Despite the fact that many Nigerian women have limited access to pharmacologic methods for pain management during labor,1,2 previous studies have indicated a demand for such options.3–5 Opioids are a frequently offered analgesic method,5,6 but there are associated risks to the fetus with this type of pain management.7 The use of epidurals, another common method of labor analgesia, has not become prevalent in Nigeria due to lack of awareness, lack of resources, expense, and women’s beliefs that it is not necessary and/or it is harmful.3 Nitrous oxide is an alternative labor analgesic that has reduced side effects compared to opioids and offers pain reduction without the loss of body movement and positioning as is seen with epidurals.7 Because Nigerian women have expressed an interest in increased options for labor analgesics, and nitrous oxide aligns with some of their cultural desires,8 offering nitrous oxide could increase maternal satisfaction.9–12 The literature review examines epidurals, opioids, and nitrous oxide for use as labor analgesics, including their mechanisms of action, benefits, and side effects. It also reviews Nigerian cultural beliefs, the advantages and disadvantages of using nitrous oxide in Nigeria, current practice in Nigeria regarding labor analgesia, Nigerian women’s and healthcare providers opinions on analgesia, additional maternal advantages of labor analgesia outside of pain relief, and birthing locations in Nigeria. The study will be an exploratory, descriptive cross-sectional study that will use a questionnaire to obtain data regarding pregnant women’s knowledge of, and attitudes toward, nitrous oxide as an analgesic during childbirth. It will be administered to 270 pregnant women who visit an antenatal clinic at the Primary Health Care facilities in Mushin Local Government Area located in the state of Lagos, Nigeria. Descriptive statistics of the participants will be reported, and the chi-squared test will be used to determine the associations between the demographics and awareness of various analgesic options, cultural acceptability of using nitrous oxide for labor pain management, and the desirability to use nitrous oxide as a labor analgesic. The use of nitrous oxide for labor analgesia could provide Nigerian women with an important option apart from only opioids or epidurals. It could decrease the use of opioids, thus decreasing their associated health risks during labor.3 Additionally, because vaginal deliveries are an important cultural desire of Nigerian women, nitrous oxide could provide a method for pain management during labor that does not lead to increased risk of cesarean section.13,14

No description available.

Background: Communicating double uterine anomalies are defined as mullerian defects which involve two hemiuteri with communication between the uterine halves. Nine subcategories of communicating uterine anomalies have been described; only two of these subcategories are associated with hemivaginal obstruction. Case: An 11-year-old white female was brought to the Emergency Department with fever and acute pelvic pain. This condition was found to be caused by abscess formation behind an obstructed left hemivagina with involvement of a communicating double uterine anomaly. Conclusion: To our knowledge, this is the first case report involving a communicating double uterine anomaly in which fever was a presenting symptom.

To determine if known androgenic hormone precursors for testosterone in the androgen pathway would be readily transformed to testosterone, eight male subjects [mean age 23.8 (SEM 3) years, bodymass 83.1 (SEM 8.7) kg, height 175.6 (SEM 8.5) cm] underwent a randomized, double-blind, cross-over, placebo-controlled oral treatment with 200 mg of 4-androstene-3,17-dione (Δ4), 4-androstene-3β,17β-diol (Δ4Diol), and placebo (PL). The periods of study were separated by 7 days of washout. Blood was drawn at baseline and subsequently every 30 min for 90 min after treatment. Analysis revealed mean area-under-the-curve (AUC) serum Δ4 concentrations to be higher during Δ4 treatment [2177 (SEM 100) nmol.l-1] than Δ4Diol [900 (SEM 96) nmol.l-1] or PL [484 (SEM 82) nmol.l-1; P < 0.0001]. The Δ4 treatment also revealed a significant effect on total testosterone with a mean AUC [1632.5 (SEM 121) nmol.l-1] that was greater than PL [1418.5 (SEM 131) nmol.l-1; P < 0.05] but not significantly different from those observed after Δ4Diol treatment [1602.9 (SEM 119) nmol.l-1; P = 0.77]. Free testosterone concentrations followed a similar pattern where mean AUC for the Δ4 treatment [6114.0 (SEM 600) pmol.l-1] was greater than after PL [4974.6 (SEM 565) pmol.l-1; P < 0.06] but not significantly different from those observed after Δ4Diol [5632.0 (SEM 389) pmol.l-1; P = 0.48]. The appearance and apparent conversion to total and free testosterone over 90 min was stronger for the Δ4 treatment (r = 0.91, P < 0.045) than for Δ4Diol treatment (r = 0.69, NS) and negatively correlated for PL (r = -0.90, P < 0.02). These results would suggest that Δ4, and perhaps Δ4Diol, taken by month are capable of producing in vivo increases in testosterone concentrations in apparently healthy young men as has already been observed in women after treatment with Δ4.

