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OBJECTIVE: To identify longitudinal variables related to children's body mass index (BMI) (kg/m(2)) at age 8 y. DESIGN: A longitudinal design, with nine interviews per child from ages 2 to 8 y. SUBJECTS: In all, 70 white children (37 males, 33 females) who were continuous participants since infancy in the longitudinal study. Families were primarily middle and upper socioeconomic status. MEASUREMENTS: At each interview, children's height and weight were measured, and mothers provided 3 days of the child's intake data (a 24-h recall and 2 days of food records). ANALYSES: Analyses used were means+/-s.d., correlations, repeated measures analysis of variance, and forward stepwise regression. BMI at each interview was calculated and age of adiposity rebound was determined. RESULTS: Children's BMI at 8 y was negatively predicted by age of adiposity rebound and positively predicted by their BMI at 2 y. Additionally, each model included one longitudinal dietary variable; mean protein and fat intakes recorded between 2 and 8 y were positive predictors of BMI at 8 y; mean carbohydrate intake over the same time period was negatively related to BMI at 8 y. R(2) values indicated that these three-variable models predicted 41-43% of the variability in BMI among children. BMI of 23% of the children exceeded the 85th CDC percentile. CONCLUSIONS: The results of this study show that factors in early life are associated with children's BMI at age 8 y.

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OBJECTIVE: To assess the short-term acceptability and functionality of the eZ.on condom compared with currently marketed latex (Gossamer) and polyurethane (Avanti) condoms. Method Healthy, sexually active volunteers aged 18-50 years, self-selected from among the UK population, were enrolled in a randomized cross-over trial. Participants were required to test six of each of three condom variants. Data were collected on structured questionnaires by means of postal and telephone contacts. Main outcome measures were breakage and slippage rates, and short-term user acceptability based on participants' ratings documented in end-of-study questionnaires. RESULTS: Forty-three couples entered the study, of whom 37 tested the condoms on 512 occasions. There was no statistically significant difference in the clinical breakage rate between eZ.on (3.7%) and the comparator condoms (3.5% for Gossamer and 2.9% for Avanti). Complete slippage rates were similar for eZ.on (2.4%) and Avanti (2.9%). Gossamer had the lowest slippage rate (1.2%), but this difference was not statistically significant. User acceptability was similar for the three condom types; however, there was a trend for more participants to express dissatisfaction with eZ.on, including difficulties with putting on the condom. CONCLUSIONS: No firm conclusions can be drawn from this pilot study, but our observations suggest that eZ.on may be an acceptable option for some couples unwilling or unable to use a latex condom.

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This study aimed to identify specific haemostatic changes that might account for previous observations of higher venous thromboembolic risk among users of combined oral contraceptives (COCs) containing desogestrel (DSG) than levonorgestrel (LNG). Sixty-three current users of monophasic 30 microg oestrogen COCs containing either LNG or DSG omitted one pill-free interval (PFI), switching immediately either to the opposite formulation for one cycle or continuing with the same pill. Venesection followed the initial PFI after one cycle (21 tablets) and two cycles (42 tablets) of continuous pill taking, and after the following PFI. Protein S was lower in users of DSG than LNG formulations after the first PFI (mean +/- SD, 0.67 +/- 0.09 vs 0.76 +/- 0.10, P < 0.001) and after one cycle (0.61 +/- 0.09 vs 0.76 +/- 0.09, P < 0.0001). Protein S decreased when switching from LNG to DSG pills (0.77 +/- 0.07-0.65 +/- 0.06, P < 0.0001), mirrored by an increase at switching from DSG to LNG formulations (0.61 +/- 0.08-0.73 +/- 0.10, P < 0.005). Mean protein S levels remained within the normal range. Three different markers of thrombin generation remained unaltered. Potential explanations for COC-related thrombotic events are 'acquired resistance to activated protein C' or inhibition of fibrinolysis. A potential role has been described for protein S deficiency in both. A further triggering factor is a probable prerequisite for actual thrombosis, but pill-takers whose levels of protein S were in the lowest percentiles may be at greatest risk.

