Marcel Vekemans

Circadian Periodicity of Serum Prolactin Concentration in Man

Immunoreactive human serum prolactin of pituitary origin has been measured by a radioimmunoassay developed for ovine prolactin. Blood samples were collected at four-hour intervals during a 24-hour period from 12 non-pregnant women, three pregnant women, and seven adult men. A circadian periodicity was found in serum prolactin concentration, with peak values during the night, between 1 a.m. and 5 a.m. for the non-pregnant women, and at 5 a.m. for the adult men. Mean serum levels of prolactin were 1·5 times higher in non-pregnant women than in men. In women investigated during the last month of their pregnancy the mean serum prolactin levels were 2·3 times higher than in the non-pregnant women, but there was no circadian periodicity.

Influence of age on serum prolactin levels in women and men.

Case 1-A 51-year-old woman was admitted for cholecystectomy; at operation a peroperative choledochogram showed an enlarged duct with the suspicion of a stone within it. Formal supraduodenal exploration, together with transduodenal sphincterotomy, was performed and two stones removed. The post operative T-tube choledochogram showed two residual stones in the lower end of the duct. Three washouts were performed over the next few days and a T-tube choledochogram after the last washout showed no evidence of residual calculi. The T-tube was removed and the patient has remained well. Case 2-This man presented with recurrent episodes of cholangitis. At operation the choledochogram showed a stone in the lower end of the duct but none was found on exploration and transduodenal sphincterotomy. Two postoperative T-tube choledochograms showed two residual stones in the lower end of the bile duct. Re-exploration was performed and one crushed stone removed. A repeat choledochogram showed one residual stone and a biliary washout was then performed. A T-tube choledochogram two days later showed free flow of the contrast medium into the duodenum and no evidence of the residual stone. The T-tube was removed and the patient has remained well.

Low Mannose-Binding Lectin Concentration Is Associated with Severe Infection in Patients with Hematological Cancer Who Are Undergoing Chemotherapy

BACKGROUNDnMannose-binding lectin (MBL) is a serum lectin involved in innate immune response. Low serum MBL concentration may constitute a risk factor for infection in patients receiving myelosuppressive chemotherapy.nnnMETHODSnWe conducted a prospective, observational study that assessed MBL concentration as a risk factor for infection in patients with hematological malignancy who were hospitalized to undergo at least 1 chemotherapy cycle. MBL deficiency was defined using an algorithm that considered the serum MBL concentration and the MBL genotype. The primary end point was the ratio of duration of febrile neutropenia to the duration of neutropenia. Secondary end points included the incidence of severe infection (e.g., sepsis, pneumonia, bacteremia, and invasive fungal infection). Logistic regression analysis was conducted, and Fishers exact test was used to analyze binary outcomes, and Kaplan-Meier estimates and log rank tests were used for time-to-event variables.nnnRESULTSnWe analyzed 255 patients who received 569 cycles of chemotherapy. The median duration of neutropenia per cycle was 7 days (interquartile range, 0-13 days). Sixty-two patients (24%) were found to have MBL deficiency. Febrile neutropenia occurred at least once in 200 patients. No difference in the primary outcome was seen. The incidence of severe infection was higher among MBL-deficient patients than among non-MBL-deficient patients (1.96 vs. 1.34 cases per 100 days for analysis of all patients [P=.008] and 1.85 vs. 0.94 cases per 100 days excluding patients with acute leukemia [P<.001]).nnnCONCLUSIONSnMBL deficiency does not predispose adults with hematological cancer to more-frequent or more-prolonged febrile episodes during myelosuppressive chemotherapy, but MBL-deficient patients have a greater number of severe infections and experience their first severe infection earlier, compared with nondeficient patients.

