Using the patient-centered method to achieve excellence in care for women with breast cancer

The diagnosis of breast cancer remains one of the most threatening and emotionally debilitating diagnoses given to patients. Breast cancer elicits fears of loss of ability, control, hope, and at worst--loss of life. Patients and their families, devastated by the diagnosis of cancer, often feel unsupported or dismissed by their health care providers. Using the example of breast cancer, this paper describes how the application of the patient-centred clinical method can assist physicians in caring for patients diagnosed with breast cancer. Composite cases and quotes drawn from qualitative research studies with breast cancer patients are used to illustrate the application of the patient-centred clinical method.

Architectural characteristics of muscle in black and white college football players

PURPOSE

The purpose of this study was to determine whether architectural characteristics of skeletal muscle differ by race.

METHODS

Skeletal muscle architectural characteristics and body composition were studied in 13 black and 31 white male college football players. Fat-free mass (FFM) and percentage body fat (% fat) were determined by hydrostatic weighing technique. Muscle thickness (MTH) was measured by B-mode ultrasound at 13 anatomical sites. Isolated MTH and muscle pennation angle (PANG) of the triceps long head, vastus lateralis, and gastrocnemius medialis muscles were measured by ultrasound, and fascicle length was estimated.

RESULTS

There were no significant differences between blacks and whites in isolated MTH, PANG, and fascicle length in the triceps long head, vastus lateralis, and gastrocnemius medialis muscles. On average, % fat and FFM of black and white football players were 18.8 +/- 4.6% and 17.2 +/- 5.6% for % fat, and 89.9 +/- 15.6 kg and 89.1 +/- 10.4 kg for FFM, respectively. Blacks had a significantly greater, 30%-quadriceps (P < 0.05), 50%-hamstrings (P < 0.05), biceps (P < 0.01), and abdomen (P < 0.01) MTH than those of whites. Standing height and body weight were similar between blacks and whites, but the ratio of leg length to standing height was significantly greater in blacks compared with whites.

CONCLUSIONS

It appears that although there may be race differences in anatomical stature, muscle architecture is likely independent of race.

The progressive cost of complications in type 2 diabetes mellitus

BACKGROUND

A substantial proportion of the costs of diabetes treatment arises from treating long-term complications, particularly cardiovascular and renal disease. However, little is known about the progressive cost of these complications. Firmer knowledge would improve diabetes modeling and might increase the financial and organizational support for the prevention of diabetic complications.

METHODS

We analyzed 9 years of clinical data on 11 768 members of a large group-model health maintenance organization who had probable type 2 diabetes mellitus. We ascertained the presence of cardiovascular and renal complications, staged the members progression, and estimated their incremental costs by stage.

RESULTS

We found no significant differences between men and women in the prevalence or staging of complications. Per-person costs increased over baseline ($2033) by more than 50% ($1087) after initiation of cardiovascular drug therapy and/or use of a cardiologist, and by 360% ($7352) after a major cardiovascular event. Abnormal renal function increased diabetes treatment costs by 65% ($1337); advanced renal disease, by 195% ($3979); and end-stage renal disease, by 771% ($15 675). Both cardiovascular and renal diseases were more common among older subjects, but age did not affect the additional costs of these complications. Women had substantially higher medical care costs after controlling for age and presence of complications. Incremental cost estimates based solely on "labeled" events significantly underestimate true incremental cost.

CONCLUSIONS

In an aggregate population, the greatest cost savings would be achieved by preventing major cardiovascular events. For individuals, the greatest savings would be achieved by preventing progression to stage 3 renal disease.

Breast cancer survivors' perceptions of complementary/alternative medicine (CAM): making the decision to use or not to use

The study described in this article explored breast cancer survivors' perceptions and experiences as they decided whether to use a variety of complementary/alternative therapies. Six focus groups were conducted composed of women who had been diagnosed with breast cancer. Each 2-hour session was audiotaped and transcribed verbatim. In this article, the process by which the participants made the decision to use or not to use complementary/alternative therapies, including their discovery and investigation of complementary/alternative medicine (CAM) and their experiences using or not using CAM, are described. Barriers to using CAM included cost, access, and time. Family and friends generally supported the decision to use CAM; however, the participants described health care practitioners' reactions as mixed.

