Maternity care practices of navy family practice residency graduates after leaving the military

BACKGROUND

Nationwide, 32% of residency-trained family physicians deliver babies compared with 73% to 90% in the military. This study describes and defines issues that could ultimately help revive family practice maternity care.

METHOD

We surveyed 112 family physicians who had left the navy.

RESULTS

Ninety-one percent had delivered babies in the navy, 45% since leaving the military, and 25% currently. Principal maternity care incentives both in and out of the military were personal and professional satisfaction. Reasons for not providing civilian maternity care included malpractice risks, insurance costs, and lifestyle issues. The decision for providing maternity care was usually made before or during residency, whereas the decision against was most often made upon leaving the military. Among more recent graduates (1990-1995), 48% continued to deliver babies in civilian practice. (This is about 20% more than recent civilian graduates.) Malpractice concerns were less important to this group than to earlier graduates.

CONCLUSIONS

Factors discouraging family physicians from providing maternity care arise from their practice environment and are not easily overcome with improved training and experience. Recent navy residency graduates are not as easily discouraged.

Reported comfort with obstetrical emergencies before and after participation in the advanced life support in obstetrics course

BACKGROUND AND OBJECTIVES

Prior research has demonstrated a change in Advanced Life Support in Obstetrics (ALSO) course attendees' reported comfort with managing specific obstetrical emergencies and procedures before and immediately after participation in an ALSO course. Assessment of longer-term stability of these changes has not been performed. This study measured changes in comfort with obstetrical emergencies and reported practice patterns 1 year after ALSO training.

METHODS

ALSO course attendees (275) were given a grounded Likert scale survey measuring reported comfort with the management of specific obstetrical emergencies and procedures before, immediately after, 6 months after, and 1 year after participation in an ALSO course. Practice patterns were also surveyed. Paired data were analyzed using the Kruskal-Wallis one-way ANOVA test at a 95% confidence interval for two-tailed significance.

RESULTS

ALSO course participants reported a significant increase in their comfort with the management of each of 15 obstetrical emergencies and procedures taught in the ALSO curriculum. Reported comfort remained high at 6 months' and 1-year follow-up and was accompanied by a statistically significant change in reported practice patterns; more participants performed, in their practice 1 year after completion of ALSO training, amnioinfusion, vacuum-assisted vaginal delivery, and ultrasound for determining fetal position and placental location.

CONCLUSIONS

Affective learning is important in translating knowledge and skills into the practice of medicine. Our study demonstrates that participation in the ALSO course increases participants' knowledge in the affective domain of learning.

Perceived characteristics of successful family practice residency maternity care training programs

BACKGROUND AND OBJECTIVES

This study determined the perceived characteristics of family practice residency training programs that produce a high percentage of graduates who provide maternity care.

METHODS

We surveyed a Delphi panel of 28 family practice maternity care experts.

RESULTS

Consensus was reached after the third survey. The characteristics of the family medicine faculty and teaching service were rated as most important. Other essential characteristics were an adequate obstetrical training volume; mutual respect between obstetric and family medicine faculty and residents; support for family practice maternity care from obstetricians, administration, and nursing staff; and family physicians being accepted in the community as maternity care providers.

CONCLUSIONS

Family practice residency programs that produce a high percentage of graduates who provide maternity care have a unique, family practice maternity care-friendly environment. Residency programs wishing to increase the percentage of their graduates who provide maternity care should ensure that their faculty support family practice maternity care, are competent in maternity care, and model maternity care in their own practices. They should strive to ensure an adequate volume of obstetrical cases for resident education and work toward educating patients and local obstetricians, nursing staff, and hospital administration regarding family practice maternity care.

The maternity care practice of Navy family practice residency graduates while on active duty

BACKGROUND AND OBJECTIVES

Military family practice residency programs produce a high percentage of graduates who provide maternity care. This study will define the scope of maternity care practice for one military family practice residency program's graduates while they were serving on active duty in the U.S. Navy.

METHODS

Two hundred eight surviving graduates of the family practice residency at Naval Hospital, Jacksonville, Florida, from 1971 to 1995 were surveyed by mail regarding their maternity care practice while on active duty. One hundred eighty-one (87%) responded to the survey, and the data were analyzed with descriptive statistics.

FINDINGS

The vast majority of these Navy family practice residency graduates provided prenatal care (88.4%) and routine vaginal delivery services (85.1%) while on active duty. The majority repaired third- and fourth-degree perineal lacerations and performed vacuum- or forceps-assisted vaginal delivery. Additionally, a significant minority provided more advanced maternity care services such as dilation and curettage, tubal ligation, and cesarean section. The overwhelming majority (97%) of these graduates felt that their residency education had adequately prepared them to provide these maternity care services while on active duty.

