Reducing Unnecessary Head Computed Tomography in Mild Traumatic Brain Injury.

There is growing concern about the frequency of computed tomographic (CT) scans performed for evaluation of adults with suspected mild traumatic brain injury. The Canadian CT Head Rule and the New Orleans Criteria are the most studied head CT decision tools that aid providers in determining which patients do not require a CT scan. This article examines recent research to determine which of these tools has proven to be the most effective at safely reducing the use of head CT scans. The reviewed studies concluded that both the Canadian CT Head Rule and the New Orleans Criteria had similar sensitivities, but the Canadian CT Head Rule showed superior specificity in predicting the presence of a clinically significant brain injury. The authors of this article recommend that the Canadian CT Head Rule be used in the evaluation of minor head injury to reduce unnecessary CT scans.

Approaches to male hypogonadism in primary care.

Evidence suggests that providers are not adhering to current testosterone replacement therapy guidelines when treating male hypogonadism. Understanding the diagnosis and management of this condition is further complicated by conflicting recommendations among available guidelines. NPs must select and follow the best guideline recommendations available to optimally treat male hypogonadism.

African American students' reactions to Benjamin Cooke's "Nonverbal Communication Among Afro-Americans: An Initial Classification".

The nonverbal communication behavior of Black people continues to take new forms as time progresses. In Kochman's 1972 book, Rappin' and Stylin' Out: Communication in Urban Black America, Benjamin Cooke introduced an initial classification and code of nonverbal behaviors among people of African descent. In this study, students react to Cooke's study conducted in the late 1960s by commenting on Cooke's initial findings in comparison to nonverbal behaviors practiced among Black people as of late. Respondents suggest that while differences and variations exist between the expression of nonverbal behaviors exhibited by the original group studied and people recently observed, there yet remains a similarity in the cultural significance and motivation behind the displays.

Adolescent and young women's experience with the vaginal ring and oral contraceptive pills.

STUDY OBJECTIVE: To compare acceptability of the vaginal contraceptive ring to that of oral contraceptive pills. DESIGN: Randomized, cross-over, 6-month study. SETTING: Urban family planning clinic for young low-income patients. PARTICIPANTS: Sexually active females aged 15-21 years (n = 130). INTERVENTIONS: Participants were randomly assigned to use the vaginal ring or oral contraceptive pills for an initial study interval of three 28-day cycles, followed by three cycles of the alternate method. MAIN OUTCOME MEASURES: Participants completed surveys about method use, acceptability, and side effects at baseline, after three cycles, and after six cycles. We analyzed study data using ANOVA models for cross-over designs. RESULTS: We did not detect higher compliance with the ring as compared to oral contraceptive pills (P = 0.176), although overall approval of the ring was significantly higher on several items measured, including liked using method (P = 0.015), would recommend it to friends (P = 0.012), and not as hard to remember to use method correctly (P < or = 0.000). Participants were less worried about health risks while using the ring (P = 0.006), but reported that the ring was more likely to interfere with sex than the pill (P < or = 0.001) and that sex partners liked the pill (P = 0.034). Most women did not report bothersome side effects with either method. CONCLUSIONS: Adolescent and young women showed favorable acceptability of the vaginal contraceptive ring compared to oral contraceptive pills.

Beyond access: acceptability, use and nonuse of emergency contraception among young women.

OBJECTIVE: This study was undertaken to assess the acceptability of levonorgestrel emergency contraception (EC). STUDY DESIGN: We examined attitudes and use patterns among 1950 women in a randomized trial evaluating access to EC through advance provision, pharmacies, or clinics. RESULTS: Most women considered EC to be safe (92%) and effective (98%). Compared with women with clinic access, women with direct pharmacy access were no more likely to use EC within 24 hours (odds ratio [OR] = 1.65, 95% CI = 0.82-3.30) or to report it very convenient (OR = 1.41, 95% CI = 0.77-2.56). However, women with advance provisions were more likely to use EC promptly (OR = 2.43, 95% CI = 1.24-4.80) and report high convenience (OR = 4.25, 95% CI = 2.32-7.76). Advance provision increased use by all women, whereas pharmacy access increased use only among condom users. Inconvenience and fear of side effects were common reasons for nonuse. CONCLUSION: Women viewed EC favorably. Advance provision improved promptness and convenience of use overall, while pharmacy access benefited specific populations.

