Incidence and temporal trends of co-occurring personality disorder diagnoses in immune-mediated inflammatory diseases.

AIMS: Although immune-mediated inflammatory diseases (IMID) are associated with multiple mental health conditions, there is a paucity of literature assessing personality disorders (PDs) in these populations. We aimed to estimate and compare the incidence of any PD in IMID and matched cohorts over time, and identify sociodemographic characteristics associated with the incidence of PD. METHODS: We used population-based administrative data from Manitoba, Canada to identify persons with incident inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA) using validated case definitions. Unaffected controls were matched 5:1 on sex, age and region of residence. PDs were identified using hospitalisation or physician claims. We used unadjusted and covariate-adjusted negative binomial regression to compare the incidence of PDs between the IMID and matched cohorts. RESULTS: We identified 19 572 incident cases of IMID (IBD n = 6,119, MS n = 3,514, RA n = 10 206) and 97 727 matches overall. After covariate adjustment, the IMID cohort had an increased incidence of PDs (incidence rate ratio [IRR] 1.72; 95%CI: 1.47-2.01) as compared to the matched cohort, which remained consistent over time. The incidence of PDs was similarly elevated in IBD (IRR 2.19; 95%CI: 1.69-2.84), MS (IRR 1.79; 95%CI: 1.29-2.50) and RA (IRR 1.61; 95%CI: 1.29-1.99). Lower socioeconomic status and urban residence were associated with an increased incidence of PDs, whereas mid to older adulthood (age 45-64) was associated with overall decreased incidence. In a restricted sample with 5 years of data before and after IMID diagnosis, the incidence of PDs was also elevated before IMID diagnosis among all IMID groups relative to matched controls. CONCLUSIONS: IMID are associated with an increased incidence of PDs both before and after an IMID diagnosis. These results support the relevance of shared risk factors in the co-occurrence of PDs and IMID conditions.

Thermoregulation by kangaroos from mesic and arid habitats: influence of temperature on routes of heat loss in eastern grey kangaroos (Macropus giganteus) and red kangaroos (Macropus rufus).

We examined thermoregulation in red kangaroos (Macropus rufus) from deserts and in eastern grey kangaroos (Macropus giganteus) from mesic forests/woodlands. Desert kangaroos have complex evaporative heat loss mechanisms, but the relative importance of these mechanisms is unclear. Little is known of the abilities of grey kangaroos. Our detailed study of these kangaroos' thermoregulatory responses at air temperatures (T(a)) from -5 degrees to 45 degrees C showed that, while some differences occur, their abilities are fundamentally similar. Both species show the basic marsupial characteristics of relatively low basal metabolism and body temperature (T(b)). Within the thermoneutral zone, T(b) was 36.3 degrees + or - 0.1 degrees C (X + or - SE) in both species, and except for a small rise at T(a) 45 degrees C, T(b) was stable over a wide range of T(a). Metabolic heat production was 25% higher in red kangaroos at T(a) -5 degrees C. At the highest T(a) (45 degrees C), both species relied on evaporative heat loss (EHL) to maintain T(b); both panting and licking were used. The eastern grey kangaroo utilised panting (76% of EHL) as the principal mode of EHL, and while this was so for red kangaroos, cutaneous evaporative heat loss (CEHL) was significant (40% of EHL). CEHL appeared to be mainly licking, as evidenced from surface temperatures. Both species utilised peripheral vascular adjustments to control heat flow, as indicated by changes in dry conductance (C(dry)). At lower temperatures, C(dry) was minimal, but it increased significantly at T(a) just below T(b) (33 degrees C); in these conditions, the C(dry) of red kangaroos was significantly higher than that of eastern grey kangaroos, indicating a greater reliance on dry heat loss. Under conditions where heat flows into the body from the environment (T(a) 45 degrees C), there was peripheral vasoconstriction to reduce this inflow; C(dry) decreased significantly from the values seen at 33 degrees C in both kangaroos. The results indicated that, while both species have excellent thermoregulatory abilities, the desert red kangaroos may cope better with more extreme temperatures, given that they respond to T(a) 45 degrees C with lower respiratory evaporation than do the eastern grey kangaroos.

