Showing papers in "Obstetrical & Gynecological Survey in 1998"

Oral Sildenafil in the Treatment of Erectile Dysfunction

Abstract: Background Sildenafil is a potent inhibitor of cyclic guanosine monophosphate in the corpus cavernosum and therefore increases the penile response to sexual stimulation. We evaluated the efficacy and safety of sildenafil, administered as needed in two sequential double-blind studies of men with erectile dysfunction of organic, psychogenic, or mixed causes.Methods In a 24-week dose-response study, 532 men were treated with oral sildenaffi (25, 50, or 100 mg) or placebo. In a 12-week, flexible dose-escalation study, 329 different men were treated with sildenafil or placebo, with dose escalation to 100 mg based on efficacy and tolerance. After this doseescalation study, 225 of the 329 men entered a 32-week, open-label extension study. We assessed efficacy according to the International Index of Erectile Function, a patient log, and a global-efficacy question.Results In the dose-response study, increasing doses of sildenafil were associated with improved erectile function (P values for increases in sc...

Herpes simplex virus type 2 in the united states, 1976 to 1994

Abstract: BACKGROUND Herpes simplex virus type 2 (HSV-2) infection is usually transmitted sexually and can cause recurrent, painful genital ulcers. In neonates the infection is potentially lethal. We investigated the seroprevalence and correlates of HSV-2 infection in the United States and identified changes in HSV-2 seroprevalence since the late 1970s. METHODS Serum samples and questionnaire data were collected during the National Health and Nutrition Examination Surveys (NHANES) II (1976 to 1980) and III (1988 to 1994). HSV-2 antibody was assessed with an immunodot assay specific for glycoprotein gG-2 of HSV-2. RESULTS From 1988 to 1994, the seroprevalence of HSV-2 in persons 12 years of age or older in the United States was 21.9 percent (95 percent confidence interval, 20.2 to 23.6 percent), corresponding to 45 million infected people in the noninstitutionalized civilian population. The seroprevalence was higher among women (25.6 percent) than men (17.8 percent) and higher among blacks (45.9 percent) than whites (17.6 percent). Less than 10 percent of all those who were seropositive reported a history of genital herpes infection. In a multivariate model, the independent predictors of HSV-2 seropositivity were female sex, black race or Mexican-American ethnic background, older age, less education, poverty, cocaine use, and a greater lifetime number of sexual partners. As compared with the period from 1976 to 1980, the age-adjusted seroprevalence of HSV-2 rose 30 percent (95 percent confidence interval, 15.8 to 45.8 percent). The seroprevalence quintupled among white teenagers and doubled among whites in their twenties. Among blacks and older whites, the increases were smaller. CONCLUSIONS Since the late 1970s, the prevalence of HSV-2 infection has increased by 30 percent, and HSV-2 is now detectable in roughly one of five persons 12 years of age or older nationwide. Improvements in the prevention of HSV-2 infection are needed, particularly since genital ulcers may facilitate the transmission of the human immunodeficiency virus.

Outcome of cord-blood transplantation from related and unrelated donors

Abstract: Background Cord-blood banks have increased the use of cord-blood transplantation in patients with hematologic disorders. We have established a registry containing information on the outcome of cord-blood transplantation. Methods We sent questionnaires to 45 transplantation centers for information on patients receiving cord-blood transplants from 1988 to 1996. Reports on 143 transplantations, performed at 45 centers, were studied, and the responses were analyzed separately according to whether the donor was related or unrelated to the recipient. Results Among 78 recipients of cord blood from related donors, the Kaplan–Meier estimate of survival at one year was 63 percent. Younger age, lower weight, transplants from HLA-identical donors, and cytomegalovirus-negative serologic results in the recipient were favorable prognostic factors. Graft-versus-host disease of at least grade II occurred at estimated rates of 9 percent in 60 recipients of HLA-matched cord blood and 50 percent in 18 recipients of HLA-misma...

Effects of raloxifene on bone mineral density, serum cholesterol concentrations, and uterine endometrium in postmenopausal women

Abstract: Background Long-term estrogen therapy can reduce the risk of osteoporotic fracture and cardiovascular disease in postmenopausal women. At present, however, these beneficial effects are not separable from undesirable stimulation of breast and endometrial tissues. Methods We studied the effect of raloxifene, a nonsteroidal benzothiophene, on bone mineral density, serum lipid concentrations, and endometrial thickness in 601 postmenopausal women. The women were randomly assigned to receive 30, 60, or 150 mg of raloxifene or placebo daily for 24 months. Results The women receiving each dose of raloxifene had significant increases from base-line values in bone mineral density of the lumbar spine, hip, and total body, whereas those receiving placebo had decreases in bone mineral density. For example, at 24 months, the mean (±SE) difference in the change in bone mineral density between the women receiving 60 mg of raloxifene per day and those receiving placebo was 2.4±0.4 percent for the lumbar spine, 2.4±0.4 per...