Provider practice models for and costs of delivering medication abortion -- evidence from 11 US abortion care settings.

PURPOSE: Understanding practice models and provider costs for medication abortion (MAB) provision may elucidate ways to facilitate MAB integration into a larger arena of health care services. This study provides descriptive data on the diverse MAB practice models currently being utilized by US health care providers and the costs associated with the components of those models. METHOD: Data were gathered from a sample of 11 abortion care settings, using clinic administrative records and patient satisfaction surveys. RESULTS: Practice models varied dramatically, with a wide range in the type of staff employed to provide MAB. The total episode cost for providing MAB ranged from 252 to 460 US Dollars, and patient satisfaction was high across all practices. CONCLUSION: Information from this study can be used to guide decisions regarding MAB integration into practices not currently providing abortion or which provide only aspiration abortions. The information may also be useful for providers wishing to refine their MAB services.

Impact of increased access to emergency contraceptive pills: a randomized controlled trial.

OBJECTIVE: To assess how a strategy to maximize access to emergency contraceptive pills would affect rates of pregnancy and sexually transmitted infections. METHODS: Sexually active women, 14-24 years old, were randomly assigned to two methods of access to emergency contraceptive pills: increased access (two packages of pills dispensed in advance with unlimited resupply at no charge) or standard access (pills dispensed when needed at usual charges). Participants were followed for 1 year to assess incidence of pregnancy, gonorrhea, chlamydia, and trichomonas. RESULTS: The numbers of women enrolled in the increased and standard access groups were 746 and 744, respectively. More than 93% of participants completed a full year of follow-up. The incidence of pregnancy was similar in both groups (increased access group: 9.9/100 woman years, 95% confidence interval [CI] 7.7-12.6; standard access group: 10.5/100 woman years, 95% CI 8.2-13.2). Aggregate rates of gonorrhea, chlamydia, and trichomonas were also similar in the two groups (increased access group: 6.9/100 woman years, 95% CI 5.1-9.1; standard access group: 7.6/100 woman years, 95% CI 5.7-9.9). The increased access group used emergency contraceptive pills substantially more often and sooner after coitus than the standard access group. No other differences were noted between groups in self-reported measures of sexual behavior and contraceptive use. CONCLUSION: This intensive strategy to enhance access to emergency contraceptive pills substantially increased use of the method and had no adverse impact on risk of sexually transmitted infections. However, it did not show benefit in decreasing pregnancy rates. LEVEL OF EVIDENCE: II-1.

Estimates of pregnancies averted through California's family planning waiver program in 2002.

CONTEXT: During its first year of operation (1997-1998), California's family planning program, Family PACT, helped more than 750,000 clients to avert an estimated 108,000 pregnancies. Given subsequent increases in the numbers of clients served and contraceptive methods offered by the program, updated estimates of its impact on fertility are needed. METHODS: Claims data on contraceptives dispensed were used to estimate the number of pregnancies experienced by women in the program in 2002. Medical record data on methods used prior to enrollment were used to predict client fertility in the absence of the program. Further analyses examined the sensitivity of these estimates to alternative assumptions about contraceptive failure rates, contraceptive continuation and contraceptive use in the absence of program services. RESULTS: Almost 6.4 million woman-months of contraception, provided primarily by oral contraceptives (57%), barrier methods (19%) and the injectable (18%), were dispensed through Family PACT during 2002. As a result, an estimated 205,000 pregnancies-which would have resulted in 79,000 abortions and 94,000 births, including 21,400 births to adolescents-were averted. Changing the base assumptions regarding contraceptive failure rates or method use had relatively small effects on the estimates, whereas assuming that clients would use no contraceptives in the absence of Family PACT nearly tripled the estimate of pregnancies averted. CONCLUSION: Because all contraceptive methods substantially reduce the risk of pregnancy, Family PACT's impact on preventing pregnancy lies primarily in providing contraceptives to women who would otherwise not use any method.

