Impact of pediatric ethics consultations on patients, families, social workers, and physicians.

OBJECTIVE: To evaluate whether health providers and families find ethics consultations helpful in identifying, analyzing, and resolving ethical problems. STUDY DESIGN: Forty consecutive pediatric ethics consultations at the San Diego Children's Hospital and Health Center were evaluated retrospectively through chart reviews and structured interviews with physicians, social workers, and family members. RESULTS: In 23 of 40 cases, physicians or social workers were successfully interviewed. Of these 23 cases, four family interviews were completed. Over 90% of physicians and social workers found the ethics consultation to be helpful and would recommend an ethics consultation to others in the same circumstances. Two of the four families were strongly dissatisfied with the consultation and identified miscommunication of the ethics consultant's role as a major problem. CONCLUSION: The disparity observed in this study between satisfaction levels of health providers and families raises concerns. More studies that evaluate ethics consultations are needed, especially those that are designed prospectively and explore both these perspectives.     

The influence of social and cultural factors on infertility and new reproductive technologies

Two hundred and eight second-year students were matched with respect to gender, age, academic standing, minority status, and prior pelvic examination experience. After didactic instruction, individuals from each matched pair were randomly assigned to alternate training modalities—a plastic pelvic model (Gynny) and surrogate patients (Gynecology Teaching Associates, GTAs)—for pelvic examination instruction. A sample of 52 study- and 54 control-group students were then evaluated while they examined women with normal or deviant (hysterectomy/ pregnancy) pelvic anatomy. Communication and manual skills were evaluated on the basis of specially designed instruments in which the components of a ‘good’ pelvic examination were identified and described. Immediately after the objective evaluation, each student was interviewed to determine his/her subjective feelings about the training experience. The subjective data obtained in this way indicated that students evaluated the GTA modality significantly more favorably than the Gynny experience and strongly preferred the former to the latter. They preferred the GTA experience because they felt 1) knowledge gained from examining a human being (as opposed to a plastic model) was directly transferable to other patients and 2) it helped defuse sexual embarrassment involved in conducting one's first pelvic examination. Examining a trained surrogate (as opposed to either a plastic model or a clinic patient) also assured immediate identification and correction of errors through instant and direct feedback in an optimal learning environment, which resulted in increased competence and self-confidence. These data provide a likely explanation for previously published objective results indicating superior performance on the part of GTA-trained students.     

Job and life satisfaction among remote physicians in Taiwan.

To determine the nature and current level of job and life satisfaction among remote physicians in Taiwan, 115 physicians practicing in 31 aboriginal townships and on 3 offshore islands were interviewed through a mail survey. Out of 95 respondents, 93% were male. The average age was 46.0 years, and 82% of the physicians practiced only primary care. About half of the respondents had not received any residency training prior to their beginning practice. Physicians aboriginal areas and on offshore islands appear to be moderately satisfied with their jobs and with their lives in general. In aggregate, the areas of greatest job satisfaction included their contacts with other physicians and their relationships with other health care workers. Areas of least satisfaction included physicians' salary/income and their opportunities for promotion in the future. Most respondents felt that the greatest causes of work stress were the realities of medical practice and the time pressures. Areas of least stress included clinical competence/interpersonal relations and anxieties about the future. In aggregate, the areas of lowest life satisfaction included the physicians' incomes and the lack of leisure activities. It is suggested that a family practice residency training course prior to practice and access to continuing medical education programs are urgently needed for remote physicians in Taiwan. On the other hand, economic incentives seem to be the best strategy to increase the job and life satisfaction of these physicians.     

