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1.  Contraceptive care at the time of medical abortion: experiences of women and health professionals in a hospital or community sexual and reproductive health context 
Contraception  2016;93(2):170-177.
Objective
To examine experiences of contraceptive care from the perspective of health professionals and women seeking abortion, in the contexts of hospital gynaecology departments and a specialist sexual and reproductive health centre (SRHC).
Materials and methods
We conducted in-depth semistructured interviews with 46 women who had received contraceptive care at the time of medical abortion (gestation≤9 weeks) from one SRHC and two hospital gynaecology-department-based abortion clinics in Scotland. We also interviewed 25 health professionals (nurses and doctors) involved in abortion and contraceptive care at the same research sites. We analysed interview data thematically using an approach informed by the Framework method, and comparison was made between the two clinical contexts.
Results
Most women and health professionals felt that contraceptive counselling at abortion was acceptable and appropriate, if provided in a sensitive, nonjudgemental way. Participants framed contraceptive provision at abortion as significant primarily as a means of preventing subsequent unintended conceptions. Accounts of contraceptive decision making also presented tensions between the priorities of women and health professionals, around ‘manoeuvring’ women towards contraceptive uptake. Comparison between clinical contexts suggests that women's experiences may have been more positive in the SRHC setting.
Conclusions
Whilst abortion may be a theoretically and practically convenient time to address contraception, it is by no means an easy time to do so and requires considerable effort and expertise to be managed effectively. Training for those providing contraceptive care at abortion should explicitly address potential conflicts between the priorities of health professionals and women seeking abortion.
Implications
This paper offers unique insight into the detail of women and health professionals' experiences of addressing contraception at the time of medical abortion. The comparison between hospital and community SRHC contexts highlights best practise and areas for improvement relevant to a range of settings.
doi:10.1016/j.contraception.2015.09.016
PMCID: PMC4712046  PMID: 26434646
Medical abortion; Postabortion contraception; Long-acting reversible contraception (LARC); Qualitative research
2.  Instability of Misoprostol Tablets Stored Outside the Blister: A Potential Serious Concern for Clinical Outcome in Medical Abortion 
PLoS ONE  2014;9(12):e112401.
Introduction
Misoprostol (Cytotec) is recognised to be effective for many gynaecological indications including termination of pregnancy, management of miscarriage and postpartum haemorrhage. Although not licensed for such indications, it has been used for these purposes by millions of women throughout the world. Misoprostol tablets are most often packaged as multiple tablets within an aluminium strip, each within an individual alveolus. When an alveolus is opened, tablets will be exposed to atmospheric conditions.
Objective
To compare the pharmaco technical characteristics (weight, friability), water content, misoprostol content and decomposition product content (type A misoprostol, type B misoprostol and 8-epi misoprostol) of misoprostol tablets Cytotec (Pfizer) exposed to air for periods of 1 hour to 720 hours (30 days), to those of identical non exposed tablets.
Methods
Four hundred and twenty (420) tablets of Cytotec (Pfizer) were removed from their alveoli blister and stored at 25°C/60% relative humidity. Water content, and misoprostol degradation products were assayed in tablets exposed from 1 to 720 hours (30 days). Comparison was made with control tablets (N = 60) from the same batch stored in non-damaged blisters. Statistical analyses were carried out using Fisher’s exact test for small sample sizes.
Results
By 48 hours, exposed tablets demonstrated increased weight (+4.5%), friability (+1 300%), and water content (+80%) compared to controls. Exposed tablets also exhibited a decrease in Cytotec active ingredient dosage (−5.1% after 48 hours) and an increase in the inactive degradation products (+25% for type B, +50% for type A and +11% for 8-epi misoprostol after 48 hours) compared to controls.
Conclusion
Exposure of Cytotec tablets to ‘typical’ European levels of air and humidity results in significant time-dependent changes in physical and biological composition that could impact adversely upon clinical efficacy. Health professionals should be made aware of the degradation of misoprostol with inappropriate storage of misoprostol tablets.
doi:10.1371/journal.pone.0112401
PMCID: PMC4266501  PMID: 25502819
3.  Can we reduce costs and prevent more unintended pregnancies? A cost of illness and cost-effectiveness study comparing two methods of EHC 
BMJ Open  2013;3(12):e003815.
Objectives
To calculate the cost of an unintended pregnancy in 2011 and use this cost in a cost-effectiveness model comparing ulipristal acetate (UPA) with levonorgestrel (LNG) for emergency hormonal contraception (EHC).
Design
Retrospective analysis of published data sources and published cost-effectiveness model.
Setting
Women presenting in primary care in England for EHC within 24 or 72 h of unprotected sexual intercourse (UPSI).
Interventions
EHC of either LNG (1.5 mg) or UPA (30 mg).
Primary and secondary outcome measures
The primary outcome measure is the number and direct and indirect costs of an unintended pregnancy. The secondary outcome measure is the consequence of unintended pregnancy: miscarriage, abortion, ectopic pregnancy, stillbirth or live birth.
Results
From the comparative clinical studies of EHC we observe that if 125 women receive either LNG or UPA within 72 h of UPSI, there will be one less pregnancy due to method failure in the UPA group than in the LNG group. We calculate the cost of an unintended pregnancy to be £1663 in direct healthcare costs rising to £2922 with the inclusion of social costs. Using these costs in the comparative cost-effectiveness model shows that it costs £194 less in direct health costs alone to prevent one more pregnancy with UPA than with LNG. The inclusion of social costs of pregnancy increases this cost-saving potential to £1453 for each extra pregnancy avoided with UPA compared with LNG.