Pharmacy access to emergency contraception in California.

CONTEXT: California is one of eight states that allow a woman to obtain emergency contraceptives from a pharmacy without a physician prescription. Because many women do not know about emergency contraception or direct pharmacy access, it is important to understand barriers to getting the method and women's reasons for choosing the pharmacy option. METHODS: In a 2004 survey at 25 predominantly independent pharmacies across California that offered pharmacy access, 426 women completed questionnaires after obtaining emergency contraceptives. They were asked about their reasons for seeking the method, the time of unprotected intercourse, barriers to access, how they learned about pharmacy access and their reasons for choosing it. Chi-square tests and analysis of variance were used to assess differences between subgroups. RESULTS: Eighty-six percent of women wanted emergency contraceptives for immediate use, and women obtained the method an average of 36 hours after unprotected intercourse. Those younger than 16, those who had had unprotected sex on the weekend and those who were embarrassed to ask for the method or who did not know about it all took a longer time to get the medication than did their respective comparison groups. Women who chose pharmacy access did so because they thought it was faster (54%) and more convenient (47%) than seeking a physician prescription. The majority reported that talking to a pharmacist was very helpful (84%) and that it was very important to be able to get the method directly from a pharmacy (81%). CONCLUSIONS: Increasing women's knowledge about emergency contraception and its availability directly from pharmacies has the potential to improve the effectiveness of this contraceptive method by reducing the time interval between unprotected intercourse and initiation of treatment.

Patient costs for medication abortion: results from a study of five clinical practices.

PURPOSE: In 2000, the FDA approved mifepristone as a medication abortion alternative. There is limited understanding of the patient costs associated with use of this method. Our objective was to determine total patient costs for medication abortion. This information may be useful for improving counseling and patient decision making. METHODS: We surveyed 212 women who received a medication abortion from a convenience sample of 5 health care practices. Patient costs including direct medical costs (pregnancy test costs, charges), direct nonmedical costs (child care, travel, lodging), and productivity losses (value of time away from work or other activities) were determined. RESULTS: The mean total cost for medication abortion was 351 dollars (0-1,140 dollars). The average charge paid by women themselves for the procedure itself was 306 dollars. Three quarters of total costs were direct medical costs and almost one quarter was time away from work and other activities. Although nearly three quarters of the women were insured, only 1% used insurance to cover their abortion--many (44%) did not know if their insurance covered abortion. CONCLUSIONS: This study provides descriptive information on patient costs associated with medication abortion that may be integrated into patient counseling to enhance informed decision making by women. The study raises questions about why women who report having insurance are not aware of whether their insurance will cover abortion and suggests that we are unclear about women's and providers' preferences for using insurance. We should continue to develop our knowledge of the clinical and nonclinical trade-offs for women choosing between abortion methods to benefit patient decision making.

Safety of mifepristone abortions in clinical use.

OBJECTIVES: Extensive data from clinical trials document mifepristone's safety and efficacy for induced abortion, but less information is available about its safety in routine clinical use. METHODS: Data on mifepristone abortion use from the Planned Parenthood Federation of America, the largest provider of mifepristone abortion in the United States, from 2001 through the first quarter of 2004 were collected using a centralized reporting system. Over the study period, 95,163 mifepristone abortions were provided. Reportable events are complications requiring inpatient or outpatient hospital treatment. RESULTS: Overall, 2.2 per 1000 women (95% CI 1.9-2.5) experienced a complication, most commonly, heavy bleeding. Mifepristone abortion mortality is estimated to be 1.1 per 100,000 based on one death (95% CI 0.3-5.9). CONCLUSIONS: The safety of mifepristone is high; few serious medical complications occur in routine clinical use.

Cervical cancer screening continues to limit provision of contraception.

