Continuation Of Use Research Articles

How to become Proficient with Insertion of Frameless IUDS?

Millions of women start using an IUD because doctors tell them that an IUDs are safe, effective and long-lasting. Unlike the pill, vaginal ring or the contraceptive patch, IUDs are fit and forget methods. In many women, this statement is true. Many women are happy with their IUD and don’t complain. However, about 50 to 60% have their IUD removed long before the usual 5-year lifespan of the IUD. Early IUD/IUS removal is frequent due to side effects, mostly bleeding and pain, because the uterus, like any organ, cannot tolerate a foreign body that is cumbersome for long periods of time. Young women are specifically vulnerable to side effects. They are also the most vulnerable to unintended pregnancy and this is precisely why many organizations and institutions advocate IUDs in order not to become pregnant unintendedly. However, early IUD discontinuation undermines their potential to prevent unintended pregnancy and has numerous drawbacks as many women switch to other, less effective methods or to no method at all. Continuation over time is the primary determinant of effectiveness for IUDs. As researchers, active in the field of intrauterine contraception since several decades, we have tried to maximize continuation of use by designing non-hormonal and hormonal intrauterine devices that accommodate to every anatomically normal uterus. Frameless devices are small; they are flexible as they have no frame; they provide highly effective and well tolerated contraception simply because they fit. Embedment, a frequent complication of current, framed IUDs, is not possible if the frameless IUD as the uterine contractions have no impact on the flexible body and can therefore not be forced in the uterine wall. However, frameless IUDs need to be attached to the uterus to prevent expulsion. Precisely how correct anchoring is accomplished, including the pitfalls, and how to check the correct position of the anchored IUD is the subject of this paper.

Femilis(®) 60 Levonorgestrel-Releasing Intrauterine System-A Review of 10 Years of Clinical Experience.

OBJECTIVEThe aim of this study was to update the clinical experience with the Femilis® 60 levonorgestrel-releasing intrauterine system (LNG-IUS), now up to 10 years in parous and nulliparous women, particularly with regard to ease and safety of insertion, contraceptive performance, retention, acceptability, continuation of use, impact on menstrual blood loss (MBL), and duration of action.STUDY DESIGNUsing the Femilis® 60 LNG-IUS releasing 20 µg of levonorgestrel/day, the following studies were conducted: an open, prospective noncomparative contraceptive study, an MBL study, a perimenopausal study, a study for the treatment of endometrial hyperplasia, and early cancer of the uterus, a residue study.RESULTSA total of 599 Femilis LNG-IUS were inserted in various clinical trials, the majority for contraceptive purposes. The total exposure in the first and second contraceptive studies, covering 558 parous and nulliparous women, was 32,717 woman-months. Femilis has high contraceptive effectiveness as only one pregnancy occurred. Expulsion of the LNG-IUS was rare with only two total and no partial expulsions (stem protruding through the cervical canal) occurred. Femilis was well tolerated, with continuation rates remaining high. Several MBL studies were conducted, totaling 80 heavy and normal menstrual bleeders, using the pictorial bleeding assessment chart method or the quantitative alkaline hematin technique. Virtually all women responded well with strongly reduced menstrual bleeding. Amenorrhea rates were high, up to 80% after three months, and ferritin levels simultaneously increased significantly. The Femilis LNG-IUS was tested in 104 symptomatic perimenopausal women for seamless transition to and through menopause, adding estrogen therapy when required. Patient tolerability appeared high as >80% requested a second and a third LNG-IUS. Twenty women presenting with nonatypical and atypical hyperplasia and one woman presenting with early endometrial carcinoma were treated with Femilis LNG-IUS. All histology specimens showed full regression, and patients remained in remission without signs of hyperplasia or cancer at yearly and ongoing follow-up examinations up to 10 years. Residual content of LNG was measured in 37 women having the Femilis LNG-IUS for up to 10 years. In 10 of the 102 women who had the Femilis 60 in situ for 10 years between 20% and 30% of the original 60 mg was recovered confirming the long duration of action of the Femilis 60 LNG-IUS.CONCLUSIONThese studies suggest that the Femilis 60 LNG-IUS releasing 20 µg of LNG/day is an effective, well-tolerated, and well-retained contraceptive both in parous and in nulliparous women. The design of the LNG-IUS, with flexible transverse arm(s) length of 28 mm, allows for a simplification of the insertion technique and training requirements facilitating the use by nonspecialist providers in either developed or developing countries. For nulliparous women, additional evaluation of devices with a 24 mm transverse arm(s), as it relates to tolerability, retention, and continuation of use, still needs to be undertaken.

