National assessment of physicians' breast-feeding knowledge, attitudes, training, and experience

OBJECTIVE

Previous reports have demonstrated that physician counseling can improve rates of breast-feeding initiation and duration but suggest that physicians are ill-prepared for this role. It is unclear whether residency training for pediatricians, obstetrician/gynecologists, and family physicians provides the knowledge and skills necessary for effective breast-feeding promotion.

DESIGN

Survey.

PARTICIPANTS

A national random sample of 3115 residents and 1920 practicing physicians in pediatrics, obstetrics/gynecology, and family medicine.

OUTCOMES

Assessment of breast-feeding knowledge, attitudes, training, and experience.

RESULTS

Overall response rate was 68%. All groups demonstrated significant deficits in knowledge of breast-feeding benefits and clinical management; for example, less than 50% of residents chose appropriate clinical management for a breast-fed jaundiced infant or a breast abscess. Practicing physicians performed slightly better, but still more than 30% chose incorrect advice for mothers with low milk supply. Residents reported that their breast-feeding instruction consisted mainly of didactic lecture, not patient experience. Only 55% of senior residents recalled even one instance of precepting related to breast-feeding, and less than 20% had demonstrated breast-feeding techniques at least five times during residency. Regarding preparation for breast-feeding counseling, more than 50% of all practicing physicians rated their residency training as inadequate. Overall, physician involvement in breast-feeding promotion was endorsed by 90% of respondents, yet only half rated themselves as effective in counseling breast-feeding patients. The greatest predictor of physician self-confidence was previous personal or spousal breast-feeding experience.

CONCLUSIONS

In this national sample of residents and practicing physicians in three specialties, physicians were ill-prepared to counsel breast-feeding mothers. Deliberate efforts must be made to incorporate clinically based breast-feeding training into residency programs and continuing education workshops to better prepare physicians for their role in breast-feeding promotion.

A prospective randomized crossover comparison of zygote intrafallopian transfer and in vitro fertilization-embryo transfer in unexplained infertility

60 couples aged under 38 with unexplained infertility were recruited in this prospective randomized crossover study to compare the efficacy of treatment between ZIFT and IVF-ET. A total of 150 stimulation cycles were commenced and 132 proceeded to successful egg collection (88%). Fertilization successfully occurred in 114 cycles (86.36%). A total of 110 embryo replacements were carried out, (52 uterine transfer and 58 tubal transfer). This prospective randomized cross over trial demonstrated the trend for higher implantation rate, pregnancy rate, and ongoing pregnancy rate with ZIFT over IVF-ET for patients with unexplained infertility. The actual implantation rate, pregnancy rate, and ongoing pregnancy rate with ZIFT were 13.7, 34.5, 31.0 per cent respectively compared to the results from IVF-ET which were 12.1, 26.9, 25.0 per cent respectively. However, the difference was not statistically significant. Although this study showed a 5 per cent ectopic pregnancy rate with ZIFT and none with IVF-ET, the difference was not statistically significant. Similarly, there was no difference in the overall miscarriage rate and multiple pregnancy rate between the two protocols. In conclusion, this prospective randomized crossover trial demonstrated the trend for higher reproductive outcomes in term of implantation rate, pregnancy rate, and ongoing pregnancy rate with ZIFT over IVF-ET in unexplained infertility but the difference was not statistically significant.

Effect of low-dose prednisolone on sperm fertilizing capacity in subfertile men with circulating antisperm antibodies

To assess if low-dose prednisolone reduced circulating antisperm antibodies and improved sperm fertilizing capacity, the hamster oocyte penetration test (HOPT) was used to evaluate treatment in 36 males with significant serum antisperm antibodies, measured by the tray agglutination test (TAT). Prednisolone 5 mg three times a day for 3 months was used. Only couples in whom all tests in the female partner were normal were entered into the study. A significant increase in sperm density, normal morphology, and HOPT were noted after therapy (p < .001). A significant decrease in antisperm antibody titer was noted (p < .0001) and correlated with improvement of HOPT (p < .05). There were no significant side effects. Six pregnancies (17%) occurred. Three pregnancies (18%) occurred in partners of an untreated group of 17 men. Prednisolone therapy in this regime does not significantly improve pregnancy rates. The HOPT does not offer any additional information for predicting patients who will show an improvement in antibody titers or achieve pregnancy after steroids.

Utilization of ketorolac tromethamine for control of severe odontogenic pain

Ketorolac tromethamine (KT) (Toradol, 60 mg to 2 ml), an injectable nonsteroidal anti-inflammatory drug, was compared with a placebo (sodium chloride, 0.9%) for analgesic effects in patients presenting with severe odontogenic pain. Utilizing a double-blind protocol, KT and placebo were administered and evaluated. Forty patients presenting with severe odontogenic pain (75 to 100 mm and above utilizing the visual analog scale of 100 mm) recorded their visual analog scale score once every 10 min for 90 min after injection of either KT or placebo and before initiating traditional incision and drainage, endodontic therapy, and/or extraction. Results indicate that KT patients had significantly less pain from 20 to 90 min postadministration than those receiving placebo. By the 90-min period, KT patients were reporting negligible discomfort. Observed side effects included lightheadedness and injection site pain. It was concluded that KT effectively reduces severe odontogenic pain within 40 min after administration in human subjects, with minimal side effects.