PURPOSE: Balancing needs for contraception and cervical cancer screening is challenging for clinicians. We assessed US obstetrician/gynecologists' practices regarding requirement of Pap testing before prescribing oral contraceptive or emergency contraceptive pills. METHODS: Questionnaires structured as clinical vignettes describing women desiring contraception with different risks of cervical dysplasia were mailed to a national sample of 355 obstetrician/gynecologists. RESULTS: A minority (3%) of the 185 obstetrician/gynecologists who responded would refill 12 months of oral contraceptives without requiring Pap testing. However, most would provide a limited supply of oral contraceptives until Pap testing could be performed. A substantial proportion (11-16%) would refuse to prescribe emergency contraception to women who they felt required Pap testing. Younger physicians, those practicing in academic settings and those who follow American Cancer Society guidelines were more willing to prescribe contraceptives without Pap testing. CONCLUSIONS: Cervical cancer screening continues to limit prescription of routine and emergency contraception by many US obstetrician/gynecologists.

Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial.

OBJECTIVE: To compare bleeding profiles and satisfaction among women using a norelgestromin/ethinyl estradiol (E2) transdermal contraceptive patch in an extended regimen to those among women using a traditional 28-day patch regimen. METHODS: Healthy, regularly menstruating women (N = 239) were randomly assigned (2:1 ratio) to receive the norelgestromin/ethinyl E2 transdermal patch in an extended regimen (weekly application for 12 consecutive weeks, 1 patch-free week, and 3 more consecutive weekly applications, n = 158) or a cyclic regimen (4 consecutive cycles of 3 weekly applications and 1 patch-free week, n = 81). Subjects recorded bleeding data daily and completed satisfaction questionnaires. Subjects and investigators provided overall assessments of the regimens. RESULTS: Extended use of the norelgestromin/ethinyl E2 transdermal patch resulted in fewer median bleeding days (6 compared with 14, P < .001), bleeding episodes (1 compared with 3, P < .001), and bleeding or spotting episodes (2 compared with 3, P < .001) compared with cyclic use during days 1-84; median numbers of bleeding or spotting days were similar between regimens (14 compared with 16, P = .407) during this time. Extended use delayed median time to first bleeding to 54 days compared with 25 days with cyclic (P < .001). Subjects were highly satisfied with both regimens. Although not statistically significant, slightly more adverse events were reported with the extended than with the 28-day regimen. CONCLUSION: Compared with cyclic use, extended use of the norelgestromin/ethinyl E2 transdermal patch delayed menses and resulted in fewer bleeding days. This regimen may represent a useful alternative for women who prefer fewer episodes of withdrawal bleeding.

A qualitative study of insurers' coverage for mifepristone-induced abortion.

In this qualitative evaluation of 14 U.S. health insurers' coverage policies concerning mifepristone-induced medical abortion, the findings suggest that a significant proportion of health plans do not include evidence-based clinical information obtained from recent research, data, and practice. This omission may hinder the adoption of new, evidence-based protocols for medical abortion by physicians. A model coverage policy that contains comprehensive clinical information regarding appropriate clinical regimens for mifepristone is provided as an example for insurers and others in the field.

Willing and able? Provision of medication for abortion by future internists.

INTRODUCTION AND BACKGROUND: The development of medications such as mifepristone (RU486) has created the opportunity to introduce medication abortion as a component of office practice. METHODS: Two hundred twelve residents training in internal medicine, family practice, and gynecology at 11 residency programs completed anonymous surveys assessing willingness to provide medication for abortion and perceived barriers to future provision of mifepristone. RESULTS: Residents training in internal medicine knew less about mifepristone and preabortion screening than other primary care trainees. Forty-two percent of internists, 84% of family practitioners, and 83% of gynecologists were willing to prescribe mifepristone (p < .001). Many internists were concerned about lacking adequate "backup" access to vacuum aspiration services (84% of internists, 74% of family practitioners, 35% of gynecologists; p < .001). In multivariable analysis, the training-related factors most predictive of whether an internist was willing to provide medication for abortion were feeling that mifepristone is very safe, abortion services are needed by the patients served, knowing to check an ultrasound before inducing abortion, and having no concern of how to manage bleeding or of lacking adequate backup should vacuum aspiration be needed. CONCLUSIONS AND DISCUSSION: Many (42%) future internists are willing to provide mifepristone, but most lack adequate knowledge of mifepristone and preabortion screening. As access to abortion services is limited in many U.S. counties, internists who are willing to provide mifepristone should be offered the necessary training to do so safely.