CONCLUSIONS

During the past 25 years, Navy residency-trained family physicians provided a wide range of maternity care services while on active duty and felt that their Navy residency training program had prepared them well to meet this responsibility.

Indexing events in memory: evidence for index dominance

Research on narrative comprehension and autobiographical memory converge on three hypotheses which make different predictions about event organisation. The availability of different event components as indexes may explain the convergence on three hypotheses rather than one. In this paper, three experiments assessed event indexing in narratives with different available indexes. In Experiment 1, participants read event descriptions organised by character or time. In Experiment 2, event descriptions were organised by character or location. In Experiment 3, participants read event descriptions where events were grouped by activity. In each experiment, memory could be organised by any of the available components alone, by both components, or by using the organisation imposed by the discourse. Participants indexed events by character in Experiment 1, re-indexing information when necessary. Results of Experiment 2 indicated equal use of character and location indexes. In this case, participants used the discourse organisation. In Experiment 3, participants indexed events using activity groupings, again re-indexing events when necessary. Results are interpreted as indicating reliance on a single organising index with flexibility in the selection of different event components as indexes.

beta-Galactosidase gene mutations in patients with slowly progressive GM1 gangliosidosis

Three unrelated North American cases with slowly progressive forms of GM1 gangliosidosis were found to have two unique point mutations and a 9 bp insertion in the coding region of the gene encoding beta-galactosidase. Case 1 was noted to have a 9 bp insertion ¿CAGAATTTT¿ on one allele between nucleotides 730 and 731 with no other mutations identified in the other allele. In case 2, two point mutations were found: a unique G-->A transition at nucleotide 602 causing an Arg-->His substitution in codon 201 (mutation R201H); and a previously identified G-->T transition at nucleotide 1527 causing a Trp-->Cys substitution in codon 509 (mutation W509C), which has been noted in adult and chronic forms of GM1 gangliosidosis. Case 3 had a unique point mutation (A-->G transition at nucleotide 797) resulting in a Asn-->Ser amino acid substitution in codon 266 (mutation N266S), with no other mutations found in the same or the other allele. Single-strand conformation polymorphism performed on over 100 controls did not demonstrate the presence of the point mutations R201H or N266S. Also, the mutant proteins coded by the two point mutations did not show enzymatic activity in the Cos-1 cell expression system confirming that these mutations are associated with low enzyme activity.

Long-term survival of African Americans in the Coronary Artery Surgery Study (CASS)

OBJECTIVES

This study sought to determine the long-term (> 15 years) outcome of a clinically well characterized cohort of African Americans with known or suspected coronary artery disease (CAD).

BACKGROUND

The mortality rate from CAD is higher in African Americans than in whites. An earlier analysis of data from the Coronary Artery Surgery Study (CASS) registry suggested that African American and white patients treated surgically had equal 5-year survival rates.

METHODS

Survival data from the CASS registry were analyzed to determine whether 1) African American race is an independent predictor of mortality; and 2) initial therapy is predictive of mortality among African American patients.

RESULTS

Overall, 60% of white and 52% of African American patients survived 16 years (p < 0.00001). Multivariate Cox models confirmed that African American race was independently associated with higher mortality in both the medical group (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.11 to 1.63) and the surgical group (HR 1.63, 95% CI 1.19 to 2.23). Initial therapy was not predictive of survival among African American patients (p = 0.81). However, smoking status significantly influenced survival: African Americans who did not smoke experienced significantly improved survival (60% vs. 48% for smokers), which equaled survival for white nonsmokers (61%, p = NS).

CONCLUSIONS

In contrast to results from shorter term studies, African Americans experienced higher overall mortality rates than whites over the long term, regardless of the type of initial treatment. Survival among nonsmoking African Americans at 16 years equaled survival among nonsmoking whites.

Providing the Advanced Life Support in Obstetrics Course within the military family practice training system

"The Advanced Life Support in Obstetrics (ALSO) Course is designed to assist health professionals in developing and maintaining the knowledge and skills they will need to effectively manage the emergencies which arise in obstetrics." Given the fact that the vast majority of military family physicians provide maternity care, often in small overseas facilities without in-hospital obstetrician backup, inclusion of this course into the military family practice residency training curriculum would be very beneficial to the mission of family practice within the military. A brief background of the ALSO movement and the ALSO course curriculum are provided. Lessons learned to aid military family practice departments in providing quality ALSO courses are described, as are arguments for the inclusion of ALSO training into military family practice training curriculums.

