Effect of antenatal milk expression education on lactation outcomes in birthing people with pre-pregnancy body mass index ≥25: protocol for a randomized, controlled trial

BACKGROUND

Birthing people with pre-pregnancy body mass indices (BMIs) ≥ 25 kg/m², particularly those without prior breastfeeding experience, are at increased risk for suboptimal lactation outcomes. Antenatal milk expression (AME) may be one way to counteract the negative effects of early infant formula supplementation common in this population.

METHODS

This ongoing, randomized controlled trial in the United States evaluates the efficacy of a telelactation-delivered AME education intervention versus an attention control condition on lactation outcomes to 1 year postpartum among 280 nulliparous-to-primiparous, non-diabetic birthing people with pre-pregnancy BMI ≥ 25 kg/m². The assigned study treatment is delivered via four weekly online video consultations between gestational weeks 37-40. Participants assigned to AME meet with study personnel and a lactation consultant to learn and practice AME. Instructions are provided for home practice of AME between study visits. Control group participants view videos on infant care/development at study visits. Participants complete emailed surveys at enrollment (34^0/7-36^6/7 gestational weeks) and 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postpartum. Surveys assess lactation and infant feeding practices; breastfeeding self-efficacy, attitudes, and satisfaction; perception of insufficient milk; onset of lactogenesis-II; lactation support and problems; and reasons for breastfeeding cessation. Surveys also assess factors associated with lactation outcomes, including demographic characteristics, health problems, birth trauma, racial discrimination, and weight stigma. Health information and infant feeding data are abstracted from the pregnancy and birth center electronic health record. Milk samples are collected from the intervention group at each study visit and from both groups at each postpartum follow-up for future analyses. Qualitative interviews are conducted at 6 weeks postpartum to understand AME experiences. Primary outcomes of interest are breastfeeding exclusivity and breastfeeding self-efficacy scores at 2 weeks postpartum. Outcomes will be examined longitudinally with generalized linear mixed-effects modeling.

DISCUSSION

This is the first adequately powered trial evaluating the effectiveness of AME among U.S. birthing people and within a non-diabetic population with pre-pregnancy BMI ≥ 25 kg/m². This study will also provide the first evidence of acceptability and effectiveness of telelactation-delivered AME.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04258709.

First Feed Type Is Associated With Birth/Lactating Parent's Own Milk Use During NICU Stay Among Infants Who Require Surgery

BACKGROUND

Early exclusive birth/lactating parent's own milk (B/LPOM) feeds have been associated with longer duration of B/LPOM use for infant feedings in healthy term and hospitalized preterm infants. This relationship has not been explored in infants undergoing neonatal surgery (surgical infants).

PURPOSE

To evaluate the relationship between early exclusive B/LPOM feeds and cumulative B/LPOM patterns during surgical infants' neonatal intensive care unit (NICU) hospitalization.

METHODS

A secondary cross-sectional analysis was performed using the electronic health record data of surgical infants admitted to a level IV NICU between January 2014 and March 2015. Multiple linear regression and Fisher's exact test were used to examine the associations between first NICU feed type and total percentage of diet composed of B/LPOM during NICU stay and continuation of any or exclusive B/LPOM feedings at NICU discharge, respectively.

RESULTS

The analysis included 59 infants who required surgery for gastrointestinal, cardiac, or multisystem defects or pregnancy-related complications. Receipt of B/LPOM as the first NICU feed was associated with higher percentage of B/LPOM feeds ( P < .001) throughout NICU stay, as well as continuation of any or exclusive B/LPOM feedings at NICU discharge ( P = .03).

IMPLICATIONS FOR PRACTICE

Early exclusive B/LPOM feeds may be an important predictor for continuation of any B/LPOM use throughout the NICU stay and at NICU discharge. Continued efforts to identify and address gaps in prenatal and postpartum lactation support for parents of surgical infants are needed.

IMPLICATIONS FOR RESEARCH

Powered studies are needed to corroborate these findings and to explore the potential impact of other factors on duration and exclusivity of B/LPOM use.

VIDEO ABSTRACT AVAILABLE AT

https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx .

Antenatal Milk Expression as a Lactation Support Intervention for Parents of Infants With Severe Birth Defects: A Case Series

BACKGROUND

A diet high in parent's own milk (parental milk) is a lifesaving intervention for critically ill infants. Lactating parents whose infants are born with birth defects that require surgical repair (surgical infants) shortly after birth often struggle to initiate and maintain a milk supply that meets their infant's nutritional needs. Antenatal milk expression has been identified as a safe, feasible, and potentially effective strategy that promotes parents' direct chest/breastfeeding or milk expression (lactation) confidence and helps parents attain their lactation goals. Two cases are presented to illustrate the potential for using antenatal milk expression as a lactation support intervention for parents of surgical infants.

CASE PRESENTATION

Cases were drawn from a pilot study exploring the feasibility of implementing antenatal milk expression among pregnant parents of surgical infants. Participants were healthy women recruited after 30 weeks of gestation who received a fetal diagnosis of a complex congenital heart defect. Despite variability in clinical course and length of stay, parental milk was provided for the duration of each infant's hospitalization. Participant perceptions of antenatal milk expression varied.

CONCLUSION

More research is needed to evaluate the feasibility, efficacy, and parent or provider perceptions of antenatal milk expression as a lactation support intervention for parents of surgical infants.

Structured antenatal milk expression education for nulliparous pregnant people: results of a pilot, randomized controlled trial in the United States

BACKGROUND

Hand-expression, collection, and storage of breast milk during pregnancy (i.e., antenatal milk expression or AME) is a safe, potentially effective practice to reduce early, undesired infant formula supplementation among women with diabetes. The feasibility and potential impact of AME on lactation outcomes in the United States (U.S.) and among non-diabetic birthing people is unknown.