Functional coherence of the human y chromosome

Abstract: A systematic search of the nonrecombining region of the human Y chromosome (NRY) identified 12 novel genes or families, 10 with full-length complementary DNA sequences. All 12 genes, and six of eight NRY genes or families previously isolated by less systematic means, fell into two classes. Genes in the first group were expressed in many organs; these housekeeping genes have X homologs that escape X inactivation. The second group, consisting of Y-chromosomal gene families expressed specifically in testes, may account for infertility among men with Y deletions. The coherence of the NRY's gene content contrasts with the apparently haphazard content of most eukaryotic chromosomes.

Prevention of Bone Loss With Alendronate in Postmenopausal Women Under 60 Years of Age

Abstract: BACKGROUND Estrogen-replacement therapy prevents osteoporosis in postmenopausal women by inhibiting bone resorption, but the balance between its long-term risks and benefits remains unclear. Whether other antiresorptive therapies can prevent osteoporosis in these women is also not clear. METHODS We studied the effect of 2.5 mg or 5 mg of alendronate per day or placebo on bone mineral density in 1174 postmenopausal women under 60 years of age. An additional 435 women who were prepared to receive a combination of estrogen and progestin were randomly assigned to one of the above treatments or open-label estrogen-progestin. The main outcome measure was the change in bone mineral density of the lumbar spine, hip, distal forearm, and total body measured annually for two years by dual-energy x-ray absorptiometry. RESULTS The women who received placebo lost bone mineral density at all measured sites, whereas the women treated with 5 mg of alendronate daily had a mean (+/-SE) increase in bone mineral density of 3.5+/-0.2 percent at the lumbar spine, 1.9+/-0.1 percent at the hip, and 0.7+/-0.1 percent for the total body (all P<0.001). Women treated with 2.5 mg of alendronate daily had smaller increases in bone mineral density. Alendronate did not increase bone mineral density of the forearm, but it slowed the loss. The responses to estrogen-progestin were 1 to 2 percentage points greater than those to the 5-mg dose of alendronate. Alendronate was well tolerated, with a safety profile similar to that of placebo or estrogen-progestin. CONCLUSIONS Alendronate prevents bone loss in postmenopausal women under 60 years of age to nearly the same extent as estrogen-progestin.

Trial of calcium to prevent preeclampsia

Abstract: BACKGROUND Previous trials have suggested that calcium supplementation during pregnancy may reduce the risk of preeclampsia. However, differences in study design and a low dietary calcium intake in the populations studied limit acceptance of the data. METHODS We randomly assigned 4589 healthy nulliparous women who were 13 to 21 weeks pregnant to receive daily treatment with either 2 g of elemental calcium or placebo for the remainder of their pregnancies. Surveillance for preeclampsia was conducted by personnel unaware of treatment-group assignments, using standardized measurements of blood pressure and urinary protein excretion at uniformly scheduled prenatal visits, protocols for monitoring these measurements during the hospitalization for delivery, and reviews of medical records of unscheduled outpatient visits and all hospitalizations. RESULTS Calcium supplementation did not significantly reduce the incidence or severity of preeclampsia or delay its onset. Preeclampsia occurred in 158 of the 2295 women in the calcium group (6.9 percent) and 168 of the 2294 women in the placebo group (7.3 percent) (relative risk, 0.94; 95 percent confidence interval, 0.76 to 1.16). There were no significant differences between the two groups in the prevalence of pregnancy-associated hypertension without preeclampsia (15.3 percent vs. 17.3 percent) or of all hypertensive disorders (22.2 percent vs. 24.6 percent). The mean systolic and diastolic blood pressures during pregnancy were similar in both groups. Calcium did not reduce the numbers of preterm deliveries, small-for-gestational-age births, or fetal and neonatal deaths; nor did it increase urolithiasis during pregnancy. CONCLUSIONS Calcium supplementation during pregnancy did not prevent preeclampsia, pregnancy-associated hypertension, or adverse perinatal outcomes in healthy nulliparous women.

Diagnosis and management of placenta percreta: a review.

