Maria I. Rodriguez

Varicella‐Zoster Immunization in Pediatric Liver Transplant Recipients: Safe and Immunogenic

Varicella can have a severe course in immunosuppressed patients. Although prevention is fundamental, live‐attenuated varicella‐zoster (VZV) vaccine is not currently recommended in transplant recipients. Our aims were to (1) evaluate VZV immunity in pediatric liver transplant (LT) recipients; (2) immunize (two doses) seronegative patients post‐LT; (3) monitor vaccine safety, (4) assess B and T cell vaccine responses. All patients followed at the Swiss National Pediatric LT Center were approached and 77/79 (97.5%) were enrolled (median age 7.8 years). Vaccine safety was monitored by standardized diary cards and phone calls. VZV‐specific serology and CD4+ T cells were assessed before and after immunization. Thirty‐nine patients (51.1%) were seronegative including 14 children immunized pre‐LT. Thirty‐six of 39 seronegative patients were immunized post‐LT (median 3.0 years post LT). Local (54.8%) and systemic (64.5%) reactions were mild and transient. The frequency of VZV‐specific CD4+ T cells and antibody titers increased significantly (respectively from 0.085% to 0.16%, p = 0.04 and 21.0 to 1134.5 IU/L, p < 0.001). All children reached seroprotective titers and 31/32 (97%) patients assessed remained seroprotected at follow‐up (median 1.7 years). No breakthrough disease was reported during follow‐up (median 4.1 years). Thereby, VZV vaccine appears to be safe, immunogenic and provide protection against disease in pediatric LT patients.

Advance supply of emergency contraception: a systematic review

BACKGROUNDnEmergency contraceptive pills (ECPs) are an underutilized means to reduce unintended pregnancy. Advance provision of ECPs may increase timely use, thereby decreasing risk of unintended pregnancy.nnnSTUDY DESIGNnWe searched MEDLINE and EMBASE through February 2012 for randomized, controlled trials (RCTs) pertaining to safety and efficacy of advance provision of ECP. The quality of each individual study was evaluated using the United States Preventive Services Task Force evidence grading system.nnnRESULTSnThe search strategy identified 714 articles. Seventeen papers reported on safety or efficacy of advance ECPs in adult or adolescent women. Any use of ECPs was two to seven times greater among women who received an advanced supply of ECP. However, a summary estimate (RR 0.90, 95% CI 0.69-1.18) of four RCTs did not demonstrate a significant reduction in unintended pregnancy over 12 months when advance provision was compared with standard provision of ECPs. Patterns of contraceptive use, pregnancy rates and incidence of sexually transmitted infections did not vary between treatment and control groups in the majority of studies among either adults or adolescents.nnnCONCLUSIONnAvailable evidence supports the safety of advance provision of ECPs. Efficacy of advance provision compared with standard provision of ECPs in reducing unintended pregnancy rates at the population level has not been demonstrated.

Clitoral Reconstruction after Female Genital Mutilation/Cutting: Case Studies

INTRODUCTIONnClitoral reconstruction following female genital mutilation/cutting (FGM/C) is a new surgical technique reported to be a feasible and effective strategy to reduce clitoral pain, improve sexual pleasure, and restore a vulvar appearance similar to uncircumcised women. However, data on safety, care offered, and evaluation of sexual and pain outcomes are still limited.nnnAIMSnThis study aims to present the care offered and clinical outcomes of two women who received multidisciplinary care, including psychosexual treatment, with clitoral reconstruction. We report their long-term outcomes, and the histology of the removed periclitoral fibrosis.nnnMETHODSnWe report the cases of two women with FGM/C types II and III who requested clitoral reconstruction for different reasons. One woman hoped to improve her chronic vulvar pain, as well as improve her sexual response. The other woman requested surgery due to a desire to reverse a procedure that was performed without her consent, and a wish to have a genital appearance similar to non infibulated women. They both underwent psychosexual evaluation and therapy and surgery. The histology of the periclitoral fibrosis removed during surgery was analyzed.nnnRESULTSnAt 1-year postoperatively, the first woman reported complete disappearance of vulvar pain and improved sexual pleasure, including orgasm. Our second patient also described improved sexuality at 1-year follow-up (increased sexual desire, lubrication, vulvar pleasure, and sensitiveness), which she attributed to a better self body image and confidence. Both women reported feeling satisfied, happy, and more beautiful.nnnCONCLUSIONnWe show a positive outcome in pain reduction and improved sexual function, self body image, and gender after psychosexual therapy and clitoral reconstruction. More evidence is needed about clitoral reconstruction to develop guidelines on best practices. Until research is conducted that rigorously evaluates clitoral reconstruction for its impact on pain and sexuality, we advise always offering a multidisciplinary care, including sexual therapy before and after the surgery.