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OBJECTIVE: To determine nutrient and food intakes of 72 white preschool children primarily from families of middle and upper socioeconomic status and to compare children's nutrient intakes with current recommendations. DESIGN: Six in-home interviews were conducted with mothers when children were 24 to 60 months old; at each time mothers provided 3 days of dietary information on the child. Children and mothers independently provided information on the child's favorite and least favorite foods at 42 and 54 months. SUBJECTS: Preschool children (24 to 60 months old) participating in a longitudinal study. STATISTICAL ANALYSES: Mean nutrient intakes were compared with the most recent Recommended Dietary Allowances/Adequate Intakes. Differences over time were tested with repeated-measures analysis of variance; gender differences were determined with t tests. Food frequencies (i.e., percentage of children consuming specific foods) were determined from dietary recalls and food records. Dietary variety was assessed with the Variety Index for Toddlers or the Variety Index for Children. RESULTS: Means were consistently less than the RDA/AI for energy, zinc, folate, and vitamins D and E. Energy, carbohydrate, and fat intakes were highest (P < or = .01) at 60 months. Boys consumed more (P < or = .05) protein (10 g), calcium (197 mg), magnesium (35 mg), and pantothenic acid (0.8 mg) at 60 months than did girls. Foods most commonly eaten were fruit drink, carbonated beverages, 2% milk, and french fries. The vegetable group consistently had the lowest variety scores; vegetables also dominated least favorite foods lists. APPLICATIONS: Parents need to be encouraged to include more sources of zinc, folate, vitamin E, and vitamin D in children's diets. Parents should also encourage their children to eat more vegetables, zinc- and folate-fortified cereals, lean red meats, seafood, vegetable oils, and low-fat milk.

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Prevention of osteoporosis is a major public health issue. Amenorrhoeic women have lower bone density than normally menstruating women, which is related to the duration of amenorrhoea and the severity of oestrogen deficiency. Bone mineral density (BMD) in amenorrhoeic women can be improved by oestrogen replacement in the form of the combined oral contraceptive pill (COCP), so increased BMD might be an important non-contraceptive benefit of the COCP in menstruating women. Previous studies have been variably reported, but have used different methodologies for measurement of BMD. We measured BMD using the DEXA technique in long term COCP users and compared this with menstruating women who had never used the COCP. No differences in bone density were found, suggesting that the COCP does not improve bone mass in menstruating women who are adequately oestrogenised by their own ovaries.

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OBJECTIVE: To assess the short term patient acceptability and aspects of use of the Lea's Shield(R). DESIGN: Observational study. Ten women were each invited to use the Lea's Shield on 10 occasions and to report their observations and experiences on structured questionnaires after each use. Thus, data on a maximum of 100 uses would become available for analysis. Answers were recorded on numerical scales and in descriptive terms. On conclusion of their study participation, patients and their partners were required to document their overall experience with the product. SETTING AND SUBJECTS: Women aged 18 to 40 years, self-selected from clients attending the Margaret Pyke Family Planning Centre. They had to be in a stable monogamous relationship, gynaecologically healthy, and willing to continue their use of oral contraceptives, IUD, or injectable. MAIN OUTCOME MEASURE: Ability to use the method without formal teaching, assessed after vaginal examination by the investigator at end of first visit. User satisfaction, as expressed in structured questionnaires and by premature withdrawal from trial. RESULTS: Ten women used Lea's Shield on a total of 70 occasions, of which 46(66 per cent) were associated with sexual intercourse. Five subjects withdrew from the trial prematurely on account of discomfort to either or both partners (four), and recurrent cystitis (one). At the enrolment visit, all but one woman inserted the device correctly without formal teaching, but there was considerable inter-patient variation in their responses concerning ease of insertion/removal, and comfort during subsequent uses. CONCLUSIONS: These preliminary observations suggest that the Lea's Shield may be acceptable to a highly select minority of women. However, much more research is required to permit a reliable assessment of its acceptability to the wider public. The product's potential for causing pain and discomfort also needs further exploration.

PIP: The cup-shaped, reusable, one-size Lea's Shield barrier contraceptive is commercially available in Canada and a few European countries. In advance of its introduction to the UK, a study was conducted to assess the short-term acceptability of this device. Enrolled were 10 clients 18-40 years of age from the Margaret Pyke Family Planning Center in London, England, who used the device a total of 70 times, 46 of which were associated with sexual intercourse. Nine women inserted the device correctly on the basis of reading the manufacturer's instructions. However, five women reported continued problems with insertion and seven found removal to be difficult, suggesting a need for formal instruction in use of the device. Ease of insertion, ease of removal, and female comfort scores fluctuated widely between both participants and episodes of use, with no trend of progressive improvement over time. Four women discontinued the trial because of discomfort to themselves and/or their partner and another women withdrew because of recurrent cystitis. These generally negative responses may impact on the product's use effectiveness.