Type 2 diabetes: incremental medical care costs during the first 8 years after diagnosis

OBJECTIVE

To describe and analyze the time course of medical care costs caused by type 2 diabetes, from the time of diagnosis through the first 8 postdiagnostic years.

RESEARCH DESIGN AND METHODS

From electronic health maintenance organization (HMO) records, we ascertained the ongoing medical care costs for all members with type 2 diabetes who were newly diagnosed between 1988 and 1995. To isolate incremental costs (costs caused by the diagnosis of diabetes), we subtracted the costs of individually matched HMO members without diabetes from costs of members with diabetes.

RESULTS

The economic burden of diabetes is immediately apparent from the time of diagnosis. In year 1, total medical costs were 2.1 times higher for patients with diabetes compared with those without diabetes. Diabetes-associated incremental costs (type 2 diabetic costs minus matched costs for people without diabetes) averaged $2,257 per type 2 diabetic patient per year during the first 8 postdiagnostic years. Annual incremental costs varied relatively little over the period but were higher during years 1, 7, and 8 because of higher-cost hospitalizations for causes other than diabetes or its complications.

CONCLUSIONS

For the first 8 years after diabetes diagnosis, patients with type 2 diabetes incurred substantially higher costs than matched nondiabetic patients, but those high costs remained largely flat. Once the growth in costs due to general aging is controlled for, it appears that diabetic complications do not increase incremental costs as early as is commonly believed. Additional research is needed to better understand how diabetes and its diagnosis affect medical care costs over longer periods of time.

Peer consultation reflection exercise

OBJECTIVE

To explore participants' overall perception of the value of the Peer Consultation Reflection Exercise (PCRE); of barriers and facilitators to participation and learning during a PCRE; and of the transferability of the experience to participants' own settings.

DESIGN

This study used the qualitative techniques of key informant interviews and a focus group.

SETTING

Focus group and key informant interviews at the 1996 Annual Meeting of the College of Family Physicians of Canada's Section of Teachers.

PARTICIPANTS

Family medicine teachers attending a PCRE.

METHOD

Five key informant interviews and one focus group composed of five participants were conducted to explore participants' experience of participating and learning during a PCRE.

MAIN FINDINGS

Participants viewed the PCRE as a valuable opportunity to interact and learn from colleagues a were especially impressed with the opportunity to listen. Confidentiality and the important role of the facilitator were identified as key components. The greatest perceived barrier was the formal structure of the PCRE.

CONCLUSIONS

The PCRE is an innovative strategy for personal and professional development. It could be used in other settings.

Ten-year follow-up of antidiabetic drug use, nonadherence, and mortality in a defined population with type 2 diabetes mellitus

Studies performed for drug registration provide little insight into the long-term use and effectiveness of drugs in "real world" populations and settings. To obtain such insight, we used 10 years of electronic medical-record data from Kaiser Permanente Northwest Division, a large, group-model health maintenance organization in the United States, to study drug transitions, lapses in drug therapy, and mortality among 693 persons with newly diagnosed type 2 diabetes mellitus in 1988. We also studied an equivalently defined cohort of 1071 persons with new diagnoses in 1994, for whom the availability of laboratory results via electronic data permitted additional analyses. Cumulative mortality in the 1988 cohort increased steadily to 207 of 571 patients (36%) by 1997 (year 10). In 1988, 548 of 693 patients (79%) received initial monotherapy with a sulfonylurea. Insulin use rose as the use of sulfonylureas declined. Over this period, 504 of 693 patients (73%) discontinued or added drug therapy. Eight percent to 10% of both sulfonylurea users and insulin users discontinued drug use during the study period. In the 1994 cohort, two thirds of the subjects who discontinued therapy and were tested for glycosylated hemoglobin (Hb A1c) (n = 86) maintained good-to-excellent glycemic control. However, 78 discontinuers (38%) were not tested for Hb A1c, and, among this subset, 32% failed to visit a primary care clinician. The results of this study suggest that 5% to 10% of persons with type 2 diabetes mellitus avoid contact with the medical care system. Avoidance persists for at least the first 10 years after diagnosis but is more common in the first year after diagnosis. In addition, secondary failure of sulfonylureas begins within 1 year of diagnosis and continues at a steady pace. Almost 80% of patients initially treated with sulfonylureas added or switched to metformin or insulin within 10 years of diagnosis.