Linkages among reproductive health, maternal health, and perinatal outcomes

Some interventions in women before and during pregnancy may reduce perinatal and neonatal deaths, and recent research has established linkages of reproductive health with maternal, perinatal, and early neonatal health outcomes. In this review, we attempted to analyze the impact of biological, clinical, and epidemiologic aspects of reproductive and maternal health interventions on perinatal and neonatal outcomes through an elucidation of a biological framework for linking reproductive, maternal and newborn health (RHMNH); care strategies and interventions for improved perinatal and neonatal health outcomes; public health implications of these linkages and implementation strategies; and evidence gaps for scaling up such strategies. Approximately 1000 studies (up to June 15, 2010) were reviewed that have addressed an impact of reproductive and maternal health interventions on perinatal and neonatal outcomes. These include systematic reviews, meta-analyses, and stand-alone experimental and observational studies. Evidences were also drawn from recent work undertaken by the Child Health Epidemiology Reference Group (CHERG), the interconnections between maternal and newborn health reviews identified by the Global Alliance for Prevention of Prematurity and Stillbirth (GAPPS), as well as relevant work by the Partnership for Maternal, Newborn and Child Health. Our review amply demonstrates that opportunities for assessing outcomes for both mothers and newborns have been poorly realized and documented. Most of the interventions reviewed will require more greater-quality evidence before solid programmatic recommendations can be made. However, on the basis of our review, birth spacing, prevention of indoor air pollution, prevention of intimate partner violence before and during pregnancy, antenatal care during pregnancy, Doppler ultrasound monitoring during pregnancy, insecticide-treated mosquito nets, birth and newborn care preparedness via community-based intervention packages, emergency obstetrical care, elective induction for postterm delivery, Cesarean delivery for breech presentation, and prophylactic corticosteroids in preterm labor reduce perinatal mortality; and early initiation of breastfeeding and birth and newborn care preparedness through community-based intervention packages reduce neonatal mortality. This review demonstrates that RHMNH are inextricably linked, and that, therefore, health policies and programs should link them together. Such potential integration of strategies would not only help improve outcomes for millions of mothers and newborns but would also save scant resources. This would also allow for greater efficiency in training, monitoring, and supervision of health care workers and would also help families and communities to access and use services easily.     

Timing,characteristics and determinants of infertility diagnostic work up before admission to eleven second-level assisted reproductive techniques (ART) centres in Italy

Objective

To describe the time-course of infertile couples not conceiving spontaneously or with medical or surgical therapies before assisted reproductive techniques (ART).

Study design

Multicentre study of consecutive couples seen for the first time in eleven second-level infertility centres in Italy. A total of 464 couples entered the study and completed a structured questionnaire with the assistance of a clinician. Information was collected on general characteristics, reproductive and gynaecological history, and presumed causes of infertility. Further information was collected on: date of first trying for pregnancy and first consultation for infertility; doctor first consulted by the couple and who decided the diagnostic work-up; instrumental and laboratory tests performed during the diagnostic work-up.

Results

The first medical consultation for infertility occurred after an average of 13 months of unprotected intercourse. This interval was statistically significantly longer for women with low educational level. The median interval between the first medical consultation and the consultation in a second-level infertility centre was 9.5 months. This interval was shorter when the first clinician consulted was a specialist in infertility working in a first-level public centre. Moreover, this interval was longer among women with low educational level. At the time of the consultation in a second-level infertility centre, most of the female patients had already been examined for ovarian, hypophyseal and thyroid function, but only 12% had undergone an anti-Mullerian hormone (AMH) determination: 56% had microbiological culture performed. Nearly 40% had been studied for tubal patency and karyotype. More than 50% of the male partners had not a complete semen evaluation, but 46.0% had second-level examinations.

Conclusion

Educational level is linked to a higher possibility of recognizing fertility problems. The referral process to a second-level centre is quicker in the public sector.     

Effects of smoking on ovulation induction for assisted reproductive techniques.

OBJECTIVE: To determine the effects of smoking on ovulation induction for assisted reproductive techniques. DESIGN: Matched, retrospective, cohort study. SETTING: Outpatient University endocrine/infertility program. PATIENTS: Eighteen smokers and 36 nonsmokers: 2 nonsmokers matched to each smoker for age, weight, and history of ovarian surgery. MAIN OUTCOME MEASURES: During a stimulation cycle, the serum estradiol (E2) level, number of follicles, number of oocytes, number of embryos, and ampules of gonadotropins used were compared in the smoking versus the nonsmoking groups by Wilcoxon's signed rank test for paired data. Follicular fluid (FF), testosterone (T), androstenedione (A), E2, A:E2 ratios, and T:E2 ratios were measured and compared between groups by Mann-Whitney U-tests. RESULTS: Smokers had significantly lower serum E2 levels, fewer follicles, fewer oocytes retrieved, and fewer embryos per cycle than nonsmokers, despite equal amounts of gonadotropin administration. Follicular fluid obtained from mature follicles had a higher A:E2 ratio and a higher T:E2 ratio in smokers compared with nonsmokers. CONCLUSIONS: Smoking adversely affects ovulation induction parameters and alters the FF hormonal milieu.     