Linking HIV & family planning services to improve dual methods of contraception among women infected with HIV in Mumbai, Maharashtra, India.

Background & objectives:Preventing unintended pregnancies among people living with HIV (PLHIV) is one of the strategies of WHO for preventing parent-to-child transmission (PPTCT). Given the limitation of only condom use, the objective of this study was to improve use of dual contraceptive methods among HIV infected women.Methods:An experimental study among HIV positive women was conducted at two tertiary care level hospitals in Mumbai. Linking HIV with family planning services was the focus of intervention at one site and standard level of care was maintained at the control site. At each site, 150 HIV+ve women attending counselling and testing centres, who did not intend to get pregnant in the next one year and were eligible to use dual methods, were enrolled and followed up to one year.Results:At the end of one year, 60 per cent women in the intervention group reached Family Planning Centres compared to eight per cent in the control group. There was three times more acceptance and continuation of use of dual methods along with increase in consistent use of condoms and less number of unplanned pregnancies in the intervention group than the control group.Interpretation & conclusions:The study findings demonstrate that linking HIV and family planning services may facilitate the uptake of dual methods of contraception without reducing consistent condom use among HIV infected women. The PPTCT programmes need to focus on the component of Prong 2 of PPTCT which aims to prevent unintended pregnancies among HIV positive women.

Postpartum and Post‐Abortion Contraception: From Research to Programs

Contraception following delivery or an induced abortion reduces the risk of an early unintended pregnancy and its associated adverse health consequences. Unmet need for contraception during the postpartum period and contraceptive counseling and services following abortion have been the focus of efforts for the last several decades. This article provides an introduction to the more focused contributions that follow in this special issue. We discuss the validity and measurement of the concept of unmet need for family planning during the postpartum period. We then present key findings on postpartum contraceptive protection, use dynamics, and method mix, followed by an assessment of interventions to improve postpartum family planning. The evidence on postabortion contraceptive uptake and continuation of use remains thin, although encouraging results are noted for implementation of comprehensive abortion care and for the impact of post-abortion contraceptive counseling and services. Drawing on these studies, we outline policy and program implications for improving postpartum and post-abortion contraceptive use.

Unmet need for family planning: past achievements and remaining challenges.

Globally, the percentage of married fecund women with unmet need-who use no contraceptive method despite wishing to avoid childbearing for two years or more-fell from 22% in 1970 to 12% in 2010. Substantial health, economic and environmental, and demographic benefits have resulted from this change. Promotion of contraception is one of the great success stories of the past 50 years. However, unmet need remains high in sub-Saharan Africa, at 25%, because of insufficient knowledge of methods, social opposition, and fear of health effects. In addition to obvious factors such as political commitment and adequate funding, success in this region will require improvement in continuation of use and the range of available methods.

Adolescent Intrauterine Contraception: IUD Size and Comfort during Insertion are Essential (IUD use in adolescents)

Background: Unintended pregnancies and induced abortion in adolescent women are soaring. The use of longacting reversible contraceptives (LARC), particularly the intrauterine device (IUD) and implant, are advocated as they don’t require daily adherence. Objective: To provide expert advice on the use of IUDs in young nulliparous and adolescent women in order to maximize continuation of use of the method. Results: Clinical studies suggest that high continuation of use of an IUD can be achieved by giving attention to the geometric relationship between the IUD and the host uterine cavity. Frameless IUDs virtually eliminate pain complaints and embedment caused by too large IUDs resulting often in early discontinuation. Conclusion: Appropriate intrauterine devices could enhance continuation of use and result in fewer unintended pregnancies and induced abortions. It is imperative to attach importance to comfort during device insertion to motivate young women to use the method.