METHODS

The purpose of this study was to examine the feasibility of a structured AME intervention among nulliparous birthing people in the United States. We recruited 45 low-risk, nulliparous individuals at 34-36^6/7 weeks of gestation from a hospital-based midwife practice. Participants were randomized to AME or a control group receiving lactation education handouts. Interventions were delivered at weekly visits at 37-40 weeks of pregnancy. The AME intervention involved technique demonstration and feedback from a lactation consultant and daily independent practice. Lactation outcomes were assessed during the postpartum hospitalization, 1-2 weeks postpartum, and 3-4 months postpartum.

RESULTS

Between December 2016 and February 2018, 63 individuals were approached and screened for eligibility, and 45 enrolled into the study (71%). Of 22 participants assigned to AME, 18 completed at least one AME study visit. Participants reported practicing AME on at least 60% of days prior to their infant's birth. Most were able to express milk antenatally (15/18), more than half collected and froze antenatal milk (11/18), and 39% (7/18) supplemented their infants with antenatal milk after birth. No major problems were reported with AME. Perinatal and lactation outcomes, including infant gestational age at birth, neonatal intensive care unit admissions, delayed onset of lactogenesis II, and use of infant formula were similar between AME and control groups. Among participants in both groups who were feeding any breast milk at each assessment, breastfeeding self-efficacy increased and perceptions of insufficient milk decreased over the postpartum course.

CONCLUSIONS

In a small group of nulliparous birthing people in the U.S., AME education and independent practice beginning at 37 weeks of pregnancy was feasible. In some cases, AME provided a back-up supply of milk when supplementation was indicated or desired. The relationship between AME and lactation outcomes requires further study with adequately powered samples.

TRIAL REGISTRATION

This trial was retrospectively registered at ClinicalTrials.gov on May 11, 2021 under the following registration ID: NCT04929301. https://clinicaltrials.gov/ct2/show/NCT04929301 .

1063 THE CHALLENGES OF PROVIDING ADEQUATE AND APPROPRIATE NUTRITION AND HYDRATION CARE TO HOSPITAL MEDICAL INPATIENTS

Introduction

Nutrition and hydration are essential components of hospital inpatient care. Inadequate provision has been shown to be linked to poorer outcome. We performed a cross-sectional study of nutritional care in a London teaching hospital.

Method

Data collection was undertaken in October 2021 across two medical wards. Data for demographics; morbidity factors including: Charlson Comorbidity index (CCI), length of stay (LoS), cognitive score (AMTS); nutrition parameters and their recorded accuracy including: weight, ‘MUST’ score, fluid balance, food chart, and evidence of dietetic referral and review were examined.

Results

52 patients were assessed [male 24/52 (46.15%), median age 80.5 (IQR 61.75–85.25, range 30–98)]. The median CCI score was 5, corresponding to 21.36% estimated 10-year mortality, with median LoS of 8 days (IQR 3–15.25). AMTS was recorded in 12/52 (23.08%). Variable recording of nutrition parameters was observed (weight: 57.69%, ‘MUST’ score 23.1%, fluid balance 63.5%, food chart 15.4%). Only 54.6% of the recorded fluid balance charts were clinically accurate. Where oral nutritional supplement (ONS) was prescribed, 57.1% (8/14) of patients had not received a dietetic review. Upon comparison the care of the elderly ward demonstrated a significantly higher accuracy of fluid balance chart (60% vs 46%, p &lt; 0.001).

Discussion

Supporting patients to meet nutrition and hydration goals is a core component of clinical care. Our results demonstrate that nutrition and hydration care is poorly documented across several parameters, and by inference, poorly delivered irrespective of age, co-morbidity or cognitive impairment. Less than 1/3 of patients had a formal nutrition screen suggesting that identification of patients at risk of malnutrition should be the priority for future work. An electronic health record allows easy access to data that can be used for improvement. As an achievable first step, an improvement in awareness of nutritional scores, such as MUST, will be important in identification of malnutrition.

106 A Whole Hospital Delirium Audit with 20 Week Follow-Up

Introduction

Delirium is a common manifestation of acute illness, characterised by fluctuating changes in mental state. Its aetiologies and presentations are diverse. This can lead to underdiagnosis. We screened all adult inpatients at Barnet Hospital for delirium. 20 weeks follow-up data was collected, including mortality and admission to institutional care.

Methods

The 4AT and Clinical Frailty Score (CFS) were recorded for every adult inpatient (n = 220) in Barnet Hospital on 13/03/2019. Hospital notes were reviewed to establish whether delirium assessments were performed during admission. Electronic records were used to establish length of stay, discharge destination, mortality and readmission rate over 20 weeks.

Results

30% (n = 65) of inpatients had possible delirium (4AT score ≥ 4). Delirium was more common in older, frailer patients (Table 1). Most patients with delirium were under the care of geriatric (40%) or acute medicine (26%). Only gastroenterology and gynaecology had no patients with delirium. Patients with delirium were 3 times more likely to die during their admission and were twice as likely to be discharged to institutional care (Table 1). 20 week mortality of patients with delirium was 26%.

Conclusion

Delirium is common in hospital inpatients. Delirium has a high morbidity and mortality. Better diagnosis of delirium in hospital may improve outcomes. Table 1: Mean(SD) unless stated. *p &lt; 0.05 Delirium (n = 65) No Delirium (n = 155) Male: % 46 46 Age* 81(11) 71(20) Clinical Frailty Score* 5.6(1.7) 3.8(1.8) Dementia (%)* 53 10 Assisted living: n(%) o Pre-admission * 18.5 3.2 o Post Admission * 44.6 22.6 Length of stay 33 (25) 30.6 (28) Mortality (%) o Hospital * 10.7 3.9 o 20 Weeks * 26.2 14.2 Readmission rate (%) 30.8 31.

