Abortion Provision and Delays to Care in a Clinic Network in Washington State After Dobbs.

Importance: The Supreme Court decision Dobbs v Jackson Women's Health Organization (Dobbs) overturned federal protections to abortion care and altered the reproductive health care landscape. Thus far, aggregated state-level data reveal increases in the number of abortions in states where abortion is still legal, but there is limited information on delays to care and changes in the characteristics of people accessing abortion in these states after Dobbs. Objective: To examine changes in abortion provision and delays to care after Dobbs. Design, Setting, and Participants: Retrospective cohort study of all abortions performed at an independent, high-volume reproductive health care clinic network in Washington state from January 1, 2017, to July 31, 2023. Using an interrupted time series, the study assessed changes in abortion care after Dobbs. Exposure: Abortion care obtained after (June 24, 2022, to July 31, 2023) vs before (January 1, 2017, to June 23, 2022) Dobbs. Main Outcome and Measure: Primary outcomes included weekly number of abortions and out-of-state patients and weekly average of gestational duration (days) and time to appointment (days). Results: Among the 18 379 abortions during the study period, most were procedural (13 192 abortions [72%]) and funded by public insurance (11 412 abortions [62%]). The mean (SD) age of individuals receiving abortion care was 28.5 (6.44) years. Following Dobbs, the number of procedural abortions per week increased by 6.35 (95% CI, 2.83-9.86), but then trended back toward pre-Dobbs levels. The number of out-of-state patients per week increased by 2 (95% CI, 1.1-3.6) and trends remained stable. The average gestational duration per week increased by 6.9 (95% CI, 3.6-10.2) days following Dobbs, primarily due to increased gestations of procedural abortions. The average gestational duration among out-of-state patients did not change following Dobbs, but it did increase by 6 days for in-state patients (5.9; 95% CI, 3.2-8.6 days). There were no significant changes in time to appointment. Conclusions and Relevance: These findings provide a detailed picture of changes in abortion provision and delays to care after Dobbs in a state bordering a total ban state. In this study, more people traveled from out of state to receive care and in-state patients sought care a week later in gestation. These findings can inform interventions and policies to improve access for all seeking abortion care.

IUD self-removal: A randomized controlled trial of a self-removal guide in clinical and nonclinical settings.

OBJECTIVES: Intrauterine device (IUD) users often encounter barriers to desired removal. Self-removal, while previously found to be successful only 19% of the time, may mitigate these obstacles. Our primary objective was to evaluate the effectiveness of our previously developed IUD self-removal guide. Our secondary objectives were to evaluate the acceptability of the guide and characterize the self-removal process. STUDY DESIGN: This was a randomized controlled trial comparing IUD self-removal success rates with and without a guide. Participants selected a clinical or nonclinical setting for self-removal. The primary outcome was the rate of successful IUD self-removal. Covariates of interest included demographic characteristics, parity, body mass index, and attempted removal setting. RESULTS: Of the 116 participants, 35 (30%) successfully removed their IUDs, 20 (32%) randomized to the guide, and 15 (28%) randomized to no guide (p = 0.7). While our guide was not associated with increased successful self-removal, the majority (97%) of those randomized to it reported it to be helpful. Those who selected a nonclinical setting (80%) were more successful at self-removal (35% vs 9%, p = 0.01). Most participants would recommend IUD self-removal to a friend (68%) and attempt again with a future IUD (80%). CONCLUSIONS: The proportion of participants who successfully removed their IUDs was higher than previously shown, with or without the use of our guide. Our inclusion of a nonclinical setting was novel, in which the proportion of successful self-removal was significantly higher. Providers should consider discussion of IUD self-removal, with a reasonable expectation about the likelihood of success, as a means of increasing reproductive autonomy. IMPLICATIONS: IUD self-removal was feasible and acceptable.

Operative vs Nonoperative Management of Acute Cholecystitis During the Different Trimesters of Pregnancy.