Plac Nowy Targ we Wrocławiu w świetle badań wykopaliskowych w latach 2010–2012

Nowy Targ square is located in the eastern part of the Old Town in Wroclaw, in an area of long and varied history, bursting with rich relics of the past deposited in the form of cultural layers. A necessity of undertaking there excavations in 2010 resulted from the commencement of investment activities related to the construction of an underground car park. The location and size of the trench were determined by the construction project. The excavations covered an area of nearly 40 ares in the southern part of the square, obtaining previously unreachable scientific possibilities. The excavations were carried out in accordance with the principles of stratigraphic methods. It was assumed that the order of formation of excavated features was diachronic, and by their registration a modified and adapted to the nature of the site Edward Harris’s system was applied. To this method was subject the documentation scheme. The results illustrated several events or time breakthrough trends for the area in question, fixed by relevant material sources. We identify them as phases of land use, being aware of the arbitrariness of the term. A simplification introduced in this way will help to organize the description of the history of use of the area in question. The area is located on the left bank terrace of the Odra River, formed in this place by riverine sands covered with a layer of light brown alluvial soil with a thickness of 30 cm. The soil survived only in small portions and its top parts were mixed in the initial stage of land use. The level of its top was between 115.35–115.60 m above sea level, showing a slight inclination from the west to the east. Eight successive phases of use of this place (I–VIII) were determined. Phase I represents the beginnings of settlement on the left bank of the Odra River. Features related to it are mostly pits of indeterminate function – perhaps parts of semi-sunken buildings and postsholes – some with remains of wattle or log constructions. This phase is dated to the 11th–12th century. Phase II is a continuation of the development of the left bank settlement. In a related layer features and artefacts were recorded, which can be dated to the second half of the 12th and early 13th century. Phase III (proto-urban) is a stage in the development of settlement characterized by a considerable intensification of exploitation of land, reflected by the richness of a complex stratigraphic sequence. In the layer corresponding to this phase numerous pottery fragments and various metal items were found. The source material as well as the dendrochronological dates allow to date the phase to the 13th century – from its first decades to about the 1260s–1270s. Phase IV – associated with the liquidation of the built-up area and demarcation of Nowy Targ square, probably along with a regular grid of streets surrounding it – is dated to the second half of the 13th century. Phase V reflects an early stage of Nowy Targ square functioning, in layers associated with it wooden troughs and pipes for transport of water were found connected with wells built of laths. This phase is dated to the second half of the 13th and early 14th century. Phase VI represents the continuation of use of the market square in the 14th century. The corresponding layers contained remains of wooden structures (post, wattle constructions). Phase VII determines the period of the square use at the end of the 14th century. Remains of this stage are fragments of pottery, leather, animal bones, metal artefacts as well as relics of brick and wooden structures. Phase VIII corresponds to the period of the square use in Post-medieval period, between the 16th and 18th centuries. In layers associated with it relics of a Baroque fountain were recorded. This paper is a preliminary presentation of the results of excavations at Nowy Targ square in Wroclaw. Further analysis will allow to create clear conclusions concerning the beginnings of settlement and spatial changes in the area in question.

Predictors of alcohol and tobacco use prior to and during pregnancy in the US: the role of maternal stressors.

The purpose of the study was to understand the association between stressful life events prior to conception (PSLEs) and women's alcohol and tobacco use prior to and during pregnancy, and the continuation of such use through pregnancy. Data were from the Early Childhood Longitudinal Study-Birth Cohort (n = 9,350). Data were collected in 2001. Exposure to PSLEs was defined by indications of death of a parent, spouse, or previous live born child, divorce or marital separation, or fertility problems prior to conception. Survey data determined alcohol and tobacco usage during the 3months prior to and in the final 3months of pregnancy. Weighted regressions estimated the effect of PSLEs on alcohol and tobacco use at each time point and on the continuation of use, adjusting for confounders. Experiencing any PSLE increased the odds of tobacco use prior to (adjusted odds ratio [AOR] 1.52, 95% confidence interval (CI) 1.23-1.87) and during pregnancy (AOR 1.57, 95% CI 1.19-2.07). Women exposed to PSLEs smoked nearly five additional packs of cigarettes in the 3months prior to pregnancy (97 cigarettes, p = 0.011) and consumed 0.31 additional alcoholic drinks during the last 3months of pregnancy than unexposed women. PSLEs are associated with tobacco use before pregnancy and alcohol and tobacco use during pregnancy. Alcohol and tobacco screening and cessation services should be implemented prior to and during pregnancy, especially for women who have experienced PSLEs.