Attitudes on the ethics of abortion, sex selection, and selective pregnancy termination among health care professionals, ethicists, and clergy likely to encounter such situations

The ethical attitudes of health care providers toward abortion, sex selection, and selective termination of normal and anomalous fetuses in singleton or multiple pregnancies were evaluated by questionnaires distributed to members of the American Society of Human Genetics, the International Fetal Medicine and Surgery Society, the Society of Perinatal Obstetricians, ethicists, and clergy. Demographic characteristics of respondents exhibited a preponderance of men (76%), age greater than 40 (68%), and of United States residents (82%). Seventy-nine percent of respondents were in the medical profession. Approximately half of the respondents were Protestant, the rest being evenly distributed among Catholic, Jewish, and other religions. Acceptance of abortion for social indication varied by religion and gestational age but not by religious conviction, age, country, or gender of respondent. First-trimester abortion of a normal singleton pregnancy was considered more acceptable than selective termination of normal fetuses in multifetal gestations. Sex selection was considered unethical by most respondents. Selective termination was deemed ethically appropriate in quadruplets or multifetal gestations of more than five fetuses and in multiple pregnancies bearing one anomalous fetus. In the latter situation, acceptance increased with the severity of fetal anomalies and decreased from the first to the third trimester. The medical specialty of respondents was the only independent factor strongly associated with acceptance of selective termination by trimester, indication, and number of fetuses. Acceptance of selective termination among health care professionals appears to reflect not only perceptions of procedure-related risks and benefits in the index pregnancy but also individual training and religious beliefs.     

Oral contraceptives: views among primary health-care physicians and the general population.

OBJECTIVES: To ascertain the views of physicians and the general population concerning oral contraceptive (OC) use and the risk of thrombosis after the pill scare and, moreover, to investigate whether respondents' smoking habits had any impact on these perceptions. METHOD: A questionnaire on family planning was mailed to randomly selected Finnish health-center physicians (n = 351) and to a random sample of Finnish women (n = 393) and men (n = 395). All were asked to evaluate statements concerning OCs using a visual analog scale from 0 (strongly disagree) to 100 (strongly agree). RESULTS: The response rate for physicians was 69%, for women 56% and for men 45%. Respondents in all subgroups agreed to some extent that OCs increase the risk of thrombosis. Among the population, more women than men were of the opinion that it is dangerous to smoke while using OCs and non-smokers were more aware of the risk of OC use and simultaneous smoking than were smokers. Physicians' personal smoking habits had no evident impact on opinions concerning OC use, risk of thrombosis and smoking. CONCLUSIONS: Although differences existed between the perceptions of physicians and those of the general population concerning OCs, their opinions are realistic and in harmony.     

High pregnancy rates and reproductive health indicators among female injection-drug users in Vancouver, Canada.

OBJECTIVE: To determine the incidence of pregnancy among active injection-drug users and to identify factors associated with becoming pregnant. METHODS: The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study that began in 1996. Women who had completed a baseline and at least one follow-up questionnaire between June 1996 and January 2002 were included in the study. Parametric and non-parametric methods were used to compare characteristics of women who reported pregnancy over the study period with those who did not over the same time period. RESULTS: A total of 104 women reported a primary pregnancy over the study period. The incidence of pregnancy over the follow-up period was 6.46 (95% confidence interval (CI) 5.24-7.87) per 100 person-years. The average age of women who reported pregnancy was younger than that of women who did not report pregnancy (27 vs. 32 years, p < 0.001). Women of Aboriginal ethnicity were more likely to report pregnancy (odds ratio 1.6, 95% CI 1.0-2.5). Comparison of drug use showed no significant differences in pregnancy rate with respect to the use of heroin, cocaine or crack (p > 0.05). In examining sexual behavior, women who reported having had a regular partner in the previous 6 months were three times more likely to have reported pregnancy. Despite the fact that 67% of women in this study reported using some form of contraception, the use of reliable birth control was low. Only 5% of women in our study reported the use of hormonal contraceptives. CONCLUSION: There were a high number of pregnancies among high-risk women in this cohort. This corresponded with very low uptake of reliable contraception. Innovative strategies to provide reproductive health services to at-risk women who are injecting drugs is a public health priority.     