The Development and Evaluation of a Text Message Program to Prevent Perceived Insufficient Milk Among First-Time Mothers: Retrospective Analysis of a Randomized Controlled Trial

Background

Several recent trials have examined the feasibility and efficacy of automated SMS text messaging to provide remote breastfeeding support to mothers, but these texting systems vary in terms of design features and outcomes examined.

Objective

This study examined user engagement with and feedback on a theory-grounded SMS text messaging intervention intended to prevent perceived insufficient milk (PIM)—the single, leading modifiable cause of unintended breastfeeding reduction and cessation.

Methods

We recruited 250 nulliparous individuals intending to breastfeed between 13 and 25 weeks of pregnancy in southwestern Pennsylvania. Participants were randomly assigned with equal allocation to either an SMS intervention to prevent PIM and unintended breastfeeding reduction or cessation (MILK, a Mobile, semiautomated text message–based Intervention to prevent perceived Low or insufficient milK supply; n=126) or a control group receiving general perinatal SMS text messaging–based support via the national, free Text4Baby system (n=124). Participants in both groups received SMS text messages 3 to 7 times per week from 25 weeks of pregnancy to 8 weeks postpartum. The MILK intervention incorporated several automated interactivity and personalization features (eg, keyword texting for more detailed information on topics and branched response logic) as well as an option to receive one-on-one assistance from an on-call study lactation consultant. We examined participant interactions with the MILK system, including response rates to SMS text messaging queries. We also sought participant feedback on MILK content, delivery preferences, and overall satisfaction with the system via interviews and a remote survey at 8 weeks postpartum.

Results

Participants randomized to MILK (87/124, 70.2% white and 84/124, 67.7% college educated) reported that MILK texts increased their breastfeeding confidence and helped them persevere through breastfeeding problems. Of 124 participants, 9 (7.3%) elected to stop MILK messages, and 3 (2.4%) opted to reduce message frequency during the course of the study. There were 46 texts through the MILK system for individualized assistance from the study lactation consultant (25/46, 54% on weekends or after-hours). The most commonly texted keywords for more detailed information occurred during weeks 4 to 6 postpartum and addressed milk volume intake and breastfeeding and sleep patterns. MILK participants stated a preference for anticipatory guidance on potential breastfeeding issues and less content addressing the benefits of breastfeeding. Suggested improvements included extending messaging past 8 weeks, providing access to messaging for partners, and tailoring content based on participants’ pre-existing breastfeeding knowledge and unique breastfeeding trajectory.

Conclusions

Prenatal and postpartum evidence–based breastfeeding support delivered via semiautomated SMS text messaging is a feasible and an acceptable intervention for first-time mothers. To optimize engagement with digital breastfeeding interventions, enhanced customization features should be considered.

Trial Registration

ClinicalTrials.gov NCT02724969; https://clinicaltrials.gov/ct2/show/NCT02724969

A screening questionnaire for occupational and hobby exposures during pregnancy

BACKGROUND

Occupational and environmental exposures during the prenatal period may be associated with adverse pregnancy outcomes and lifelong health effects. Yet, identification and evaluation of these potential hazards is lacking in routine obstetric care.

AIMS

To assess the feasibility of incorporating a self-administered occupational and environmental exposure questionnaire into obstetric clinics.

METHODS

A cross-sectional survey assessed prenatal clinic patients at a public hospital who were currently employed and <20 weeks gestation. Questionnaires evaluated job characteristics, workplace and hobby exposures, protective equipment use and symptoms during pregnancy.

RESULTS

Of 69 participants (96% response rate), 46% were predominantly Spanish-speaking. Primary occupations were caregiver (16%), cleaner (14%) and administrative assistant (14%). Overall, 93% were exposed to a workplace hazard, with most participants reporting physical stressors (82%) or organic solvent exposure (78%). Most women (74%) used some personal protective equipment. Nearly half (54%) reported at least one non-pregnancy symptom, and 52% were referred for follow-up with an occupational medicine practitioner. Household and hobby-related chemical exposures were common in our sample (91%). We observed moderate consistency between job task and chemical use responses: 67-99% of intentionally redundant questions were fully or partially matched. Closed- compared to open-ended activity questions identified a higher proportion of physical stressors (82% versus 12%) and cleaning product (76% versus 30%) exposures.

CONCLUSIONS

A self-administered questionnaire is an effective screening tool for identifying women with occupational and hobby-related exposures during pregnancy. Consistent incorporation of exposure assessment into prenatal care can improve clinical communications and early interventions for at-risk pregnant women.

"It gave me so much confidence": First-time U.S. mothers' experiences with antenatal milk expression

Antenatal milk expression (AME) involves maternal hand-expression, collection, and storage of breast milk during pregnancy for the purposes of reducing the early formula use in breastfed infants. AME is not widely practiced in the United States, despite its growing popularity elsewhere. In this study, we examined the experiences of first-time mothers recruited from a U.S. midwife practice who engaged in AME within the context of a pilot randomized controlled trial. The AME intervention involved demonstration and practice of AME with a lactation consultant beginning at 37 weeks of gestation, reinforcement at weekly study visits until delivery, and daily home practice. Nineteen women participated in a semistructured interview at 1-2 weeks postpartum regarding their study experiences. Major themes included (1) perceived benefits and impact of AME, (b) AME implementation, and (c) use of AME milk. Women perceived multiple benefits of AME, most notably that it increased their confidence that they would be able to make milk and breastfeed successfully postpartum. Women expressed some concern that no/little milk expressed could be indicative of postpartum milk production problems. Regarding implementation, women found that the AME protocol fit well into their daily routine. There was mixed feedback regarding comfort with practicing AME in the presence of partners. Reasons for postpartum use of AME milk varied; barriers to provision included inadequate milk storage options at the birth hospital and unsupportive hospital providers/staff. With few caveats, AME appears to be an acceptable breastfeeding support intervention among a sociodemographically homogeneous group of first-time mothers in the United States.