Ventilatory accommodation of oxygen demand and respiratory water loss in kangaroos from mesic and arid environments, the eastern grey kangaroo (Macropus giganteus) and the red kangaroo (Macropus rufus).

We studied ventilation in kangaroos from mesic and arid environments, the eastern grey kangaroo (Macropus giganteus) and the red kangaroo (Macropus rufus), respectively, within the range of ambient temperatures (T(a)) from -5 degrees to 45 degrees C. At thermoneutral temperatures (Ta=25 degrees C), there were no differences between the species in respiratory frequency, tidal volume, total ventilation, or oxygen extraction. The ventilatory patterns of the kangaroos were markedly different from those predicted from the allometric equation derived for placentals. The kangaroos had low respiratory frequencies and higher tidal volumes, even when adjustment was made for their lower basal metabolism. At Ta>25 degrees C, ventilation was increased in the kangaroos to facilitate respiratory water loss, with percent oxygen extraction being markedly lowered. Ventilation was via the nares; the mouth was closed. Differences in ventilation between the two species occurred at higher temperatures, and at 45 degrees C were associated with differences in respiratory evaporative heat loss, with that of M. giganteus being higher. Panting in kangaroos occurred as a graded increase in respiratory frequency, during which tidal volume was lowered. When panting, the desert red kangaroo had larger tidal volumes and lower respiratory frequencies at equivalent T(a) than the eastern grey kangaroo, which generally inhabits mesic forests. The inference made from this pattern is that the red kangaroo has the potential to increase respiratory evaporative heat loss to a greater level.

Integrating services involves cost issues.

PIP: This article discusses the integration of sexually transmitted disease (STD) care within family planning (FP) programs and the cost effectiveness of integrated services in development countries. Examples are taken from experiences in Colombia, India, the US, and Kenya. The 1994 International Conference on Population and Development urged the integration of reproductive health care within FP. The more than 330 million annual new STD cases increase HIV transmission and cause pain and infertility. Women are biologically more susceptible to STDs, are more likely to be asymptomatic, and face harsher consequences, including death. Women with STDs should avoid the IUD and use barrier methods. Maintaining laboratories, training staff, and supplying drugs can overburden strained health budgets, but may lower long-term medical costs, increase productivity in employment, and decrease pain and suffering. STDs are viewed by some US health professionals as a "best buy" for being one of the least expensive of the reproductive health options. A Kenyan study found that treating STDs and providing oral contraceptives saved money by collapsing treatment into one instead of two visits. The savings were in overhead and staff costs. Evaluations of cost effectiveness should consider local STD prevalence, cultural setting, client needs, and available resources. In some cases, referral of cases to STD clinics may be the most cost-effective. A US study found that chlamydia screening for all FP clients was more cost-effective than screening selectively. Another US study found that universal screening for chlamydia would provide long-term medical savings even if prevalence was only 2%. Developing countries have the lower-cost option of offering syndromic management of STDs for symptomatic women rather than lab tests. A program in India cut costs by educating and encouraging barrier methods.^ieng

Abused women have special needs.

PIP: In population-based studies in both developed and developing countries, 20-50% of ever-married women have reported a history of domestic violence. Abused women have urgent needs for medical, psychological, and reproductive health care. Family planning providers are well placed to intervene because they come into contact with women during their reproductive years--the time of highest risk for domestic violence. Awareness of the impact of gender-based power imbalances on women's reproductive health is critical. A lack of sensitivity to the fact that many women cannot control when they have sex can lead to inappropriate contraceptive counseling and method selection. Fear of violence further makes women unable to insist on condom use and thus protect themselves from sexually transmitted diseases. Emergency contraception is a pressing need for many battered women. Screening for violence, development of referral networks of legal and other resources, treatment tailored to a victim's needs, and involvement of men in family planning (if it will not compromise women's safety) all facilitate the provision of quality reproductive health care to abused women. Training about domestic violence should be integrated into existing provider training programs rather than presented as an isolated issue.^ieng

Training: an essential step.

