Debra C. Bass

Cognitive Problem-Solving Skills Training and Parent Management Training in the Treatment of Antisocial Behavior in Children

This study evaluated the effects of problem-solving skills training (PSST) and parent management training (PMT) on children (N = 97, ages 7-13 years) referred for severe antisocial behavior. Children and families were assigned randomly to 1 of 3 conditions: PSST, PMT, or PSST and PMT combined. It was predicted that (a) each treatment would improve child functioning (reduce overall deviance and aggressive, antisocial, and delinquent behavior, and increase prosocial competence); and (b) PSST and PMT combined would lead to more marked, pervasive, and durable changes in child functioning and greater changes in parent functioning (parental stress, depression, and overall symptoms). Expectations were supported by results at posttreatment and 1-year follow-up. PSST and PMT combined led to more marked changes in child and parent functioning and placed a greater proportion of youth within the range of nonclinic (normative) levels of functioning.

Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina

OBJECTIVE To study how frequency, recentness, and reason for douching impact bacterial vaginosis‐related vaginal microflora and the occurrence of cervical pathogens. Douching has been linked to bacterial vaginosis as well as to chlamydial cervicitis in some, but not all, studies. METHODS A total of 1200 women at high risk for sexually transmitted infections were enrolled from five clinical sites around the United States. Cross‐sectional, structured interviews were conducted and vaginal swabs were self‐obtained for Gram stain, culture, and DNA amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis. RESULTS Douching at least once per month was associated with an increased frequency of bacterial vaginosis. Those who douched recently (within 7 days) were at highest risk [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3, 3.1]. Douching for symptoms (OR 1.7, 95% CI 1.1, 2.6) and for hygiene (OR 1.3, 95% CI 1.0, 1.9) both related to bacterial vaginosis risk. The associations between douching and Gardnerella vaginalis, Mycoplasma hominis, and lack of hydrogen peroxide‐producing lactobacilli were similar to those between douching and bacterial vaginosis. Gonococcal or chlamydial cervicitis was not associated with douching. CONCLUSION Douching for symptoms or hygiene, particularly frequent or recent douching, was associated with bacterial vaginosis and bacterial vaginosis‐associated vaginal microflora, but not with gonococcal or chlamydial cervicitis.

Bacterial Vaginosis and Anaerobic Bacteria Are Associated with Endometritis

BACKGROUND Chlamydia trachomatis and/or Neisseria gonorrhoeae account for approximately one-third to one-half of pelvic inflammatory disease (PID) cases. Thus, up to 70% of cases have an unknown, nongonococcal/nonchlamydial microbial etiology. METHODS We investigated the associations of N. gonorrhoeae, C. trachomatis, bacterial vaginosis, anaerobic bacteria, facultative bacteria, and lactobacilli with endometritis among 278 women with complete endometrial histology and culture from the PID Evaluation and Clinical Health Study. RESULTS Women with acute endometritis were less likely to have H(2)O(2)-producing Lactobacillus species (odds ratio [OR], 0.1; 95% confidence interval [CI], 0.01-0.8) and more likely to be infected with C. trachomatis (OR, 16.2; 95% CI, 4.6-56.6), N. gonorrhoeae (OR, 11.6; 95% CI, 4.5-29.9), diphtheroids (OR, 5.0; 95% CI, 2.1-12.2), black-pigmented gram-negative rods (OR, 3.1; 95% CI, 1.4-7.0), and anaerobic gram-positive cocci (OR, 2.1; 95% CI, 1.0-4.3) and to have bacterial vaginosis (OR, 2.4; 95% CI, 1.3-4.3). CONCLUSIONS We conclude that bacterial vaginosis-associated organisms are frequent among women with PID. Because these organisms were strongly associated with endometritis, we recommend that all women with PID be treated with regimens that include metronidazole.

Bacterial vaginosis and risk of pelvic inflammatory disease.