Delayed Lactogenesis II and potential utility of antenatal milk expression in women developing late-onset preeclampsia: a case series

Background

Preeclampsia is a multi-system, hypertensive disorder of pregnancy that increases a woman’s risk of later-life cardiovascular disease. Breastfeeding may counteract the negative cardiovascular sequela associated with preeclampsia; however, women who develop preeclampsia may be at-risk for suboptimal breastfeeding rates. In this case series, we present three cases of late-onset preeclampsia and one case of severe gestational hypertension that illustrate a potential association between hypertensive disorders of pregnancy and suboptimal breastfeeding outcomes, including delayed onset of lactogenesis II and in-hospital formula supplementation.

Case presentation

All cases were drawn from an ongoing pilot randomized controlled trial investigating the impact of antenatal milk expression versus an education control on breastfeeding outcomes. All study participants were healthy nulliparous women recruited at 34–36^6/7 gestational weeks from a hospital-based midwife practice. The variability in clinical presentation among the four cases suggests that any effect of hypertensive disorders on breastfeeding outcomes is likely multifactorial in nature, and may include both primary (e.g., preeclampsia disease course itself) and secondary (e.g., magnesium sulfate therapy, delayed at-breast feeding due to maternal-infant separation) etiologies. We further describe the use of antenatal milk expression (AME), or milk expression and storage beginning around 37 weeks of gestation, as a potential intervention to mitigate suboptimal breastfeeding outcomes in women at risk for preeclampsia and other hypertensive disorders of pregnancy.

Conclusions

Additional research is needed to address incidence, etiology, and interventions, including AME, for breastfeeding issues among a larger sample of women who develop hypertensive disorders of pregnancy.

Are evaluated respiratory service developments implemented into clinical practice?

INTRODUCTION

Evaluation of the way in which respiratory care is delivered is increasingly recognised to be an important area for research. When service developments are reported, it is not always clear whether they are subsequently implemented within the reporting institution, and if not why not.

METHODS

3281 abstracts from three specialist journals and one general journal were reviewed, and 36 reported evaluated service developments identified. The authors of each of these were approached to determine whether the reported service developments were in use in their institution.

RESULTS

30 of the 36 authors responded (83%). 10 reports were of sharing care with nurses and five with other health professionals, and the remainder involved new technologies, education, patient information or guideline implementation. 15/30 had implemented the reported development into practice, 11 of which were implemented immediately. Delays were due to staffing, funding and organisational issues. 10/15 studies were not put into practice, the main reason being that the key person had left. Four respondents embarked upon further study to confirm their preliminary published findings.

CONCLUSIONS

Reports of apparently positive service developments are only implemented in approximately one-half of institutions reporting the development. In a third of cases, non-implementation reflects the original authors believing that further study is necessary to confirm effectiveness.

Addressing issues of maldistribution of health care workers

INTRODUCTION

The maldistribution of health care workers is a near-universal problem, particularly in developing countries. Shortages have become most critical over the past 2 decades with both out-migration of health care workers from developing to developed countries, and intra-country disparities between urban centres and rural regions. A variety of solutions have been proposed and tried, but in recent years the problem has become increasingly serious.

PROGRAMME DESCRIPTION

Over the past 15 years, we have conceptualised and implemented a programme directed at the re-supply of rural physicians to our own state, Illinois, which was recently ranked as low as sixth worse in the US with regard to physician manpower shortages in rural areas. More recently, this programme has been expanded to include other health care workers where there are equivalent shortages in health services accessibility, and the entire programme is now designated as the National Center for Rural Health Professions.

PROGRAMME EVALUATION

Currently, the physician programme enjoys a 65% to 70% success rate in terms of the return of physicians to rural communities; a success largely due to the unique selection process, training, and the close relationship between students and faculty. Here, we describe this programme in detail, in the hope that elements of this somewhat unique programme may be "exportable".

Cycle of child sexual abuse: links between being a victim and becoming a perpetrator

BACKGROUND

There is widespread belief in a 'cycle' of child sexual abuse, but little empirical evidence for this belief.

AIMS

To identify perpetrators of such abuse who had been victims of paedophilia and/or incest, in order to: ascertain whether subjects who had been victims become perpetrators of such abuse; compare characteristics of those who had and had not been victims; and review psychodynamic ideas thought to underlie the behaviour of perpetrators.

METHOD

Retrospective clinical case note review of 843 subjects attending a specialist forensic psychotherapy centre.

RESULTS

Among 747 males the risk of being a perpetrator was positively correlated with reported sexual abuse victim experiences. The overall rate of having been a victim was 35% for perpetrators and 11% for non-perpetrators. Of the 96 females, 43% had been victims but only one was a perpetrator. A high percentage of male subjects abused in childhood by a female relative became perpetrators. Having been a victim was a strong predictor of becoming a perpetrator, as was an index of parental loss in childhood.

CONCLUSIONS

The data support the notion of a victim-to-victimiser cycle in a minority of male perpetrators but not among the female victims studied. Sexual abuse by a female in childhood may be a risk factor for a cycle of abuse in males.

Medical student evaluation of family nurse practitioners as teachers

BACKGROUND

Demands on family medicine faculty to generate clinical revenue may negatively impact the undergraduate medical education program. To minimize this possibility and better model interprofessional education, family nurse practitioners (FNPs) were hired as clinicians and teachers as part of a longitudinal family medicine clerkship. This paper reports the results of a pilot study of student evaluations of nurse practitioner teaching.