Patients as subjects for research: ethical dilemmas for the primary care clinician-investigator

BACKGROUND

Past studies suggested an association between human papillomavirus (HPV) and cervical intraepithelial neoplasia (CIN). In 1987, University of North Carolina (UNC) Hospitals Family Practice Center clinicians were approached for a control population to study this association.

METHODS

One hundred five patients attending the UNC Hospitals Neoplasia Clinic with biopsy-proven CIN 2 or 3 and 268 control patients attending the UNC Family Practice Center for a routine Papanicolaou smear were enrolled in this case-control study. Case and control patients consented to having an additional cervical specimen taken and to being interviewed. The cervical specimens were classified by the Southern blot and polymerase chain reaction techniques for HPV.

RESULTS

Early results suggested the control patients who had HPV were at high risk of developing CIN. Interventions were made to inform these patients of this risk and need for closer follow-up, causing a wide range of patient reactions. The final results showed no association of HPV with CIN, indicating the early interventions were premature.

CONCLUSIONS

Physicians engaged in research need to be prepared to deal with the discovery of health risks in the otherwise "normal" control patient. They bear the ethical responsibility of scrutinizing study design and methods and planning communication with patients from the inception of a study.

Pretreatment with gonadotrophin releasing hormone (GnRH) analogue prior to in vitro fertilisation for patients with endometriosis

To assess the effect of GnRH pretreatment prior to IVF-ET on fertilisation and pregnancy rates in patients with endometriosis compared with tubal infertility, a retrospective analysis of 228 cycles of tubal infertility cases (Group 1) and 92 cycles of endometriosis has been performed. Patients with endometriosis were classified by the revised AFS scoring system to two groups: 37 cycles of minimal and mild endometriosis (Group 2) and 55 cycles of moderate and severe endometriosis (Group 3). The GnRH analogue buserelin was used for pituitary desensitisation in all IVF cycles. Endometriosis patients have a minimum of 6 weeks GnRH treatment prior to superovulation therapy. Although the fertilisation rate per oocyte (51%) was significantly lower in Group 3 (P < 0.001), the percentage of cycles in which fertilisation occurred (86%, 78%, 78%) and the pregnancy rates per embryo transfer (17.7%, 17.2%, 18.6%) for Groups 1, 2 and 3, respectively, were not significantly different. Pretreatment with GnRH analogues allows patients with endometriosis to achieve similar success rates to patients with tubal infertility alone.

The effect of prazosin on patients with symptoms of benign prostatic hypertrophy

OBJECTIVE

To evaluate the effect of prazosin on the symptoms of benign prostatic hypertrophy for patients of general practitioners.

SETTING AND PATIENTS

Eighty-two general practitioner patients from 317 who were identified as being eligible for inclusion in the trial. They were randomly allocated to receive either prazosin or placebo for the first 3 month arm then crossed-over for the second 3 months.

RESULTS

Seventy-six patients completed the trial. An analogue scale of patient rating of symptoms showed a statistically significant decrease in symptoms for patients taking prazosin when compared with patients taking placebo, regardless of the order in which they had been administered. A total symptom score and an obstructive symptom score for benign prostatic hypertrophy showed a statistically significant difference between the two treatments at 4 weeks. A difference was still apparent at 8 and 12 weeks but it was not statistically significant. No difference was detected for irritative symptoms.

CONCLUSION

Prazosin may have a limited place in the management of benign prostatic hypertrophy.

Direct inhibition of ovarian steroidogenesis by cortisol and the modulatory role of 11 beta-hydroxysteroid dehydrogenase

OBJECTIVE

The association of adrenal hyperactivity with ovarian dysfunction may involve direct inhibition of ovarian steroidogenesis by glucocorticoids. Therefore, the objectives of this study were to investigate the direct effects of cortisol on luteinizing hormone (LH) action in human granulosa-lutein cells and the modulation of this interaction by ovarian 11 beta-hydroxysteroid dehydrogenase (11 beta HSD).

DESIGN AND PATIENTS

Effects were investigated in cultured human granulosa-lutein cells isolated from the follicular aspirates of 14 patients undergoing oocyte collection for in-vitro fertilization and embryo transfer.

MEASUREMENTS

Pregnenolone production and 3H-cortisol oxidation to 3H-cortisone (11 beta HSD activity) by cultured cells were measured.