BACKGROUND: Bacterial vaginosis commonly is found in women with pelvic inflammatory disease (PID), but it is unclear whether bacterial vaginosis leads to incident PID. METHODS: Women (n = 1,179) from 5 U.S. centers were evaluated for a median of 3 years. Every 6–12 months, vaginal swabs were obtained for gram stain and culture of microflora. A vaginal microflora gram stain score of 7–10 was categorized as bacterial vaginosis. Pelvic inflammatory disease was diagnosed by presence of either histologic endometritis or pelvic pain and tenderness plus one of the following: oral temperature greater than 38.3°C; sedimentation rate greater than 15 mm/hour; white blood count greater than 10,000; or lower genital tract detection of leukorrhea, mucopus, or Neisseria gonorrhoeae or Chlamydia trachomatis. RESULTS: After adjustment for relevant demographic and lifestyle factors, baseline bacterial vaginosis was not associated with the development of PID (adjusted hazard ratio 0.89, 95% confidence interval 0.55–1.45). Carriage of bacterial vaginosis in the previous 6 months before a diagnosis (adjusted risk ratio 1.31, 95% confidence interval 0.71–2.42) also was not significantly associated with PID. Similarly, neither absence of hydrogen peroxide–producing Lactobacillus nor high levels of Gardnerella vaginalis significantly increased the risk of PID. Dense growth of pigmented, anaerobic gram-negative rods in the 6 months before diagnosis did significantly increase a womans risk of PID (P = .04). One subgroup of women, women with 2 or more recent sexual partners, demonstrated associations among bacterial vaginosis, Gardnerella vaginalis, anaerobic gram-negative rods, and PID. CONCLUSION: In this cohort of high-risk women, after adjustment for confounding factors, we found no overall increased risk of developing incident PID among women with bacterial vaginosis. LEVEL OF EVIDENCE: II-2

Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study.

Background Douching has been related to risk of pelvic inflammatory disease (PID). Goal To examine the association between douching and PID in a large, multicenter, clinical trial of PID after adjustment for race/ethnicity. Study Design Interviews were conducted with 654 women who had signs and symptoms of PID. Vaginal Gram stains and upper genital tract pathology/cultures were obtained from all the women. Women with evidence of plasma cell endometritis and/or gonococcal or chlamydial upper genital tract infections were compared with women who had neither endometritis nor upper genital tract infection. Results Women with endometritis or upper genital tract infection were more likely to have douched more than once a month or within 6 days of enrollment than women who never douched. These associations remained after adjustment for confounding factors, after analysis of black women only; and among women with normal or intermediate vaginal flora but not bacterial vaginosis. Conclusion Among a predominantly black group of women with clinical PID, frequent and recent douching was associated with endometritis and upper genital tract infection.

Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial.

Objective: Among all women with pelvic inflammatory disease (PID), prevention of adverse reproductive consequences appears to be similarly achieved by outpatient treatment and inpatient treatment. We assessed whether outpatient is as effective as inpatient treatment in relevant age, race, and clinical subgroups of women with PID. Methods: Women with clinical signs and symptoms of mild-to-moderate pelvic inflammatory disease (n = 831) were randomized into a multicenter trial of inpatient treatment, initially employing intravenous cefoxitin and doxycycline compared with outpatient treatment consisting of a single intramuscular injection of cefoxitin and oral doxycycline. Comparisons between treatment groups during a mean of 84 months of follow-up were made for pregnancies, live births, time to pregnancy, infertility, PID recurrence, chronic pelvic pain, and ectopic pregnancy. Results: Outpatient treatment assignment did not adversely impact the proportion of women having one or more pregnancies, live births, or ectopic pregnancies during follow-up; time to pregnancy; infertility; PID recurrence; or chronic pelvic pain among women of various races; with or without previous PID; with or without baseline Neisseria gonorrhoeae and/or Chlamydia trachomatis infection; and with or without high temperature/white blood cell count/pelvic tenderness score. This was true even in teenagers and women without a previous live birth. Ectopic pregnancies were more common in the outpatient than the inpatient treatment group, but because these were so rare, the difference did not reach statistical significance (5 versus 1, odds ratio 4.91, 95% confidence interval 0.57–42.25). Conclusion: Among all women and subgroups of women with mild-to-moderate PID, there were no differences in reproductive outcomes after randomization to inpatient or outpatient treatment. Level of Evidence: I