A prospective study of marijuana use change and cessation among adolescents

BackgroundWith marijuana use increasing among American adolescents, better understanding of the factors associated with decreasing use and quitting can help inform cessation efforts. This study evaluates a range of neighborhood, family, peer network, and individual factors as predictors of marijuana use, change, and non-use over one year, and cessation over six years. MethodsData come from adolescents in Waves I and II of the National Longitudinal Study of Adolescent Health (N=458, one-year sample), or Waves I and III (N=358, six-year sample), and reported using marijuana at least four times in the past month at Wave I. ResultsEighteen percent of adolescents stopped using marijuana after six years. Results suggest neighborhood context affects overall use level, whereas neighborhood context and friends were critical to cessation vs. continuation of use. Decrease in use were more likely among adolescents in disadvantaged or less cohesive neighborhoods, or who moved between waves. Non-use after one year was more likely among adolescents who did not move, had fewer marijuana-using friends, and did not exclusively have outside-of-school friends. Cessation at six years was more likely among adolescents in less disadvantaged and more cohesive neighborhoods, and for those with within-school friends. ConclusionsResults highlight the importance of both objective and subjective neighborhood characteristics, as well as peer networks, on adolescent marijuana use. Factors associated with decreases in use appear distinct from those that predict quitting, suggesting that continuation vs. cessation is linked to peers as well as neighborhood context. Relocated and isolated individuals may face challenges with cessation.

Use of frameless intrauterine devices and systems in young nulliparous and adolescent women: results of a multicenter study.

BackgroundThe purpose of this study was to provide additional data on the experience with frameless copper and levonorgestrel (LNG) intrauterine devices (IUDs) in nulliparous and adolescent women.MethodsNulliparous and adolescent women, 25 years of age or younger, using the frameless copper IUD or the frameless LNG-releasing intrauterine system (IUS), were selected from previous studies and a current multicenter post-marketing study with the frameless copper IUD. The small copper-releasing GyneFix® 200 IUD consists of four copper cylinders, each 5 mm long and only 2.2 mm wide. The frameless FibroPlant® LNG-IUS consists of a fibrous delivery system releasing the hormone levonorgestrel (LNG-IUS). The main features of these intrauterine contraceptives are that they are frameless, flexible, and anchored to the fundus of the uterus.ResultsOne hundred and fifty-four nulliparous and adolescent women participated in the combined study. One pregnancy occurred with the GyneFix 200 IUD after unnoticed early expulsion of the device (cumulative pregnancy rate 1.1 at one year). Two further expulsions were reported, one with the GyneFix 200 IUD and the other with the FibroPlant LNG-IUS. The cumulative expulsion rate at one year was 1.1 with the copper IUD and 2.2 with the LNG-IUS. The total discontinuation rate at one year was low (3.3 and 4.3 with the copper IUD and LNG-IUS, respectively) and resulted in a high rate of continuation of use at one year (96.7 with the copper IUD and 95.7 with the LNG-IUS, respectively). Continuation rates for both frameless copper IUD and frameless LNG-IUS remained high at 3 years (>90%). There were no cases of perforations or pelvic inflammatory disease reported during or following insertion.ConclusionThis report confirms earlier studies with frameless devices and suggests that the high user continuation rate is attributable to the optimal relationship between the IUD and the uterine cavity. IUD studies have shown that an IUD that does not fit well will often lead to side effects (ie, pain, bleeding, embedment, expulsion) and subsequent removal of the IUD. Early discontinuation is not the aim of long-acting reversible contraception.