Importance: Acute cholecystitis (AC) management during pregnancy requires balancing the risk of pregnancy loss or preterm delivery (adverse pregnancy outcomes [APOs]) with or without surgery. Guidelines recommend cholecystectomy across trimesters; however, trimester-specific evidence on the risks of AC and its management is lacking. Objective: To assess cholecystectomy frequency in pregnant people with AC, compare the rates of APOs in pregnant people with or without AC, and compare the rates of APOs in people with AC who did or did not undergo cholecystectomy. Design, Setting, and Participants: This retrospective, population-based cohort study used data for pregnant people with AC from the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2007, to December 31, 2019, and a propensity score-matched cohort of pregnant people without AC. Trimester status (first [T1], second [T2], and third [T3]), APOs, and cholecystectomy were defined by administrative claims. Data were analyzed from October 2021 to July 2022. Exposures: Pregnant patients with or without AC. Pregnant patients with AC who did or did not receive cholecystectomy. Main Outcomes and Measures: The main outcomes were cholecystectomy during pregnancy and APOs (ie, preterm delivery and pregnancy loss). Pregnant patients with and without AC were compared to assess the association of AC with risk of APOs. Propensity score inverse-probability weighting was used to calculate treatment-associated APO risk among patients with 1-year follow-up. Results: The study included 5759 pregnant patients with AC (mean [SD] age, 30.1 [6.6] years) and 23 036 controls (mean [SD] age, 29.9 [6.7] years) after propensity score matching. Among 3426 pregnant patients with AC and 1-year follow-up, 1182 (34.5%) underwent cholecystectomy during the pregnancy (684 [41.7%] presenting with AC in T1, 404 [40.4%] in T2, and 94 [12.0%] in T3). Acute cholecystitis during pregnancy, irrespective of treatment, was associated with higher odds of APO compared with no AC during pregnancy across all trimesters (odds ratio [OR], 1.69 [95% CI, 1.54-1.85]). Compared with nonoperative management, receipt of surgery was associated with lower odds of APOs across all trimesters (OR, 0.75 [95% CI, 0.63-0.87]), in T1 (OR, 0.81 [95% CI, 0.66-1.00]), in T2 (OR, 0.71 [95% CI, 0.50-1.00]), and in T3 (OR, 0.45 [95% CI, 0.28-0.70]). Conclusions and Relevance: In this study, cholecystectomy was associated with lower risk of APO in patients with AC across all trimesters, with the greatest benefit in T3. However, only 34.5% overall and 12.0% of patients in T3 had a cholecystectomy. These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC.

Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting.

Importance: Early pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ. Objective: To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics. Design, Setting, and Participants: This retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022. Exposures: The primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities. Main Outcomes and Measures: The primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis. Results: A total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service. Conclusions and Relevance: In this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

Developing an intrauterine device self-removal guide: a mixed methods qualitative and small pilot study.

BACKGROUND: The intrauterine device (IUD) is a highly effective form of long-acting reversible contraception (LARC) with few contraindications. Users, however, often encounter barriers to desired removal. IUD self-removal may mitigate these obstacles. We sought to develop a guide for IUD self-removal with the aim of increasing user control over the method. METHODS: This was a two-phase mixed-methods qualitative and small pilot study with the aim of developing an IUD self-removal guide. We conducted an online content analysis of advice for IUD self-removal as well as interviews with expert key informants to develop an IUD self-removal guide. We next recruited IUD-users who had previously attempted self-removal to participate in focus group discussion and individual interviews to further refine the guide. In the second phase of the study, we piloted the guide among eight IUD-users seeking removal interested in attempting self-removal. RESULTS: Expert key informants agreed that IUD self-removal was safe and low risk. The primary components of successful IUD self-removal elicited were ability to feel and grasp the strings, a crouched down position, and multiple attempts. A preference for presenting IUD self-removal as safe was emphasized. In the second phase, participants in the clinical pilot suggested more information for non-palpable strings, but liked the style and information provided. One participant successfully removed their IUD. CONCLUSIONS: IUD-users reported satisfaction with our guide. In our small pilot, the majority were unable to remove their own IUD. A larger study is needed to assess acceptability, feasibility, and efficacy in increasing successful self-removal.

