Alan E C Holden

Pathophysiology and management of proximal tubal blockage.

OBJECTIVE To review the physiology, pathology, and treatment of proximal tubal disease. DATA IDENTIFICATION Relevant reports on the pathophysiology of proximal tubal disease were reviewed. All studies in English of microsurgery and macrosurgery, and of radiographic and hysteroscopic cannulation in women with proximal tubal blockage were identified through MEDLINE searches. STUDY SELECTION All studies of therapy for proximal blockage that included pregnancy rates were considered. Series of sterilization reversals, series of unilateral or combined procedures, and series in which the location of tubal blockage was not given were excluded from the data analyses. DATA ANALYSIS Raw data were assessed for homogeneity, then standardized and pooled. Total and ongoing pregnancy rates after microsurgery and macrosurgery, as well as radiographic and hysteroscopic transcervical cannulation, were compared by the chi2 test. Relative risks for total and ongoing pregnancies were calculated for all treatment methods. RESULT(S) This meta-analysis suggests that, overall, microsurgical anastomosis results in higher total and ongoing pregnancy rates than macrosurgery or radiographic tubal cannulation. However, pregnancy rates in selected series of transcervical tubal cannulation are similar to those reported for microsurgery. CONCLUSION(S) Ongoing intrauterine pregnancy rates near 50% can be achieved in patients with proximal blockage of the fallopian tube. Selective salpingography and transcervical cannulation under fluoroscopic guidance are effective at establishing patency in appropriately selected patients and are less invasive and costly than the surgical alternatives.

Prevention of gonorrhea and chlamydia through behavioral intervention: Results of a two-year controlled randomized trial in minority women

Background: Sexually transmitted disease (STD), including AIDS, disproportionately affects African-American and Hispanic women. Goal: To evaluate efficacy of standard and enhanced (addition of optional support groups) gender- and culture-specific, small-group behavioral interventions, compared to interactive STD counseling, in high risk minority women for two years. Methods: Women with a non-viral STD were treated and enrolled in a randomized trial. Follow-up screens and interviews occurred at 6 months, 1 year, 18 months (short interview, optional exam) and 2 years. The primary outcome was subsequent infection with chlamydia and/or gonorrhea. Secondary outcomes included risky sexual behaviors. We employed logistic regression based on intention-to-treat. Results: Data from 775 women were included; the retention rate was 91%. Adjusted infection rates were higher in the controls in Year 1 (26.8%), Year 2 (23.1%), and cumulatively (39.8%) than in the enhanced (15.4%, P = 0.004; 14.8%, P < 0.03; 23.7%, P < 0.001, respectively) and standard (15.7%, P = 0.006; 14.7%, P = 0.03; 26.2%, P < 0.008, respectively) intervention arms at these time points. Enhanced-intervention women who opted to attend support groups (attendees) had the lowest adjusted infection rates in Year 1 (12.0%) and cumulatively (21.8%). Intervention women in general, but particularly attendees, were significantly less likely than controls to have repeat infections. Multiple partners and unprotected sex with an untreated or incompletely treated partner helped explain group differences in infection. Conclusions: Risk-reduction interventions significantly decreased both single and multiple infective episodes with chlamydia and/or gonorrhea and risky sexual behaviors in the two-year study period. Support-group attendance appeared to contribute additional risk reduction in Year 1.

Cancer Patient Navigator Tasks across the Cancer Care Continuum

Cancer patient navigation (PN) programs have been shown to increase access to and utilization of cancer care for poor and underserved individuals. Despite mounting evidence of its value, cancer patient navigation is not universally understood or provided. We describe five PN programs and the range of tasks their navigators provide across the cancer care continuum (education and outreach, screening, diagnosis and staging, treatment, survivorship, and end-of-life). Tasks are organized by their potential to make cancer services understandable, available, accessible, affordable, appropriate, and accountable. Although navigators perform similar tasks across the five programs, their specific approaches reflect differences in community culture, context, program setting, and funding. Task lists can inform the development of programs, job descriptions, training, and evaluation. They also may be useful in the move to certify navigators and establish mechanisms for reimbursement for navigation services.

