online survey response appears to be an effective mode of data collection. IMPLICATIONS: Text message prompts for an online survey may optimize longitudinal real-time data collection response rates of sensitive data.

TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States.

OBJECTIVES: To evaluate the safety, feasibility, and acceptability of a direct-to-patient telemedicine service that enabled people to obtain medical abortion without visiting an abortion provider in person. STUDY DESIGN: We offered the service in five states. Each participant had a videoconference with a study clinician and had pre-treatment laboratory tests and ultrasound at facilities of her choice. If the participant was eligible for medical abortion, the clinician sent a package containing mifepristone, misoprostol, and instructions to her by mail. After taking the medications, the participant obtained follow-up tests and had a follow-up consultation with the clinician by telephone or videoconference to evaluate abortion completeness. The analysis was descriptive. RESULTS: Over 32 months, we conducted 433 study screenings and shipped 248 packages. The median interval between screening and mailing was 7 days (91st percentile 17 days), and no participant took the mifepristone at ≫71 days of gestation. We ascertained abortion outcomes of 190/248 package recipients (77%): 177/190 (93%) had complete abortion without a procedure. Of the 217/248 package recipients who provided meaningful follow-up data (88%), one was hospitalized for postoperative seizure and another for excessive bleeding, and 27 had other unscheduled clinical encounters, 12 of which resulted in no treatment. A total of 159/248 participants who received packages (64%) completed satisfaction questionnaires at study exit; all were satisfied with the service. CONCLUSIONS: This direct-to-patient telemedicine abortion service was safe, effective, efficient, and satisfactory. The model has the potential to increase abortion access by enhancing the reach of providers and by offering people a new option for obtaining care conveniently and privately. IMPLICATIONS: Provision of medical abortion by direct-to-patient telemedicine and mail has the potential to increase abortion access by increasing the reach of providers and by offering people the option of obtaining abortion care without an in-person visit to an abortion provider.

Use of medications to decrease bleeding during surgical abortion: a survey of abortion providers' practices in the United States.

OBJECTIVE: Our objective was to document current practices of abortion providers on the use of medications to decrease bleeding during surgical abortion. STUDY DESIGN: We emailed surveys to 336 abortion providers through a professional listserv to elicit information on their use of medications to prevent and treat bleeding during first- and second-trimester surgical abortion. RESULTS: One hundred sixty-eight (50%) providers responded to our survey. The majority were obstetrician-gynecologists (83%) working in an academic practice (66%). Most completed a fellowship in family planning (87%) and currently perform abortions up to 22 or 24weeks of gestation (63%). Seventy-two percent routinely used prophylactic medications for bleeding. Providers who routinely used medications to prevent bleeding most commonly chose vasopressin (83%). Providers preferred methylergonovine as a treatment for excessive bleeding in the second trimester, followed by misoprostol. CONCLUSION: We found that most providers routinely use medications to prevent bleeding and use several different regimens to treat bleeding during abortion. IMPLICATIONS: We found that surgical abortion providers use a range of medications to prevent and treat hemorrhage at the time of surgical abortion. Scant evidence is available to guide abortion providers on the use of medications to decrease hemorrhage during surgical abortion. To provide evidence-based recommendations for the prevention and treatment of clinically significant bleeding, researchers should target the most commonly used interventions.

Economic evaluation of dental sealants: A systematic literature review.

OBJECTIVES: To systematically review the literature on economic evaluations of dental sealants and examine the costs and effectiveness of caries prevention using sealants. METHODS: Of 21 full-text articles examined, a total of 13 were included in this study. These studies are grouped by the type of intervention as follows: (i) sealants compared with no sealants; (ii) sealants compared with other forms of caries prevention; (iii) resin-based sealants compared with glass-ionomer sealants; (iv) different sealing strategies in primary teeth; (v) different sealing strategies in permanent teeth; and (vi) sealants based on school- or clinic-based setting of delivery. All currency is reported in constant 2010 US$. RESULTS: Cost-effectiveness analyses differed due to varying study designs, assumptions, sealant delivery settings, outcomes, caries risk assessment and study durations. Findings varied on the cost-effectiveness of sealants compared with other caries-preventive strategies. Under the assumption of equal caries risk, always sealing primary molars appeared to be the most effective strategy, whereas risk-based sealing was the optimal strategy with differing caries risk. Studies that assessed sealing strategies in permanent teeth reported that risk-based sealing was more cost-effective than not sealing, but they differed on the cost-effectiveness of risk-based seal compared with non-risk-based seal. Sealants delivered in school settings had mixed results on costs but were as equally effective as sealants delivered in private practices. CONCLUSIONS: The cost-effectiveness of sealants is dependent on the conditions of delivery. The list of cost-effectiveness ratios for each intervention can support policy makers to estimate expected returns on their investments in dental sealants.

Diffusible gas transmitter signaling in the copepod crustacean Calanus finmarchicus: identification of the biosynthetic enzymes of nitric oxide (NO), carbon monoxide (CO) and hydrogen sulfide (H2S) using a de novo assembled transcriptome.

