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US teenagers have had access to the injectable contraceptive depot medroxyprogesterone acetate (DMPA; Depo-Provera) since the US Food and Drug Administration approved it in 1992. DMPA suppresses follicle stimulating hormone and luteinizing hormone (LH) levels, which in turn prevents the LH surge and thus inhibits ovulation. It also causes a thick cervical mucus (reducing sperm penetration). Since DMPA also changes tubal mobility and creates shallow and atrophic endometrium, implantation is prevented. DMPA must be administered every 3 months to be effective. Its first-year failure rate is 0.3%, which is lower than that of oral contraceptives (3%). Advantages of DMPA are that it: allows for privacy; improves compliance (since action is required every 3 months rather than every day); has no estrogen-related complications (e.g., thrombophlebitis); is effective; is safe for breast feeding teenagers; reduces seizure frequency in teenagers with epilepsy; has a favorable effect on sickle cell disease or coagulopathy; reduces menstrual flow, thus preventing iron-deficiency anemia; reduces menstrual pain and pre-menstrual symptoms; and decreases risk of pelvic inflammatory disease. The leading disadvantages are menstrual irregularities and spotting. Some other possible disadvantages include weight gain (most common reason for discontinuation), delayed return of fertility, headaches, acne, and nervousness. Health providers must perform a complete history of teenagers requesting DMPA. They should determine the presence or absence of absolute and relative contraindications to DMPA. Absolute contraindications are known or suspected pregnancy, undiagnosed or abnormal vaginal bleeding, known or suspected history of breast cancer, acute liver disease or jaundice, thromboembolism, and sensitivity to DMPA. DMPA is administered intramuscularly at a concentration of 150 mg/ml. Health providers need to use a frank, nonjudgmental, empathic, and unhurried approach to facilitate a trusting relationship and rapport with teenagers. Advanced counseling on the pros and cons of DMPA, how DMPA works, and DMPA's inability to protect against sexually transmitted diseases is essential.
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PMID:Use of depo-provera in teens. 892 Mar 51

Liver transplantation is complicated by specific medical problems. Diabetes mellitus occurs in 4-20% of patients undergoing liver transplantation. Patients with primary sclerosing cholangitis and ulcerative colitis experience up to a 13% incidence of colon cancer after transplantation. Lymphomas occur in 1-3% of patients after transplantation and account for 57% of malignancies occurring in adult patients. Atraumatic bone fractures occur in 22-38% of patients and neurological complications, including seizures, headache, and neuropathy occur in 19-47% of patients following liver transplantation. Patients undergoing liver transplantation may experience recurrence of their primary liver disease: hepatitis B, hepatitis C, primary biliary cirrhosis, autoimmune hepatitis, or primary sclerosing cholangitis. In patients not receiving immunoprophylaxis after transplantation for chronic hepatitis B, recurrent hepatitis B is seen in up to 90% of patients. This can be markedly reduced with hyperimmune globulin immunoprophylaxis. Recurrent hepatitis C is seen in the majority of patients; current treatment modalities are inadequate. Recurrence of primary biliary cirrhosis or primary sclerosing cholangitis in the allograft is infrequent. Autoimmune hepatitis may recur in up to 26% of patients following liver transplantation. Primary disease recurrence in the allograft and preventive strategies are discussed.
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PMID:Medical problems occurring after orthotopic liver transplantation. 928 32

Quality of life is an important factor to consider when assessing the value of liver transplantation. Using a large, prospective database of liver transplantation recipients from three clinical centers in the United States, we examined the quality of life of 346 adults before and 1 year after surgery. Five quality of life domains were evaluated (measures of disease, psychological distress and well-being, personal function, social/role function, and general health perception) with standardized questionnaires completed according to established protocol. The largest numbers of patients were distressed by fatigue and muscle weakness, both before transplantation and 1 year after surgery. Compared to baseline, recipients at follow-up noted fewer disease-related symptoms (P < .001) and lower levels of distress overall (P < .001). However, levels of distress due to excess appetite (P < .001), headaches (P = .02), and poor/blurred vision (P = .05) were more likely to increase than decrease. Although 57% to 64% of the recipients were distressed by each of the psychological conditions examined at follow-up, distress was more likely to decrease than increase (P < .001), and well-being was comparable to the general population. All measures of personal functioning improved significantly (P < .05). Fifty-eight percent of the patients prevented by their disease from going to work or school before transplantation were no longer so limited at follow-up. With the exception of marriage (P = .23), all facets of social/role functioning improved more often than worsened (P < .01). Perception of health improved remarkably, with 13.4 times as many recipients reporting improved health as reporting worse health (P < .001). We conclude that liver transplantation markedly improves the quality of life of patients with end-stage liver disease.
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PMID:Changes in quality of life after liver transplantation among adults. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database (LTD). 934 22

