Mifepristone.

OBJECTIVE: To review the efficacy and safety of mifepristone (with misoprostol) for the termination of early pregnancy. DATA SOURCES: A MEDLINE search (1966-October 2000) was conducted, and additional references listed in articles were included; unpublished data obtained from the manufacturer were used to identify data from the scientific literature. Studies evaluating mifepristone were considered for inclusion. STUDY SELECTION: Human clinical studies in the English language were reviewed and evaluated. Clinical trials selected for detailed review were limited to those including the regimens of mifepristone and misoprostol, recently approved by the Food and Drug Administration for early pregnancy termination. DATA SYNTHESIS: Mifepristone is an antiprogestin available for pregnancy termination in combination with a prostaglandin such as misoprostol. Mifepristone offers efficacy similar to, if not better than, other drugs used for pregnancy termination, but appears less efficacious overall than surgical termination of pregnancy. Mifepristone in combination with misoprostol commonly causes adverse effects such as abdominal pain and, less commonly, can cause serious adverse effects such as incomplete abortion; endometritis; and bleeding warranting transfusion, hospitalization, or surgery. Mifepristone is metabolized by the cytochrome P450 system. Thus, the potential for drug interactions with this agent exists, although this has not been well studied. Data are included from clinical trials evaluating the safety, tolerability, efficacy, and pharmacoeconomics of mifepristone combined with misoprostol for early pregnancy termination. Data comparing the use of these agents with surgical abortion and other drugs used for pregnancy termination are included where available. CONCLUSIONS: Mifepristone in combination with misoprostol for the termination of early pregnancy (amenorrhea of < or = 49 d) is effective in 92-95% of women. Incomplete abortion requiring surgical abortion after the fact occurs in 3-5% of women, and pregnancy continues 1-2% of the time. Mifepristone with misoprostol treatment is not without significant risks, including hemorrhage, infection, and potential for long-term emotional consequences.

Qualifying for certification in the specialty of occupational medicine.

There are currently a variety of pathways toward certification in occupational medicine. These options may be a source of confusion for potential candidates. As such, this report is offered as a guide for those attempting to complete the requirements for Board eligibility in occupational medicine.

Clinical preventive medicine in business and industry: the economic impact.

Profits and earnings are the most important objectives for companies. Clinical preventive medicine programs reduce an employee's risk factors for illness, reduce absenteeism, and increase productivity. These programs can produce significant physiologic benefits for the employee, regardless of involvement level by the company. Cost-benefit analysis reveals benefit from smoking cessation, fitness, and some educational programs. The employer benefits from a happier and healthier work force which impacts on the public image.

Clinical preventive medicine in business and industry: a rational foundation.

The individual educational and intervention emphasis of clinical preventive medicine programs is successful in reducing an employee's risk for disease and injury. Although some studies note that decreased risk is found predominantly in those with low initial risk, a critical mass of healthful lifestyles may spread to non-participants in the organization, the halo effect. Thus, the more employees there are modeling a health lifestyle, the greater likelihood others will follow. Preventive medicine programs offer intangible advantages to the employer. Such programs demonstrate an attitude of caring for the employee which has an influence on the public. Happier employees tend to increase their level of socialization within a company. The ultimate effect is decreased employee risk, improved productivity, reduced absenteeism, and improved health at reduced cost.

A combined family practice and occupational medicine residency program.

Family physicians deliver a significant proportion of occupational medicine services in this country. A shortage of physicians specifically trained in occupational and environmental medicine (OEM) has been well documented. A 1991 report from the Institute of Medicine recommends an alternative approach to certification of OEM physicians by creating a streamlined graduate training program that would result in dual certification in a primary care specialty and OEM. For the past three years, the University of Oklahoma has offered such a combined track program, comprising four years of training in family practice and occupational medicine. This article describes the development and structure of the combined program.

Occupational illness in Oklahoma.