RESULTS

In cells from nine (of 14) patients, cortisol inhibited LH-stimulated steroidogenesis in a concentration dependent manner with an ID50 of 1250 +/- SEM 377 nmol/l. In these cultures, the 11 beta HSD activities were high (133 +/- SEM 23 pmol/mg protein/4h) and inhibition of the enzyme with carbenoxolone potentiated the action of cortisol. Conversely, cells from the remaining five patients lacked detectable 11 beta HSD activity and exhibited an increased sensitivity to the inhibitory action of cortisol (ID50 = 158 +/- SEM 41 nmol/l in the absence of carbenoxolone).

CONCLUSIONS

Cortisol acts directly in human granulosa-lutein cells to inhibit the support of steroidogenesis by LH and this interaction is modulated by ovarian 11 beta HSD in the majority of patients.

In search of the 'back mouse'

The "back mouse" is a tender, fibrous, fatty subcutaneous nodule found in the lumbosacral area in up to 16% of people. It can be a treatable cause of low back pain that may be unrecognized by both specialists and generalists.

Papanicolaou smear quality assurance: providing feedback to physicians

BACKGROUND

The effective management of Papanicolaou (Pap) smears depends on the reliability and accuracy of obtaining and interpreting the specimen. Provider sampling error is one of the important factors contributing to inadequate specimens. Feedback on provider performance may be an effective way to improve the quality of Pap smears.

METHODS

A pilot study in a university-based residency program involving resident and faculty physicians was initiated to assess the impact of feedback on performance of Pap smears. After establishing adequacy and inadequacy criteria and recording adequacy rates for 3 months, individual and group feedback was implemented. No formal educational intervention on Pap smear technique was undertaken.

RESULTS

The quality of 836 Pap smears performed by 9 faculty and 13 resident physicians showed continued improvement in both sampling and slide preparation to 90% adequacy over a 9-month period. This improvement, though clinically useful, was not statistically significant owing to the relatively small numbers of smears performed by each physician. This form of feedback may be useful in both practice and educational settings.

CONCLUSIONS

Feedback without any formal educational intervention led to a clinically useful trend of improvement in the quality of Pap smears, which has been sustained since the study began. This type of simple feedback may be useful in practice settings and particularly valuable in pinpointing areas for improvement for learners in residency programs.

The prevalence of endometriosis in women with infertile partners

Laparoscopy was performed on a consecutive series of 174 women complaining of infertility. Forty of these women were the partners of oligospermic or azoospermic men. There was no difference in the prevalence of endometriosis between those women whose partners were fertile and those whose partners were infertile. Women with azoospermic partners had a prevalence of endometriosis of 20.7%, and this is likely to reflect the true prevalence of endometriosis in a group of randomly selected normal women.

Adverse effects on sperm movement characteristics in women with minimal and mild endometriosis

OBJECTIVE

To test the effect of peritoneal fluid from infertile women with minimal or mild endometriosis on sperm movement characteristics in comparison with fertile and infertile women with no endometriosis.

DESIGN

A prospective observer-blind trial.

SETTING

Academic infertility department.

SUBJECTS

57 women undergoing diagnostic laparoscopy or laparoscopic sterilisation.

MAIN OUTCOME MEASURES

Changes in sperm movement characteristics in semen samples provided during routine infertility investigation or from sperm donors. Computer assisted semen analysis (CASA) performed using a Celltrack-S system.

RESULTS

Significant reductions in linearity (P < 0.05), amplitude of lateral head displacement (P < 0.01), straight line velocity (P < 0.01), and curvilinear velocity (P < 0.01) (but not percentage motility) were observed.

CONCLUSIONS

Peritoneal fluid from women with minimal or mild endometriosis adversely effects sperm movement characteristics in comparison to fertile women.

Development of a Pap smear quality-assurance system in family practice

BACKGROUND AND OBJECTIVES

To improve the effectiveness of cervical cancer screening, quality assurance programs can be designed to ensure that normal Pap smear results are dealt with appropriately and that Pap smears yielding inadequate specimen material are brought to a physician's attention. The objective of this study was to use a new Pap Smear Quality Assurance (PAPQA) system to determine and monitor the performance of physicians in a family practice over a two-year period.

METHODS

We developed a PAPQA system designed to gather data and report on: 1) Pap smear adequacy, 2) reporting of abnormal results to physicians, and 3) follow-up of patients who had abnormal Pap smear results. We followed these parameters for two years.

RESULTS

Over a two-year period, 2,771 cervical Pap smears were performed, of which 64% were normal. The percentage of Pap smears that yielded adequate specimen material improved from 82% to 91%, an improvement we attributed to feedback the system provided to physicians. Overall, Pap smear results and follow-up appeared in the medical record of 94% of patients who had abnormal findings. However, during the second year, the quality assurance system detected a deterioration in documentation of results and follow-up plans that coincided with moving the practice to a new facility. The operating cost for this program was approximately $950 per year.

CONCLUSIONS

Quality assurance programs can effectively monitor physicians' performance in dealing with abnormal Pap smears, can detect deteriorations in performance, and can improve some aspects of performance through feedback reporting to physicians.