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How to attract and retain hospital registered nurses (RNs) has become a recurring theme discussed by hospital boards, administrators and physicians in the U.S. This study seeks to provide current data on this situation. The exploratory research effort consisted of 13 depth interviews with physicians in a major metropolitan area in the southeastern U.S. and less formal discussions with six hospital nurse administrators. The formal research effort involved hand-delivering questionnaires to nurse administrators for distribution to nurses in six hospitals in the same region. The principle reasons nurses change jobs fall into four categories: salary or benefits, convenience, work schedule, and job-related stress. After one or more hospital moves the nurses become more satisfied. Hospital administrators should institute motivational and hospital commitment programs to improve retention/reduce turnover, e.g., work schedule rotation, work responsibility rotation, team approaches to health care and award/recognition programs.

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Early versions of a female condom were available in the 1920s and 1960s, but they were little used and soon forgotten. It took the arrival of AIDS, and the urgent need for a wider range of female-controlled barrier techniques, to rekindle scientific interest in this method. In the 1980s, three groups in Europe and the USA began development of new female condom designs, comprising 'Femidom (Reality)', the 'Bikini Condom', and 'Women's Choice'. Apart from differences in their physical design, Femidom differs from the others in that it is made of a polyurethane membrane, which has several advantages over latex. Of the three, Femidom is the most advanced in terms of development and clinical testing, and it is the only one to have reached the marketing stage. Laboratory studies and clinical trials suggest that its contraceptive efficacy is similar to that documented for the male condom, though a direct comparison is not possible because no comparative clinical trials have, as yet, been undertaken. Reported 'typical-use' pregnancy rates range from 12.4 to 22.2% at 6 months of use in the USA and Latin America, respectively, while a study in the UK observed a rate of 15% at 12 months. As with all barrier methods, most failures appear to be associated with poor compliance or incorrect use. 'Perfect-use' pregnancy rates were substantially lower, indicating that Femidom can be very effective, if used consistently and correctly. Evidence for Femidom's effectiveness to protect against transmission of sexual disease-causing organisms, including HIV, is still very limited and based largely on laboratory studies. Whilst, in theory, the condom should confer reliable protection, its efficacy in clinical use will depend upon correct and consistent use and upon the product's ability to maintain an effective physical barrier throughout penetrative intercourse. In this respect, the results of recent and ongoing clinical studies are expected with much interest. How valuable Femidom will prove to be, in terms of sexual health and contraception, will also depend largely on its long-term user-acceptability. As is generally the case with new methods, initial public interest in Femidom is expected to be high, as was documented in numerous surveys, and there undoubtedly exists a sub-group of women who view the product as their most appropriate contraceptive/sexually transmitted disease prevention option. However, more information on the product's acceptability, based on continuation rates, as is usually applied to other contraceptive techniques, is urgently needed to permit a more reliable assessment of Femidom's position among current methods. The arrival of a female condom represents a welcome addition to the range of female-controlled barrier contraceptives and, because of its numerous potential advantages over the male condom, may play an important role in the prevention of unwanted pregnancy and sexually transmitted diseases.