Using a Group-Based Trajectory Approach to Assess Risk and Protective Factors of Marijuana Use

Marijuana is the most widely used illegal substance in the world, and persistent and frequent use during adolescence has been associated with precocious transitions and deleterious consequences in adulthood. This study used a group-based trajectory approach to analyze panel data collected from 1,725 youth participating in the National Youth Study to describe pathways of marijuana use and to explore protective factors that may reduce the continuation of use. A trajectory approach allowed us to operationalize risk based on prior within-person patterns of self-reported marijuana use. Three trajectory groups of marijuana users were identified: chronic users (17%), rising users (40%), and abstainers (43%). Our results show that some protective factors are significantly associated with decreases in marijuana use for each trajectory group (e.g., parent disapproval and non-using peer associations), but others are significantly associated with decreases in marijuana for a particular trajectory group and not others (e.g., school attachment for chronic marijuana users). The implications of our findings are discussed for the risk and protective factor framework, as well as their importance in a society where opinions of marijuana are currently changing.

Architectural foundation No. 5 of the Northern Wei Palace found at Han-Wei Luoyang City, Henan

Abstract In 2010 through 2011, the Sino-Japanese Joint Archaeological Team organized by the Institute of Archaeology, Chinese Academy of Social Sciences and Nara National Research Institute for Cultural Properties (Nabunken), Japan, recovered the foundation of the southwestern corner structure (numbered Architectural foundation No. 5) of the Northern Wei Dynasty Palace City to the west of Changhe Gate. This excavation not only found the exact location of the southwestern corner of the Northern Wei Dynasty Palace City and the orientations, scales and structures of the palace wall and drainage system but also made us more clearly understand the first building date and the continuation of use of this section of the palace wall. This discovery is significantly meaningful for the researches on the layout of the Northern Wei Luoyang City and the evolution of the planning of the capital cities in ancient China.

Precision intrauterine contraception may significantly increase continuation of use: a review of long-term clinical experience with frameless copper-releasing intrauterine contraception devices

ObjectiveThe purpose of this paper is to review the experience with the frameless, anchored, GyneFix copper-releasing intrauterine contraceptive devices (IUCDs/IUDs) (Contrel Europe, Belgium), and to demonstrate their high acceptability and low rate of discontinuation of use, which could contribute to current efforts that aim to reduce radically the high number of unintended pregnancies and induced abortions, particularly in young women.Materials and methodsThis paper is based on studies that examined the differences in uterine volume and cavity size, related to age and parity, and on original clinical research data and practical experience with frameless copper IUDs, as well as on literature data on the IUD–endometrial cavity relationship of conventional IUDs, with special reference to side effects and user discontinuation.ResultsThe mean transverse diameter in nulliparous and parous women is significantly less than the length of the transverse arm of the TCu380A IUD (ParaGard, Duramed, NY, USA) or the levonorgestrel intrauterine system (Mirena, Bayer, Germany). Small, frameless, flexible, and unidimensional copper IUDs appear to be well tolerated, with less impact on menstrual bleeding, resulting in low discontinuation rates when compared with standard-size conventional IUDs, which often result in increased expulsion rates, complaints of pain and erratic or increased menstrual bleeding, and subsequent high rates of discontinuation, particularly in young women.ConclusionThe unidimensional GyneFix IUDs fit the majority of uterine cavities. An IUD that fits is likely to result in increased tolerance and continued use of the method. As this would appeal to women, the logical result should be greater use of the method and fewer unintended pregnancies and induced abortions. Recommending the standard TCu380A (ParaGard) IUD or the Mirena levonorgestrel intrauterine system, primarily developed for use in parous women, for general use in nulliparous and adolescent women should be done with caution in the light of current scientific evidence, except if 3-D sonography indicates that the uterine cavity is sufficiently large.

Potential health benefits of continuous LNG-IUS combined with parenteral ERT for seamless menopausal transition and beyond – a commentary based on clinical experience

Objective: To comment on the acceptability and potential health benefits of the continuous use of the levonorgestrel-releasing intrauterine system (LNG-IUS), combined with estrogen substitution, for seamless transition through the menopause, in women with climacteric symptoms.Design and method: Evaluation of the recent hormone replacement therapy literature and the acceptability of the combined parenteral estrogen and intrauterine LNG-IUS regimen in a group of approximately 100 women, above 48 years of age, using LNG-IUS for contraception, who developed climacteric symptoms requiring estrogen substitution. Main outcome measures: acceptability and continued use of the method for the treatment of climacteric symptoms and for prevention.Results: The combination of intrauterine progestogen delivery to suppress the endometrium, in combination with systemic estrogen, is highly acceptable resulting in a high continuation of use due to the absence of side effects and erratic bleeding in the large majority of women.Conclusion: The study suggests that parenteral estrogen replacement therapy combined with intrauterine progestogen delivery for endometrial suppression in the perimenopause is highly practical and beneficial, providing enhanced quality of life. There are strong arguments to categorize the regimen as probably the most effective, safest and best accepted route resulting in high patient compliance as well as potentially providing maximal benefits for peri- and postmenopausal women.