Society of Family Planning Clinical Recommendations: Contraceptive Care in the Context of Pandemic Response.

The coronavirus disease 2019 (COVID-19) pandemic has posed a burden to healthcare systems around the world and has changed the way people access health services, including contraception. This document sets forth guidance from the Society of Family Planning for providing contraceptive care in the context of the COVID-19 pandemic, including when access to healthcare is restricted due to pandemic response. It also outlines the role of telehealth for providing contraceptive care beyond the pandemic. Clinicians can use synchronous telemedicine visits and other forms of telehealth to provide many aspects of contraceptive care. Both audio-video and audio-only visits are acceptable forms of telemedicine. Access to permanent contraception should be maintained, especially in the postpartum period. Combined hormonal contraceptive (CHC) users who have asymptomatic or mild COVID-19 infection may continue their contraceptive method, while those admitted to the hospital with severe infection should suspend CHC use until they are clinically recovered. CHC users who take Paxlovid for mild-moderate COVID-19 infection can consider a back-up contraceptive method for the duration of therapy, but clinically relevant drug interactions are unlikely. Future research should examine contraceptive outcomes in people who receive care via telemedicine; and access to telemedicine among historically excluded populations such as adolescents, people of color, people of low socioeconomic status, disabled people, or people who do not speak English as a primary language.

Same-day mifepristone prior to second-trimester induction termination with misoprostol: A retrospective cohort study.

OBJECTIVE: To evaluate whether same-day administration of mifepristone and misoprostol, compared with misoprostol alone, reduces the duration of second-trimester induction of labor for termination of pregnancy or increases the rate of fetal expulsion within 24 hours. STUDY DESIGN: We conducted a retrospective analysis of patients undergoing induction of labor for pregnancy termination in the second trimester between 2009 and 2018. We compared patients who received mifepristone on the same day as the first dose of misoprostol to those who received misoprostol alone. The primary outcome was expulsion within 24 hours after the first dose of misoprostol. RESULTS: Two hundred ninety-eight patients met criteria for inclusion, of whom 94 (31.5%) received same-day mifepristone. Expulsion within 24 hours occurred in 93.6% of the mifepristone-plus-misoprostol group and 79.9% of the misoprostol-only group (RR 1.17, 95%CI 1.07-1.28). Expulsion within 12 hours occurred in 56.4% of the mifepristone-plus-misoprostol group and 34.0% of the misoprostol-only group (RR 1.66, 95%CI 1.28-2.16). After adjusting for demographic and clinical characteristics, the rate of expulsion within 24 hours was similar between groups (RR 1.07, 95%CI 0.92-1.26), while the rate of expulsion within 12 hours remained different (RR 1.69, 95%CI 1.01-2.83). Median time to expulsion was shorter in the mifepristone-plus-misoprostol group than the misoprostol-only group (689 minutes vs 901 minutes, p < 0.001). CONCLUSION(S): Patients who received mifepristone on the same day as misoprostol had a shorter duration of induction termination and higher rate of success within 12 hours.

Early pregnancy loss in the emergency department, 2006-2016.