METHODS

All M3 and M4 students were asked to evaluate one of three FNPs who had precepted them multiple times during their previous year of ambulatory care practice. Two previously studied closed-ended questionnaires were used to assess quality of teaching by the FNPs. Students also responded to a series of open-ended questions.

RESULTS

Ninety-one percent of 97 students responded to the survey. Responses to the closed-ended questions as well as comments by the students and physicians were positive regarding the teaching by FNPs. The teaching skills most highly regarded by the students tended to be different than those most highly regarded in physicians.

CONCLUSIONS

This pilot study suggests FNPs can be successfully integrated into undergraduate medical education settings, offering teaching strengths that complement those of physicians. Integrating the two professions in a family medicine clerkship may prove beneficial to students and expand departmental teaching resources without further straining finances. Efforts at evaluating the teaching contributions of FNPs at other institutions are needed to substantiate the present study results.

Screening applicants for a rural medical education program

The goal of the Rural Medical Education (RMED) Program of the University of Illinois College of Medicine at Rockford is to train rural family physicians. This article describes the screening instrument developed by RMED to identify appropriate candidates.

Illinois RMED: a comprehensive program to improve the supply of rural family physicians

BACKGROUND

Rural areas of the United States are perennially medically underserved, and the state of Illinois is no exception. A recent survey showed that 75 of Illinois' 84 rural counties are primary care physician shortage areas. In response to this chronic physician shortage, the Illinois Rural Medical Education (RMED) Program was developed by the University of Illinois College of Medicine at Rockford. The RMED program is a comprehensive, multifaceted program that combines recruitment, admissions, curriculum, support, and evaluation components and is longitudinal across all 4 years of the medical school experience. The admissions process seeks to select students who possess traits indicative of success in eventual rural family practice. These traits are fostered and developed by the 4-year rural curriculum, which emphasizes family medicine, community-oriented primary care, the physician functioning in the context of community, relevant aspects of the "hidden" curriculum, and service learning. After 6 years, RMED has graduated 39 physicians; 69% have gone into family practice, and a total of 82% have selected primary care residencies.

On violence. A preliminary communication

The author argues that although aggression is a central feature of psychoanalytic theory and clinical thinking, little attention has been given by psychoanalysts to the matter of violence. Manifest violence is heterogenous and an adequate understanding of it would involve a multi-disciplinary approach. The author focuses on consideration of a psychoanalytic contribution to this understanding. From this point of view all acts of violence may be characterised as one of two types, or a combination of them, namely self-preservative violence and sado-masochistic violence. These are characterised and differentiated; and the relationship between the two is considered, while use is made of clinical material. The issue of 'violence in the transference' is illustrated and briefly discussed.

Quality of life, health care utilization, and costs among women undergoing hysterectomy in a managed-care setting

OBJECTIVE

We compared quality of life, utilization, and costs for women undergoing elective abdominal, laparoscopically assisted vaginal, or vaginal hysterectomy within a managed-care organization.

STUDY DESIGN

A prospective study of 287 women who underwent an elective hysterectomy was performed.

RESULTS

Patients undergoing a vaginal hysterectomy reported returning to normal activity levels sooner and had more favorable quality-of-life scores than did those undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy. Laparoscopically assisted vaginal hysterectomy was often nearly as favorable as vaginal hysterectomy, particularly at 28 days after the operation, whereas the abdominal hysterectomy group consistently reported the poorest postoperative quality-of-life scores. No significant differences were noted in utilization or costs in the 60-day preoperative period, whereas hospitalization and postoperative costs were highest among the abdominal hysterectomy group and lowest for those undergoing a vaginal hysterectomy.

CONCLUSIONS

Vaginal hysterectomy resulted in better quality-of-life outcomes and lower utilization and costs compared with laparoscopically assisted vaginal or abdominal hysterectomy.

Assessment and treatment of geriatric depression in primary care settings

OBJECTIVE

To examine primary care physicians' practices relating to the diagnosis and management of geriatric depression, attitudes regarding responsibilities for and barriers to management, self-assessments of their needs in providing this care, and physician characteristics that correlate with attitudes and practices.

DESIGN

Descriptive and analytic needs assessment.

SETTING

A midwestern city and surrounding county and the suburb of another midwestern city.

MEASUREMENTS

A self-administered survey consisting mainly of close-ended, Likert scale questions.

PARTICIPANTS

One hundred forty-one family physicians and general internists (53.2%) responded. Respondents were 75.4% male and 50.8% general internists and ranged in age from 29 to 75 years (mean, 43 years; SD, 11 years).

RESULTS

No standard test to screen for depression was used by 66.7% of respondents. The 2 most common laboratory studies ordered were thyroid studies (41.1%) and chemistry panels (37.6%). Selective serotonin reuptake inhibitors were most commonly prescribed for depression (53.2%). Although 98.6% of respondents agreed that treatment of depression in elderly patients was important, 29.0% reported that depressed elderly patients frustrated them, and 24.2% were too pressured for time to routinely investigate depression in the elderly. The most frequently identified needs in caring for these patients were increased time with patients (97.1%); increased reimbursement for counseling (87.8%); greater emphasis in medical training on the link between physical and mental health (85.6%); improved patient compliance with treatment (84.3%); and more training and attention to depression in residency (82.1%). In general, family physicians were more active and positive in their approach toward geriatric depression.

CONCLUSIONS

Potential interventions to improve the diagnosis and management of geriatric depression include the following: use of screening instruments in a more efficient and timely manner; increased reimbursement for counseling of patients; more educational programs at the undergraduate, graduate, and continuing medical education levels; and clinical practice guidelines specific to geriatric depression.