PIP: This article highlights the importance of training in postpartum contraception and of linking women's health care to infant care and family planning. Training should meet specific needs for spacing or stopping childbearing, for local conditions, and for reaching the underserved. In the Central Asian Republics, women come to hospitals only for delivery. Medical staff need to counsel women and help women with their contraceptive options at the time of delivery. Family Health International (FHI) held a training workshop in 1996 on family planning and postpartum care for medical personnel in the Central Asian Republics in order to show providers how to make their clients aware of the contraceptive choices available to them. The training targeted a variety of specialists and was tailored to local conditions, in which women see different physicians and medical personnel depending upon their status as pregnant or postpartum women. In Latin American countries, where women are accustomed to seeking health care, FHI conducted a series of postpartum family planning workshops that explored options for improving the quality of care, informing providers about suitable contraceptive methods for postpartum use, and encouraging providers to integrate postpartum services into existing programs. In Egypt, AVSC International provided training to health care workers in reaching out to underserved women with postpartum and postabortion services. Five hospitals in Egypt are training sites and pilot models for delivering integrated reproductive health services in inpatient care. Most family planning in Egypt is done on an outpatient basis. AVSC gives providers instruction in developing standards of practice, client record systems, and better infection prevention practices. AVSC trains all levels of medical staff, including administrators.^ieng

Involving men after pregnancy.

PIP: This article discusses the role of counseling men in the postpartum period in addition to individual counseling and services for postpartum women. About 30% of couples rely on contraceptive methods that require men's active participation, such as condoms, vasectomy, withdrawal, or periodic abstinence. Communication between spouses about fertility and contraception and involvement of men in contraceptive services is constrained by cultural barriers, providers' lack of training on how to counsel men, health systems that discourage men from using services, and men's attitudes toward reproductive health. Counselors also must understand what husbands need to know and what women would like husbands to know. Couples need to know when women's fertility resumes in the postpartum period. Fertility returns shortly after an abortion (within 3 weeks) and after 6 weeks in postpartum women who are not breast feeding. Full breast feeding can delay the return to menses for 6 months. All male methods are appropriate in the postpartum period for breast-feeding women. Condoms are important for AIDS and sexually transmitted disease prevention. Natural family planning is unreliable until menstrual cycles become regular and ovulation resumes. Men need to be informed about family planning methods and about their own reproductive health. Men could be encouraged to help with child care and to value a girl child. Messages must be culturally specific and address the needs of both partners. Post-abortion counseling for men might address the issues of wives' need for recuperation, warning signs of complications, the importance of iron for prevention of anemia, and fertility return. Research findings indicate that counseling mattered, particularly in Turkey where the failure of withdrawal was related to repeat abortions. Brochures were the best means of conveying information to men.^ieng

Important needs follow pregnancy.

PIP: This article discusses postpregnancy programs that include family planning. Empirical evidence suggests that postpartum care is underused and does not include provision of contraceptive supplies before a hospital departure. Postpartum women have a need to space or limit childbearing that is not being met. The International Planned Parenthood Federation encourages affiliates to integrate family planning with other health services. The 1994 International Conference on Population and Development called for integrated services. The World Health Organization will be recommending, by the end of 1997, appropriate postpartum care for mother and baby. Family Health International recommends integrating family planning with maternal and child care. Many providers in Mexico, Chile, Zambia, and the Philippines are developing integrated postpartum services that include family planning. The FEMAP program in Mexico includes family planning information among its comprehensive prenatal care services. After delivery at FEMAP's seven hospitals or hospitals linked with FEMAP, health workers reinforce the messages given during prenatal visits. Then promoters visit mothers at home, provide more information, and urge regular postpartum check-ups along with child health check-ups. Almost 40% of FEMAP clients return for postpartum check-ups and about 80% receive prenatal care. The continuation rate is about 72% after 5 years. FEMAP offers a variety of long- and short-term options for contraception that satisfy women's needs. ICMER in Chile also offers integrated postpartum health services in poor neighborhoods. Programs can recommend methods suitable to women's needs. For example, the IUD is a good option for breast-feeding women. Lactational amenorrhea can be used in the immediate postpartum period. At 6 months, hormonal methods can be used. Providers must be sensitive to women's needs and sense of timing.^ieng

Experimental HIV drugs may improve prevention.