Is psychotic disorder associated with increased levels of craving for cannabis? An Experience Sampling study

Although cannabis use among individuals with psychotic disorder is considerable, little is known about patterns of use and factors contributing to continuation of use. Therefore, we investigated craving in relation to cannabis use in patients with psychotic disorder and healthy controls. The study included 58 patients with non-affective psychotic disorder and 63 healthy controls; all were frequent cannabis users. Craving was assessed with the Obsessive Compulsive Drug Use Scale (OCDUS) for cannabis, as well as in daily life using the Experience Sampling Method (ESM). Patients scored higher on the OCDUS (B = 1.18, P = 0.022), but did not differ from controls in ESM indices of craving (all P > 0.05). In daily life, ESM craving predicted cannabis use and this was stronger in controls (χ(2) = 4.5, P = 0.033; Bcontrols = 0.08, P < 0.001; Bpatients = 0.06, P < 0.001). In both groups ESM craving was predicted by negative affect, paranoia, and hallucinations (Bnegativeaffect = 0.12, P = 0.009; Bparanoia = 0.13, P = 0.013; Bhallucinations = 0.13, P = 0.028), and followed by an increase in negative affect at non-cannabis-using moments (B = 0.03, P = 0.002). The temporal dynamics of craving as well as craving intensity in daily life appear to be similar in patients and controls. Further research is needed to elucidate the inconsistencies between cross-sectional and daily-life measures of craving in psychosis.

Experiences of handwriting and using a computerized ATD in school: Adolescents with Asperger's syndrome

Adolescents with Asperger's syndrome (AS), often have handwriting difficulties that affect their academic performance. The purpose of this descriptive multiple-case mixed-method study was to highlight how adolescents with AS experience writing in the school setting when writing by hand and when using a computerized Assistive Technology Device (ATD), for writing. A qualitative content analysis approach was used, including interviews with five adolescents, their parents, and their teachers. This was complemented by asking the adolescents to rate their perceived performance and satisfaction of writing with and without the ATD. All adolescents described handwriting difficulties, but a reduced ability to express oneself in writing was also common. Initiating and completing writing tasks was often so demanding that it caused resistance to the activity. Several advantages when using the ATD were described by the participants and the self-ratings showed higher scores for performance of and satisfaction with writing when the ATD was used. The results show that teachers' encouragement seemed to be important for the initiation and continuation of use of the ATD.

Uptake and continuous use of copper intrauterine device in a cohort of HIV-positive women

Copper intrauterine device (IUD) is not commonly used in many countries, though it provides effective reversible contraception with no or minimal primary systemic side effects. We assessed its uptake and continuation of use among HIV-positive Thai women. Sixty-six of 322 women of reproductive age, whom we approached for the study, met the eligibility criteria. Sterilization (62%) was the main reason for failure to enroll. Twenty-nine of them (44%) underwent IUD insertion. Considering condom use sufficient for pregnancy prevention (12%) was the main reason among eligible women for the refusal to participate in the study. At six months, 54% of enrolled participants reported one or more side effects such as increased menstrual flow (43%), spotting (21%) and dysmenorrhea (11%). The continuation rate of IUD use was high (93%), in spite of the persistent non-systemic side effects. The study showed that copper IUD could be an acceptable contraceptive choice for Thai HIV-positive women. Easy access to the method in a setting linked with the HIV service, and education on IUD risks and benefits is needed to promote the use of IUD in addition to condoms as an effective contraceptive option in HIV-infected women.