Harms of excluding pregnant women from clinical research: the case of HIV-infected pregnant women

Since the beginning of the AIDS epidemic, the proportion of AIDS cases among women has continued to rise. Women constituted 23 percent of the AIDS cases reported to the Centers for Disease Control and Prevention (CDC) in 1995, and 81 percent of these women were of childbearing age (13 to 44 years). It was not until 1991, however, that epidemiological studies of women were initiated. By comparison, the representation of HIV-infected women in clinical trials gradually has grown. Undoubtedly, a consequence of the increased numbers of women in clinical and epidemiological research is the earlier identification of and more appropriate treatments for HIV-related syndromes when women present in the clinical setting. Despite this expanded focus on women, however, clear information to guide the treatment of HIV-infected women who are pregnant is still lagging behind.

Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience

BACKGROUND

Observational and randomized studies designed to compare surgical and medical therapies in patients with left main coronary artery disease (LMCD) have shown that coronary artery bypass graft (CABG) surgery prolongs life in most patients with LMCD. The present report of 1484 patients with LMCD in the Coronary Artery Surgery Study (CASS) Registry extends the originally published 5-year surgical and medical group survival analysis to more than 16 years of follow-up and permits analysis of LMCD patient subgroups.

METHODS AND RESULTS

The CASS Registry contains 1484 patients with > or = 50% left main coronary artery stenosis initially treated with either surgical or nonsurgical therapy. The 15-year cumulative survival estimates were 37% for the 1153 patients in the surgical group compared with 27% for the 331 patients in the medical group. Median survival in the surgical group was 13.3 years (12.8 to 13.8 years, 95% confidence limits) compared with only 6.6 years (5.4 to 7.9 years) in the medical group (difference, 6.7 years; P < .0001). Median survival was also significantly longer in the surgical group stratified by age, sex, anginal class, left ventricular (LV) function, coronary anatomy, and the extent of LMCD. However, CABG surgery did not significantly prolong median survival in patient subgroups with (1) left main coronary stenosis of 50% to 59%; (2) normal LV systolic function; (3) normal or mildly abnormal LV systolic function and a right coronary artery stenosis > or = 70%; and (4) a nonstenotic (< or = 70%) right coronary artery. The 15-year cumulative survival for patients with normal LV systolic function in the surgical and medical groups was 42% and 51%, respectively. Median survival was 14.7 years in the surgical group and > 15 years in the medical group (P = NS). In patients with normal LV systolic function and a right coronary artery stenosis > or = 70%, the 15-year cumulative survival rates were also similar in the surgical and medical groups (40% and 48%, respectively). Median survival was 14.3 years in the surgical group and 14.2 years in the medical group (P = NS). The 15-year cumulative survival estimates for all subgroups were affected by convergence of the surgical and medical survival group curves owing to a disproportionate increase in the late surgical group mortality. Overall, 25% of patients in the medical group ultimately underwent CABG surgery. If all medical group patients had survived long enough, about 47% would be estimated to have had surgery by 15 years.

CONCLUSIONS

This report, which extends follow-up of more than 16 years in CASS Registry patients with LMCD, shows that CABG surgery prolongs life in most clinical and angiographic subgroups. However, median survival was not prolonged by CABG surgery in patients with normal LV systolic function, even if a significant right coronary artery stenosis (> or = 70%) also was present. These results extend our understanding of the natural history of LMCD and permit a more accurate estimate of long-term surgical and medical group survival.

Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience

BACKGROUND

Combined severe proximal left anterior descending and proximal left circumflex coronary artery disease, or left main equivalent (LMEQ) disease, defines a prognostic high-risk angiographic subset of patients with chronic ischemic heart disease. While numerous observational and randomized clinical trials showed prolonged survival in surgically compared with medically treated patients with left main coronary artery disease, relatively few observational studies compared surgical and medical therapies in patients with LMEQ disease. The present report of 912 patients with LMEQ disease in the Coronary Artery Surgery Study (CASS) Registry extends the originally published 5-year surgical and medical group survival analysis to more than 16 years of follow-up and permits analysis of LMEQ patient subgroups.