Individuals with Down syndrome have an increased risk formany conditions, including cardiovascular disease, cancer, infections, and osteoporosis, and endocrine, neurological, orthopedic, auditory, and ophthalmic disorders.They also are at increased risk for abuse and human rights violations and receive fewer screenings and interventions than the population without Down syndrome. In this literature review, the most common health conditions associated with Down syndrome are examined, along with the topics of sexual abuse, menstrual hygiene, contraception, and human rights. Clinical guidelines for this population are summarized in an effort to assist practicing physicians in improving their provision of health care to the adult patient with Down syndrome.

Glucans are fungal cell wall glucose polymers that are released into the blood of infected patients. The role of glucans in infection is unknown. We examined serum glucan and cytokine levels in intensive care unit (ICU) patients with infections. There was an inverse correlation (p<0.001) between serum glucan levels and interleukin (IL)-2), IL-4, tumor necrosis factorα (TNFα) and granulocyte macrophage-colony stimulating factor (GM-CSF) levels in infected ICU patients. The correlation between serum cytokines and serum glucan was only observed at glucan concentrations <40 pg/ml. No change was observed at serum glucan levels of >40 pg/ml. There was no correlation between serum glucan levels and systemic levels of IL-1β, IL-5, IL-6, IL-8, IL-10 or IFNγ. Interestingly, blood borne glucans did not suppress systemic cytokine levels in infected ICU patients, instead they were maintained at control levels. We conclude that circulating glucans may prevent cytokine upregulation in response to infection. This may represent an adaptive response to septic injury.

Background: Women with communicating double uterine anomalies are at increased risk for obstetric complications, including early pregnancy loss, preterm delivery, and breech presentation. We present the pregnancy of a woman with a previously diagnosed communicating double uterine anomaly. Case: An 18-yr-old white female with a previous diagnosis at age 11 of a communicating double uterus, double cervix, and obstructed left hemivagina was followed during the course of her pregnancy. She experienced no complications until 36 6/7 weeks, when she was found to have signs and symptoms of mild preeclampsia. The fetus was in a breech presentation and a cesarean section was performed. Two hemiuteri were identified intraoperatively. The communication was not visualized. A viable male infant was delivered without complications. Conclusion: This patient represents only the sixth report of successful pregnancy in a woman with a Toaff type 5A communicating uterine anomaly.

Objectives This study is a follow-up to previous research regarding buprenorphine medication-assisted therapy (MAT) in Johnson City, Tennessee. For-profit MAT clinics were surveyed to determine changes in tapering practice patterns and insurance coverage during the last 3 years. Methods Johnson City for-profit MAT clinics; also called office based opioid treatment centers, were surveyed by telephone. Clinic representatives were asked questions regarding patient costs for therapy, insurance coverage, counseling offered onsite, and opportunities for tapering while pregnant. Results All of the MAT clinics representatives indicated that tapering in pregnancy could be considered even though tapering in pregnancy is contrary to current national guidelines. Forty-three percent of the clinics now accept insurance as compared with 0% in the 2016 study. The average weekly cost per visit remained consistent. Conclusions The concept of tapering buprenorphine during pregnancy appears to have become a standard of care for this community, as representatives state it is offered at all of the clinics that were contacted. Representatives from three clinics stated the clinics require tapering, even though national organizations such as the American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine do not recommend this approach. Although patients who have government or other insurance are now able to obtain buprenorphine with no expense at numerous clinics, the high cost for uninsured patients continues to create an environment conducive to buprenorphine diversion.

BACKGROUND: In the United States, racial and income disparities in maternity care outcomes are large and persistent. Research demonstrates that community doulas (specialized community health workers for pregnant, birthing and postpartum people) can improve maternal and infant outcomes. Despite this evidence, doulas have not yet been widely adopted in health services for low-income communities. One barrier to scale-up is understanding the costs and benefits of integrating doula services into maternity care payment systems. METHODS: An exploratory, sequential mixed methods study design was used to understand decision-maker perspectives on doulas in maternity care and apply these priorities to an economic evaluation of a randomized trial of enhanced doula support. 16 in-depth, semi-structured interviews with Medicaid, Accountable Care Organization (ACO) and maternity care decision makers in Massachusetts were conducted. Results from the qualitative study informed the design of an economic analysis of a pragmatic trial of doula support. A return on investment analysis, with a focus on areas of high financial impact and organized by segments of health care services was conducted. Program costs were analyzed using a micro-costing approach. Hospital data on health care costs and payments were used to calculate financial outcomes for both intervention and control groups. Sensitivity and sub-group analyses were developed to understand variations in impact for different populations, settings and doula program models. RESULTS: Decision-maker interviews revealed that health care organizations prioritize investments that promote improved population health, patient experience, cost reduction, and elimination of racial disparities in outcomes. Participants universally expressed interest in an analysis approach that provides information on return-on-investment outcomes, as well as the clinical and cost areas with the largest impact. The time frame of interest was primarily in the pregnancy and newborn episodes of care, with some participants expressing interest in longer term outcomes related to fewer first cesarean deliveries or preterm birth. The economic analysis found an 18% return on investment for the Best Beginnings for Babies doula intervention overall. Sensitivity analyses demonstrated the largest impact was for people with medical and social risk factors and for those who received at least 5 hours of prenatal home visits, as well as labor support. CONCLUSION: Medicaid and maternity care decision-makers are supportive of doula programs if they are affordable and can create cost savings. An economic analysis of the Birth Sisters Best Beginnings for Babies program found a positive return on investment, benefiting both health care payers and families. Community doula programs are a high-value innovation that should be reimbursed by Medicaid agencies. / 2021-09-25T00:00:00Z