Genome-Wide Identification of Chlamydia trachomatis Antigens Associated with Tubal Factor Infertility

OBJECTIVE To identify Chlamydia trachomatis antigens that can be used to differentially diagnose tubal factor infertility in comparison with previously reported heat shock protein 60. DESIGN In vitro study. SETTING Academic medical center. PATIENT(S) Infertile women with and without tubal pathology diagnosed laparoscopically. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Antibody responses to C. trachomatis in infertile women with or without tubal pathologies using a C. trachomatis genome-wide proteome array. RESULT(S) Comparison of the antibody profiles revealed 30 C. trachomatis antigens that were preferentially recognized in women with tubal factor infertility, with a detection sensitivity and specificity of 80.6% and 56.5%, respectively, 10 of which showed 100% specificity. A combination of CT443 and CT381 antigens yielded the highest detection sensitivity (67.7%) while maintaining 100% specificity. CONCLUSION(S) These findings have demonstrated that antibodies to CT443 and CT381, when used in combination, have higher sensitivity and specificity in predicting tubal factor infertility than other indicators for tubal factor infertility, such as heat shock protein 60 antibodies (35.5%, 100%) or hysterosalpingogram (65%, 83%). Using a panel of C. trachomatis antigens to serologically diagnose tubal factor infertility can save the patients from undertaking expensive and invasive procedures for determining tubal pathology and choosing treatment plans.

Behaviors changed by intervention are associated with reduced STD recurrence: the importance of context in measurement.

Background Evaluations of STD/HIV interventions incorporating behavioral and biologic outcomes have not reported strong correspondence. Goal The goal of the study was to demonstrate that behaviors, measured comprehensively, are associated with infection and to delineate the behaviors responsible for reduced infection rates in Project SAFE (Sexual Awareness For Everyone). Study Design Follow-up data from an intervention trial were analyzed to determine: (1) study versus control differences in complex risk behaviors and (2) the overall relationship between these behaviors and infection status (chlamydia and/or gonorrhea), with use of multiple logistic regression. Results Lower infection rates among 249 women who received intervention (compared with 228 controls) were explained by reduced-risk status in 5 modifiable behaviors. The 0 to 12–month logistic regression model (including sex with untreated partner [OR = 5.6], lack of mutual monogamy [OR = 2.4], unsafe sex [OR = 1.9], rapid partner turnover [OR = 2.7], and douching after sex [OR = 1.9]) correctly predicted infection status for 75.3% of participants (71.8% of infected, 76.2% of uninfected). Women in nonmutually monogamous unions who had sex with partners who were untreated or incompletely treated were 13 times more likely to be infected than those who were monogamous and avoided sex with an untreated/incompletely treated partner. Conclusion This intervention reduced infection rates by maintaining low-risk behaviors and changing high-risk behaviors. We elucidated the complex relationship between behavior and infection by incorporating context into variable conceptualization and considering several behaviors simultaneously.

Cervicitis and genitourinary symptoms in women culture positive for Mycoplasma genitalium.

Problem  Mycoplasma genitalium has been associated with male urethritis. We sought to relate M. genitalium to genitourinary signs and symptoms in women.

Antibodies to Chlamydia trachomatis and risk for tubal pregnancy

We performed a case-control study of the effect of exposure to Chlamydia trachomatis on the risk for tubal pregnancy. Sixty women with tubal pregnancies and 60 matched control women with normal second-trimester intrauterine pregnancies were studied. Cases were more likely than controls to have detectable antichlamydial IgG antibodies (82% versus 58%, p less than 0.01) and their mean titers were higher. The prevalence of IgM antibody seropositivity was not different between cases and controls (20% versus 12%, not significant). Compared with women with IgG antibody titers of less than or equal to 1:8 the relative risk for tubal pregnancy for women with titers greater than or equal to 1:128 was 6.6 (95% confidence interval, 2.0 to 21.6). Among women with tubal pregnancies, antichlamydial antibody titers of greater than or equal to 1:128 were significantly associated with pelvic adhesions and inflammatory tubal mucosal damage. Only 17.6% of women with detectable antichlamydial antibody or inflammatory tubal damage reported a history of pelvic inflammatory disease or gonorrhea.