Postpartum contraception: The lactational amenorrhea method

Breastfeeding still accounts for a significant proportion of all fertility reduction, the average birth interval being longer among populations that breastfeed. However, per se it is not reliable for individual fertility suppression. The lactational amenorrhea method (LAM) is a highly efficient tool for the individual woman to utilize physiology to space births. Suckling induces a reduction in gonadotropin releasing hormone, luteinizing hormone and follicle stimulating hormone release, resulting in amenorrhea, through an intracerebral opioid pathway: beta-endorphins inhibit gonadotropin releasing hormone and dopamine secretions, which, in turn stimulates prolactin secretion and milk production. Reduced suckling precipitates the return of ovulation. During lactation, menses before 6 months are mostly anovulatory, and fertility remains low. The lactational amenorrhea method is based on three simultaneous conditions: (1) the baby is under 6 months; (2) the mother is still amenorrheic; and (3) she practises exclusive or quasi-exclusive breastfeeding on demand, day and night. Experiments with LAM extended to 9-12 months are ongoing. We use a standardized algorithm to present LAM. The lactational amenorrhea method is a way both to space births and to support breastfeeding, which should be replaced by a contraceptive method in due course. A Breastfeeding-LAM-Family Planning team is very helpful in maternity wards for promoting modern breastfeeding, LAM, and contraception, and for alleviating barriers and misconceptions. The lactational amenorrhea method is at least 98% effective, comparing favorably with other contraceptive methods. Acceptability and continuity are not very well known; as with other natural methods the figures are probably low in a general population but high for motivated couples. The lactational amenorrhea method avoids double protection, and thus saves resources, is especially (but not exclusively) suitable for couples interested in natural family planning and is accepted by religious authorities. The lactational amenorrhea method gives time to decide upon a long-term method of contraception. Unwanted pregnancies, although infrequent, conceived while using LAM result in very short, high-risk birth intervals. Introduction of LAM in family planning programs demands training, attention to be given to working mothers, positive attitudes of health personnel, close links between postpartum and family planning teams, situation analysis, budgets, evaluations, follow-up activities, modifications of record keeping systems and computing programs, and of national family planning guidelines. In conclusion, LAM is an efficient family planning method which should be promoted. The lactational amenorrhea method should always include the shift to another method when its criteria are no longer implemented.

Family planning in Rwanda: status and prospects.

This article analyzes the status and future prospects of family planning in Rwanda. The use of traditional contraceptive methods is examined and major constraints to modern contraceptive use are discussed, both for potential users (low demand) and family planning delivery systems (poor supply). Current contraceptive prevalence, as well as evidence of potentially higher demand, are analyzed. Contraceptive prevalence for modern methods is estimated at 3-4 percent, for 1988, of women of reproductive age who are at risk of exposure to conception. An attempt is also made to target future contraceptive prevalence rates needed to attain specific levels of fertility. Finally, the prospects for family planning as well as recommendations to increase contraceptive use are reviewed.

Continuation rates with a levonorgestrel-releasing contraceptive implant (Norplant®): A prospective study in belgium

Contraceptive protection offered by a method depends on its duration of use, which reflects costs, side effects, and relatives opinions. This study investigated in Norplant implants users the continuation rates, some of their determinants, and the motives for removals. Since 1988, 612 Norplant implants sets, designed to protect for 5 years, have been inserted. Observing 13,907 months of use, we determined over time the continuation rates and how age, parity, circumstances at insertion (postpartum, postabortum, others), and patronymic origins (surrogate for sociocultural factors) influenced them. Statistics included Kaplan-Meiers method and log rank tests, and uni- and multivariate Cox models. Continuation increased with age and depended on sociocultural factors. Parity exerted influence only in younger women. Median duration of use was 3 years 11 months. Removals before 5 years related almost equally to irregular bleeding, other side effects, and pregnancy wish. The cumulative 5-year failure rate was 1.5%. Unsatisfied users returned earlier, distorting the first results. A literature search showed that implants yield, in the mean, slightly better continuation figures than do intrauterine devices, and clearly higher than those obtained with pills and injectables. To optimize costs and counseling, warnings about the risk of short duration of use in young nullipara, especially if negative sociocultural influences prevail, are recommended. In no category are the implants absolutely to be avoided. Individual and programmatic contraceptive choice should take into account the expected continuation of use.

Serum alpha-fetoprotein in adults, in women during pregnancy, in children at birth, and during the first week of life: A sex difference

In order to investigate whether a sex difference exists in alpha-fetoprotein serum concentration, blood samples were collected from 133 adult men, 52 adult women, 239 pregnant women at different ages of gestation, 16 girls and 18 boys at birth, and seven girls and seven boys during the first week of life. In the case of 15 boys and 10 girls, blood samples were also collected from their mothers at the time of delivery. Serum AFP was measured by a radioimmunoassay method. In all neonates the mean value was 625 times higher than in all mothers at the time of delivery and 13,000 times higher than in adults. No difference was found between mothers of girls and those of boys both during pregnancy and at the time of delivery. However, at birth, the fetal AFP serum concentration was 1.8 (p less than 0.001) times higher in boys than in girls. This sex difference was maintained during the first week of life. The half-life of serum AFP was 5 to 6 days in the neonate. The origin and the possible physiologic significance of such sex difference in AFP deserve further investigations.