OBJECTIVES: Women experiencing early pregnancy loss (EPL) frequently present to the emergency department (ED), but little is known about who receives EPL care in these settings. We aimed to estimate the proportion of ED visits for EPL-related care and determine characteristics associated with seeking care for EPL in the ED in a national sample. METHODS: We conducted a secondary analysis of the 2006-2016 National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative survey of US ED visits. We identified women ages 15-44 years who presented to the ED for threatened or confirmed EPL based on diagnosis code or chief complaint. We estimated the proportion of ED visits attributable to EPL-related care among all ED visits and among women 15-44 years old. Using multivariable logistic regression, we evaluated patient and visit characteristics associated with receiving EPL-related care versus all other care. RESULTS: The 2006-2016 NHAMCS dataset included 325,037 visits (weighted n = 1,447,144,423), including 82,871 visits among women ages 15-44 years (weighted n = 371,016,125). Of all ED visits for women ages 15-44 years, 2.7% (95% confidence interval, 2.5-2.9) were for EPL-related care. This equates to ≈900,000 visits annually. Compared with women ages 15-44 years presenting to the ED for other reasons, those presenting for EPL-related care were younger and more likely to be Black or Hispanic. CONCLUSIONS: EPL-related care accounts for over 900,000 ED visits in the United States each year. These findings highlight the current burden of EPL visits upon EDs nationally.

Clinical availability of the copper IUD in rural versus urban settings: A simulated patient study.

OBJECTIVE: To assess the proportion of Washington state clinics that offer the copper IUD in rural vs urban settings. STUDY DESIGN: We employed a simulated patient model to survey clinics in the Human Health Resources and Services Administration 340B database to primarily assess the availability of the copper IUD. RESULTS: We successfully surveyed 194/212 (92%) clinics. More urban than rural clinics reported copper IUD availability (76/97 [78%] vs 49/97 [51%]; p < 0.01). CONCLUSIONS: Rural clinics are less likely than urban clinics to have the copper IUD available. IMPLICATIONS: The frequency of unintended pregnancies is high in the United States. We should focus our attention on decreasing barriers to the copper IUD as a long-acting reversible contraceptive, particularly for women living in rural settings.

Leukocytosis during cervical preparation with osmotic dilators for dilation and evacuation.

OBJECTIVES: To describe leukocytosis trends during cervical preparation with osmotic dilators for second-trimester dilation and evacuation procedures, and to determine whether there is a difference in leukocytosis seen with laminaria versus Dilapan-S. METHODS: We conducted a retrospective cohort study of 986 women presenting for dilation and evacuation from April 2008 through March 2009 at an outpatient clinic network. We included all procedures at ⩾14 weeks' gestation where laminaria or Dilapan-S dilators were used for overnight dilation. All women had routine white blood cell testing during the study period. RESULTS: There was a median increase of 2.4 × 103/µL white blood cell count (95% confidence interval 2.2-2.7 × 103/µL) from beginning of cervical preparation to the day of procedure (95% confidence interval and p value). Women receiving laminaria (n = 805) versus Dilapan-S (n = 181) had a greater increase in white blood cell count from baseline (median increase 2.7 versus 1.2 × 103/µL, p < 0.001), including when adjusting for age, gestational age, parity, baseline white blood cell count, and number of dilators placed. CONCLUSION: There is increased leukocytosis during the course of cervical preparation with osmotic dilators, and this is increased with use of laminaria versus Dilapan-S. Rates of clinically recognized infection in second-trimester abortion are low regardless of dilator type used.

Perceptions of Anal Intercourse Among Heterosexual Women: A Pilot Qualitative Study.

INTRODUCTION: More than one-third of women in the U.S. have engaged in heterosexual anal intercourse (HAI), but little is known regarding women's perceptions of HAI and motivations for engaging in this sexual behavior. AIM: This study aimed to explore U.S. women's motivations for engaging in HAI and to investigate how they navigate HAI in the context of sexual relationships. METHODS: Semi-structured interviews were conducted with 20 women, ages 18-50 years old, who had engaged in anal intercourse with a male partner within the past 3 months. The interview guide was developed utilizing a conceptual framework based on the Theory of Planned Behavior. MAIN OUTCOME MEASURE: Thematic content analysis was performed, and salient themes were identified. RESULTS: Salient themes were identified in all key components of the construct, including attitudes toward the behavior, subjective norms, and perceived behavioral control. Women's intent to engage in HAI was influenced by their attitudes toward HAI and level of control and trust with their partners. Primary motivators were partner and personal pleasure and sexual curiosity and experimentation. CONCLUSION: The Theory of Planned Behavior construct was well suited to explore factors influencing women's intent to engage in HAI. Most women perceive negative societal norms toward HAI. Although this does not appear to affect intention to engage in HAI, it does affect disclosure of this sexual activity with friends and healthcare providers. It is important for healthcare providers to provide open, non-judgmental counseling regarding HAI to decrease stigma, enhance communication, and improve sexual health. Benson LS, Gilmore KC, Micks EA, et al. Perceptions of Anal Intercourse Among Heterosexual Women: A Pilot Qualitative Study. Sex Med 2019;7:198-206.