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Lysosome-associated membrane proteins (LAMPs) are transmembrane lysosomal glycoproteins which are detectable at the cell surface of lymphocytes in patients with scleroderma and systemic lupus erythematosus. While these proteins have been shown to mediate adhesion of tumor cells to vascular endothelial selectins, the function of LAMPs expressed at the cell surface of peripheral blood lymphocytes has not been previously examined. In the present study, the role of lamp2 (CD107b) in lymphocyte adhesion to vascular endothelium and the factors which influence in vitro cell surface expression of both lamp1 (CD107a) and lamp2 (CD107b) are examined. Freshly isolated PBMCs and unstimulated PBMCs in the culture had low levels of cell surface lamp1 and lamp2 expression which were significantly increased following PHA stimulation (P < 0.0001). A dose-dependent response to PHA and the effect of varying concentrations of serum were defined. Kinetic analysis revealed that the majority of the increase in both lamp1 and lamp2 occurred within the first 2 hr of incubation and that a subset of PBMCs maintained expression for at least 96 hr. Incubation of cells with colchicine and cycloheximide modified the cell surface expression of these proteins. Interleukins 2, 4, 6, and 8 had only a modest effect on the degree of cell surface lamp1 and lamp2 expression, though they did significantly affect the distribution of expression among different subtypes of lymphoid cells. Under the conditions utilized in this study, cell surface LAMP expression was confined primarily to CD56+ cells and to CD3+ cells. Functional analysis utilizing a fluorescence-based adhesion assay revealed that cell surface lamp2 mediates adhesion of PBMCs to vascular endothelium, possibly by interacting with endothelial selectins. LAMPs likely contribute to the migration of activated leukocytes to sites of inflammation in vivo.

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OBJECTIVE: To determine the relative contraceptive efficacy of a diaphragm used with spermicide as compared to one used without. STUDY DESIGN: Two hundred sixteen women entered the study between September 1985 and December 1990. Of these, 84 were randomly assigned to the diaphragm-only group and 80 to the diaphragm-with-spermicide group as their primary method of contraception. In addition, a spermicide-only group was planned originally to serve as a control group to assess the contribution to efficacy made by a spermicide alone. Thirty-nine women were randomly assigned to this group, and 13 selected themselves for it. All were followed for a maximum of 12 months. The primary outcome variable was accidental pregnancy. The statistical difference between the two diaphragm groups was analyzed. RESULTS: The 12-month "typical use" failure rates for the diaphragm-only group were 28.6 per 100 women and for the diaphragm-with-spermicide group, 21.2. The 12-month cumulative consistent-use failure rates were 19.3 per 100 women for the diaphragm-only group as compared to 12.3 per 100 women for users of a diaphragm with spermicide. CONCLUSION: Although the consistent use rates were not significantly different, this study had low statistical power and hence gives no support to the hypothesis that adjunctive spermicide use fails to improve the effectiveness of the diaphragm method, especially in view of the magnitude and direction of the difference observed. Unless a study with sufficient power proves that the use of a diaphragm alone is statistically as effective as use of a diaphragm with spermicide, use of a spermicide in conjunction with the diaphragm continues to be the appropriate clinical recommendation.

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The effect of limited and intermittent alcohol ingestion on the immune response in humans has not been extensively studied. The authors, in this study, evaluate peripheral blood mononuclear cell cytotoxicity before and after alcohol ingestion in a setting designed to mimic social drinking. Eleven healthy volunteers consumed two 12 oz (355 mL) cans of beer in 30 minutes while eating pizza. Five control individuals ingested non-alcoholic beverages. Natural killer and lymphokine-activated killer activity were determined for peripheral blood mononuclear cells obtained before and 30 minutes after alcohol ingestion. Interleukin 2-induced lymphokine-activated killer activity was significantly reduced in blood samples obtained after alcohol ingestion when compared with pre-alcohol samples (p < 0.01). Natural killer activity (unstimulated) was not affected by alcohol ingestion. The authors demonstrate that ingestion of a small amount of alcohol impairs the cytotoxic capacity of peripheral blood mononuclear cells. Alcohol in the context of social drinking may have deleterious effects on the immune system's ability to clear virus-infected cells or cells that have undergone neoplastic transformation, especially for individuals with pre-existing immunosuppression.

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Male breast cancer is a rare tumor consisting only 1% of all breast cancers. Although 90% of breast masses in men are malignant, delay in diagnosis often occurs with resultant advanced local or systemic disease common. The few clinical studies on male breast cancer suggest that the disease behaves similarly to female breast cancer. Management, therefore, should be similar to the management of female breast cancer. Stage I, II, and III disease require a multimodal approach with regional therapy, adjuvant chemotherapy, and hormonal therapy. Most male breast cancers are estrogen or progesterone receptor positive and responses to hormonal therapy are high. A trial of hormonal therapy is warranted in most patients with stage IV disease.