Evidence on patient-doctor communication

This chapter covers important and well-studied aspects of patient-doctor communication. First the paper describes the lessons learned from studies about patients' satisfactions or dissatisfactions related to patient-doctor communication, making the point that complaints about doctors are usually due to communication problems and not technical competency issues. The next section of the chapter deals with time. It is often assumed that effective communication is inefficient. While this is not necessarily the case, the research results are complex and very interesting. The third part of the chapter covers communication in relation to patient adherence with the management plan recommended by the doctor. There is strong evidence that communication affects patient adherence and that there are four key aspects of communication that can enhance the patients' co-operation with the management plan. The final topic is patients' health. Twenty-two studies indicate the generally positive effect of key dimensions of communication on actual patient health outcomes such as pain, recovery from symptom, anxiety, functional status, and physiologic measures of blood pressure and blood glucose.

First 20 months' experience with use of metformin for type 2 diabetes in a large health maintenance organization

OBJECTIVE

To assess adherence to prescribing guidelines, continuation rates, population effects on glycemic control, and occurrence of lactic acidosis during the first 20 months of the availability of metformin in a large health maintenance organization.

RESEARCH DESIGN AND METHODS

A retrospective cohort study was performed in the 90,000-member diabetes registry of Kaiser Permanente, northern California. Principal study measures were the proportions of patients started on metformin who met prescribing guidelines (previously on sulfonylureas, HbA1c, obesity, creatinine), the change in HbA1c at 6 months after starting metformin, and hospitalization rates for lactic acidosis.

RESULTS

A total of 9,875 patients received metformin during this interval. At least 74% were previously treated with sulfonylureas alone, 81% had baseline HbA1c > or = 8.5%, 71% were obese, and 99% had a serum creatinine < or = 1.5 mg/dl. Among patients on sulfonylureas at baseline, those starting metformin had significantly lower HbA1c levels 6 months later than those not started, after adjustment for age, sex, and the higher baseline levels in those started (adjusted difference: 0.5%, P < 0.0001). Patients starting metformin as initial monotherapy also improved significantly, but patients previously treated with insulin (with or without sulfonyl-ureas) had slightly higher follow-up HbA1c levels than similar patients not starting metformin. Continuation of metformin at 12 months was significantly higher for patients previously treated with sulfonylureas than other groups. One probable case of lactic acidosis was identified during 4,502 person-years on metformin.

CONCLUSIONS

Adherence to prescribing guidelines was relatively high during metformin's first 20 months of availability. Glycemic control improved substantially for patients previously treated with sulfonylureas. Lactic acidosis was rare.

Practical methods to increase use of advance medical directives

OBJECTIVE

To compare the effectiveness of two means for increasing the use of advance medical directives: written materials only versus written materials and an educational videotape.

DESIGN

Population-based, randomized controlled trial with 3-month follow up.

SETTING

Kaiser Permanente Colorado Region, a not-for-profit group-model health maintenance organization.

PARTICIPANTS

A population-based sample of all 1,302 members aged 75 years and older who used the Franklin Medical Office, excluding 55 persons who died or disenrolled during the study period or were identified by their physicians as blind or cognitively impaired.