Successful serology-based intervention to increase protection against vaccine-preventable diseases in liver-transplanted children: a 19-yr review of the Swiss national reference center

L’Huillier AG, Wildhaber BE, Belli DC, Diana A, Rodriguez M, Siegrist CA, Posfay‐Barbe KM. Successful serology‐based intervention to increase protection against vaccine‐preventable diseases in liver‐transplanted children: A 19‐yr review of the Swiss national reference center. u2028Pediatr Transplantation 2012: 16: 50–57.

Is Cystatin C a promising marker of renal function, at birth, in neonates prenatally diagnosed with congenital kidney anomalies?

BACKGROUNDnDespite the increased prenatal diagnosis of congenital abnormalities of the kidney and urinary tract (CAKUT), no reliable renal marker for glomerular filtration rate (GFR) has been validated yet in neonates. Cystatin C (CysC) is specific to the neonate and is proposed as a sensitive marker for this population. The aims of the study were first to define a reference interval in our center of CysC at birth in normal term babies and assess CysC as a marker of GFR in a group of term neonates prenatally diagnosed with CAKUT compared to controls.nnnMETHODSnOne hundred normal term neonates (control group) and 33 neonates with kidney malformation (KM) had the CysC levels in their cord blood measured. A reference interval for CysC in controls was calculated using non-parametric methods. CysC from controls was compared first to the whole group of neonates with KM, then with KM group divided in infants (n = 20) with unilateral kidney malformation (UKM) and those (n = 13) with bilateral kidney malformation (BKM). A multivariable analysis was performed to assess the difference in CysC between the groups with adjustment on other factors. The ability of CysC to discriminate neonates with BKM from the controls was assessed by a non-parametric receiver-operated characteristics (ROC) curve.nnnRESULTSnIn the control group, the CysC reference interval was [1.54-2.64] mg/L with a median (M) CysC of 2.02 IQR [1.86-2.23]. In the neonates with KM, M CysC was 1.98 IQR [1.79-2.34]; 1.88 IQR [1.76-2.01] in the UKM group and 2.52 IQR [2.16-2.71] in BKM group. Using a multivariate regression analyses, CysC was significantly increased (P < 0.001) in BKM compared to controls with an increment of CysC of 24.5%, and independent from gender, weight and size. The ROC curve analyses, comparing BKM versus controls with a chosen cut-off for CysC of 2.34, showed a sensitivity of 69% and a specificity of 86%.nnnCONCLUSIONSnComparing CysC with a reference interval of CysC validated in our center, we showed a significant increase of CysC in neonates presenting BKM compared to controls and those with UKM.

How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review

BACKGROUNDnThe review was conducted to examine studies that assess whether the number of pill packs dispensed, or prescribed, affects method continuation and other measures of use.nnnSTUDY DESIGNnPubMed database was searched from inception through March 2012 for all peer-reviewed articles, in any language, that examined the effect of the number of oral contraceptive pill packs dispensed on method continuation, and other measures of use. The quality of each study was assessed using the United States Preventive Services Task Force grading system.nnnRESULTSnFour studies met the inclusion criteria for this review. Studies that compared 1 vs. 12, 1 vs. 12-13, or 3 vs. 7 packs found increased method continuation. However, one study that examined the difference between providing one and then three packs versus providing four packs all at once did not find a difference in continuation. In addition to continuation, evidence from the individual studies included found that a greater number of pill packs was associated with fewer pregnancy tests, fewer pregnancies and less cost per client. A greater number of pill packs was, however, also associated with increased pill wastage.nnnCONCLUSIONSnA small body of evidence suggests that dispensing a greater number of oral contraceptive pill packs may increase continuation of use.

Postpartum sterilization with the titanium clip: A systematic review

OBJECTIVE: To estimate the efficacy of the titanium clip in postpartum sterilization. DATA SOURCES: We searched the Medline and Cochrane databases from their inception through January 2011 for all articles in any language pertaining to the titanium clip use in postpartum sterilization. Reference lists and device registration files were also searched. METHODS OF STUDY SELECTION: We identified 13 articles for this review, 10 observational trials and three reports from one single randomized controlled trial. Studies were included if they used the titanium clip for sterilization during the postpartum period and reported subsequent pregnancy as an outcome. Studies of the Hulka clip (spring-loaded) without a titanium comparison group or of the postabortion population were excluded. TABULATION, INTEGRATION, AND RESULTS: Data abstraction was independently performed by two authors. Standard data abstraction templates were used to systematically assess and summarize the data. Quality of the evidence was rated with the U.S. Preventive Task Force System. Efficacy of the titanium clip was estimated from the only randomized controlled trial identified. This trial found a significantly increased risk of pregnancy at 24 months with clip sterilization postpartum (cumulative rate 1.7 compared with 0.04, P=.04) compared with postpartum partial salpingectomy. CONCLUSION: Based on limited data, the titanium clip has decreased efficacy than partial salpingectomy in the postpartum population. Routine use of the titanium clip during the postpartum period should not be recommended.