This study estimates the extent of work-related chronic disease fatalities in Oklahoma. Occupational cancer, pneumoconiosis, and chronic respiratory, cardiovascular, renal, and neurological diseases are addressed specifically. Also, the costs of chronic occupational illness are estimated. Because many cases of work-related disease find their way to the primary care physician, an individual who often has little formal training in the recognition and diagnosis of occupational or environmental illness, the education of primary care physicians and medical students in occupational disease recognition and prevention is encouraged.

Decompression sickness: an increasing risk for the private pilot.

Decompression sickness is not an appreciated hazard among the private pilot community. This is of growing concern with the increasing number of nonpressurized aircraft capable of flying to altitudes in excess of 5,468 m (18,000 ft). A case report is presented of a 42-year-old pilot who apparently experienced decompression sickness at flight level 250 which went unrecognized until several months after the incident.

Medication and the work environment.

Each year in the United States physicians write more than 1.5 billion prescriptions for their patients. Considering this scope of drug ingestion it seems safe to assume that medication is taken by some people while they are at work. The therapeutic effects or adverse reactions of drugs may compromise safety in the workplace. Furthermore, the conditions of the job or work environment may adversely alter the expected pharmacokinetics of some agents.

Occupational medicine support for international air carriers.

Although aviation medical support to flight deck crews and cabin staff has been the subject of numerous articles, information about occupational medical support to ground crews, maintenance personnel, and other behind-the-lines personnel who help to "keep them flying" has rarely been presented. This report discusses the occupational medical support provided by six major U.S. international air carriers. Each carrier arranges for medical support of employees through a variety of health care systems, ranging from an airline medical department to total use of contract medical services. Approximately 70% of the airline personnel are non-flying and consequently come under the provisions of classical occupational medical services. Further, many of the flying personnel who may have sustained injuries or illnesses as a result of their aviation occupation also are managed in classical occupational medicine terms. Several airline medical directors interviewed estimate that 65% or more of their professional time is concerned with classical occupational medicine activities rather than aviation medicine programs as usually defined. A major challenge to international air carriers is the numerous jurisdictional arenas concerned with workers' compensation regulations and law under which they operate.

Coronary heart disease: an expensive Air Force problem.

Death or disability from CHD is a major public health problem that costs the Air Force about $50 million annually. Statistically, 20% of 30,000 pilots in the Air Force could have a significant degree of coronary atherosclerosis. In-flight incapacitation due to "heart attack" is a real possibility. Fortunately, aircraft accidents related to coronary events have been very uncommon. The basic mechanisms leading to the development of CHD, a multifactorial condition, are not fully understood. The significance of various risk factors associated with an increased incidence of CHD are discussed. It is hoped that preventive programs designed to identify, educate, and treat those at high risk will reduce the incidence of premature death and disability due to CHD. Two such programs (HEW's MRFIT and USAF's HEART) are briefly described. The costs, benefits, risks, sensitivity, and predictive value of tests available to detect CHD in asymptomatic individuals are outlined.

Aeromedical considerations for flight operations from high-elevation airfields.

High-elevation airfields are available to commercial and military aviation. Rapid ascent to locations at high elevations may result in symptoms of altitude sickness in aircrew, support personnel, and passengers. In the United States there are 302 airfields at altitudes in excess of 1,524 m (5,000 ft); in other areas of the world, field elevations can exceed 4,267 m. The symptom complex which may occur at altitude is reviewed and recommendations are offered to prevent, ameliorate, or manage the symptoms.

Aircrew medical standards and their application in the Royal Australian Air Force.

Aircrew selection and health maintenance are key factors in the Aviation Medicine Program of the Royal Australian Air Force. The physical standards employed by the RAAF in selecting aircrew are reviewed. The aircrew selection process for the 5 years 1969 to 1973 are presented with emphasis given to medical causes for rejection. A careful analysis of reasons for failure to complete aircrew training was conducted. The results of this analysis are presented with special emphasis being given to medical wastage. The process of medical evaluation of trained aircrew is discussed along with the 1969-1973 experience with aircrew duty restrictions and waivers granted for medical conditions. The RAAF experience with medical wastage of trained aircrew is similar to the experience of other nations, both as to wastage rates and body systems involved.