Abstract: A review of the clinical decisions, diagnostic, and surgical methods in managing patients with placenta percreta was done by conducting a MEDLINE computerized search from January 1991 to January 1997 using the key words "placenta percreta," "placenta previa," "acute normovolemic hemodilution," and "erythropoietin use." Additional sources were identified through cross-referencing. We reviewed all published reports and articles regarding the clinical and surgical management of placenta percreta and nontraditional ways to treat or prevent anemia in these cases (including acute normovolemic hemodilution and erythropoietin use). The diagnosis of placenta percreta using different ultrasonographic criteria is reliable. Clinical and surgical methods of managing placenta previa with a high risk of percreta are all based on prevention of uncontrolled hemorrhage. Ninety percent of these patients will lose more than 3000 ml intraoperatively and will require blood transfusion. To avoid serious maternal morbidity secondary to hypovolemia, several options are available: erythropoietin use, acute normovolemic hemodilution, selective arterial embolization, prophylactic uterine, or hypogastric artery ligation. With the increasing incidence of placenta percreta, the clinician must use all available methods to accurately diagnose this condition. Adequate preparation and good surgical technique will help reduce maternal mortality and morbidity related to this condition.

Gabaa Receptor alpha 4 Subunit Suppression Prevents Withdrawal Properties of an Endogenous Steroid

Abstract: The hormone progesterone is readily converted to 3alpha-OH-5alpha-pregnan-20-one (3alpha,5alpha-THP) in the brains of males and females. In the brain, 3alpha,5alpha-THP acts like a sedative, decreasing anxiety and reducing seizure activity, by enhancing the function of GABA (gamma-aminobutyric acid), the brain's major inhibitory neurotransmitter. Symptoms of premenstrual syndrome (PMS), such as anxiety and seizure susceptibility, are associated with sharp declines in circulating levels of progesterone and, consequently, of levels of 3alpha,5alpha-THP in the brain. Abrupt discontinuation of use of sedatives such as benzodiazepines and ethanol can also produce PMS-like withdrawal symptoms. Here we report a progesterone-withdrawal paradigm, designed to mimic PMS and post-partum syndrome in a rat model. In this model, withdrawal of progesterone leads to increased seizure susceptibility and insensitivity to benzodiazepine sedatives through an effect on gene transcription. Specifically, this effect was due to reduced levels of 3alpha,5alpha-THP which enhance transcription of the gene encoding the alpha4 subunit of the GABA(A) receptor. We also find that increased susceptibility to seizure after progesferone withdrawal is due to a sixfold decrease in the decay time for GABA currents and consequent decreased inhibitory function. Blockade of the alpha4 gene transcript prevents these withdrawal properties. PMS symptoms may therefore be attributable, in part, to alterations in expression of GABA(A) receptor subunits as a result of progesterone withdrawal.

A role for oestrogens in the male reproductive system

Abstract: Oestrogen is considered to be the 'female' hormone, whereas testosterone is considered the 'male' hormone. However, both hormones are present in both sexes. Thus sexual distinctions are not qualitative differences, but rather result from quantitative divergence in hormone concentrations and differential expressions of steroid hormone receptors. In males, oestrogen is present in low concentrations in blood, but can be extraordinarily high in semen, and as high as 250 pg ml(-1) in rete testis fluids, which is higher than serum oestradiol in the female. It is well known that male reproductive tissues express oestrogen receptors, but the role of oestrogen in male reproduction has remained unclear. Here we provide evidence of a physiological role for oestrogen in male reproductive organs. We show that oestrogen regulates the reabsorption of luminal fluid in the head of the epididymis. Disruption of this essential function causes sperm to enter the epididymis diluted, rather than concentrated, resulting in infertility. This finding raises further concern over the potential direct effects of environmental oestrogens on male reproduction and reported declines in human sperm counts.

Immune maladaptation in the etiology of preeclampsia: a review of corroborative epidemiologic studies.

Abstract: Genuine preeclampsia is a disease of first pregnancies.The protective effect of multiparity, however, is lost with change of partner. Also, exposure to semen provides protection against developing preeclampsia. Analogous to altered paternity, artificial donor insemination and oocyte donation are rep

DDAVP use during pregnancy: an analysis of its safety for mother and child.

Abstract: Synthetic 1-deamino-8-D-arginine-vasopressin (DDAVP) is used in the management of diabetes insipidus (DI). We conducted a systematic literature review of DDAVP use during pregnancy, with particular attention to its safety for both mother and infant. Studies were identified through Ovid MEDLINE from 1976 to July 1997 using the combined terms "desmopressin," "DDAVP," and "pregnancy". Review articles and published letters were also explored. One hundred one articles were retrieved, of which 20 met all the inclusion criteria. Included in the 20 articles were 53 cases with the use of DDAVP for the management of DI. The therapeutic daily dose of DDAVP was approximately 29 micrograms intranasally (range 7.5-100 micrograms), with adequate DI control observed. Three of 14 women with sufficient information developed preeclampsia, a nonsignificant difference from the expected rate of 5 percent (the Fisher exact test, 2-P = .08). The mode of delivery was defined for 22 cases, with 16 uneventful vaginal births, and six cesarean delivery. There was no evidence of a drug interaction among the five women who received both DDAVP and intravenous oxytocin. Information was available on 49 live births born to DI mothers on DDAVP. The mean gestational age at delivery was 37.4 weeks (SD 1.3 weeks), with an estimated mean birth weight of 2963.8 gm (range 2000-4420 gm). Forty-three offspring were reported as healthy (event rate 87.8 percent; 95 percent CI 77.2-95.3 percent). Of the remaining six infants, one developed DI at 18 months of age; a second was under 2500 gm at birth, but survived; the third developed hypotonia and failure to thrive at 21 months, two others had Down syndrome; and the sixth died of severe cardiac anomalies. Similar data were seen among the 41 infants whose mothers had used DDAVP throughout pregnancy. In conclusion, DDAVP use during pregnancy seems to be safe for both mother and child. Delivery does not seem to be augmented by its use, nor are there likely any associated adverse neonatal effects. A large database of DDAVP use during pregnancy is needed to confirm these findings.