Why women douche and why they may or may not stop

Background Although douching is common, it is a potentially harmful habit. Goal We studied attitudes and knowledge around the behavior of douching. Study Design Of 1200 women enrolled in this multisite study, 532 douched and answered questions on a structured interview regarding douching behaviors. Results Over half had douched for 5 or more years. Douching was most often initiated on the recommendation of female relatives and practiced for reasons of hygiene. Half of women considered douching to be healthy. Those who considered douching to be unhealthy reported that douching may disrupt vaginal flora but did not cite more serious risks. Nonetheless, women who had been advised by a health professional to stop douching were less likely to consider douching healthful and were more likely to have tried to stop. Conclusion Women had a limited understanding of potential adverse health consequences associated with douching. Targeted health messages may influence women to initiate douching cessation.

Chlamydia antibodies, chlamydia heat shock protein, and adverse sequelae after pelvic inflammatory disease: the PID Evaluation and Clinical Health (PEACH) Study.

Background: Among women with pelvic inflammatory disease (PID), we assessed the associations among antibodies to Chlamydia trachomatis elementary bodies (EB), antibodies to chlamydia heat shock protein (Chsp60), rates of pregnancy, and PID recurrence. Methods: Four hundred forty-three women with clinical signs and symptoms of mild to moderate PID enrolled in the PID Evaluation and Clinical Health Study were followed for a mean of 84 months for outcomes of time-to-pregnancy and time-to-PID recurrence. Antibodies to EB and Chsp60 were assessed in relation to these long-term sequelae of PID. Results: Rates of pregnancy were significantly lower (adj. hazard ratio 0.47, 95% confidence interval 0.28–0.79) and PID recurrence higher (adj. hazard ratio 2.48, 95% confidence interval 1.00–6.27) after adjusting for confounding factors among women whose antibody titers to chlamydia EB measured in the final year of follow-up were in the highest tertile. Conclusion: Among women with mild to moderate PID, antibodies to C. trachomatis were independently associated with reduced rates of pregnancy and elevated rates of recurrent PID.

Condom Use and the Risk of Recurrent Pelvic Inflammatory Disease, Chronic Pelvic Pain, or Infertility Following an Episode of Pelvic Inflammatory Disease

Among 684 sexually active women with pelvic inflammatory disease (PID) followed up for a mean of 35 months, we related contraceptive use to self-reported PID recurrence, chronic pelvic pain, and infertility. Persistent use of condoms during the study reduced the risk of recurrent PID, chronic pelvic pain, and infertility. Consistent condom use (about 60% of encounters) at baseline also reduced these risks, after adjustment for confounders, by 30% to 60%. Self-reported persistent and consistent condom use was associated with lower rates of PID sequelae.

Design of the PID Evaluation and Clinical Health (PEACH) Study

This paper describes the PID Evaluation and Clinical Health Study (PEACH), a multicenter, randomized clinical trial designed to compare treatment with outpatient and inpatient antimicrobial regimens among women with pelvic inflammatory disease (PID). PEACH is the first trial to evaluate the effectiveness and cost-effectiveness of currently recommended antibiotic combinations in preventing infertility, ectopic pregnancy, chronic pelvic pain, recurrent PID, and other health outcomes. It is also the largest prospective study of PID ever conducted in North America. We describe the PEACH studys specific aims, study organization, patient selection criteria, conditions for exclusion, data collected upon entry, randomization and treatment, adherence measures, follow-up activities, quality-of-life measures, outcomes, and statistical analyses. In the first 11 months of enrollment (March 1996-January 1997), 312 women were randomized. Of eligible women, 59% consented to enroll. Participating women are primarily black (72%) and young (mean age 24 years). After a median of 5.5 months of follow-up, we were in contact with 95% of study participants. The PEACH study will provide a rationale for selecting between inpatient and outpatient antibiotic treatment, the two most common treatment strategies, for PID.