Symptoms, diagnoses, and time to key diagnostic procedures among older U.S. women with ovarian cancer

OBJECTIVE: To examine the types of symptoms and diagnostic procedures reported in Medicare claims 12 months before diagnosis for women with ovarian cancer by stage, and to assess the association between types of symptoms and time to key diagnostic procedures. METHODS: Medicare claims linked to records in the Surveillance, Epidemiology, and End Results (SEER) cancer registries were used to examine diagnosis and procedure codes in 3,250 women aged 65 years and older before a diagnosis of ovarian cancer. RESULTS: Over 81% of women with ovarian cancer had at least one target sign or symptom before diagnosis. Gastrointestinal symptoms such as nausea and vomiting (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.40-2.98), and constipation, diarrhea, or other digestive disorders (aOR 2.01, 95% CI 1.58-2.56) were associated with later-stage cancer. In contrast, gynecologic symptoms such as abnormal bleeding (aOR 0.44, 95% CI 0.34-0.58) and genital organ pain (aOR 0.66, 95% CI 0.53-0.80) were associated with earlier disease. Among those with at least one symptom, the rate at which women with gynecologic symptoms went to surgery was higher (hazard ratio 5.5, 95% CI 5.1-6.0) than the rate for women with other nongastrointestinal ovarian cancer-related symptoms. CONCLUSION: Women with ovarian cancer presenting with gastrointestinal symptoms were more likely to have later-stage disease and longer time to key diagnostic tests than those with gynecologic symptoms. Clinicians should be aware of the potential for unresolved gastrointestinal symptoms to be indicators for ovarian cancer.     

Current status of in vitro fertilization and the new reproductive technologies.

The rapid pace of development and refinement of in vitro fertilization and ancillary assisted reproductive techniques warrants periodic review to keep the reader abreast of the growth in this clinical and scientific arena. Although not exhaustive, this review targets key areas of special interest and significance, including oocyte and embryo micromanipulation for assisted fertilization and genetic analysis, advances in the approach to ovarian stimulation, and examination of the scientific model afforded by ovum donation.     

Efficacy of assisted reproductive technology during diagnostic and operative infertility laparoscopy

Women being evaluated for infertility were offered assisted reproductive technology at the time of diagnostic laparoscopy. Oocyte retrieval was performed after ovulation induction in 33 women, of whom 19 had concurrent operative laparoscopy. Gamete intrafallopian transfer (GIFT) or in vitro fertilization (IVF) and embryo transfer were performed subsequently depending on laparoscopic assessment of pelvic architecture, oocyte maturity, and semen parameters. The clinical pregnancy rate was 24% per cycle and 28% per gamete or embryo transfer (four pregnancies after GIFT and four after IVF/embryo transfer). The clinical pregnancy rate per transfer did not differ significantly between the 19 women who had therapeutic operations in conjunction with laparoscopy (lysis of adhesions and/or fulguration of endometriosis) and the 13 who did not (25 versus 30%; P greater than .05). Assisted reproductive technology can be performed successfully during diagnostic infertility laparoscopy. Operative endoscopic manipulation did not adversely influence pregnancy outcome.     

Breastfeeding education, treatment, and referrals by female physicians.

The female membership of the Mississippi State Medical Association and female physician employees of the Mississippi State Department of Health were surveyed (N = 350) to examine their practice-related decisions relative to breastfeeding; 215 (61%) responded to the survey. Discussion was commonly used for educating patients, with face-to-face demonstrations used by less than half of respondents. Female physicians with breastfeeding experience were more comfortable than others in treating sore nipples, plugged ducts, infected nipples, and inadequate infant weight gain. There was no difference in the proportion of physicians with and without breastfeeding experience who treated mastitis, low milk supply, and poor latch. The largest percentages of referrals to other providers were in response to infants' poor weight gain and poor latch; the fewest were for nipple infections. Seventy percent of the respondents were not taught lactation management in medical school or residency. Better education for physicians regarding lactation management is needed.     

医源性尿瘘预防与新的尿瘘治疗方法

分娩损伤及妇科手术损伤是医源性尿瘘的主要病因,针对病因的预防措施是降低医源性尿瘘的根本所在。随着现代医学的进步和科学技术的日新月异,机器人辅助内镜手术将成为未来治疗的趋势。