A total of 159 cases of chloracne reported in 1969-1975 in TCDD-contaminated production of the herbicide 2,4,5-T have been followed for mortality and morbidity up to 1996 when blood and urine tests were performed on 50 survivors of these exposed chemical workers and matched controls. In exposed, the most frequent cause of sick leave was chloracne which persisted in 32%. Neurological symptoms were reported frequently (44% sleep disturbance, 32% headache, 30% neuralgia). BSR, leucocytes, gamma-GT, SGOT, and SGPT were significantly higher in exposed than in controls. The effects of exposure (P= 0.002) and alcohol (P= 0.002) on gamma-GT were found to be independent of each other. Comparisons within the chloracne cohort showed significantly exposed TCDD per gram blood lipid in patients with a history of liver disease (mean 801 pg/g) than without (mean 407 pg/g). Other congeners were not found elevated but some higher chlorinated furans and PCBs were found reduced in patients with liver disease. In multiple regression analysis with the factors age, alcohol, and log TCDD, the effects of TCDD and its interaction with age were found significant, indicative of chronic liver damage after high TCDD exposure at a young age. The prevalence of neurological symptoms and signs of chronic liver disease were related to TCDD in blood and abnormal poryphyrins in urine. In 48% coproporphyrin I > III ratio was elevated, this group showing increased TCDD (mean 719 pg/g). These results contribute to the evidence that chloracne is not the only chronic disease which can be related to TCDD exposure, even 23 years after exposure and despite high intersubject variability of TCDD half-life and other exposures.
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PMID:Persistent health effects of dioxin contamination in herbicide production. 1058 16

Methotrexate has a long history of use in the treatment of various immunologic diseases, including rheumatoid arthritis and psoriasis. Although the drug is usually prescribed by a subspecialist, a family physician may assume responsibility for monitoring methotrexate therapy. Major toxic effects, such as hepatic, pulmonary, renal and bone marrow abnormalities, require careful monitoring. Minor toxic effects, such as stomatitis, malaise, nausea, diarrhea, headaches and mild alopecia, are common but respond to folate supplementation. Methotrexate is administered once weekly as a single dose or in divided doses given over a 24-hour period. To reduce the incidence of major toxic effects, methotrexate should never be given in daily doses. Relative contraindications include renal dysfunction, liver disease, active infectious disease and excessive alcohol consumption. Both women and men of reproductive age should use birth control during methotrexate therapy. Potential drug interactions include salicylates and nonsteroidal anti-inflammatory drugs, which are both commonly used in patients with rheumatoid arthritis or psoriasis. A premethotrexate evaluation is important to ensure proper patient selection for this effective but potentially toxic drug.
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PMID:A family physician's guide to monitoring methotrexate. 1103 77

Acute liver failure and haemolytic syndrome appeared quite suddenly as the first manifestations of Wilson disease (WD) in five of our patients previously regarded as healthy persons (although an interview showed that 2-4 weeks prior to the illness the patients complained of several non-specific symptoms, such as abdominal pain, headaches, fever, weakness or behavioural changes). All the patients were young women (17-23 years), none of them had any history of liver disease. They were admitted with icterus, nausea, vomiting and symptoms of increasing haemolysis. The diagnosis of WD was given as disturbed copper metabolism. After a short period of observation ascites and anasarca occurred, haemorrhagic diathesis and other symptoms of liver failure increased. Levels of clotting factors decreased rapidly. Despite treatment with D-penicillamine, plasmapheresis, and symptomatic drugs, three of the women died in irreversible liver coma, due to the unavailability of liver transplantation. The fourth woman was carried to the Transplantation Centre, due to aggravation of the symptoms of liver failure, where liver transplantation was performed. Histopathologically micronodular cirrhosis was shown in all these cases. The fifth patient survived having undergone the above treatment without liver transplantation. The main differences between the patient who survived and those who died or underwent transplantation were relatively higher activity of alkaline phosphatase (26 U/l vs. 10-20 U/l), slightly higher levels of clotting factors and prothrombin time, which never fall below 68% of the control (versus 14-44% in other patients). Only in the surviving patient was the Kayser-Fleischer ring present. In four of our patients we found family members who were carriers of WD.
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PMID:Acute haemolytic syndrome and liver failure as the first manifestations of Wilson's disease. 1221 29