Intrauterine Device Training Workshop for Preclinical Medical Students.

Introduction: Medical school reproductive health curricula often lack adequate education regarding intrauterine devices (IUDs). When placed in clinical scenarios, students may have insufficient knowledge and training to counsel patients about IUDs. Methods: We developed a workshop for preclinical medical students and assessed whether it improved knowledge of and comfort with counseling patients on IUDs. The workshop consisted of a 45-minute lecture and a 45-minute IUD simulation training. Each session was taught to groups of 40 to 50 students. The workshop was evaluated between January 2016 and November 2017. Participants completed pre- and postsurveys. The primary outcome was comfort level with IUD counseling. Results: One hundred forty-two students completed the workshop, and 137 completed both pre- and postsurveys (96% response rate). At baseline, more than half (56%, n = 77) had not seen an IUD inserted. Students scoring 75% or higher on the IUD knowledge questions increased from 51% (n = 70) on presurveys to 87% (n = 119) on postsurveys (p < .0001). Students agreeing or strongly agreeing that they felt comfortable counseling patients on IUDs increased from 27% (n = 37) to 92% (n = 122, p < .0001) on postsurveys. All students felt the workshop was worthwhile. Discussion: Preclinical students showed increased knowledge of and comfort with IUDs after a simple IUD simulation. Medical schools could utilize this workshop to ensure students have hands-on training and experience related to IUDs prior to clinical rotations and for their future careers.

Safety of Outpatient Surgical Abortion for Obese Patients in the First and Second Trimesters.

OBJECTIVE: To evaluate the relationship between obesity and surgical abortion complications in the outpatient setting. METHODS: We conducted a retrospective cohort study of 4,968 women undergoing surgical abortion at a large outpatient clinic network from September 2012 to July 2014. We used log-binomial regression to evaluate body mass index (BMI) as an independent risk factor for first- and second-trimester abortion complications. Body mass index was analyzed as both a continuous and categorical predictor. We assessed complications including need for uterine reaspiration (including same-day reaspiration), uterine perforation, cervical laceration, infection, emergency department visit or hospitalization, and excessive blood loss defined as estimated blood loss greater than or equal to 100 mL. RESULTS: The majority (77%) of procedures was performed in the first trimester. Forty-seven percent of women were normal weight or underweight, 28% were overweight, and 25% were obese, including 4% with BMI greater than or equal to 40. The overall complication rate was 1.7%; the most common complications were need for uterine reaspiration (1.0%) and excessive blood loss (0.6%). Obesity was not associated with increased risk of surgical complications, including when adjusting for age, gestational age, and history of prior cesarean delivery. CONCLUSION: In a high-volume outpatient abortion clinic with experienced health care providers, abortion is very safe. Obesity does not appear to be an independent predictor for abortion complications and should not be used in isolation to refer women to hospital-based facilities for abortion care in the first or second trimester.

Why Stop Now? Extended and Continuous Regimens of Combined Hormonal Contraceptive Methods.

Combined hormonal contraceptives (CHCs) have traditionally been prescribed in 28-day cycles, with 21 days of active hormones followed by a 7-day hormone-free interval. Extended and continuous CHC regimens, defined as regimens with greater than 28 days of active hormones, offer many benefits, including a decrease in estrogen-withdrawal symptoms and likely greater efficacy because of more reliable ovulation suppression. Bleeding profiles are favorable, and unscheduled bleeding decreases over time with these regimens. Extended and continuous regimens of combined oral contraceptives and the contraceptive vaginal ring are safe and have high user acceptability and satisfaction. However, despite numerous benefits, extended and continuous CHC regimens are underused.