PIP: Condom use, preventing and treating sexually transmitted diseases, and reducing the number of sex partners remain effective strategies against the spread of HIV and should continue to be promoted. While data have not confirmed that HIV-infected people are more infectious in the weeks and months shortly after initial infection, new research findings suggest that focusing upon recently infected people during that early stage could help to prevent the spread of HIV; viral levels are high, AIDS has not yet weakened the host, and recent carriers are likely to be having sex with other high-risk partners. Vaccines, microbicides, and other drugs are being developed to prevent the spread of HIV, although most are years away from becoming widely available. Promising developments such as combination therapy are also coming out of research to treat people who are infected with HIV. The early diagnosis of HIV leading to early treatment should prolong life. New treatment regimens may encourage people to get tested for HIV infection.^ieng

Contraceptive needs after age 40.

PIP: Men and women are fertile and sexually active beyond age 40 years, with up to 50% of women able to conceive well into their 50s. However, the pregnancy-related risks among women over age 40 are up to 50 times greater than for women in their 20s. An unexpected pregnancy late in life is an unwelcome event for many women, leading many to abort their fetus. In 1992, more than a third of pregnant US women aged 40-44 years chose induced abortion, a higher rate than any other age group except for pregnant women 19 years old and younger. Women over age 40 therefore still need effective contraception and providers should be prepared to help those women choose methods which suit their circumstances and needs. Men can also play an important role by supporting their partners when choosing options or in practicing contraception themselves. Providers must carefully screen for health conditions which may increase the risk of using a contraceptive method. Methods for older couples, the IUD, barrier methods, and hormonal methods are discussed.^ieng

OCs provide emergency contraception option.

PIP: Administered in high doses, certain types of oral contraceptives (OCs) can be used after unprotected intercourse to prevent pregnancy. This regimen is safe and 75% effective; it appears to alter the uterine lining, thereby preventing implantation. The usual regimen consists of a dose of at least 100 mcg of ethinyl estradiol and 0.5 mg of levonorgestrel taken within 72 hours of unprotected sex and repeated 12 hours later; alternatively, 0.75 mg of levonorgestrel administered within 48 hours and repeated 12 hours later can be used. The US Food and Drug Administration has identified the following OCs as appropriate for use as emergency contraception: Wyeth's Ovral, Nordette, Lo/Ovral, or Triphasil and Berlex Laboratories' Levlen or Tri-Levlen. Despite the high doses required, these OCs can be taken safely for emergency purposes even by women with contraindications to regular OC use. A single dose of 600 mg of RU-486 or insertion within 5 days of a copper-bearing IUD represent two other approaches. In the US, more widespread use of emergency contraception has been hindered by equation of the method with abortion, the misperception that pills must be taken the morning after unprotected sex, lack of staff training, lack of consumer awareness of its availability and source, concerns women will substitute the method for consistent contraceptive use, and the lack of any formulation specifically marketed for this purpose. On the other hand, the method is used widely in parts of Africa to protect women from the risks of illegal abortion. The Consortium for Emergency Contraception plans to work with industry to produce an inexpensive emergency contraceptive that will be introduced in up to 15 developing countries over the next 5 years.^ieng

Beyond Beijing: putting words into action.

PIP: The Fourth World Conference on Women acknowledged that environmental degradation 1) disproportionately affects poor women who are powerless to control it, 2) is linked to poverty, and 3) jeopardizes women's reproductive health. Thus, the Platform for Action addresses environmental inequalities among its 12 areas of critical concern, and the governments who signed the consensus agreed to take almost two dozen specific environmental actions in the areas of 1) involving women in environmental decision-making, 2) integrating gender concerns in sustainable development, and 3) assessing the impact of developmental and environmental policies on women. The NGO (nongovernmental organization) Forum held in conjunction with the Conference acted as the environmental conscience of the Conference. In their discussions of environmental matters, NGO Forum participants introduced new concepts, such as that of environmental injustice or imperialism, into the international lexicon. They sought to develop a worldwide network working for social changes through the power of information sharing. Specific commitments to provide clean water to citizens were made by several countries, Cambodia pledged to include women in sustainable development programs, and Lesotho agreed to educate women about alternative energy sources. The US created the President's Interagency Council on Women to follow through on platform pledges. The environmental efforts of this Council will focus on improving women's health. NGOs throughout the world are holding a series of meetings to exchange information about the Conference and to suggest implementation methods.^ieng

POPs are very safe, have few side effects.