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In recent years, several new cervical sampling techniques have been introduced to try to improve the accuracy of the cervical smear. In the present study four such techniques were compared: the Aylesbury spatula, Rolon spatula, Cervex device and Aylesbury spatula used in conjunction with a Cytobrush. The total number of smears collected was 14,172, 80% of which were from women under age 35. Despite large differences between the techniques with regard to the presence of endocervical cells in smears, no differences were found in the detection of dysplasia. Endocervical cells were seen significantly more often in dysplastic smears than in negative smears. There was little difference in the rate of unsatisfactory samples. It appears that in a young population, the instruments used for cervical sampling are not likely to significantly influence the detection of dysplasia if skilled personnel take the smears.

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OBJECTIVE: To evaluate blood pressure changes in the pill-free interval and from baseline among women taking four different low-dose monophasic oral contraceptives. DESIGN: 131 women were randomized to four different oral contraceptives. Pressures were obtained at baseline, at the end of treatment cycles and at the end of the 7 pill-free days, during 6 months of treatment. Pressures were obtained at 4 and 8 weeks after discontinuation. Group 1 received norethisterone acetate 1000 micrograms, group 2 received levonorgestrel 150 micrograms, group 3 received desogestrel 150 micrograms, and group 4 received gestodene 75 micrograms, all combined with ethinyloestradiol 30 micrograms. RESULTS: All four groups showed an increase in pressure during treatment, with return to baseline levels four weeks after treatment. At the end of the pill-free interval, the readings did not differ significantly from on treatment except for women in Group 4, who experienced an increase in diastolic pressure. CONCLUSIONS: Use of the four oral contraceptives was associated with a small increase in systolic and diastolic pressure. Whatever mechanism causes the increase is not entirely reversible by 7 days without treatment.

PIP: The authors sought to evaluate blood pressure changes during the pill- free interval and from baseline among women taking 4 different low-dose monophasic oral contraceptives (OCs). 131 women were randomized to 4 different OC groups; pressures were obtained at baseline, at the end of treatment cycles, and at the end of the 7 pill-free days over 6 months of treatment. Pressures were obtained at 4 and 8 weeks after discontinuation. Group 1 received norethisterone acetate 1000 mcg, group 2 received levonorgestrel 150 mcg, group 3 received desogestrel 150 mcg, and group 4 received gestodene 75 mcg, all combined with ethinyl estradiol 30 mcg. All 4 groups showed an increase in pressure during treatment, with return to baseline levels 4 weeks after treatment. At the end of the pill-free interval, the readings did not differ significantly from those during treatment, except for women in group 4 who experienced an increase in diastolic pressure. Use of the 4 OCs was associated with a small increase in systolic and diastolic pressure. Whatever mechanism causes the increase is not entirely reversible after 7 days without treatment.

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This is the first report of vaginal erythematous areas associated with the use of a levonorgestrel-releasing contraceptive ring. Of 139 female subjects, 48 developed lesions of varying size and degrees of redness. Sixteen of these have undergone serial colposcopy and thirteen have also had biopsy examinations, which revealed acetowhite areas and, histologically, chronic inflammation with widely dilated vessels and frequently with thinning of the epithelium. The cause remains uncertain but hormonal, chemical and physical effects might all have a role.

PIP: Between August 1990 and May 1992 in London, England, researchers enrolled 139 women aged 18-40 years in a clinical trial of a levonorgestrel-releasing contraceptive vaginal ring. All the women had a negative cervical smear. They underwent a thorough initial gynecological examination (i.e., visualization of entire vaginal area and the cervix). Clinicians reexamined them at 6 weeks, 3 months, and a 3-month intervals thereafter. 48 women (34.5%) had erythematous lesions on at least 1 occasion. They were at the vaginal vault, and sometimes on the cervix, where the vaginal ring usually lies. Most women had no symptoms. All the women were unaware that they had lesions. The lesions disappeared spontaneously in 16 women (33.3%) with the vaginal ring still in place. During colposcopy with vaginal ring in place, a clinician took vaginal/cervical swabs in 16 women to test for common sexually transmitted diseases (STDs). All but 1 woman tested negative for STDs. The erythematous lesion responded to 5% acetic acid in 14 of the 16 women, indicating an abnormality. Clinicians took biopsies in 13 of these women and did repeat colposcopy at 3-4 week intervals. Histological examination showed congestion with considerable dilated vessels, chronic inflammatory changes of varying severity, and frequent intracellular edema of the squamous mucosa. The mucosa was abnormally thin in some women, while in others it was entirely missing. Changes in 4 women were caused by HPV. 1 woman had grade 1 cervical intraepithelial neoplasia (CIN). The researchers could not conclude that the HPV-induced changes or CIN occurred during vaginal use because the women were not colposcoped before entry into the study. All of the study's findings prompted the ethics committee to halt the study in May 1992. In July 1992, the manufacturer shut down the entire UK study, stating that accumulation of enough data on efficacy and acceptability had been achieved. Further research is needed to determine what caused the lesions.