Neurochemical signaling is a major component of physiological/behavioral control throughout the animal kingdom. Gas transmitters are perhaps the most ancient class of molecules used by nervous systems for chemical communication. Three gases are generally recognized as being produced by neurons: nitric oxide (NO), carbon monoxide (CO) and hydrogen sulfide (H2S). As part of an ongoing effort to identify and characterize the neurochemical signaling systems of the copepod Calanus finmarchicus, the biomass dominant zooplankton in much of the North Atlantic Ocean, we have mined a de novo assembled transcriptome for sequences encoding the neuronal biosynthetic enzymes of these gases, i.e. nitric oxide synthase (NOS), heme oxygenase (HO) and cystathionine ß-synthase (CBS), respectively. Using Drosophila proteins as queries, two NOS-, one HO-, and one CBS-encoding transcripts were identified. Reverse BLAST and structural analyses of the deduced proteins suggest that each is a true member of its respective enzyme family. RNA-Seq data collected from embryos, early nauplii, late nauplii, early copepodites, late copepodites and adults revealed the expression of each transcript to be stage specific: one NOS restricted primarily to the embryo and the other was absent in the embryo but expressed in all other stages, no CBS expression in the embryo, but present in all other stages, and HO expressed across all developmental stages. Given the importance of gas transmitters in the regulatory control of a number of physiological processes, these data open opportunities for investigating the roles these proteins play under different life-stage and environmental conditions in this ecologically important species.

Identification and developmental expression of the enzymes responsible for dopamine, histamine, octopamine and serotonin biosynthesis in the copepod crustacean Calanus finmarchicus.

Neurochemicals are likely to play key roles in physiological/behavioral control in the copepod crustacean Calanus finmarchicus, the biomass dominant zooplankton for much of the North Atlantic Ocean. Previously, a de novo assembled transcriptome consisting of 206,041 unique sequences was used to characterize the peptidergic signaling systems of Calanus. Here, this assembly was mined for transcripts encoding enzymes involved in amine biosynthesis. Using known Drosophila melanogaster proteins as templates, transcripts encoding putative Calanus homologs of tryptophan-phenylalanine hydroxylase (dopamine, octopamine and serotonin biosynthesis), tyrosine hydroxylase (dopamine biosynthesis), DOPA decarboxylase (dopamine and serotonin biosynthesis), histidine decarboxylase (histamine biosynthesis), tyrosine decarboxylase (octopamine biosynthesis), tyramine ß-hydroxylase (octopamine biosynthesis) and tryptophan hydroxylase (serotonin biosynthesis) were identified. Reverse BLAST and domain analyses show that the proteins deduced from these transcripts possess sequence homology to and the structural hallmarks of their respective enzyme families. Developmental profiling revealed a remarkably consistent pattern of expression for all transcripts, with the highest levels of expression typically seen in the early nauplius and early copepodite. These expression patterns suggest roles for amines during development, particularly in the metamorphic transitions from embryo to nauplius and from nauplius to copepodite. Taken collectively, the data presented here lay a strong foundation for future gene-based studies of aminergic signaling in this and other copepod species, in particular assessment of the roles they may play in developmental control.

Prediction of the protein components of a putative Calanus finmarchicus (Crustacea, Copepoda) circadian signaling system using a de novo assembled transcriptome.

Diel vertical migration and seasonal diapause are critical life history events for the copepod Calanus finmarchicus. While much is known about these behaviors phenomenologically, little is known about their molecular underpinnings. Recent studies in insects suggest that some circadian genes/proteins also contribute to the establishment of seasonal diapause. Thus, it is possible that in Calanus these distinct timing regimes share some genetic components. To begin to address this possibility, we used the well-established Drosophila melanogaster circadian system as a reference for mining clock transcripts from a 200,000+ sequence Calanus transcriptome; the proteins encoded by the identified transcripts were also deduced and characterized. Sequences encoding homologs of the Drosophila core clock proteins CLOCK, CYCLE, PERIOD and TIMELESS were identified, as was one encoding CRYPTOCHROME 2, a core clock protein in ancestral insect systems, but absent in Drosophila. Calanus transcripts encoding proteins known to modulate the Drosophila core clock were also identified and characterized, e.g. CLOCKWORK ORANGE, DOUBLETIME, SHAGGY and VRILLE. Alignment and structural analyses of the deduced Calanus proteins with their Drosophila counterparts revealed extensive sequence conservation, particularly in functional domains. Interestingly, reverse BLAST analyses of these sequences against all arthropod proteins typically revealed non-Drosophila isoforms to be most similar to the Calanus queries. This, in combination with the presence of both CRYPTOCHROME 1 (a clock input pathway protein) and CRYPTOCHROME 2 in Calanus, suggests that the organization of the copepod circadian system is an ancestral one, more similar to that of insects like Danaus plexippus than to that of Drosophila.