PIP: Though not as well known or widely used as combined oral contraceptives, progestin-only pills (POPs) are very safe, highly effective when used as directed, and cause a smaller range of side effects than combined pills. POPs are also known as mini-pills or progestin-only contraceptives (POCs). Combined pills are not recommended for breastfeeding women because the estrogen in them affects lactation. POPs, however, contain no estrogen and have a smaller amount of progestin than combined pills. They are therefore particularly suitable for women seeking a hormonal method who are breastfeeding and those who cannot tolerate estrogen. POPs have the added advantage of being fully controlled by users, which is not the case for other progestin-only methods. On the down side, POPs are somewhat less effective, must be taken within three hours of the same time every day to be most effective, and frequently cause irregular menstrual bleeding. These negative aspects have led providers and users to largely prefer combined pills. It follows that many providers have little experience offering POPs or counseling on their correct use. The author points out that since combined pills and POPs bear the same product labeling in the US, potential users and users can mistakenly believe that POPs have the same contraindications and side effects as combined pills.^ieng

POPs less widely used.

Progestin-only pills (POPs) are less widely used and available than combined pills. For example, the U.S. Agency for International Development (USAID) shipped only 3 million packets of POPs worldwide in 1994, compared with 62 million packets of combined pills, according to Mark Rilling, program analyst with USAID's Office of Population. While USAID considers POPs to be an acceptable contraceptive option for some women and intends to continue providing them, the worldwide market for them is small, Rilling says. The London-based International Planned Parenthood Federation (IPPF) reports a similar trend. IPPF shipped 16 times more combined pills than POPs during 1994, says Dr. Carlos Huezo, the organization's medical director. New efforts to clarify the role of progestin-only pills may make them more acceptable. For example, new studies have provided additional evidence that POPs do not harm breastfed infants whose mothers use them. A new label that reflects these findings, and clarifies other distinctions from combined pills, is being developed for POPs by the U.S. Food and Drug Administration, based on a draft developed by FHI. The pills also are being more actively promoted among some family planning organizations, and may prove useful for community-based distribution.

New approaches seek greater safety, appeal.

PIP: Researchers are developing new progestin-only contraceptives that are more appealing and may improve safety for certain users than such existing progestin methods as injectables (e.g., DMPA), the contraceptive implant Norplant, and progestin-only contraceptive pills (POPs). Progestin-only vaginal methods (rings and suppositories) allow users control over when to start and to discontinue their use. After removal of vaginal rings, the progestin level decreases within 24 hours and fertility returns quickly. Potential concerns about rings include expulsion, interference with intercourse, cervical changes, vaginal irritation, infection, and that they are more expensive to produce than other methods. A vaginal suppository being developed by the Contraceptive Research and Development Program is inserted daily, regardless of intercourse, and releases the natural female hormone progesterone. New implant systems should ease insertion and removal (e.g., a 2- or 1- rod vs. the existing 6-rod system) or avoid the need for removal (e.g., 4-5 biodegradable rice-grain-sized capsules of norethindrone and cholesterol). New injectable contraceptives have a lower amount of hormone than do other injectables without compromising the high contraceptive effectiveness. There is a need for more research on long-term effects of progestins (e.g., cardiovascular effects) as well as on whether progestins affect HIV transmission and whether DMPA has any effect on bone density. Another issue is how to reduce menstrual irregularities among users of progestin-only methods. The US National Institute of Child Health and Development has commissioned five new studies to address menstrual irregularities. The new progestin Nestorone (ST-1435), may be more beneficial for lactating mothers because it is not readily absorbed into an infant's system. It is being used for vaginal rings, implants, and a transdermal contraceptive cream. The IUD that releases levonorgestrel may prevent pregnancy for up to five years.^ieng

Contraception after unprotected sex.