Variations in functional status among different groups of elderly people

BACKGROUND

Functional status differs among populations of elderly, although the extent of differences in types of functions among groups has not been closely examined. This study identifies and compares characteristics among different populations of elderly, using a screening test that measures self-assessment of multiple areas of function. The screening tool used was the Dartmouth COOP Charts, developed for and primarily tested in office medical practices. It has not been used to systematically compare office patients with other groups of elderly.

METHODS

Dartmouth COOP Charts were administered to five groups of elderly drawn from convenience samples of individuals age 65 and older, including elderly living in senior apartments, those attending community activities, mentally oriented nursing home patients, office patients, and elderly patients not visiting the doctor within the past 6 months. Demographic data, as well as COOP chart results, were obtained.

RESULTS

There were multiple differences in COOP chart scores among the samples of elderly individuals. The greatest differences were in self-reported physical fitness and in the level of difficulty in performing daily activities. Medical office patients not visiting in 6 months had the highest fitness levels. On the other hand, the "social support" availability scale showed no differences among groups. Results from other scales were intermediate among these extremes.

CONCLUSIONS

Different samples of elderly yield varying results on several measures of reported physical and emotional health. All convenience samples of the elderly may have somewhat poorer health than the average person age 65 and older. Of the groups studied, those with the poorest function were either older adults in nursing homes or those visiting the doctor's office for treatment.

Primary care physicians' recognition of and attitudes toward domestic violence

PURPOSE

Physicians fail to identify the majority of domestic violence victims, even though they are often the first and only individuals to whom a victim may present. The present study was designed to assess primary care physicians' recognition of and attitudes toward domestic violence.

METHOD

Of the 148 primary care physicians in three midwestern counties, all the women and a random sample of the men were included in the survey, for a total of 83. A seven-page questionnaire was developed that contained items about demographics and practice characteristics, and questions about the following aspects of domestic violence: knowledge, attitudes, importance, and prevalence in practice; attitudes toward responsibility; current practices and protocols used; level of education and domestic violence received; and opinions on how best to distribute information and/or education concerning domestic violence. The questionnaire was mailed in 1994. Follow-up was conducted through phone calls, remailings, and visits to the physicians' offices. Responses were examined using chi-square tests and two-tailed t-tests.

RESULTS

The response rate was 63% (52 of 83); 53% of those responding were family physicians and 47% were general internists; 34% were women. Although all of the physicians agreed that finding and treating domestic violence is important, less than half agreed that domestic violence was a significant problem in their patient populations. Almost 96% of the physicians believed that more should be done to educate physicians about domestic violence, and 94% agreed that domestic violence should be included in a doctor's professional medical training; yet nearly half said they would not participate in a domestic violence forum. Even though 41% noted that they had received some type of formal education about domestic violence, 57% felt that their medical education had inadequately prepared them to deal with domestic violence, and less than 25% reported that they had been trained to diagnose domestic violence. The family physicians and the female physicians had received more education about domestic violence and were more comfortable addressing domestic-violence situations. The older physicians were less comfortable addressing domestic violence and were less likely to agree that education about domestic violence should be a part of medical training.

CONCLUSION

Interventions by the medical community to increase physician awareness of domestic violence and available treatment resources are necessary, and domestic-violence information should be included in formal medical curricula.

Defining a generalist education: an idea whose time is still coming

Generalist education is different from the traditional medical curriculum as it has developed over the past 40 years. For example, in their training doctors must develop the appropriate skills, knowledge, and attitudes to understand patients' specific expectations, address wellness rather than illness only, be familiar with concepts of clinical epidemiology, concentrate on interpersonal communication, and strive to control costs. The University of Illinois College of Medicine at Rockford was established to provide community-based medical education. Beginning in their second year, all Rockford students have extensive clinical training in one of three community health centers operated by the Department of Family and Community Medicine. Several kinds of evaluation have been conducted to assess the reaction to and impact of this clinical training on the students and faculty, and follow-up studies have tracked the students after graduation. The Rockford experience has shown that the entire curriculum must give uncompromising support for generalist education, all primary care faculty must have a common knowledge base in the theory and practice of generalist medicine, and the shift to generalist education will require shifts in attitude and behavior throughout the academic medicine community at the institution.

Prenatal and postpartum Pap smears: do we need both?

PURPOSE

The need to perform a Pap smear at the time of entry to prenatal care, as well as at the postpartum check-up, is questionable. A comparison of the rates of recovery of endocervical cells and the incidence of dysplasia on the prenatal and postpartum Pap smears may be helpful in determining an optimal preventive care protocol for patients who are pregnant.

METHODS

Demographic and clinical data were collected from the records of 1,377 obstetrical patients at a midwest family practice residency. The yield of endocervical cells and the incidence of dysplasia was determined for both the prenatal and the postpartum Pap smears performed for this group of patients.

RESULTS

In women having both exams, endocervical cells were recovered in 44.1% of prenatal Pap smears compared to 82.0% of postpartum smears. The incidence of dysplasia was 2.6% on prenatal Pap smears and 4.8% on postpartum smears. In this study population, 33% of women did not return for their postpartum check-up.

CONCLUSIONS

The postpartum Pap smear is of value due to a significant yield of dysplasia. The sensitivity of the prenatal Pap test may be less than desired. Efforts directed toward increased patient compliance regarding the postpartum check-up are needed.

Dementia and depression symptomatology as assessed through screening tests of older patients in an outpatient clinic

OBJECTIVE

This study examined the prevalence of dementia and depression symptoms as assessed through screening instruments in older patients visiting a family practice clinic, compared screening results with indications of either a dementia or depression-related diagnosis as reported on patients' medical records and billing statements, and examined the relationship between screening instrument results and patients' demographics.