The Gothenburg Breast Screening Trial: First Results on Mortality, Incidence, and Mode of Detection for Women Ages 39-49 Years at Randomization

Abstract: BACKGROUND The effect of mammography screening on breast carcinoma mortality in women ages < 50 years remains unclear. METHODS A randomized trial of invitation to breast carcinoma screening with mammography was performed in the city of Gothenburg, Sweden. The purpose was to estimate the effect of mammographic screening on breast carcinoma mortality in women ages < 50 years. Randomization was initially by day-of-birth cluster (18% of subjects), and subsequently by individual (82% of subjects). Between September 1983 and April 1984, 11,724 women ages 39-49 years were randomized to the study group. This group was invited to mammographic screening every 18 months. Two-view mammography was used at each screen unless the density of the breast at the previous screen indicated that single view was adequate. Fourteen thousand two hundred and seventeen women in the same age range were randomized to a control group that was not invited to undergo screening until the fifth screen of the study group (between 6 and 7 years after randomization). Women with breast carcinoma diagnosed up to the time immediately after the first screen of the control group were followed for death from breast carcinoma until the end of December 1994. RESULTS A 45% reduction in mortality from breast carcinoma was observed in the study group compared with the control group (relative risk [RR] = 0.55, P = 0.035, 95% confidence interval [CI], 0.31-0.96). A conservative estimate based on removal of the tumors detected at the first screen of the control group gave a mortality reduction of 44% (RR = 0.56, P = 0.046, 95% CI, 0.31-0.99). In both cases, the effect was statistically significant. CONCLUSIONS Mammographic screening can reduce mortality from breast carcinoma in women ages < 50 years. The mortality reduction can be substantial if high quality mammography is used and an 18-month interscreening interval is strictly adhered to.

A longitudinal analysis of infant morbidity and the extent of breastfeeding in the united states

Abstract: Background . Studies on the health benefits of breastfeeding in developed countries have shown conflicting results. These studies often fail to account for confounding, reverse causality, and dose-response effects. We addressed these issues in analyzing longitudinal data to determine if breastfeeding protects US infants from developing diarrhea and ear infections. Methods . Mothers participating in a mail panel provided information on their infants at ages 2, 3, 4, 5, 6, and 7 months. Infants were classified as exclusively breastfed; high, middle, or low mixed breast- and formula-fed; or exclusively formula-fed. Diarrhea and ear infection diagnoses were based on mothers’ reports. Infant age and gender; other liquid and solid intake; maternal education, occupation, and smoking; household size; family income; and day care use were adjusted for in the full models. Results . The risk of developing either diarrhea or ear infection increased as the amount of breast milk an infant received decreased. In the full models, the risk for diarrhea remained significant only in infants who received no breast milk compared with those who received only breast milk (odds ratio = 1.8); the risk for ear infection remained significant in the low mixed feeding group (odds ratio = 1.6) and among infants receiving no breast milk compared with those who received only breast milk (odds ratio = 1.7). Conclusions . Breastfeeding protects US infants against the development of diarrhea and ear infection. Breastfeeding does not have to be exclusive to confer this benefit. In fact, protection is afforded in a dose-response manner. The more breast milk an infant receives in the first 6 months of life, the less likely that he or she will develop diarrhea or ear infection. longitudinal analysis, diarrhea, ear infection, breastfeeding.

Listeriosis During Pregnancy

Abstract: Listeriosis is an uncommon infection that has a unique predilection for pregnant women and may result in pregnancy loss. Contaminated food is the usual source of infection, and increased federal surveillance of foodstuffs is the most effective strategy for prevention of disease. Although dramatic epidemics have received the most publicity, more cases of perinatal listeriosis are isolated. If Listeria chorioamnionitis is diagnosed preterm, in contrast to other types of chorioamnionitis, in utero therapy with high-dose penicillin or trimethoprim-sulfamethoxazole is possible, and preterm delivery may be avoided. The clinical characteristics of neonatal listeriosis are similar to neonatal Group B Streptococcus sepsis, with early and late onset forms of disease. The epidemiology, diagnosis, and management of Listeria infection in pregnancy are reviewed.