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OBJECTIVE: To assess the relative efficacy of three disposable plastic instruments in the retrieval of 'missing' IUCD threads. DESIGN: A prospective randomised comparative single centre study. SETTING: Family Planning Clinic in London, UK. SUBJECTS: 217 of 350 IUCD users referred to the research team with 'missing' IUCD threads entered the study. INTERVENTION: All women initially underwent exploration of the endocervical canal with Spencer Wells forceps. When this procedure did not retrieve the threads, the patients were entered into the study. A maximum of two randomly chosen plastic IUCD thread retrievers were then used in any one patient to explore the uterine cavity and capture the 'missing' threads. The order in which the two retrievers were employed was also determined at random. Four separate entries into the uterine cavity were permitted with each instrument, the endocervical canal being explored with Spencer Wells forceps after each retraction of the instrument to identify the possible descent of the threads. MAIN OUTCOME MEASURES: Threads brought down beyond the external cervical os, or threads brought to within the endocervical canal and then grasped by Spencer Wells forceps. RESULTS: In approximately 40% of all patients, the threads were retrieved with Spencer Wells forceps alone and a further 40% with the disposable plastic retrievers. About 5% had no retrievable threads, and only 2.5% of the referred patients required general anaesthesia for removal of their IUCD. The analysis of the comparative trial was confined to the 197 patients with retrievable threads which could not be brought below the external os with Spencer Wells forceps. The first plastic retriever used was successful in 50% of patients. The Retrievette (59%) and the Emmett (53%) performed better than the Mi-Mark Helix (37%) in this study. The difference was statistically significant (P = 0.03) and the 95% confidence interval for the difference of the Mi-Mark Helix from the other two retrievers was 4% to 33%. This retrieval rate for the Mi-Mark Helix was much worse than in previously reported studies, though one doctor did have a better success rate with this retriever. The success rates, using a second plastic retriever randomly chosen from the two not used in the first attempt, were almost identical to those observed with the first retrievers: 63%, 56% and 36%. The success rate did not appear to be influenced by the length of thread, day of cycle, device type or parity. The success of the second retriever tried did not seem to be influenced by the retriever that had failed previously. CONCLUSIONS: Based on our experience, the initial exploration of the endocervical canal with Spencer Wells forceps is invaluable. If this simple manoeuvre fails to retrieve the 'missing' threads, either the Retrievette or the Emmett thread retrievers are useful tools in general practice or in the family planning clinic setting.

PIP: A group of 217 women of 350 IUD users with missing IUD threads were enrolled in the investigation. The final sample of the comparative trial involved 197 patients with retrievable threads which could not be brought below the external os with Spencer Wells forceps. 143 (73%) used Gravigard; 19 (10%) the Mini-Gravigard; 21 (10%) other copper-bearing devices (Multiload, Mini-Multiload, Novagard, Ortho-Gyne-T); and 12 (6%) the Lippes Loop, while in the remaining 2 (1%) the type of device was not recorded. The endocervical canal of all women was explored with a Spencer Wells forceps, and 2 randomly chosen plastic IUD thread retrievers were used to capture the missing threads. The threads were retrieved with Spencer Wells forceps alone in about 40% of patients, and with the disposable plastic retrievers in another 40%. About 5% had not retrievable threads, and only 2-5% of the patients required general anesthesia for IUD removal. The 1st plastic retriever succeeded in removing the device in 50% of patients. The Retrievette (59%) and the Emmett (53%) performed better than the Mi-Mark Helix (37%) yielding a statistically significant difference (P=0.03). The 95% confidence interval for the difference of the Mi-Mark Helix from the other 2 retrievers was 4% to 33%. The success rates of a 2nd plastic retriever randomly chosen from 2 retrievers not used in the 1st attempt were 63%, 56%, and 36%, analogous to rates with the 1st plastic retrievers. 33 of the 47 women in whom the plastic retrievers failed, had the threads/IUDS retrieved with a metal hook, preferably with the Birnberg hook. The initial exploration of the endocervical canal with Spencer Wells forceps proved valuable, and if it fails either the Retrievette or the Emmett thread retrievers are effective in general practice or in family planning clinics.