INTERVENTIONS

All subjects were mailed a 10-page cartoon-illustrated educational pamphlet on patient choices, a selection of Colorado advance medical directive forms, and a guide to their completion; 619 subjects also were mailed a 20-minute videotape on advance directives. Both groups had access to a study nurse for assistance in completing and placing advance medical directives.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure is the proportion of subjects who placed a directive in their medical record for the first time. Placement rates increased almost identically, from 21.2% to 35.0% in the written materials-only group and from 18.9% to 32.6% in the group receiving the videotape (95% confidence interval for difference -0.04, 0.04, p =.952).

CONCLUSIONS

In an elderly population with a substantial baseline placement rate, mailing of written materials substantially increased placement of an advance directive in the medical record, but the addition of a videotape did not. Mailing the video did increase the use of treatment trials and made patients more aware of reasons not to use advance directives.

Lactic acidosis rates in type 2 diabetes

OBJECTIVE

To provide a context for the interpretation of lactic acidosis risk among patients using metformin, we measured rates of lactic acidosis in patients with type 2 diabetes before metformin was approved for use in the U.S.

RESEARCH DESIGN AND METHODS

Using electronic databases of hospital discharge diagnoses and laboratory results maintained by a large, nonprofit health maintenance organization (HMO). we identified possible lactic acidosis events in three geographically and racially diverse populations with type 2 diabetes. We then reviewed hard-copy clinical records to confirm and describe each event and determine its likely cause(s).

RESULTS

From >41.000 person-years of experience, we found four confirmed, three possible, and three borderline cases of lactic acidosis. In each case, we identified at least one severe medical condition that could have caused the acidosis. The annual confirmed event rate is similar to published rates of metformin-associated lactic acidosis.

CONCLUSIONS

Lactic acidosis occurs regularly, although infrequently, among persons with type 2 diabetes, at rates similar to its occurrence among metformin users. The medical conditions with which both metformin-associated and naturally occurring lactic acidosis co-occur are also its potential causes. The observed association between metformin and lactic acidosis may be coincidental rather than causal. This possibility merits further study

Roles and influence of people who accompany patients on visits to the doctor

OBJECTIVES

To determine the proportion of patients who are accompanied by another person (ie, partner, child, relative, friend) during visits to their doctors; to describe the demographic characteristics and role(s) assumed by the main accompanying person and the nature of the presenting dyads; and to describe the influence of the main accompanying person on the patient-doctor interaction.

DESIGN

Prospective observational survey.

SETTING

Family practices in London, Ont, and surrounding area.

PARTICIPANTS

Eight family physicians completed surveys on 100 consecutive patients attending for both regularly scheduled and emergency visits.

MAIN OUTCOME MEASURES

Roles and influence of the main accompanying person.

RESULTS

Approximately one third (30.4%) of patients were accompanied during visits to their doctors. Children and patients older than 75 years most frequently had another person with them. Most patients (74.1%) were accompanied by one person who most often was female (72.6%) and between the ages of 21 and 40 years (53.6%). The accompanying person's role was most frequently described by doctors as an advocate for the patient (n = 235, 68.5%). If the accompanying person was a child, however, the role was most often described as a silent observer (n = 36, 68.6%). The influence of the main accompanying person on the patient-doctor encounter was usually described as positive (95.1%).

CONCLUSIONS

Physicians report that people accompanying patients usually have a positive influence on medical encounters. Future studies need to include patients' and accompanying persons' perspectives.

Gender differences in FFM accumulation and architectural characteristics of muscle

PURPOSE

The purpose of this study was to gain insight into the skeletal muscle development potential in women and to evaluate the contribution of muscle pennation angle (PANG) and fascicle length to gender differences in muscle size or FFM accumulation.

METHODS

Skeletal muscle architectural characteristics and FFM were studied in 29 strength-trained female and 22 age- and height-matched male college athletes. Muscle thickness (MTH) was measured by B-mode ultrasound at 13 anatomical sites. Isolated MTH and PANG of the triceps long head (TL), vastus lateralis (VL), and gastrocnemius medialis (MG) muscles were measured in vivo, and fascicle length was estimated.