Pharmacist prescription of hormonal contraception in Oregon: Baseline knowledge and interest in provision

OBJECTIVESnOregon has implemented legislation expanding the scope of pharmacists to directly prescribe short-acting hormonal contraception (pill and patch) without a medical prescription. Pharmacists are crucial to the success of the new law, but relatively little is known about their intentions to prescribe contraception, or the motivators or barriers in providing this service.nnnMETHODSnWith the use of a cross-sectional survey of pharmacists practicing in Oregon before the legislative implementation, we analyzed responses to assess contraceptive knowledge, motivation to participate in direct provision, and perception of barriers to pharmacist prescription of contraception. A logistic regression model was used to examine the association between years in pharmacy practice and intention to provide direct access to contraception.nnnRESULTSnA total of 509 pharmacists responded (17%). If training and reimbursement were offered, more than one-half of pharmacists would potentially be interested in prescribing contraception, managing side-effects, or moving women to a different hormonal method (57%, 61%, and 54%, respectively). However, only 39.1% of pharmacists surveyed planned to actually prescribe hormonal contraception when the legislation took effect. Shortage of pharmacy staff to provide services, concerns about liability, and a need for additional training were the threexa0largest barriers to participation. Pharmacists practicing in urban locations (odds ratio 1.73, 95% CI 1.11-2.70) or currently offering emergency contraception (odds ratio 2.23, 95% CI 1.47-3.40) were significantly more likely to be planning to participate.nnnCONCLUSIONnPreliminary data indicate a need to support pharmacists with education on contraceptive provision and development of interventions to facilitate counseling in the pharmacy setting.

Lack of insurance and parity influence choice between long-acting reversible contraception and sterilization in women postpregnancy

BACKGROUNDnDisparities in postpregnancy contraception utilization exist, with low-income women disproportionately undergoing sterilization. We assessed the impact of increased intrauterine device (IUD) availability on rates of female sterilization.nnnSTUDY DESIGNnHospital billing records were used to identify women with an IUD placement or sterilization within 1 year of a pregnancy at a university hospital between Oct 2005 and Jun 2007. Demographic data were compared between women receiving either an IUD or sterilization.nnnRESULTSnThere were 365 sterilizations and 223 IUD placements during the study period. IUD placements doubled over the study period from 6% to 12% of all deliveries, while sterilizations remained stable at 11% (p<.001). Demographic variables were examined for women with either public or private insurance who had financial access to both sterilization (n=253) and IUD (n=223). Women receiving sterilization were slightly older (mean age 31 years versus 30 years, p=.03), of higher parity (median three versus two, p<.01), more likely to have had cesarean delivery (69% versus 31%, p<.001) and more likely to have public insurance (77% versus 23%, p<.001) than women who received IUD. Approximately 45% of women delivering in Oregon in 2007 were publicly insured (2010 Maternal and Child Health Update: States Make Progress Towards Improving Systems of Care. National Governors Association, Table 6. Available at http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF, accessed Nov 2011). After adjusting for age, parity and type of delivery, women choosing sterilization were more likely to have public insurance than women choosing IUD (odds ratio 8.4, 95% confidence interval 4.7-14.9, p<.0001).nnnCONCLUSIONSnWomen choosing sterilization are more likely to have public insurance than women choosing IUD and may represent a continued trend toward nonreversible contraception among women of lower socioeconomic status despite available long-acting reversible methods.

INTRACAVAL LIVER WITH CARDIAC EXTENSION. A NEW DEVELOPMENTAL ANOMALY

Inferior vena cava (IVC) obstruction is uncommon in children. We report a patient with liver within a IVC extending to the right atrium who underwent successful surgical resection. A 12-year-old boy with an Arnold Chiari malformation was admitted for seizures. Premature ventricular contractions prompted an echocardiogram. This revealed a pedunculated mass in the right atrium and an IVC producing turbulent flow. He underwent a mass excision that was continuous with the liver. Histology demonstrated normal liver parenchyma. Based on the embryologic intimacy between the caudate lobe and the IVC, we postulate that the ectopic hepatic nodule was due to aberrant migration of hepatocytes into the IVC during embryogenesis.