Circulating leptin in women : a longitudinal study in the menstrual cycle and during pregnancy

Abstract: OBJECTIVE To investigate whether leptin is linked to reproduction, circulating levels were measured longitudinally throughout spontaneous menstrual cycles and during pregnancy in normal women. DESIGN Longitudinal blood samples were collected from normal volunteers, either during regular menstrual cycles or during successful singleton pregnancies. PATIENTS Six healthy, regularly cycling, women volunteers (31.5 ± 3.0 years old, BMI = 21.6 + 0.5) were recruited for serial venous blood sampling throughout one complete menstrual cycle. In addition, five healthy, women (31.8 ± 1.2 years old, pre-pregnant BMI = 30.0 ± 3.1) provided serial venous blood samples throughout one complete singleton pregnancy. MEASUREMENTS Circulating venous oestradiol, progesterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), leptin and (pregnant group only) human chorionic gonadotrophin (hCG). RESULTS In spontaneously cycling women, changes in circulating leptin levels were associated with menstrual phase (P < 0.001) and correlated with progesterone levels (P < 0.05). Peak leptin concentrations were recorded during the luteal phase (P < 0.01), coincident with maximal progesterone levels (P < 0.05). Leptin concentrations were elevated throughout gestation (P < 0.05), and especially during the second trimester (P < 0.05). Post-partum, circulating leptin levels fell sharply to below pre-pregnant values. Leptin correlated with oestradiol (P < 0.05) and human chorionic gonadotrophin (hCG, P < 0.01) levels during pregnancy. First trimester (P < 0.05) and postpartum (P < 0.05) oestradiol concentrations and post-partum hCG levels exhibited the greatest correlation with circulating leptin. CONCLUSIONS We conclude that the relationship between body mass index and circulating leptin varies during the course of spontaneous cycles in women, the best correlation occurring during the luteal phase when progesterone and leptin concentrations are highest. This, together with the correlation between circulating oestradiol, hCG and leptin levels during pregnancy, strongly suggests a dynamic relationship between leptin and reproductive events in women.

Early dating by ultrasound and perinatal outcome : a cohort study

Abstract: BACKGROUND This study aims to evaluate the impact of routine ultrasound in early pregnancy on pregnancy outcome and perinatal mortality. METHODS Using the Swedish Medical Birth Registry, a two-stage study was designed. First, an ecological study that included data from 45 hospitals, with 1,280,746 children born during the years 1974-1991, was designed by differentiating hospitals on the basis of ultrasound usage. Second, a historical cohort study (n = 60,864) was designed for the years 1982-84, including a treatment group (having had routine ultrasound in early pregnancy) and a reference group (having had no routine ultrasound). RESULTS In hospitals practicing early dating by ultrasound, post-term births were reduced from 13.3% to 7.4%, while pre-term births were increased from 5.7% to 6.8%. For the treatment group, the cohort study showed: 1) fewer post-term births, RR 0.7 (95% CL 0.7-0.8), 2) lower post-term perinatal mortality, RR 0.3 (95% CL 0.1-1.0), 3) fewer twin births post-term, RR 0.1 (95% CL 0.1-0.7), 4) fewer acute growth retarded among term, RR 0.7 (95% CL 0.6-0.9) and post-term, RR 0.3 (95% CL 0.1-1.1), and 5) a tendency towards less asphyxia among post-term births. CONCLUSION The study shows that early dating with ultrasound increases the possibilities of clinical judgment at the end of the pregnancy and also indicates that the procedure could contribute to a positive perinatal outcome.

Pathogenesis of Preeclampsia: A Comprehensive Model

Abstract: The objective of this review was to provide a comprehensive and practical concept on the pathogenesis of preeclampsia on the basis of the currently available scientific evidence. A MEDLINE search was performed of English-language articles published between 1966 and 1997, supplemented with references cited in relevant research articles. Using our data sources, we developed a scheme describing the sequence of events between implantation and the time of manifest clinical disease characterized by generalized endothelial cell dysfunction. A yet unidentified toxic circulating factor released by the ischemic placenta, is held responsible for the impaired endothelial cell function. Particularly, epidemiological studies point to a concept in which immune maladaptation to the fetal allograft plays a key role in causing defective placentation leading to placental ischaemia. The incidence of preeclampsia in sisters and daughters of women who had had preeclampsia is raised. Disease states with vascular involvement, like chronic hypertension and diabetes mellites, are associated with an increased risk for preeclampsia. Recently subclinical abnormalities in hemostasis, metabolism and volume homeostasis have been described in patients with a history of preeclampsia. Placental ischemia secondary to defective placentation, a prerequisite for the development of preeclampsia, has a multifactorial origin consisting of three major components: immune maladaptation, genetic predisposition, and vascular mediated factors. Probably, a summation of these factors will determine whether a pregnant woman is to develop the syndrome. The recently described subclinical abnormalities in hemostasis, metabolism, and vascular function in patients with a history of preeclampsia might give the clinician the opportunity to reduce the recurrence risk by pharmacotherapeutic intervention.