RESULTS

Six female athletes had more than 60 kg of FFM, with the largest being 82.1 kg. In general, male athletes had a significantly greater FFM and MTH at all sites except for the anterior thigh. Isolated MTH and PANG of the TL, VL, and MG were greater in males. There were no gender differences in limb length or fascicle length of the three isolated muscles. A significant correlation was observed between MTH and PANG for TL (r = 0.84) and MG (r = 0.41), but not for VL.

CONCLUSIONS

In contrast to previous estimates, we conclude that the theoretical upper limit of FFM accumulation and FFM-to-height ratio in women is greater than 80 kg and 0.44 kg.cm-1, respectively. Gender differences in PANG appear to be related to differences in muscle size (MTH) and do not appear to contribute independently to the gender difference in FFM.

Factors influencing palliative care. Qualitative study of family physicians' practices

OBJECTIVE

To examine factors that influence family physicians' decisions to practise palliative care.

DESIGN

Qualitative method of in-depth interviews.

SETTING

Southwestern Ontario.

PARTICIPANTS

Family physicians who practise palliative care on a full-time basis, who practise on a part-time basis, or who have retired from active involvement in palliative care.

METHOD

Eleven in-depth interviews were conducted to explore factors that influence family physicians' decisions to practise palliative care and factors that sustain their interest in palliative care. All interviews were audiotaped and transcribed verbatim. The analysis strategy used a phenomenological approach and occurred concurrently rather than sequentially. All interview transcriptions were read independently by the researchers, who then compared and combined their analyses. Final analysis involved examining all interviews collectively, thus permitting relationships between and among central themes to emerge.

MAIN OUTCOME FINDINGS

The overriding theme was a common philosophy of palliative care focusing on acceptance of death, whole person care, compassion, communication, and teamwork. Participants' philosophies were shaped by their education and by professional and personal experiences. In addition, participants articulated personal and systemic factors currently affecting their practice of palliative care.

CONCLUSIONS

Participants observed that primary care physicians should be responsible for their patients' palliative care within the context of interdisciplinary teams. For medical students to be knowledgeable and sensitive to the needs of dying patients, palliative care should be given higher priority in the curriculum. Finally, participants argued compellingly for transferring the philosophy of palliative care to the overall practice of medicine.

Understanding and preventing osteoporosis

1. Osteoporosis is a condition in which the amount of bone tissue is so low that the bones easily fracture in response to minimal force. 2. Osteoporosis affects more than 25 million Americans, 80% of whom are women. Because osteoporosis is a "silent disease" that can progress undetected for decades, early screening can identify women at risk which may help avert the escalation of this health problem. 3. Risk factors include older age; female; white or Asian ethnicity; normal or early menopause; lifestyle factors including smoking, excessive alcohol intake, little or no exercise, taking inadequate amounts of calcium; medications and disease; and heredity. 4. Prevention efforts need to be directed toward education related to the need for adequate dietary calcium and the need for weight bearing exercise. Health care providers should develop methods for screening clients to determine whether they are at risk and need a bone density test.

Hormone replacement therapy: determinants of women's decisions

Hormone replacement therapy: determinants of women's decisions. The purpose of this qualitative study was to explore the decision-making process used by menopausal women initiating or remaining on hormone replacement therapy (HRT), stopping HRT, or never starting HRT. Eight focus groups, composed of women reflecting these categories, were conducted. Four major themes or spheres of influence emerged as important in the women's decision-making process: the woman's internal influence--the interface between her perceptions and feelings including the symptoms of menopause, the benefits realized by HRT usage, and the experiences of negative side effects; interpersonal relationships, including the patient-physician relationship, family, friends and information networks; external influences, such as ageism and sexism; and consequences resulting from whichever treatment decision was chosen. A new concept was elucidated called "weighted influence" to underscore the dynamic interplay among the spheres. As information about HRT continues to grow and change, an understanding and application of these spheres of influence can assist physicians in engaging in a dialogue with their patients that allows individual evaluation and application of this new information.