Polycystic ovarian syndrome (PCOS) is the most prevalent female endocrine disorder affecting between 5-15% of women. Characterized by a combination of polycystic ovaries, androgen excess, and abnormal ovulation, untreated PCOS may progress to metabolic abnormalities and increase the risk of adverse health outcomes. Adult PCOS is evaluated using the Rotterdam Consensus Criteria, which requires two of three clinical findings. PCOS is a condition of exclusion, and it is essential to consider differential pathologies before diagnosis. PCOS is a heterogeneous condition, and treatment is fitted to the symptoms that each individual experiences. The physiological effects of PCOS present during puberty, typically around the average age of menarche. The exact etiology of PCOS is unknown, and preventing and curing the condition is not yet possible. Metabolic disturbances caused by PCOS, including insulin resistance and increased blood glucose level, are treated with similar methods as diabetes type 2. Insulin sensitizing agents are used to treat insulin resistance caused by PCOS. The primary treatment for insulin resistance in this population is metformin (Glucophage) due to its relatively safe use and effectiveness in normalizing insulin sensitivity and assisting with normalizing weight. The correlation of PCOS with insulin resistance, central obesity, and metabolic syndrome highlights the importance of diet and exercise supplementation for this population. Weight loss of only 5% in obese and overweight PCOS patients can significantly improve PCOS symptoms, including insulin resistance, androgen levels, and fertility. Exercise alone helps increase the sensitivity of skeletal muscle to insulin and decreases metabolic syndrome risk. The effect of PCOS on the hypothalamic-pituitary-gonadal axis can be detrimental to ovulation and implantation of a fertilized egg. Treatments that suppress the HPG-axis cannot be continued during attempts to become pregnant and throughout pregnancy. Ovulation-inducing agents can improve the rate of ovulation and increase fertility; however, some women may become resistant to these treatments. Clomiphene citrate (Clomid) is often the primary drug used to induce ovulation; however, monotherapy with letrozole has shown greater improvements in pregnancy and live birth rates. Gonadotropins may also be successful treatments, but there is an accompanied increased risk of ovarian hypersensitivity syndrome and multiple pregnancies. Laparoscopic ovarian drilling may help decrease androgen production in the ovary and briefly increase pregnancy capability. During pregnancy, metformin may help decrease the risk of gestational diabetes; however, the long-term effect of fetal exposure to metformin is not well studied. Cosmetic symptoms of PCOS, including hirsutism and acne vulgaris, may cause severe social stress. PCOS women are at additional risk of depression and anxiety. Cosmetic and mental health concerns, combined with the stress caused by the high prevalence of infertility in PCOS, highlight the need for psychological help to be considered in improving the overall quality of life. Combining cognitive behavioral therapy with treatments may help PCOS women maintain treatment and improve their quality of life. The most effective treatment may require modification throughout a patient’s life due to the variance in gonadocorticoid levels throughout a female’s life. Post-menopausal women continue to have excess androgens and estrogens in circulation. High levels of ovarian and adrenal production of gonadocorticoids combined with decreased circulating binding globulins can lead to stress on the metabolic and cardiovascular systems in PCOS after menopause. Continuous levels of increased triglycerides increase the risk for atherosclerosis and adverse cardiac events. PCOS women have an increased risk of endometrial and ovarian cancer, while a link between breast cancer and PCOS is widely disputed. There is 1.66 times higher risk for cardiovascular events, including 1.96 times greater risk for stroke in women with PCOS compared to non-PCOS women when controlled for weight. As we begin to understand the increased risk factors for hypertension, hyperlipidemia, and cardiovascular stress with PCOS, it is crucial to understand how to diagnose and treat PCOS patients in the early stages of the disorder. Irregularities in typical puberty and menarche in adolescents increase the difficulty of diagnosis and may delay a diagnosis.