Double-Blind Crossover Clinical Pharmacology Study Comparing Moxestrol (R 2858) and Ethinyl Estradiol in Postmenopausal Women

The potency of 5 migrogram moxestrol (R 2858). 11beta-methoxy-17alpha-ethinyl-estra-1,3,5-[10]-triene-3,17-diol, administered orally, was compared to that of 25 microgram ethinyl estradiol in a double-blind crossover clinical pharmacology study of six postmenopausal women. At these doses, both compounds increased the eosinophilic index and decreased serum LH and FSH levels. A marked effect on circulating prolactin was observed only during ethinyl estradiol treatment.

Late uterine perforation with an anchored IUD, the Gynefix: a case report.

A case of uterine perforation which occurred two months after the insertion of a Gynefix, a frameless filiform copper intrauterine device fixed into the fundal myometrium is described. Laparoscopic removal of the device had to be performed. The incidence of this complication is unknown. The appropriateness or need of assessing echo-graphically the myometrial thickness before the insertion and of controlling its correct position after the insertion remains uncertain.

Is blood testing necessary before OC prescription in Africa

We have been aware that in some African countries, screening for contraindications for oral contraceptives (OCs) includes several laboratory tests. Compulsory tests are intended as a protection, but they could also represent a barrier to OC use. We have previously published (Buekens et al., 1988) findings from an inquiry designed to determine the extent of blood testing before prescribing oral contraception in Africa. A questionnaire was completed by African family planning professionals who attended six courses run by the United Nations Fund for Population Activities in Mauritius and in Belgium in 1987 and 1988. The people attending were generally well informed of the practices in their countries. They came from 32 African countries of which 18 were French-speaking, nine were English-speaking, and five were Portuguesespeaking. Participants from 19 of the 32 countries stated that blood testing was recommended or required where they worked. Thirteen of the 19 countries were Frenchspeaking, three were English-speaking, and three were Portuguese-speaking. In more than half the cases where blood testing was recommended, it included blood sugar, cholesterol and triglycerides. Other analyses were less frequently recommended, including bilirubin, transaminases, phosphatases and other liver function tests; hemoglobin; hematocrit; sickle tests; urea and other kidney function tests. The main conclusion of this study was that blood testing before OC prescription is used in more than half the countries investigated. The usefulness of such practice is a controversial issue in industrialized countries. French authors (Serfaty, 1986; Baudet and Seguy, 1987) recommend blood testing before OC prescription. However, several English-language textbooks (Clayton et al., 1985; Govan et al., 1985) do not mention it, and the U.S. Food and Drug Administration (Corfman, 1988) only mentions the use of relevant laboratory tests without any recommendation on systematic screening. Screening before OC prescription was not even mentioned in the recent discussion about cholesterol testing in the United Kingdom (Tunstall-Pedoe, 1989; Leitch, 1989). In Africa, the usefulness of blood tests is even more questionable. In our inquiry, glycemia was the most frequently recommended test-contrasting with the fact that diabetes is uncommon in Africa (King and Zimmet, 1988), even though it has been proposed that diabetes can be induced by malnutrition (WHO, 1985), and is slightly increased with increasing parity (Kritz-Silverstein et al., 1989). Furthermore, it has been shown that disturbance of diabetic control is uncommon under oral contraception (Duffy and Ray, 1984; Steel, 1985; Skouby et al., 1986). In industrialized countries, the increased risk of cardiovascular diseases in diabetic patients has caused concern (Steel, 1985), but this risk appears to be low in African diabetics (Watkins, 1984). Under any circumstances, contraception is less hazardous than pregnancy for diabetics. The OC is one of the contraceptive methods that may be used in diabetic patients, and there is thus no case for a mass screening for diabetes before OC prescription. Screening for hyperlipidemia is also not to be recommended because it is uncommon in Africa, as has been shown by Watkins (1984) in his review of the literature, and also in more recent data (Gomo, 1985; Adams-Campbell et al., 1988). With the exception of Pierre Buekens, M.D., Ph.D., Marcel Vekemans, M.D., Bruno Dujardin, M.D., Michel Boutsen, M.D., and Elizabeth Wollast, D.P.H. are with the School of Public Health, Free University of Brussels, Route de Lennik 808, 1070 Bruxelles, Belgium. Dr. Buekens is also research associate of the Belgian National Research Fund.