Aligning Institutions of Higher Education emergency preparedness plans with the National Response Framework

Colleges and universities must be prepared to respond to events that could compromise the safety of any person in a classroom, residence hall, office, or any other campus facility as well as for any event that could jeopardize the continuation of use of any campus facility. The Federal Emergency Management Agency (FEMA) states, “Higher education institutions ... are realizing that improving their campus’ resistance to disaster will not only protect their own lives and those of their students, it will also safeguard their campus’ instruction, research, and public service.” The US Department of Homeland Security, FEMA developed the overarching strategy, the National Response Framework (NRF), for emergency preparedness for “government executives, private-sector and nongovernmental organization leaders.” FEMA and the Department of Education (DOE) developed specific guidelines for emergency preparedness for colleges and universities. This study linked these guidelines to the five principles of the NRF. Most institutions have an emergency preparedness plan, but just how effective are these plans? Do community colleges, state, independent, and proprietary institutions differ in terms of their level of emergency preparedness? The target population for this study is colleges and universities in the United States. This quantitative study measured how aligned the emergency preparedness plans of these colleges and universities are to the recommendations of FEMA and the US DOE, Office of Safe and Drug-Free Schools. The data suggest that much more needs to be done to bring college and university emergency plans into alignment with the government recommendations. Alignment with the government documents for this sample of US colleges and universities is extremely low for each principle of the NRF.

Continuation Rate of Combined Hormonal Contraception: A Prospective Multicenter Study

Data from clinical trials regarding continuation of use and contraceptive efficacy do not always apply to the general public. Therefore, a study among typical users was conducted to assess the continuation rate at the end of 12 cycles of combined hormonal contraceptive methods, reasons for discontinuation, and the Pearl index. Prospective, observational, and multicenter study of 3443 women aged 18 to 49 years starting one of the three combined hormonal contraception methods available in Spain (the vaginal ring, the contraceptive pill, and the transdermal skin patch). The study population (intention-to-treat analysis) included 3443 women, of whom 45.4% were included in the vaginal ring group, 42.6% the pill group, and 12.1% the skin patch group. The continuation rate at 12 cycles was 45.9% for the pill, 42.3% for the vaginal ring, and 26.0% for the skin patch. The Pearl index was 0.61 (95% confidence interval [CI] 0-1.2) for the pill, 0.61 (95% CI 0-1.1) for the vaginal ring, and 2.34 (95% CI 0.3-9) for the skin patch (p<0.001). At 12 cycles, the vaginal ring and the pill showed similar continuation rates and effectiveness, which were significantly higher than the skin patch.

The decision to continue or discontinue treatment: Experiences and beliefs of users of selective serotonin-reuptake inhibitors in the initial months—A qualitative study

Background Little is known about patients' views on taking selective serotonin-reuptake inhibitors (SSRIs) and their decision-making processes regarding either continuation or discontinuation within a few months of initiating therapy. Objective To explore the experiences and beliefs of SSRI users in relation to initiation and execution of treatment, with the intention to identify patterns leading to discontinuation or continuation of treatment. Methods Semistructured qualitative interview study. Eighteen patients, older than 18 years, were interviewed 3 months after starting SSRI treatment prescribed by a general practitioner (GP), 9 of whom had discontinued (discontinuers) and 9 of whom continued treatment (continuers). Results Two main patterns lead to either discontinuation or continuation of use. Continuers were satisfied with the GP's role during initiation and execution of SSRI treatment and fully trusted their decision. Continuers' attitudes toward treatment were predominantly positive; they seemed to have little doubt about the necessity of using an SSRI and hardly considered discontinuing for fear of relapse. Discontinuers, on the other hand, seemed to be less involved in decision making and often appeared to have little confidence in their GPs. Most discontinuers felt that they lacked knowledge, and their attitude toward taking SSRIs was rather negative. Discontinuers often were unconvinced about the necessity of using an SSRI and appeared to have a strong desire to discontinue treatment. Conclusion Lack of shared decision making between patient and GP, limited counseling during treatment, lack of knowledge, and patients' negative attitudes toward SSRI use and the disease itself, hampered the acceptance of the SSRI and brought on the decisional conflict to discontinue treatment. Health care professionals could be more supportive during the initial months of SSRI treatment by eliciting patients' considerations for continuing or discontinuing treatment.