Over 50 metabolic and other changes believed due to oral contraceptived (OC) have been reported in the literature. Those of clinical importance are the thromboembolic diseases, headaches, jaundice, hypertension and diabetes. The Committee on Safety of Drugs has recommended that only preparations containing 50 mcg or less of estrogen be prescribed to reduce the risk of thromboembolic disease. It is believed that changing to a lower dose of pregestogen may reduce frequency and severity of headaches. Those women with previous jaundice history or any kind of active liver disease should not take OC. Patients on OC should have blood pressure measured at regular intervals to keep close watch on the possibility of hypertension. People predisposed to diabetes should avoid OC.
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PMID:Perils of the pill-to date. 1225 99

Barrier methods of contraception and natural family planning may pose unacceptable risks of unintended pregnancy for women with medical conditions in which pregnancy could be dangerous. Although more effective at preventing pregnancy, hormonal methods may affect the course of a chronic disease. The table that comprises this article outlines contraceptive choices and contraindications for women with the following diseases: breast cancer; endometrial, ovarian, and cervical cancer; deep venous thrombosis/pulmonary embolism; hypertension (past, moderate, or severe); diabetes (with and without vascular disease); liver disease; epilepsy; headache; and sickle cell disease.
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PMID:Chronic diseases and contraceptive use. 1229 56

This report summarizes a meeting of the IPPF International Medical Advisory Panel (IMAP) held in November, 1986, at which information on steroidal oral contraception (OC), Acquired Immunodeficiency Syndrome (AIDS), and female sterility were discussed. Regarding the multiphasic OC now in use, the benefits to health and well-being outweigh the possible side-effects and infrequent complications. Use is associated with a lower incidence of pelvic inflammatory disease, 96-98% effective prevention of pregnancy, a protective effect against ovarian and endometrial cancer, and regulation of erratic menstrual cycles. Minor side effects include nausea, vomiting, dizziness, headache, fluid retention, and inter-menstrual spotting. Adverse effects are circulatory system disease, myocardial infarction, venous thromboembolism, elevated blood pressure, and liver disease. Data on possible carcinogenicity have been conflicting. For women over age 40 OCs should be prescribed with caution. IMAP also drew up recommendations to assist FPAs to play a more active role in controlling the spread of AIDS. An effective program of Information and Education is of primary importance, targeting family planning workers and clients, teachers, parents, and employers. Wide promotion of condom use is a priority. Studies in Africa have revealed a major epidemic of AIDS, with the major mode of transmission heterosexual. The only immediate practical step in prevention of spread is by changes in sexual behavior. The last topic discussed is that of sterility in African women. The naturally occurring level of infertility expected in all populations of women is 3%; high levels in Africa vary by region from 3-32%. These levels of sterility are acquired through infection with Neisseria gonorrheae and Chlamydia trachomatis. Silent infection of women with Chlamydia make treatment especially difficult.
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PMID:Statement on steroidal oral contraception. 1234 Sep 76

Tumors metastatic to the pituitary gland are an unusual complication of systemic cancer typically seen in elderly patients with diffuse malignant disease. Breast and lung are the commonest sites of the primary tumor, whereas diabetes insipidus is the most frequent symptom at presentation. Their rarity and usually indolent course, as well as the lack of specific clinical and radiological features, impede their differentiation from other more common sellar area lesions, particularly when history of malignancy is absent. Management of these patients may also be very difficult because the prognosis depends on the course of the primary neoplasm. A 68-yr-old man, with no history of malignancy, presented with recent onset of hypopituitarism, mild diabetes insipidus, headaches, left oculomotor nerve palsy, and progressive bilateral deterioration of visual acuity and visual fields. Magnetic resonance imaging revealed a large sellar mass compressing the optic chiasm and invading the left cavernous sinus, whereas a prolactin elevation at 438.6 ng/ml (19.73 nmol/liter) was noted. Decompression of the sellar region was attempted, and pathology disclosed a metastatic hepatocellular carcinoma. On postoperative investigation, primary liver tumor was identified and confirmed by biopsy. The patient improved transiently but died 3 months after diagnosis because of deterioration of the liver disease. The relevant literature is reviewed in light of this unusual case, illustrating the problems in the diagnosis and management of patients with metastasis to the pituitary.
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PMID:Tumors metastatic to the pituitary gland: case report and literature review. 1476 64


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