Leptin is inversely related to age at menarche in human females

Abstract: Over the last century there has been a trend toward an earlier onset of menarche attributed to better nutrition and body fatness. With the discovery of the obesity gene and its product, leptin, we reexamined this hypothesis from a new perspective. As delayed menarche and leanness are considered risk factors for osteoporosis, we also evaluated the relation between leptin and bone mass. Body composition and serum leptin levels were measured, and the timing of menarche was recorded in 343 pubertal females over 4 yr. Body composition was measured by dual x-ray absorptiometry, and leptin by a new RIA. All participants were premenarcheal at baseline (aged 8.3–13.1 yr). Leptin was strongly associated with body fat (r = 0.81; P < 0.0001) and change in body fat (r = 0.58; P < 0.0001). The rise in serum leptin concentration up to the level of 12.2 ng/mL (95% confidence interval, 7.2–16.7) was associated with the decline in age at menarche. An increase of 1 ng/mL in serum leptin lowered the age at menarche by 1 mont...

Learning, Satisfaction, and Mistreatment During Medical Internship: A National Survey of Working Conditions

Abstract: Context.—Concerns about the working and learning environment of residency training continue to surface. Previous surveys of residents have focused on work hours and income, but have shed little light on how residents view their training experience.Objective.—To provide a description of the internship year as seen by a large cross section of second-year residents.Design.—Mail survey conducted in 1991.Setting.—Residency programs in the United States.Participants.—Random 10% sample (N=1773) of all second-year residents listed in the American Medical Association's medical research and information database.Main Outcome Measures.—What and who contributes most to residents' learning during internships, degree of satisfaction with the internship experience, on-call and sleep schedules, incidents of perceived mistreatment or abuse, observations of unethical behavior, and experiences of harassment or discrimination.Results.—A total of 1277 surveys (72%) of 1773 mailed were returned. Overall, respondents reported a moderate level of satisfaction with their first year of residency. On a scale of 0 to 3, residents rated other residents as contributing most (score of 2.3) to their learning, with special patients ranked second (2.1). During a typical work week, residents reported that they spent an average of 56.9 hours on call in the hospital. A total of 1185 (93%) residents reported experiencing at least 1 incident of perceived mistreatment, with 53% reporting being belittled or humiliated by more senior residents. Among women residents, 63% reported having experienced at least 1 episode of sexual harassment or discrimination. A total of 45% of residents reported having observed another individual falsifying medical records, and 70% saw a colleague working in an impaired condition, most often lack of sleep. Regression analyses suggest that satisfaction with the residency experience was associated with the presence of factors that enhanced learning, and fewer experiences of perceived mistreatment.Conclusions.—Residents report significant problems during their internship experience. Satisfaction with internship is enhanced by positive learning experiences and lack of mistreatment.

Low-dose aspirin to prevent preeclampsia in women at high risk

Abstract: Background Whether low-dose aspirin prevents preeclampsia is unclear. It is not recommended as prophylaxis in women at low risk for preeclampsia but may reduce the incidence of the disease in women at high risk. Methods We conducted a double-blind, randomized, placebo-controlled trial in four groups of pregnant women at high risk for preeclampsia, including 471 women with pregestational insulin-treated diabetes mellitus, 774 women with chronic hypertension, 688 women with multifetal gestations, and 606 women who had had preeclampsia during a previous pregnancy. The women were enrolled between gestational weeks 13 and 26 and received either 60 mg of aspirin or placebo daily. Results Outcome data were obtained on all but 36 of the 2539 women who entered the study. The incidence of preeclampsia was similar in the 1254 women in the aspirin group and the 1249 women in the placebo group (aspirin, 18 percent; placebo, 20 percent; P = 0.23). The incidences in the aspirin and placebo groups for each of the four hi...