Conclusions
Clinical trials have demonstrated the superior efficacy of UPA compared with LNG as a method of EHC. Given that it costs less overall in health and social costs of pregnancy while preventing more pregnancies, UPA is said to be the dominant treatment, and primary care services should shift to offering UPA as the preferred oral option to women presenting within 24 and 72 h of UPSI.
doi:10.1136/bmjopen-2013-003815
PMCID: PMC3884700  PMID: 24353255
Health Economics; Public Health; Sexual Medicine
4.  Efficacy of the LiSN & Learn auditory training software: randomized blinded controlled study 
Audiology Research  2012;2(1):e15.
Children with a spatial processing disorder (SPD) require a more favorable signal-to-noise ratio in the classroom because they have difficulty perceiving sound source location cues. Previous research has shown that a novel training program - LiSN & Learn - employing spatialized sound, overcomes this deficit. Here we investigate whether improvements in spatial processing ability are specific to the LiSN & Learn training program. Participants were ten children (aged between 6;0 [years;months] and 9;9) with normal peripheral hearing who were diagnosed as having SPD using the Listening in Spatialized Noise - Sentences test (LiSN-S). In a blinded controlled study, the participants were randomly allocated to train with either the LiSN & Learn or another auditory training program - Earobics - for approximately 15 min per day for twelve weeks. There was a significant improvement post-training on the conditions of the LiSN-S that evaluate spatial processing ability for the LiSN & Learn group (P=0.03 to 0.0008, η2=0.75 to 0.95, n=5), but not for the Earobics group (P=0.5 to 0.7, η2=0.1 to 0.04, n=5). Results from questionnaires completed by the participants and their parents and teachers revealed improvements in real-world listening performance post-training were greater in the LiSN & Learn group than the Earobics group. LiSN & Learn training improved binaural processing ability in children with SPD, enhancing their ability to understand speech in noise. Exposure to non-spatialized auditory training does not produce similar outcomes, emphasizing the importance of deficit-specific remediation.
doi:10.4081/audiores.2012.e15
PMCID: PMC4630948  PMID: 26557330
central auditory processing disorder; spatial processing disorder; deficit-specific remediation; plasticity.
5.  Mechanisms for an effect of acetylcysteine on renal function after exposure to radio-graphic contrast material: study protocol 
Background
Contrast-induced nephropathy is a common complication of contrast administration in patients with chronic kidney disease and diabetes. Its pathophysiology is not well understood; similarly the role of intravenous or oral acetylcysteine is unclear. Randomized controlled trials to date have been conducted without detailed knowledge of the effect of acetylcysteine on renal function. We are conducting a detailed mechanistic study of acetylcysteine on normal and impaired kidneys, both with and without contrast. This information would guide the choice of dose, route, and appropriate outcome measure for future clinical trials in patients with chronic kidney disease.
Methods/Design
We designed a 4-part study. We have set up randomised controlled cross-over studies to assess the effect of intravenous (50 mg/kg/hr for 2 hrs before contrast exposure, then 20 mg/kg/hr for 5 hrs) or oral acetylcysteine (1200 mg twice daily for 2 days, starting the day before contrast exposure) on renal function in normal and diseased kidneys, and normal kidneys exposed to contrast. We have also set up a parallel-group randomized controlled trial to assess the effect of intravenous or oral acetylcysteine on patients with chronic kidney disease stage III undergoing elective coronary angiography. The primary outcome is change in renal blood flow; secondary outcomes include change in glomerular filtration rate, tubular function, urinary proteins, and oxidative balance.
Discussion
Contrast-induced nephropathy represents a significant source of hospital morbidity and mortality. Over the last ten years, acetylcysteine has been administered prior to contrast to reduce the risk of contrast-induced nephropathy. Randomized controlled trials, however, have not reliably demonstrated renoprotection; a recent large randomized controlled trial assessing a dose of oral acetylcysteine selected without mechanistic insight did not reduce the incidence of contrast-induced nephropathy. Our study should reveal the mechanism of effect of acetylcysteine on renal function and identify an appropriate route for future dose response studies and in time randomized controlled trials.
Trial registration
Clinical Trials.gov: NCT00558142; EudraCT: 2006-003509-18.
doi:10.1186/1472-6904-12-3
PMCID: PMC3293780  PMID: 22305183
Contrast-induced nephropathy; acetylcysteine; prevention; kidney; contrast media
6.  Problems Hearing in Noise in Older Adults 
Trends in Amplification  2011;15(3):116-126.
Difficulty understanding speech in background noise, even with amplification to restore audibility, is a common problem for hearing-impaired individuals and is especially frequent in older adults. Despite the debilitating nature of the problem the cause is not yet completely clear. This review considers the role of spatial processing ability in understanding speech in noise, highlights the potential impact of disordered spatial processing, and attempts to establish if aging leads to reduced spatial processing ability. Evidence supporting and opposing the hypothesis that spatial processing is disordered among the aging population is presented. With a few notable exceptions, spatial processing ability was shown to be reduced in an older population in comparison to young adults, leading to poorer speech understanding in noise. However, it is argued that to conclude aging negatively effects spatial processing ability may be oversimplified or even premature given potentially confounding factors such as cognitive ability and hearing impairment. Further research is required to determine the effect of aging and hearing impairment on spatial processing and to investigate possible remediation options for spatial processing disorder.
doi:10.1177/1084713811424885
PMCID: PMC4040826  PMID: 22072599
spatial processing; aging; simultaneous stream segregation; speech understanding in noise

Results 1-6 (6)