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Evaluating the competing risks of HIV acquisition and maternal mortality in Africa: a decision analysis.

OBJECTIVE: To model the risk of HIV acquisition and maternal mortality for women in four African countries in the light of previous data on risk of HIV acquisition and hormonal contraceptive use. DESIGN: Decision analysis. SETTING: Chad, Kenya, South Africa and Uganda. POPULATION: Women of reproductive age, at risk of HIV, who do not desire pregnancy. METHODS: A decision analysis model was built to compare the consequences of removing progestin injectables from use, assuming an increased risk of HIV acquisition. Three scenarios were considered in four African countries: replacement of progestin injectables with no method, with combined oral contraceptives (COC) or with an intrauterine device (IUD). Health outcomes measured include: life-years, maternal mortality, HIV acquisition and unsafe abortion. Sensitivity analysis, including Monte Carlo simulation, was performed around all variables. MAIN OUTCOME MEASURES: HIV acquisition, maternal mortality and life-years. RESULTS: If progestin injectables are removed from use, without a minimum of 70-100% of women switching to an IUD or COCs, up to nine additional maternal deaths will occur for every case of HIV averted. Sensitivity analysis demonstrated that this finding persisted across a broad range of variables. CONCLUSIONS: Contraception is critical to preserving life for women in Africa. In the absence of clear evidence regarding hormonal contraception and HIV acquisition, policy decisions must not overlook the very real risk of maternal mortality.

Universal prenatal HIV screening: are we there yet?

The objectives of this study were to determine the prevalence of and factors associated with prenatal HIV screening and the availability of HIV test results in medical records in Pittsburgh, PA, USA. Three hundred postpartum women were surveyed about demographics and prenatal care provider(s) and practice setting and were asked to recall prenatal HIV screening and reasons for accepting or declining a HIV test. Medical records were reviewed for documentation of HIV results. Overall, 65% of women reported screening. White race, higher annual household income and fewer lifetime sexual partners were independently associated with decreased likelihood of prenatal HIV screening. Provider presentation of screening as standard practice and provider encouragement were associated with prenatal HIV screening. Only 38% of medical records contained HIV results at the time of labour. Universal and routine offering of prenatal HIV screening as standard practice, in conjunction with encouragement from health-care providers, may increase patient acceptability and the uptake of prenatal HIV screening.

Communication of adenomyosis with the endometrial cavity: visualization with saline contrast sonohysterography.

We report four cases of a finding of communication between the endometrial cavity and adenomyotic lesions observed during saline contrast sonohysterography. In each case there was a saline-filled defect extending from the endometrial cavity into the myometrium in the region of previously suspected adenomyosis. We believe this finding represents the sonohysterographic correlate of endometrium invading the myometrium, as has been described histologically.

Endometrial thickness following medical abortion is not predictive of subsequent surgical intervention.

OBJECTIVES: To evaluate the ability of endometrial thickness after medical abortion to predict the need for subsequent dilatation and curettage (D&C). METHODS: We pooled data from two multicenter medical abortion trials involving 2208 women who received mifepristone orally followed by misoprostol vaginally. Women returned for transvaginal ultrasonography approximately 7 days later. The endometrial thickness was measured if no gestational sac was present. Final status was confirmed by a phone interview at 5 weeks. The area under the receiver-operating characteristics (ROC) curve was calculated to assess the overall ability of endometrial thickness to predict the need for subsequent D&C. Endometrial thickness was dichotomized using threshold values at 5-mm increments from 10 to 30 mm. The sensitivity, specificity, negative predictive value and positive predictive value were calculated to evaluate the ability of each endometrial thickness threshold value to predict subsequent D&C. Multivariable regression analysis was performed to adjust endometrial thickness values for study, treatment group, and study site. RESULTS: At 7 days after misoprostol treatment, 1870 women (84.7%) had endometrial thickness assessed. Thirty of these women (1.6%) subsequently underwent D&C. The mean endometrial thickness was 14.5 mm for women who underwent D&C and 10.9 mm for those who did not (difference 3.5 mm (95% CI, 1.8-5.3 mm)). Endometrial thickness was poorly predictive of the need for D&C, with an area under the ROC curve of 0.65. All endometrial thickness thresholds had positive predictive values of 25% or less. The results were unchanged by adjustment of endometrial thickness values by multivariable modeling. CONCLUSIONS: Although endometrial thickness following successful expulsion of the gestational sac is thicker in women who will eventually require surgical intervention after medical abortion, endometrial thickness is not a clinically useful predictor of the subsequent need for D&C.

Tissue-specific somatic mosaicism in spinal and bulbar muscular atrophy is dependent on CAG-repeat length and androgen receptor--gene expression level.

The factors influencing the tissue-specific pattern of somatic mosaicism in CAG-repeat diseases have not yet been fully resolved. We performed a detailed analysis of the degree of somatic mosaicism in various tissues from 20 patients with spinal and bulbar muscular atrophy (SBMA), including 4 who were deceased. The most outstanding feature was the prominent somatic mosaicism observed in the cardiac and skeletal muscles, composed predominantly of postmitotic cells, and in the skin, prostate, and testis. The CNS tissues, liver, and spleen showed the least mosaicism. The tissue distribution of somatic mosaicism in patients with SBMA was markedly different from that in patients with Huntington disease (HD) and from that in patients with dentatorubral-pallidoluysian atrophy (DRPLA). The degree of somatic mosaicism correlated with the CAG-repeat number but not with age at examination. Furthermore, tissues with a higher mosaicism level corresponded well to those with a higher expression level of androgen receptor protein. The tissue-specific pattern of somatic mosaicism related not only to cell composition with different cell turnover rates but to repeat size and gene expression levels, and postnatal cell division is unlikely to be a major cause of somatic mosaicism probably because of the relative stability of CAG repeat in SBMA.

Re-entry into the cell cycle is required for bFGF-induced oligodendroglial dedifferentiation and survival.

Remyelination in the CNS following demyelinating disease may be accomplished by surviving mature oligodendrocytes that dedifferentiate, proliferate, migrate, and finally regenerate myelin. We previously reported that basic fibroblast growth factor (bFGF) induces oligodendrocytes in primary mixed glial cultures to dedifferentiate and synthesize DNA (Grinspan et al.: J Neurosci Res 36:672-680, 1993). We now show that this effect is direct and not mediated through the effects of bFGF on other cell types, because we were able to demonstrate similar changes in oligodendrocyte phenotype in enriched oligodendrocyte cultures prepared by immunopanning. The bFGF-induced reversion to the precursor stage of the oligodendroglial lineage can be blocked by agents that inhibit entry to the cell cycle; thus oligodendroglial dedifferentiation is dependent on proliferation. We also report that 2 days of bFGF treatment inhibits oligodendroglial apoptosis. However, when oligodendroglia are prevented from entering the cell cycle in the presence of bFGF, apoptotic cell death is increased. Thus, bFGF induces oligodendroglial dedifferentiation if oligodendroglial DNA synthesis can occur but causes oligodendroglial apoptosis when oligodendroglial DNA synthesis is prevented.