Women's Satisfaction with Their Involvement in Health Care Decisions During a High‐Risk Pregnancy

ABSTRACT: Background: Increasingly, women seek involvement in decisions about their health care. The purpose of this study was to examine women's experience of, and satisfaction with, their involvement in health care decisions during a high‐risk pregnancy. Methods: Forty‐seven women with hypertension or threatened preterm delivery (including multiple births) were interviewed after the birth of their child. They received prenatal care at home from nurses in a community program or were hospitalized. The in‐depth interviews were audiotaped and transcribed; data were analyzed using constant comparative methods. Results: Women identified an increased feeling of responsibility for the health of their baby and themselves, but differed in choosing active or passive involvement in health care decisions. Women who wanted active involvement achieved it through one of three processes: struggling for, negotiating, or being encouraged. Women who wanted passive involvement and women facing health crises used the process of trusting in the expertise of nurses and physicians. Women were satisfied if the care from health care professionals was congruent with how they wanted to be involved in decision‐making. Conclusions: Although most women want to be actively involved in health decision‐making during a high‐risk pregnancy, some prefer a passive role. The setting of prenatal care, community‐based or in‐hospital, was less important than the ability of nurses and physicians to support the woman in her preferred role in decision‐making. (BIRTH 30:2 June 2003)     

Intensity-dependent regional cerebral blood flow during 1-Hz repetitive transcranial magnetic stimulation (rTMS) in healthy volunteers studied with H215O positron emission tomography: I. Effects of primary motor cortex rTMS.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) affects the excitability of the motor cortex and is thought to influence activity in other brain areas as well. We combined the administration of varying intensities of 1-Hz rTMS of the motor cortex with simultaneous positron emission tomography (PET) to delineate local and distant effects on brain activity. METHODS: Ten healthy subjects received 1-Hz rTMS to the optimal position over motor cortex (M1) for producing a twitch in the right hand at 80, 90, 100, 110, and 120% of the twitch threshold, while regional cerebral blood flow (rCBF) was measured using H(2)(15)O and PET. Repetitive transcranial magnetic stimulation (rTMS) was delivered in 75-pulse trains at each intensity every 10 min through a figure-eight coil. The regional relationship of stimulation intensity to normalized rCBF was assessed statistically. RESULTS: Intensity-dependent rCBF increases were produced under the M1 stimulation site in ipsilateral primary auditory cortex, contralateral cerebellum, and bilateral putamen, insula, and red nucleus. Intensity-dependent reductions in rCBF occurred in contralateral frontal and parietal cortices and bilateral anterior cingulate gyrus and occipital cortex. CONCLUSIONS: This study demonstrates that 1-Hz rTMS delivered to the primary motor cortex (M1) produces intensity-dependent increases in brain activity locally and has associated effects in distant sites with known connections to M1.     

Influence of hypothermic cardiopulmonary bypass on atrial natriuretic factor levels

Atrial natriuretic factor (ANF) is a peptide released from the heart in response to atrial distension. This peptide causes diuresis, vasodilatation, decreased blood pressure, and antagonizes the renin-aldosterone and antidiuretic hormone neuraxes. The influence of cardiopulmonary bypass and cardiac surgery on the circulation and release of ANF is unknown. Plasma ANF concentrations were therefore determined in patients undergoing coronary artery revascularization (CABG) and mitral valve replacement (MVR). Peptide levels were unchanged following anaesthetic induction. Plasma ANF concentrations decreased significantly during hypothermic (less than or equal to 28 degrees C) cardiopulmonary bypass in both patient groups. After 60 minutes of cardiac bypass, ANF declined from (mean +/- SEM) 512 +/- 132 to 20 +/- 6 pg.ml-1 (P less than 0.05) during MVR, and from 178 +/- 41 to 110 +/- 48 pg.ml-1 during CABG (P less than 0.05). Rewarming during bypass was associated with an increase in ANF concentration in both groups. Heparin anticoagulation and protamine reversal had no effect on immunoreactive ANF levels. In patients undergoing CABG, there was a linear relationship between plasma ANF concentration (pg.ml-1) and right atrial pressure (mmHg) prior to cardiopulmonary bypass (r = 0.86, P less than 0.005). However, one and three hours after cardiopulmonary bypass there was no significant relationship between right atrial pressure and ANF plasma levels. These results suggest that reduction in plasma ANF concentration occurs during hypothermic cardiopulmonary bypass. Furthermore, the proportional relationship between atrial distension and circulating ANF concentration was altered following cardiac surgery.     

Evaluation of a Hong Kong Chinese version of a self-administered questionnaire for assessing symptom severity and functional status of carpal tunnel syndrome: cross-cultural adaptation and reliability.