METHODS AND RESULTS

The CASS Registry contains 912 patients with LMEQ disease, defined as combined stenoses of > or = 70% in the proximal left anterior descending coronary artery before the first septal perforator and proximal circumflex coronary artery before the first obtuse marginal branch, initially treated with either surgical or nonsurgical therapy. The 15-year cumulative survival estimates were 44% for the 630 patients in the surgical group and 31% for the 282 patients in the medical group. Median survival in the surgical group was 13.1 years (12.7 to 14.1 years, 95% confidence limits) compared with only 6.2 years (4.8 to 7.9 years) in the medical group (difference, 6.9 years; P < .0001). Median survival was also significantly longer in the surgical group stratified by age, sex, anginal class, left ventricular (LV) function, and coronary anatomy. However, coronary artery bypass graft (CABG) surgery did not significantly prolong median survival in patient subgroups with (1) normal LV systolic function, even if a significant right coronary artery stenosis (> or = 70%) also was present, and (2) mildly abnormal (LV score, 6 to 10) LV systolic function. The 15-year cumulative survival in patients with normal LV systolic function in the surgical and medical groups was 63% and 54%, respectively. Median survival was > 15 years in both the surgical and medical groups (P = NS). In patients with normal LV systolic function and right coronary artery stenosis > or = 70%, the 15-year cumulative survival was also similar in the surgical and medical groups (63% and 53%, respectively). Median survival was > 15 years in both the surgical and medical groups (P = NS). The 15-year cumulative survival estimates in all subgroups were affected by convergence of the surgical and medical group survival curves caused by a disproportionate increase in late surgical group mortality. Overall, 26% of patients in the medical group ultimately underwent CABG surgery. If all medical group patients had survived long enough, about 65% would be estimated to have had surgery by 15 years. When the CASS Registry patients with LMEQ disease who participated in the randomized trial or who were randomizable were analyzed, CABG surgery did not prolong the 15-year cumulative survival estimates compared with nonsurgical therapy for randomized (71% versus 67%, respectively) and for randomizable patients (62% versus 92%, respectively) with an LV ejection fraction > or = 50%.

CONCLUSIONS

This report, which extends follow-up of more than 16 years in CASS Registry patients with LMEQ disease, shows that CABG surgery prolongs life in most clinical and angiographic subgroups. However, median survival was not prolonged by CABG surgery in patients with normal LV systolic function, even if a significant right coronary artery stenosis (> or = 70%) also was present or in patients with an LV ejection fraction > or = 50% who participated in the CASS randomized trial or who were randomizable.

Race and sex differences in rates of invasive cardiac procedures in US hospitals. Data from the National Hospital Discharge Survey

BACKGROUND

Lower rates of invasive cardiac procedures have been reported for blacks and women than for white men. However, few studies have adjusted for differences in the type of hospital of admission, insurance status, and disease severity. SETTING, DESIGN, AND PARTICIPANTS: Data from the National Hospital Discharge Survey were used to investigate race and sex differences in rates of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery among 10,348 persons hospitalized for acute myocardial infarction.

RESULTS

White men consistently had the highest procedure rates, followed by white women, black men, and black women. After matching for the hospital of admission and adjusting for age, in-hospital mortality, health insurance, and hospital transfer rates (with white men as the referent), the odds ratios for cardiac catheterization were 0.67 (95% confidence interval [CI], 0.51 to 0.87) for black men, 0.72 (95% CI, 0.63 to 0.83) for white women, and 0.50 (95% CI, 0.37 to 0.68) for black women. Similar race-sex differences were noted for percutaneous transluminal coronary angioplasty and coronary artery bypass surgery.

CONCLUSIONS

Race and sex differentials in the rates of invasive cardiac procedures remained despite matching for the hospital of admission and controlling for other factors that influence procedure rates, suggesting that the race and sex of the patient influence the use of these procedures.

Expression of PAI-1, t-PA and u-PA in cultured human umbilical vein endothelial cells derived from racial groups