Definition of the potentially fertile period from urinary steroid excretion rates. Part II. A threshold value for pregnanediol glucuronide as a marker for the end of the potentially fertile period in the human menstrual cycle

Application of time series analysis to a database containing serial pregnanediol data from 113 complete ovulatory menstrual cycles contributed by 83 women of proven fertility and 68 cycles for which pregnanediol values were available over the ovulatory period, detected the first statistically significant risk in pregnanediol excretion for all cycles for which a baseline was available (n = 170). However, even at the 99% confidence level, for 22% of cycles a rise was observed before the presumed day of ovulation. Therefore, a threshold value for pregnanediol was sought from the database as a better marker for the end of fertility. A value of 1.4 mg per 24 h was not reached before day 2 after the pre-ovulatory estrogen peak day for 96% of the cycles. In the remaining 4% of cycles it was reached one day after the total estrogen peak day. The validity of this threshold was confirmed in extensive studies using the Ovarian Monitor where the equivalent is 6.3 mumol per 24 h of pregnanediol glucuronide and measurements are performed on timed urine specimens with a minimum collection time of three hours. These studies were as follows: 1) a World Health Organization study on the use of the Ovarian Monitor as a fertility self test in the home (108 cycles), 2) a multicenter study on returning fertility during breast feeding conducted by Family Health International (73 women), and 3) the general application of the Ovarian Monitor for pregnancy achievement and avoidance during the past ten years (over 250,000 PdG assays performed in ten countries). With rare exceptions, the use of these threshold values is applicable for all women provided correction is made for urine volume.

Long-term attendance at a family practice teaching unit. Qualitative study of patients' views

OBJECTIVE

To identify the factors that contribute to patients' long-term attendance at a family practice teaching unit.

DESIGN

Qualitative method of focus groups.

SETTING

A community-based family practice teaching unit in southwestern Ontario.

PARTICIPANTS

Patients who had been coming to St Joseph's Family Medical Centre for more than 15 years were purposefully selected to participate.

METHOD

Five focus groups composed of patients who had been affiliated with one of the three practices at the Centre for more than 15 years explored factors contributing to long-term attendance.

MAIN FINDINGS

Four key themes were identified as the primary factors contributing to long-term attendance: the relationship context, the team concept, professional responsibility and attitudes, and comprehensive and convenient care.

CONCLUSION

The resource-rich era of medical care, during which participants formulated their views and opinions about the factors contributing to their long-term attendance at a family practice teaching unit, has come to a close. The findings of this study provide important information that could help maintain one of the basic tenets of family medicine-continuity of care.

Effects of age and non-hormonal contraception on menstrual cycle characteristics

The objective of this study was to investigate the effects of age and non-hormonal contraceptive method on menstrual cycle parameters. The menstrual cycle data were collected prospectively, and the study was cross-sectional with regard to age. The subjects were 142 women, including 14 asymptomatic volunteers and 128 women who presented to a premenstrual tension (PMT) clinic. The age range was 20-45 years. Contraceptive methods used were intrauterine device (IUD) (n = 12), tubal ligation (n = 61) and non-intensive methods (n = 69). Daily menstrual cycle diaries were used to calculate cycle length and number of days of menstruation. Daily 24-h urine collections were used to calculate the day of the preovulatory estrogen peak. Pearson correlations found significant relationships between age and preovulatory estrogen peak day (p < 0.001) and length of cycle (p < 0.002), but not between age and length of menstruation or luteal phase. Analysis of variance was highly significant for age and contraceptive method, for both cycle length and preovulatory estrogen peak day. Non-intrusive contraception users aged 30 years and younger had significantly longer follicular phases than did women with tubal ligation (p < 0.05). It was concluded that cycle length decreases with age due to shortening of the follicular phase. Further research on whether tubal ligation affects ovulation and follicular phase length in young women is needed.

Barriers and facilitators to seniors' independence. Perceptions of seniors, caregivers, and health care providers

OBJECTIVE

To identify barriers and facilitators to independence as perceived by seniors with chronic health problems and their caregivers. In particular, researchers sought insights into seniors' experience of medical, home-based, and public health services.