OBJECTIVES: To evaluate the application of a translated version of an established self-administered questionnaire for carpal tunnel syndrome on Chinese patients in Hong Kong. DESIGN: Evaluation of an instrument tool. SETTING: Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong; Holistic Medical Centre, Aberdeen, Hong Kong. PARTICIPANTS: Patients with carpal tunnel syndrome, translators. MAIN OUTCOME MEASURES: The adaptation was based on forward-backward translation from English to Chinese (Hong Kong) and vice versa. Meetings with translators, investigators, and patients were organised to generate an acceptable version of the questionnaire. A pilot study was carried out on 20 patients and subsequently minor adjustments were added. Fifty patients were recruited to validate the reliability and internal consistency of the questionnaire. RESULTS: The ordinality of response agreed with the original instrument. Test-retest reproducibility showed no significant difference between tests. The Pearson correlation coefficient ranged from 0.83 to 0.93. Internal consistency was good, at 0.85. CONCLUSION: Through the validation of the Hong Kong Chinese version of the questionnaire, we are able to produce an assessment tool for the local patients. Furthermore, we are able to create a platform for: (i) a cross-national and cross-cultural epidemiological comparison as well as a means of (ii) evaluating different types of treatments.     

Update on medication abortion

This article provides an overview of medication abortion in the United States 6 years after the approval of mifepristone (RU486; Mifeprex; Danco Laboratories, LLC, New York, NY) by the US Food and Drug Administration (FDA). The adoption of mifepristone is considered in the context of epidemiologic data on abortion, abortion access, and the safety of abortion. The risks of medication and aspiration abortion are discussed in the context of abortion-related mortality, recent experience with obstetric and gynecologic infection with Clostridium sordellii, and the limits of scientific knowledge on the incidence of this infection in women. Innovative protocols studied since FDA approval of mifepristone are presented, and implications for clinical practice are discussed.     

Adolescent Immunization: Focus on Implementation

ABSTRACT: On March 11–12, 1996, a workshop on how to implement new adolescent immunization (AI) recommendations was held in Atlanta, Ga. Sponsored by the Centers for Disease Control and Prevention, it was a collaborative effort of the National Immunization Program, the Division of Adolescent and School Health/National Center for Chronic Disease Prevention and Health Promotion, and the Hepatitis Branch/National Center for Infectious Diseases. The workshop brought together organizations and individuals interested in adolescent health and immunizations so they could address how new Al recommendations can be implemented most effectively. This article offers an overview of their discussions and suggestions, including issues of cooperation, education, legislation, and Al program development among health provider organizations, health departments, schools, community groups and various other agencies relating to adolescent health services.     

Laparoscopic nephrectomy is cost effective compared with open nephrectomy in a large county hospital.

BACKGROUND AND OBJECTIVES: To evaluate the experience with laparoscopic nephrectomy in a large county hospital and perform a cost comparison between uncomplicated open and laparoscopic nephrectomy. METHODS: Eleven consecutive patients who underwent an uncomplicated laparoscopic nephrectomy in a large county hospital were compared with 8 patients who underwent uncomplicated open nephrectomy during the same period. Patient charts and corresponding billing records were reviewed to determine overall hospitalization cost and individual cost components. RESULTS: No perioperative complications occurred in either the laparoscopic or open group, and no statistically significant differences existed between groups with regard to patient demographics or operative parameters. The overall operating room costs favored the open nephrectomy group by dollars 1070 (P=0.003). However, the overall cost of hospitalization, surgeon professional fees, duration of hospitalization, room and board costs, laboratory, and radiology costs, pharmacy costs, intravenous solution and infusion pump costs all significantly favored the laparoscopic patient group. The mean difference in overall hospital cost between laparoscopic and open nephrectomy was dollars 1211 in favor of laparoscopy (P=0.037). CONCLUSIONS: Our experience with laparoscopic nephrectomy in a large county hospital demonstrates a clear economic advantage in favor of the laparoscopic approach. Given limited funding for public hospitals and a clear patient benefit, laparoscopic nephrectomy should constitute first-line therapy when nephrectomy is indicated.     

Controlled Radiofrequency Endovenous Occlusion Using a Unique Radiofrequency Catheter Under Duplex Guidance to Eliminate Saphenous Varicose Vein Reflux: A 2-Year Follow-Up

BACKGROUND: Saphenous vein reflux is often the underlying anatomic cause of varicose veins. It is necessary to eliminate this reflux originating at the saphenofemoral junction (SFJ) to treat the resultant varicose veins. OBJECTIVE: To report 2-year follow-up results after closing the incompetent greater saphenous vein starting from its junction (SFJ) with the femoral vein using radiofrequency (RF) endoluminal ablation. METHODS: One hundred and forty incompetent greater saphenous veins from 120 patients with an incompetent SFJ and large painful varicosities were treated. Patients were evaluated clinically and with duplex ultrasound at 1 week, 6 weeks, 6 months, 12 months, and 24 months to determine treatment efficacy as well as adverse sequelae. RESULTS: Vein occlusion, defined as the absence of any duplex ultrasound-determined flow, was successfully achieved in 137 of 140 (98%) scanned veins at 1-week follow-up. At the 12-month follow-up, none of the treated patients developed recanalization that was not seen at 6 weeks, with a successful outcome in 90%. At the 24 month follow-up, 19 of 21 patients had complete disappearance of the treated saphenous vein, for a success rate of 90%. Side effects were minimal, and no skin burns or thromboses were observed. CONCLUSION: RF endovenous occlusion allows patients to obtain treatment with the positive attributes of surgery, that is, a single treatment and low rate of recurrent reflux, but without the morbidity, need for general anesthesia, or extensive convalescence associated with vein stripping and ligation surgery. Patient satisfaction was routinely achieved, with 98% of patients indicating a willingness to recommend the RF endovascular procedure to a friend or family member.