METHODS

A total of 214 patients were interviewed and completed a written survey relating to dementia (Mini-Mental State Exam), depression (Beck Depression Inventory), medical conditions, and demographics. Patients were 60 years of age and older visiting a family practice clinic serving an outpatient population in northwest Illinois and southern Wisconsin. The clinic is an undergraduate teaching site of the University of Illinois College of Medicine at Rockford. Patients were interviewed at the time of their visits for routine medical care as they appeared on study recruitment days.

RESULTS

The response rate was greater than 90%. About 20% of the patients scored in the range of possible cognitive impairment and over 22% scored in the range of possible mild to moderate depression. Overall, about 38% of the patients showed symptoms of either dementia or depression, or both. Based on chart review, there was significant under-reporting of dementia or cognitive difficulties and low correlation between screening results and chart and billing information related to depression.

CONCLUSIONS

The results reaffirm a significant rate of mental health problems in older patients in outpatient settings. This situation warrants examination of the reasons for under-reporting of mental health problems and the potential relationship between mental health problems and the general health status of elderly patients.

Detecting depression in elderly outpatients: findings from depression symptom scales and the Dartmouth COOP charts

BACKGROUND

The diagnosis and treatment of depression in elderly adults is a serious concern in outpatient settings, where it is well known that practicing physicians often overlook the possibility of depression in adult patients of all ages. Detecting depression in elderly patients can present different problems than detection in younger patients, and special instruments have been developed to screen for depressive symptoms in the elderly. These instruments are not commonly used in family practice settings because of time constraints and confusion about details on how to use them.

METHODS

This study compared four commonly accepted depression scales: the Geriatric Depression Scale (GDS), the Beck Depression Inventory Short Form, the Durham GRECC, and the Brief Carroll Scale, and one functional assessment instrument, the Dartmouth COOP Functional Assessment Charts/WONCA, in identifying depressive symptoms in 100 patients 65 years and older (mean 71.6 years) attending an outpatient family practice residency clinic. These results were compared with actual chart records relating to depression and depression symptoms.

RESULTS

The prevalence of depressive symptoms in this elderly outpatient population fell within the range of 16.5%-34.7%, according to scores on the various depression scales. Review of the same patients' medical records revealed that only 7% had been given a diagnosis of or were being treated for depression by their physician. The three shorter depression scales correlated well with the longer GDS, indicating that they may be substitutable for the more lengthy GDS. The Dartmouth COOP Functional Assessment Charts/WONCA proved to have a high level of consistency between the findings from its emotional condition component and the results of the depression symptom scales.

CONCLUSION

This study affirms the potential utility of depression symptom screening scales in the outpatient setting. It also points to the possible utility of the emotional condition component of the Dartmouth COOP Functional Assessment Charts/WONCA as a screening question to be followed, as appropriate, by more formal instruments or clinical interview for depression in elderly outpatients.

Medical students' understanding of ethical issues in the ambulatory setting

BACKGROUND

The education of medical students concerning ethical issues focuses mainly on critically ill hospitalized patients. However, in the outpatient setting physicians encounter many problems that require ethical decision making. The present study is an assessment of medical students' awareness and understanding of ethical issues commonly encountered in the ambulatory setting.

METHODS

A questionnaire was designed to evaluate general knowledge of medical ethics using 12 clinical vignettes. These vignettes depict situations in the ambulatory setting which involve ethical problems. The questionnaire was distributed to medical students who were asked to state whether an ethical issue was present, its significance, and what the specific issue was.

RESULTS

Students' abilities to identify that an ethical issue was involved in each vignette ranged from 34.2% to 96.4%. A majority of students identified the presence of an ethical dilemma in seven out of 12 vignettes. The significance rating varied from 2.8 to 4.4 on a scale of 1 to 5. The results indicate that traditional education in medical ethics does not necessarily prepare students to recognize these problems in the clinical setting.

CONCLUSIONS

The medical students surveyed for this study seem to be variably prepared to recognize obvious ethical dilemmas in the ambulatory setting. Medical education must prepare students to recognize and appropriately manage these commonly encountered situations.

Dual response runs in prehospital trauma care

The effects of dual responses [Basic Life Support (BLS) and Advanced Life Support (ALS)] on the outcomes of trauma patients were evaluated. Outcomes included changes in physiologic measurements between the scene and the emergency department (ED), and survival to hospital discharge. Data for 2394 patients with penetrating, motor vehicle crash (MVC), or other blunt injuries were included. Changes in physiologic measurements (Revised Trauma Scores) between the prehospital and ED settings were positively associated with documented ALS or dual response care. Survival to hospital discharge among penetrating injury patients was negatively related to dual responses, whereas that among MVC patients was positively associated with dual responses. Parallel results were found for a subset of more severely injured patients. Future research should confirm and refine these results so that protocols for the appropriate use of dual response runs can be developed.

How ambulatory care is different: a paradigm for teaching and practice

This paper reviews the issues regarding an increased emphasis on medical education and practice in the ambulatory care setting. A paradigm for ambulatory medicine is offered which combines the elements of 'traditional' medical care and teaching with the more 'distinctive' elements representative of the ambulatory setting. The former includes aetiology, history, physical examination, laboratory tests and therapy; while the latter includes continuity, context, health education, economics and responsibility. The paradigm is illustrated in relation to the problem of hypertension. The ambulatory medicine paradigm is further discussed with respect to potential barriers to its acceptance. These include: (1) the assumption that 'traditional' medical education does teach all 10 elements of the paradigm; (2) the axiom that if one learns to care for the sickest patients, the less ill ones should be manageable; (3) the intuitive aspects of the 'art' of practising ambulatory medicine; (4) the recognition that this teaching will require a longitudinal experience; and (5) perception that the five distinctive elements are not 'hard' science and objectively measurable. Nevertheless, the changing face of medical practice requires the adoption of an ambulatory medicine paradigm in medical education.

Is early onset of gray hair a risk factor?