DESIGN

This study used the qualitative method of focus groups.

SETTING

London, Ont, and surrounding area.

PARTICIPANTS

Seniors with chronic health problems and informal and formal caregivers were purposefully selected to participate.

METHOD

Seven focus groups composed of seniors, informal caregivers, and health care providers representing each of the three primary care areas (medical, home-based, and public health) explored the barriers and facilitators to seniors' independence.

MAIN FINDINGS

Four main themes characterized the barriers and facilitators to seniors' independence: attitudes and attributes, service accessibility, communication and coordination, and continuity of care.

CONCLUSIONS

Knowledge of barriers and facilitators to seniors' independence in the context of the health care system provides insight into how seniors can be empowered to remain independent. Health care providers need to communicate better, to foster more positive attitudes toward aging, and to participate in refining service access, coordination of services, and continuity of care.

Fertility of fully breast-feeding women in the early postpartum period

OBJECTIVE

To examine bleeding between 6 and 8 weeks postpartum in fully breast-feeding women and its association with fertility as assessed by hormone analysis.

METHODS

Seventy-two fully breast-feeding women were followed prospectively from 42 days postpartum. Vaginal bleeding was recorded daily. Women who experienced bleeding were compared with women who did not with respect to time of ovulation and time of first menses.

RESULTS

Nearly half of the women experienced some vaginal bleeding or spotting between 6 and 8 weeks postpartum. These women eventually menstruated and ovulated earlier than the women who did not bleed, but the differences were not significant. The study had 34% and 45% power to detect a 20% difference in the proportion menstruating and ovulating, respectively, at 6 months postpartum, and 10% and 16% power to detect the same differences at 1 year. Seven women experienced ovarian follicular development before day 56, but neither bleeding nor follicular development was associated with ovulation in any woman in the first 8 weeks postpartum.

CONCLUSIONS

It is unlikely that vaginal bleeding in fully breast-feeding women in the first 8 weeks postpartum represents a return to fertility.

Retiree awareness of levels of blood pressure and cholesterol

PURPOSE

Determine the level of awareness of cholesterol and blood pressure in a retiree population; assess factors indicating a higher risk for lack of awareness.

METHODS

A cross-sectional survey was mailed to a random sample of 9.5% of the 7,400 retiree households served by an Army community hospital. Data analysis used descriptive statistics and t test for continuous data and chi-square for categorical data.

RESULTS

Response rate was 71.4%. Overall, 45.8 and 37.9% of the respondents have accurate knowledge of the levels of their blood pressure and cholesterol, respectively. For those with documented hypertension and hyperlipidemia, the correct awareness levels are 78.5 and 63.4%, respectively. The only sociodemographic factor associated with correct awareness is age with cholesterol knowledge.

CONCLUSIONS

This population meets the objectives set by Healthy People 2000 for cholesterol awareness, but not for blood pressure. The overall levels of awareness compare favorably to results from other studied populations. Physicians are not using all opportunities to educate patients about modifiable risk factors.

Cigarette smoking and urinary oestrogen excretion in premenopausal and post-menopausal women

Cigarette smoking is associated with a reduction in the risk for endometrial cancer in post-menopausal women and it has been suggested that this is because smoking has an anti-oestrogenic effect. To investigate this, concentrations of oestrone, oestradiol and oestriol were measured in 24 h urine samples from 167 premenopausal women (53 smokers, 114 non-smokers) and 200 post-menopausal women (54 smokers, 146 non-smokers). Among premenopausal women there were no significant differences in oestrogen excretion between smokers and non-smokers. Among post-menopausal women, geometric mean excretion rates for oestrone and oestradiol did not differ significantly between groups, but oestriol excretion was 19% lower (95% confidence interval -34% to -1%) in smokers than in non-smokers. This may partly explain the reduced risk for endometrial cancer among post-menopausal smokers.