Randomised trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy

Abstract: Summary Background Laparoscopic salpingostomy is a wellestablished treatment for patients with tubal pregnancy who desire to retain fertility. Another approach that preserves the fallopian tube is medical treatment. We compared systemic methotrexate and laparoscopic salpingostomy in the treatment of tubal pregnancy. Outcome measures were treatment success, tubal preservation, and homolateral tubal patency. Methods Between January, 1994, and September, 1996, haemodynamically stable patients with laparoscopically confirmed unruptured tubal pregnancy and no signs of active bleeding were randomly assigned systemic methotrexate (four 1·0 mg/kg doses of intramuscular methotrexate alternated with 0·1 mg/kg oral folinic acid) or laparoscopic salpingostomy. Treatment success was defined as complete elimination of the tubal pregnancy (serum human chorionic gonadotropin <2 IU/L) and preservation of the tube. Homolateral tubal patency was assessed by hysterosalpingography. Analysis was by intention to treat. Findings 100 patients were included in the trial. Of 51 patients allocated systemic methotrexate, 42 (82%) were successfully treated with one course; two (4%) patients needed a second course for persistent trophoblast. Surgical intervention was needed in seven (14%) patients; salpingectomy was necessary in five of these patients for tubal rupture. Of the 49 patients allocated laparoscopic salpingostomy, 35 (72%) were successfully treated by laparoscopic salpingostomy alone; salpingectomy was needed in four (8%) patients, and ten (20%) needed methotrexate for persistent trophoblast. The tube was preserved in 46 (90%) patients in the methotrexate group versus 45 (92%) in the salpingostomy group (rate ratio 0·98 [95% CI 0·87–1·1]). Homolateral tubal patency could be assessed in 81 patients: the tube was patent in 23 (55%) of 42 patients in the methotrexate group and in 23 (59%) of 39 patients in the salpingostomy group (rate ratio 0·93 [0·64–1·4]).

Bladder injury during laparoscopic surgery.

Abstract: The objective of this review is to present the incidence of latrogenic bladder injury associated with diagnostic and/or operative laparoscopic surgery; to determine the type of primary laparoscopic operation, the time at which the reported injuries occurred, the location of injuries, and the method(s) used to repair those injuries; to decide which laparoscopic procedure carries the highest risk for bladder injury; and to establish the most frequent surgical instruments with which injuries happened. World literature published between 1970 and 1996 was reviewed. The appropriate Medical Subject Heading (MeSH) terms were selected and used in a search of the MEDLINE, ACOGNET, OVID Compact Disk Version database. A total of 1372 articles on laparoscopic surgery complications were reviewed. Of that number, a total of 77 articles identified bladder injuries, and these were analyzed for the objectives of this study. There are a wide range of bladder injuries during laparoscopic procedures. In the studied articles, the incidence of bladder injury during laparoscopic procedures ranged from 0.02 to 8.3 percent of cases. Most frequently, these injuries occurred during laparoscopic-assisted vaginal hysterectomy. Sharp electrosurgical dissection was the leading instrument causing injury. An intraoperative diagnosis of bladder injury was made in 53.24 percent of all bladder injury cases. The bladder dome was the most commonly injured structure. Less than half (29.87 percent) of the bladder injuries were corrected laparoscopically.

Positive Predictive Rate of Colposcopic Examination of the Cervix Uteri: An Overview of Literature

Abstract: Study of literature revealed that the positive predictive rate of the colposcopic impression is better as the cervical lesion is more severe. When directed biopsies are taken, the positive predictive rate of colposcopy increases considerably. For microinvasive disease, the positive predictive rate is quite poor, probably because of the absence of characteristic features. Large loop biopsies diagnosed all cases of microinvasive disease missed by directed biopsies, but this technique has the disadvantage of considerable "overtreatment" when integrated in the management of all patients with abnormal cytology. The restrictions of colposcopy are the invisibility of the squamocolumnar junction and observer variability in the assessment of the impression. The levels of agreement among experienced colposcopists are in the same range as those in cytological and histopathological diagnosis. It is concluded that colposcopy is an indispensable tool in the management of premalignant cervical disease, as long as the restrictions of the technique are kept in mind by the colposcopist.

Pregnancy outcome following maternal use of the new selective serotonin reuptake inhibitors : a prospective controlled multicenter study

Abstract: Context.—Although a large number of women of reproductive age use new selective serotonin reuptake inhibitors (SSRIs) and half of all pregnancies are unplanned, no data exist on the safety of these agents for the human fetus.Objective.—To assess fetal safety and risk of fluvoxamine, paroxetine, and sertraline.Design.—A prospective, multicenter, controlled cohort study.Setting.—Nine Teratology Information Service centers in the United States and Canada.Patients.—All women who were counseled during pregnancy following exposure to a new SSRI and followed up by the participating centers. Controls were randomly selected from women counseled after exposure to nonteratogenic agents.Main Outcome Measures.—Rates of major congenital malformations.Results.—A total of 267 women exposed to an SSRI and 267 controls were studied. Exposure to SSRIs was not associated with either increased risk for major malformations (9/222 live births [4.1%] vs 9/235 live births [3.8%] in the controls, relative risk, 1.06, 95% confidence interval, 0.43-2.62) or higher rates of miscarriage, stillbirth, or prematurity. Mean (SD) birth weights among SSRI users (3439 [505] g) were similar to the controls (3445 [610] g) as were the gestational ages (39.4 [1.7] weeks vs 39.4 [1.9] weeks).Conclusion.—The new SSRIs, fluvoxamine, paroxetine, and sertraline, do not appear to increase the teratogenic risk when used in their recommended doses.

Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature.

Abstract: This study was conducted to evaluate the role of antepartum laparoscopic cholecystectomy (LC). Patients who underwent LC were identified from a hospital database with the use of CPT/ICD codes. Of 2093 cases performed at a major center (October 1991 to November 1997), only six were performed during pregnancy. On reviewing the English literature, gestational age at surgery and delivery and outcome of delivery were provided in only 69 of 105 patients (33 papers with 1-10 cases) and we tabulated different variables from the cases in this review. In this series, two patients who had LC in the first trimester underwent elective termination of pregnancy. Of the seven published cases of first trimester LC followed to delivery, one had preterm delivery. First trimester open cholecystectomy (OC) has a 12 percent spontaneous abortion rate. The four patients who had second trimester LC had normal deliveries at term. Of the 43 published cases of second trimester LC followed to delivery, 39 ended in uncomplicated, full-term deliveries. Three of four second trimester cases at one institution had spontaneous abortions. None of our patients underwent LC in the third trimester. Of the 12 published cases of third trimester LC followed to delivery, one had preterm delivery. Third trimester OC is reported to have a 40 percent rate of preterm delivery. There were no intraoperative cholangiograms (IOC), prophylactic or postoperative use of tocolytics, or intraoperative fetal monitoring in our series. We added six cases of LC during pregnancy to the previously reported 105 cases. The successful outcome in all trimesters suggests that LC is a safe procedure throughout pregnancy; however, surgery in the second trimester is preferable. Compared with OC, there is a decreased risk of spontaneous abortion in the first trimester and preterm labor in the third trimester.

Estrogen-progestin replacement therapy and endometrial cancer

Abstract: Background: It has been known for more than 20 years that estrogen replacement therapy substantially increases a woman’s risk of developing endometrial cancer. To reduce this increased risk, progestins have been added to estrogen replacement therapy for between 5 and 15 days (usually 7 or 10 days) per “month” in a sequential fashion (sequential estrogen‐progestin replacement therapy) or with each dose of estrogen replacement therapy (continuous combined replacement therapy). At the present time, however, little is known about the effects of varying the number of days that progestin is used in sequential estrogen‐progestin replacement therapy. Purpose: We sought to determine the effects of sequential estrogen‐progestin replacement therapy and continuous combined replacement therapy on a woman’s risk of developing endometrial cancer. Methods: A populationbased, case‐control study of 833 case subjects and 791 control subjects was conducted. Women were postmenopausal, white, and aged 50-74 years when first diagnosed with invasive endometrial cancer or were aged 50-74 years at the matching date for control subjects. All subjects were interviewed in person with the aid of a month-by-month calendar. Relative risks were estimated by odds ratios (ORs); ORs were adjusted simultaneously for the different forms of hormone replacement therapy and for the known endometrial cancer risk factors. Results: The adjusted OR was 2.17 (95% confidence interval [CI] = 1.91-2.47) per 5 years of estrogen replacement therapy use (based on 422 users among the case subjects and 262 users among the control subjects). For women who received sequential estrogen‐progestin replacement therapy with the progestin given for less than 10 days (effectively 7 days) per month, the adjusted OR was only slightly reduced to 1.87 (95% CI = 1.32-2.65) per 5 years of use (74 case subjects and 47 control subjects). However, when progestin was given for 10 or more days (effectively 10 days), there was essentially no increased risk (adjusted OR = 1.07 per 5 years of use; 95% CI = 0.82-1.41) (79 case subjects and 88 control subjects). Continuous combined replacement therapy was also associated with essentially no increased risk (adjusted OR = 1.07 per 5 years of use; 95% CI = 0.80-1.43) (94 case subjects and 81 control subjects). Conclusions: The progestin in sequential estrogen‐progestin replacement therapy needs to be given for at least 10 days to block effectively any increased risk of endometrial cancer. Continuous combined estrogen‐progestin therapy is similarly effective. Neither regimen reduces a woman’s underlying risk of endometrial cancer. The sharp distinction between the effects of less than 10 days (effectively 7 days) and 10 or more days (effectively 10 days) of progestin use in sequential estrogen‐ progestin replacement therapy suggests that the extent of endometrial sloughing may play a critical role in determining e ndometrial c ancer r isk. [ J N atl C ancer I nst 1997;89:1110-6]