PIP: Women who have had unprotected intercourse can use emergency contraception to prevent pregnancy. Emergency contraception can be a backup contraceptive method under circumstances of incorrect method use or method failure. It can also be used in cases of sexual assault. Oral contraceptives (OCs) and IUDs can be used as safe and effective postcoital contraceptive methods. Since postcoital contraception is less effective and may cause bothersome side effects (e.g., nausea), it should not be used often. Women need to know about and have access to emergency contraception. Some family planning providers do not offer emergency contraception. Many providers do not have adequate knowledge of emergency contraception. Other barriers to emergency contraceptive use are that clinics are closed at night and during the weekend when the need is highest, and the requirements for prescription. Emergency contraception protects against pregnancy by blocking ovulation, fertilization, transport of the fertilized ovum, or implantation. Combined OCs (2 doses of 100 mcg ethinyl estradiol + 0.5 mg levonorgestrel taken 12 hours apart) are the most common emergency contraceptive method. Other hormonal methods of postcoital contraception are progestin-only OCs (2 doses of 0.75 mg levonorgestrel taken 12 hours apart), estrogen (5 mg ethinyl estradiol for 5 days), a synthetic androgen (2 doses of 400-600 mg danazol taken 12 hours apart), and an antiprogestin (600 mg mifepristone [RU-486]). The combined OC, the androgen, and the antiprogestin need to be taken within 72 hours of unprotected intercourse. The progestin-only OC and the estrogen must be taken within 8 hours and 48 hours of unprotected intercourse, respectively. The IUD must be inserted within 5 days. It should be avoided in women at high risk of sexually transmitted diseases, however. When a woman seeks emergency contraception, providers should counsel her about effective, regular contraception and ask her about her plans should she become pregnant.^ieng

Long-acting methods require special care.

PIP: Long-acting contraceptive methods including IUDs, implants, and sterilization are among the most effective and convenient contraceptive methods, requiring little or no effort on the part of the user once provided by a trained healthcare provider. Some women, however, oppose the development and use of provider-dependent contraceptive methods due to the potential for method misuse. These methods, for example, could be provided without women's fully informed choice, access to removal could be blocked, or the method could be provided to an inappropriate client. Making a contraceptive method unavailable because of potential abuse instead restricts women's reproductive choices. After all, abuse generally comes from the legal or delivery system, not from the method itself. Efforts should be made to satisfy users with standard norms for performance and without targets for specific methods. Good service delivery along with revised approaches to contraceptive introduction and program evaluation can help prevent inappropriate method use and ensure that women receive adequate information and counseling to help them make reproductive choices without undue influence. The author discusses Norplant delivery, providing IUDs, offering sterilization, and improving access.^ieng

Informed consent plays key role.

PIP: Contraceptive research is conducted in developed and developing countries with the objective of developing safe and acceptable contraceptive methods and improved family planning programs. Volunteers who participate in biomedical and social science research in the field of family planning may, however, be at risk since some of the effects of new drugs, devices, or programs are unknown. It is imperative in such research that volunteers be informed and protected in terms of their health, safety, well-being, rights, and privacy. The responsibility for conferring such protection lies with the organizations which are sponsoring the research. International guidelines and safeguards exist to prevent research participants from being taken advantage of, but the integrity and commitment of researchers is the most essential element. Experts say that communicating all necessary information about the research to participants and obtaining their voluntary informed consent are important protection measures. Ethical review before research and communication between investigators and staff who conduct studies are also important. Contraceptive research, informed consent, the history of consent arising in response to Nazi experimentation upon prisoners in concentration camps during World War II, consent in practice, and improving the protection of volunteers are discussed.^ieng

Clients at STD risk need barrier methods.

PIP: Consistent use of barrier methods of contraception is the recommendation for family planning clients at risk of sexually transmitted diseases (STDs). For such methods to be effective, however, the conditions of user motivation, correct use, partner cooperation, and consistent supply must be met--conditions that are difficult to achieve for condom. A newly developed polyurethene condom may allow more physical sensation during sex, thereby increasing acceptability. The recently released female condom has the advantage of placing women in control of their protection from pregnancy and STDs; however, affordability and continued use over time remain concerns. Under development are new spermicides based on polysaccharides and defensins. Such microbicides would not involve the disruption of vaginal tissues associated with frequent use of the detergent spermicide, nonoxynol-9. Also under investigation is a microbicide based on carrageenan, a component of seaweed, that prevents human immunodeficiency virus (HIV) from infecting cervical cells in the laboratory. Although the next generation of barrier methods has the potential to increase acceptability, effectiveness, and safety, the need for counseling by providers on proper use and partner negotiation remains essential.^ieng