Correlates of Heterosexual Anal Intercourse among Women in the 2006-2010 National Survey of Family Growth.

INTRODUCTION: Heterosexual anal intercourse (HAI) is common among U.S. women. Receptive anal intercourse is a known risk factor for HIV, yet there is a paucity of data on HAI frequency and distribution in the United States. Condom use is lower with HAI vs. vaginal intercourse, but little is known regarding of correlates of HAI with and without condoms. AIMS: The aims of this study were to describe recent (past 12 months) and lifetime HAI among sexually active reproductive-aged U.S. women, and to characterize women who engage in HAI with and without condoms. METHODS: We analyzed a sample of 10,463 heterosexually active women aged 15-44 years for whom anal intercourse data were available in the 2006-2010 National Survey of Family Growth. MAIN OUTCOME MEASURES: Weighted bivariate and multivariable analyses were used to determine HAI prevalence and correlates. Primary outcomes were lifetime HAI, recent (last 12 months) HAI, and condom use at last HAI. RESULTS: In our sample, 13.2% of women had engaged in recent HAI and 36.3% in lifetime HAI. Women of all racial and ethnic backgrounds and religions reported recent anal intercourse. Condom use was more common at last vaginal intercourse than at last anal intercourse (28% vs. 16.4%, P < 0.001). In multivariable analysis, correlates of recent HAI included: less frequent church attendance, younger age at first intercourse, multiple sexual partners, history of oral intercourse, history of unintended pregnancy, and treatment for sexually transmitted infections (all P < 0.05). Correlates of lifetime HAI were similar, with the addition of older age, higher education, higher income, and history of drug use (all P < 0.05). CONCLUSION: Women of all ages and ethnicities engage in HAI, at rates higher than providers might realize. Condom use is significantly lower for HAI vs. vaginal intercourse, putting these women at risk for acquisition of sexually transmitted infections.

Buccal misoprostol plus laminaria for cervical preparation before dilation and evacuation at 21-23 weeks of gestation: a randomized controlled trial.

OBJECTIVE: To describe the effectiveness of buccal misoprostol as an adjunct to laminaria for cervical ripening before later second-trimester abortion by dilation and evacuation (D&E). METHODS: A randomized, double-blinded, placebo-controlled trial of 196 women undergoing D&E between 21 and 23 weeks of gestation. Subjects had overnight laminaria and 400 mcg buccal misoprostol or placebo 3-4 h before the abortion. We used logarithmic transformation of the primary outcome--D&E procedure duration--to achieve a normal distribution. RESULTS: Mean D&E duration was 1.7 min shorter with misoprostol (p=.02). The median duration was 9.7 versus 10.4 min in the misoprostol and placebo groups, respectively (p=.09). Cervical dilation was slightly greater with misoprostol (median 75 mm vs. 73 mm, p=.04); however, physicians did not find the misoprostol D&Es easier to complete. Half of subjects reported severe pain after misoprostol vs. 11% with placebo (p<.001). CONCLUSION: Adjuvant buccal misoprostol results in slightly shorter D&Es at the cost of more side effects.

Effect of shared contraceptive experiences on IUD use at an urban abortion clinic.