Structural and reliability analysis of a patient satisfaction with cancer‐related care measure

Patient satisfaction is an important outcome measure of quality of cancer care and 1 of the 4 core study outcomes of the National Cancer Institute (NCI)‐sponsored Patient Navigation Research Program to reduce race/ethnicity‐based disparities in cancer care. There is no existing patient satisfaction measure that spans the spectrum of cancer‐related care. The objective of this study was to develop a Patient Satisfaction With Cancer Care measure that is relevant to patients receiving diagnostic/therapeutic cancer‐related care.

Association of tubal factor infertility with elevated antibodies to Chlamydia trachomatis caseinolytic protease P

OBJECTIVE The objective of the study was to assess antibodies against Chlamydia trachomatis heat shock proteins (HSP) in patients with tubal factor infertility (TFI), infertility controls (IFC), and fertile controls (FC). HSPs assist organisms in surviving caustic environments such as heat. STUDY DESIGN Twenty-one TFI, 15 IFC, and 29 FC patients were enrolled after laparoscopic tubal assessment. The titers of antibodies against C trachomatis organisms and 14 chlamydial HSPs were compared among the 3 groups. RESULTS TFI patients developed significantly higher levels of antibodies against C trachomatis and specifically recognizing chlamydial HSP60 and caseinolytic protease (Clp) P, a subunit of the ATP-dependent Clp protease complex involved in the degradation of abnormal proteins. CONCLUSION In addition to confirming high titers of antibodies against C trachomatis organisms and HSP60 in TFI patients, we identified a novel link of TFI with anti-ClpP antibodies. These findings may provide useful information for developing a noninvasive screening test for TFI and constructing subunit anti-C trachomatis vaccines.

Beneficial Effects of a Combined Navigator/Promotora Approach for Hispanic Women Diagnosed with Breast Abnormalities

Background: Patient navigation (PN) is an emerging strategy to overcome barriers to cancer care. We evaluated the efficacy of PN in improving time of key events in cancer care, including positive screening tests, definitive diagnosis, initiation of therapy, and completion of initial therapy. Methods: We evaluated PN in a prospective observational study of predominantly poor Hispanic women with an abnormal breast cancer screening or untreated biopsy proven breast cancer (control = 200, intervention = 260). Controls were contemporary record-based patients with positive screening. Analyses were conducted for the entire cohort and separately by ethnic strata. We used χ2 tests to compare differences in proportions and Kaplan–Meier followed by Cox regression to compare time-to-event curves of the intervention and control groups. Results: The average days from definitive diagnosis to initiation of therapy was significantly reduced overall with PN (PN vs. control, 57 vs. 74 days, P = 0.04). This effect was more pronounced in the Hispanic strata (56 vs. 81 days, P = 0.02). More navigated Hispanic women were diagnosed within 60 days of abnormal screening (62.6% vs. 47.5%, P < 0.01) and more began treatment within 60 days of diagnosis (80% vs. 56.3%, P < 0.01). Navigated Hispanic and other ethnic minority women had a shorter time from positive screening test to definitive diagnosis (16 and 32 days, respectively). Conclusions: Minority women may have benefited from navigation with shorter times from definitive diagnosis to initiation of therapy. Impact: PN intervention may show promise in decreasing some delays that contribute to health disparities among minority women with breast cancer. Cancer Epidemiol Biomarkers Prev; 21(10); 1639–44. ©2012 AACR.