To determine whether inherent fibrinolytic differences may exist in racial groups (black americans, BA vs. white americans, WA), 55 different individual racially-derived human umbilical vein endothelial cell (HUVEC) cultures (35 BA and 20 WA) were analyzed in terms of their fibrinolytic protein (t-PA, u-PA and PAI-1) antigen and mRNA levels. Values (mean +/- SD) for measured fibrinolytic component levels include: cell-associated t-PA antigen (ELISA), 1.14 +/- 0.82 ng/ml/8.6 x 10(5) cells/24 hr in BA and 0.70 +/- 0.85 ng/ml in WA (p = 0.0624); secreted t-PA antigen, 18.65 +/- 17.06 ng/ml in BA and 10.37 +/- 6.38 ng/ml in WA (p = 0.0422); t-PA/cyclophilin mRNA ratios (Northern blot analysis), 1.90 +/- 1.34 in BA and 1.32 +/- 0.70 in WA (p = 0.0776); cell-associated PAI-1 antigen, 71.10 +/- 30.16 ng/ml/8.6 x 10(5) cells/24 hr in BA and 108.85 +/- 56.89 ng/ml in WA (p = 0.0022); secreted PAI-1 antigen, 1,582.13 +/- 612.67 ng/ml in BA and 1,992.17 +/- 711.50 ng/ml in WA (p = 0.0285); 2.4 kb PAI-1/cyclophilin mRNA ratios, 0.59 +/- 0.39 in BA and 0.79 +/- 0.31 in WA (p = 0.1085); 3.4 kb PAI-1/cyclophilin mRNA ratios, 0.70 +/- 0.47 in BA and 0.77 +/- 0.54 in WA (p = 0.6322). These combined data suggest that cultured HUVECs from BA express significantly higher levels of t-PA, lower levels of PAI-1 and approximately 1.72-fold lower molar ratio of PAI-1/t-PA antigen (183.99 +/- 168.81 vs. 315.92 +/- 164.99) (p < 0.05) than cultured HUVECs from WA, presumably reflecting an apparent inherent increased fibrinolytic potential in cultured HUVEC derived from BA.

Race and prognosis after myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) phase II trial

BACKGROUND

To better understand the role of race/ethnicity in survival after acute myocardial infarction, we compared clinical and laboratory data, response to thrombolytic therapy, and clinical outcome in 2885 patients participating in the Thrombolysis in Myocardial Infarction Phase II (TIMI II) Trial among three groups of patients (2564 whites, 174 blacks, and 147 Hispanics).

METHODS AND RESULTS

Differences were found in baseline characteristics among the three groups including (1) age (mean age for whites, 57.2 years; blacks, 54.8 years; Hispanics, 52.8 years; P < .001), (2) sex (percentage of women for whites, 17.6; blacks, 28.7; Hispanics, 14.3; P < .001), and (3) risk factor prevalence: current smoking (percent for whites, 49.4; blacks, 62.1; Hispanics, 55.1; P < .003), history of hypertension (percent for whites, 36.6; blacks, 55.7; Hispanics, 39.5; P < .001), and diabetes mellitus (percent for whites, 11.9; blacks, 22.4; Hispanics, 19.7; P < .001). Changes in hemostatic factors 5 hours after infusion of recombinant tissue plasminogen activator (rt-PA) revealed a more profound fall in fibrinogen levels in black patients compared with the response seen in Hispanic or white patients (mean change in fibrinogen +/- SD, mg/dL: 151.3 +/- 107.4, 112.2 +/- 97.0, 109.4 +/- 98.6; P < .001, respectively) without more frequent infarct-related artery patency or hemorrhagic complications. Mortality was similar in the white, black, and Hispanic patients through the first year after adjustment for baseline variables.

CONCLUSIONS

TIMI II data yield evidence that (1) corroborates published reports of a high prevalence of classic cardiovascular risk factors among minority patients with acute myocardial infarction, (2) there is a greater decrease in fibrinogen levels 5 hours after the start of rt-PA infusion among black patients than in white and Hispanic patients without evidence of more frequent infarct-related artery patency or hemorrhagic complications, and (3) thrombolytic therapy with appropriate supplemental measures is associated with comparable 1-year mortality in white, black, and Hispanic patients.

Descriptions and depictions of environments

Subjects studied maps with the expectation that they would draw or describe them from memory. In fact, subjects did both. Order of drawing or describing landmarks revealed the mental organization of environments. Organization was quite similar across maps and descriptions of the same environments, revealing hierarchical structures based on spatial and functional features of the environments and on conventions for sequencing the landmarks.

Cytogenetic, biochemical, and molecular analyses of a 22q13 deletion

We report on a 3-year-old boy with a terminal deletion of 22q. The activity of alpha-N-acetylgalactosaminidase was normal while arylsulfatase A activity was reduced. Molecular analysis demonstrated the lack of paternal alleles of D22S45 and D22S55.

Deletion mapping of plasminogen activator inhibitor, type I (PLANH1) and beta-glucuronidase (GUSB) in 7q21----q22

DNA from a male fetus with an interstitial deletion of 7q22 [(46,XY,del(7)(pter----q22.10::q31.10----qter)] was analyzed using probes in this region of 7q. The results localize plasminogen activator inhibitor type I (PLANH1) to 7q22.1----q22.3 and beta-glucuronidase to band 7q21.11.