An office and autopsy study was performed to see if early graying was associated with increased morbidity, earlier age at death, and specific cause of death. 195 consecutive office patients over the age of 40 were studied to see if premature graying of scalp hair (50% or more gray before age 50) was associated with increased incidence of disease before age 50 (P = ns). Their parents' mean ages at death, prematurely gray or not, were compared. For fathers, mean age at death if prematurely gray was 68.27 years; if not prematurely gray, 66.03 years (P = 0.35). For mothers, the values were 70.55 years and 70.37 years respectively (P = greater than 0.50). 874 autopsy patients dying over a 23-year period (1966-1989) were studied to see if the median age at death (of patients 50% or more gray) differed for any of the six categories of disease (myocardial infarction, congestive heart failure, cancer, stroke, pneumonia/bronchitis, or cirrhosis of the liver/GI problems) when compared to the entire autopsy sample of 19 categories of disease (P = ns for each comparison). This dual office and autopsy study provides no evidence to support the contention that early gray hair is a risk factor.

Cesarean section: science or ritual surgery?

Cesarean section has proven to be a powerful weapon in saving fetal and maternal life when scientific criteria are used in a variety of emergency conditions. However, because of the high incidence of false positive readings with fetal heartrate monitoring, cesareans are often resorted to unnecessarily. In addition, there are other marginal, nonscientific human concerns such as patient and doctor preference, convenience, fear of litigation, wish to avoid pain of labor, and other unspoken and often unrecognized issues that can lead to cesarean section. When cesarean section is resorted to for the above reasons, it becomes ritual surgery. It is time to recognize two sets of criteria for cesarean sections: first, scientific criteria that would save the life of the mother or fetus, or unequivocally guarantee better fetal outcome; and second, nonscientific criteria based on personal preference of doctors and patients. If doctors were candid about these two sets of criteria, patients would not be pressured into cesareans by minor, often transient and misleading, abnormalities on fetal monitors. They would not have to experience ritual surgery unless it was clearly their choice to do so.

Males' use of public health department family planning services

Information was obtained from over 200 males visiting a family planning service either to obtain free-of-charge condoms or incidental to accompanying their female partner. The former group was younger and more likely to reside near the health department: over 40 percent of this group used the health department as sole condom source. Both groups indicated willingness to share in costs for male services. Future programs need to more effectively plan public health family planning for these males.

Gender and the educational experience in a primary care training setting

As the number of women entering medical school increases, patient contacts with female physicians will similarly increase. As a result, educators have begun to consider the relationship between gender and both performance and career preference. The current study explores the relationship between a student's gender and the educational experience of the student. In the setting of established primary care teaching physicians' offices at the University of Illinois College of Medicine at Rockford, gender and diagnosis data were collected on all patient encounters over the course of one year for the 129 students enrolled in the program. Women medical students were 29% less likely than chance to see male patients, and male students were 5% less likely than chance to see female patients in this setting. This finding was especially marked for encounters with younger adult patients and for sexually sensitive examinations, but was noted with all groups of adult patients. The qualitative effect of this on both educational experiences and health care delivery needs to be addressed.

Characteristics of males at a public health department contraceptive service

To effectively confront teenage pregnancy, the characteristics, attitudes, and behaviors of males, along with females, need to be better understood. This pilot study examined young males who visited the family planning clinic of a public health department to obtain free condoms. Questionnaires were distributed over a 4-week period. Nearly 30% of males reported having sex 11+ times a month. However, an equal proportion reported having sex three or fewer times in the same interval. Most males reported using condoms during sex, although one quarter reported use as "seldom." The health department was a major source of condoms and was positively evaluated because condoms were free and there were "no questions asked." Only one third of the males reported using another method of contraception. Results suggest a major role of the health department in condom availability and the potential need for contraceptive services for males.

Sulfonylurea-induced decrease of muscle capillary basement membrane thickness in diabetes

Three muscle biopsies were performed in 53 overt type 2 diabetics over a period of approximately 2 years. At baseline, 21 (40%) had an increased capillary basement membrane width in muscle. Thirty-five patients received glipizide and 18 received placebo. In the patients receiving placebo, the mean of the muscle capillary basement membrane width increased from 158.7 +/- 11.5 nm (SEM) to 170.9 +/- 14.7 nm (P = NS), but in those receiving glipizide the value decreased from 192.9 +/- 13.2 nm to 161.0 +/- 10.2 nm (P = 0.02). Plasma glucose and glycosylated hemoglobin A1 decreased significantly (P less than 0.001) after 2 years in patients receiving glipizide. In 15, mean glycosylated hemoglobin A1 reached a normal range, and mean basement membrane width decreased to a level close to that found in subjects without diabetes (P = NS). These findings are consistent with the hypothesis that effective response to oral medication can decrease the basement membrane thickening, suggesting that diabetic microangiopathy is not necessarily progressive.

Patient, parent, and physician perspectives on pediatric oncology rounds

To provide data to guide physicians regarding the extent to which pediatric patients and their families should be involved in decision-making discussions by their health care teams, we compared the standard rounding procedure in a pediatric oncology unit (rounds conducted out of earshot) with bedside rounds in which management was discussed in front of patients and parents. Type of rounds was alternated in 2-week blocks for 4 months. The impact of the two types of rounds of 35 parents and children was studied. Parents preferred bedside rounds to standard rounds, and perceived increased opportunities to obtain information and ask questions. Parents and children differed in their reports of how much bedside rounds upset children. Older children, compared with younger children, more strongly disliked standard rounds; this appeared to be related to feelings of exclusion. The two types of rounds differed in their effectiveness in providing specific types of education to residents. The findings suggest that bedside rounds have a positive impact on parents' attitudes toward physicians, that they do not dilute the child's sense of relationship with the primary attending physician, and that they contribute to certain aspects of resident education.