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Nurses' perceptions of their jobs are influenced by information provided by others, who often are labeled role models. This study suggests that role models are not limited to co-workers and preceptors as implied in previous research. Nurses' evaluations of job satisfaction, job attitudes, and the appeal of other professions is influenced by information provided by co-workers, supervisors, preceptors, family, friends, patients, and physicians. Although all employees appear to be influenced to some degree by information from others, new employees appear most prone to use information from others to shape feelings, attitudes, and job behavior.

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OBJECTIVE: To investigate the changes in haemostasis in the three months immediately after stopping the combined contraceptive pill. DESIGN: Prospective randomised study. SETTING: Family planning centre in London. SUBJECTS: 24 women aged 35-45 investigated before, during, and after six months' use of combined oral contraceptives containing 30 micrograms ethinyl oestradiol together with the progestogens desogestrel or gestodene. MAIN OUTCOME MEASURES AND RESULTS: Blood samples were taken immediately before and after six months of oral contraceptive use and one, two, four, six, eight, and 12 weeks after the pill had been stopped. During the six months of oral contraceptive use the plasma concentration of factor X and fibrinogen increased and that of antithrombin III decreased. Between two and six weeks after stopping the pill a rebound phenomenon occurred with plasma concentrations of antithrombin III increasing (mean change from baseline at two weeks 0.06 IU/l and at six weeks 0.10 IU/l) and fibrinogen decreasing (0.26 g/l change at two weeks and 0.40 g/l at six weeks). Factor X concentrations fell gradually and the values at eight weeks were not significantly different from those found before the combined pill was started. CONCLUSION: The combined pill should be stopped at least four weeks before major surgery, which carries the risk of postoperative thrombosis, to allow the potentially prothrombotic haemostatic changes that occur during its use to be corrected.

PIP: This study investigated the changes in hemostasis in the 3 months immediately after cessation of the combined oral contraceptive (OC). This prospective, randomized study has based at a family planning center in London and 24 women, ages 35-45, were investigated before, during, and after 6 months use of these combined OCs containing 30 mcg ethinyl estradiol along with the progestogens desogestrel or gestodene. Blood samples were taken immediately before and after 6 months of OC use and 1,2,4,6,8, and 12 weeks after the pill had been stopped. During the 6 months of OC use, the plasma concentration of factor X and fibrinogen increased and that of antithrombin III decreased. Between 2-6 weeks after stopping the pill, a rebound phenomenon occurred with plasma concentrations of antithrombin III increasing (mean change from baseline at 2 weeks 0.06 IU/l and at 6 weeks 0.10 IU/l) and fibrinogen decreasing (0.26 g/l change at 2 weeks and 0.40 g/l at 6 weeks). Factor X concentrations fell gradually and the values at 8 weeks were not significantly different from those found before the combined pill was begun. The combined OC should be stopped at least 4 weeks prior to major surgery (which carries the risk of postoperative thrombosis) in order to allow the potentially prothrombotic hemostatic changes that occur during its use to reverse themselves.

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Forty women aged 35-45 years were investigated to determine changes in haemostasis, lipids and lipoproteins whilst taking combined contraceptive pills containing the new third generation progestogens, desogestrel and gestodene. There was no statistically significant difference between the two preparations in any of the parameters studied. Women taking the combined pill showed increases in fibrinogen and factor X and a reduction in antithrombin III when compared with their control values. There were also small but significant increases in triglycerides and triglyceride-rich lipoproteins. Total high density lipoprotein cholesterol (HDL), high density lipoprotein-2 cholesterol (HDL2), high density lipoprotein-3 cholesterol (HDL3) and apolipoprotein A-1 were all increased at some stages of the treatment cycle, whereas low density lipoprotein cholesterol (LDL) showed a reduction in the first cycle of treatment. The changes in lipids and lipoproteins would not appear to increase the risk of cardiovascular disease, however the effects of the increase in the pro-coagulant factors are uncertain.

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