BACKGROUND: We studied the effect of contraceptive social networking on postabortion intrauterine device (IUD) uptake. This study explores whether women who have heard personal stories of IUD use are more likely to use an IUD for postabortion contraception. STUDY DESIGN: We surveyed 299 women undergoing induced abortion at San Francisco General Hospital's Women's Options Center before and after contraceptive counseling. Both English- and Spanish-speaking women, aged 15 years and older, were surveyed. RESULTS: Fifty percent of women surveyed chose to use an IUD for postabortion contraception. Women choosing IUDs were more likely than women choosing other contraceptives or no contraceptives to be multiparous, Latina and interested in IUDs prior to contraceptive counseling. Disclosure of personal IUD use by a clinic staff member was independently associated with the decision to use an IUD (odds ratio 8.1, 95% confidence interval 3.8-17.2). CONCLUSIONS: Women undergoing abortion in an urban clinic have knowledge and high acceptance of IUDs, and sharing of contraceptive experiences is common among women of all demographics. Controlling for demographics and prior knowledge of IUDs, sharing of personal IUD experiences by providers is significantly associated with IUD use.

Evidence against roles for phorbol binding protein Munc13-1, ADAM adaptor Eve-1, or vesicle trafficking phosphoproteins Munc18 or NSF as phospho-state-sensitive modulators of phorbol/PKC-activated Alzheimer APP ectodomain shedding.

BACKGROUND: Shedding of the Alzheimer amyloid precursor protein (APP) ectodomain can be accelerated by phorbol esters, compounds that act via protein kinase C (PKC) or through unconventional phorbol-binding proteins such as Munc13-1. We have previously demonstrated that application of phorbol esters or purified PKC potentiates budding of APP-bearing secretory vesicles at the trans-Golgi network (TGN) and toward the plasma membrane where APP becomes a substrate for enzymes responsible for shedding, known collectively as alpha-secretase(s). However, molecular identification of the presumptive "phospho-state-sensitive modulators of ectodomain shedding" (PMES) responsible for regulated shedding has been challenging. Here, we examined the effects on APP ectodomain shedding of four phorbol-sensitive proteins involved in regulation of vesicular membrane trafficking of APP: Munc13-1, Munc18, NSF, and Eve-1. RESULTS: Overexpression of either phorbol-sensitive wildtype Munc13-1 or phorbol-insensitive Munc13-1 H567K resulted in increased basal APP ectodomain shedding. However, in contrast to the report of Rossner et al (2004), phorbol ester-dependent APP ectodomain shedding from cells overexpressing APP and Munc13-1 wildtype was indistinguishable from that observed following application of phorbol to cells overexpressing APP and Munc13-1 H567K mutant. This pattern of similar effects on basal and stimulated APP shedding was also observed for Munc18 and NSF. Eve-1, an ADAM adaptor protein reported to be essential for PKC-regulated shedding of pro-EGF, was found to play no obvious role in regulated shedding of sAPPalpha. CONCLUSION: Our results indicate that, in the HEK293 system, Munc13-1, Munc18, NSF, and EVE-1 fail to meet essential criteria for identity as PMES for APP.

Motor neuron inhibition-based gene therapy for spasticity.

Spasticity is a condition resulting from excess motor neuron excitation, leading to involuntary muscle contraction in response to increased velocity of movement, for which there is currently no cure. Existing symptomatic therapies face a variety of limitations. The extent of relief that can be delivered by ablative techniques such as rhizotomy is limited by the potential for sensory denervation. Pharmacological approaches, including intrathecal baclofen, can be undermined by tolerance. One potential new approach to the treatment of spasticity is the control of neuromuscular overactivity through the delivery of genes capable of inducing synaptic inhibition. A variety of experiments in cell culture and animal models have demonstrated the ability of neural gene transfer to inhibit neuronal activity and suppress transmission. Similarly, enthusiasm for the application of gene therapy to neurodegenerative diseases of motor neurons has led to the development of a variety of strategies for motor neuron gene delivery. In this review, we discuss the limitations of existing spasticity therapies, the feasibility of motor neuron inhibition as a gene-based treatment for spasticity, potential inhibitory transgene candidates, strategies for control of transgene expression, and applicable motor neuron gene targeting strategies. Finally, we discuss future directions and the potential for gene-based motor neuron inhibition in therapeutic clinical trials to serve as an effective treatment modality for spasticity, either in conjunction with or as a replacement for presently available therapies.