摘要:

Background.Screening mammography, particularly for women in their 40s, has become a confusing issue for many physicians. Recent scientific and political controversies regarding screening guidelines have added to this confusion.Methods.Many randomized clinical trials have shown the benefits of mammographic screening for women over the age of 50, and recent studies show a statistically significant benefit for women in their 40s as well. Understanding the screening controversy requires an understanding of the principle of screening for disease, the epidemiology of breast cancer, and the results of the many randomized clinical trials, particularly recent data from the Swedish two-county trials. An appreciation of the improvements in mammographic quality in recent years, and in the education of the radiologists who interpret these studies, will also heighten clinical acceptance of this screening technique.Results.Both the American Cancer Society and American College of Radiology endorse annual mammographic screening for women over age 40, and there is compelling evidence to support these recommendations.Conclusion.Radiologists, primary care providers, surgeons, and pathologists should work together to enhance the benefits of and access to screening mammography.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.Medically disabled persons have traditionally encountered obstacles when seeking and maintaining employment. Integration of the medically disabled worker is the goal of recent legislation that directs removal of physical barriers and protects disabled workers from discrimination. The major force driving this social policy is the Americans With Disabilities Act (ADA).Methods.Current disability laws and related judicial opinions are reviewed. Primary attention is focused on the ADA.Results.Legislation addressing employment discrimination has serious deficiencies. Medical support of this important social policy is hampered by vague statutory definitions and seemingly capricious judicial opinions.Conclusion.Disability laws require precise language identifying specific, qualifying medical conditions. The laws should require comprehensive medical assessment that objectively establishes a connection between a medical disorder and severe, sustained impairment. Some currently included conditions, such as personality disorders, should be considered for exclusion.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.Prospective randomized studies show reduced breast cancer mortality among women offered mammographic screening; yet, few women 70 or older were represented in these trials. We examine the impact of mammography on stage at diagnosis of breast cancer, over the years when mammography came into general use, comparing women aged 40 to 69 with those aged 70 and older.Methods.We reviewed the records of 1,001 consecutive patients 40 and older treated for invasive or in situ breast cancer in the surgical practice of one of us (H.S.C.) between 1979 and 1993, comparing trends in mammography use, means of diagnosis, tumor size, axillary node status, and pathology.Results.The proportion of cases diagnosed by mammography increased over time to a comparable degree in both age groups, as did the proportion of Tl and DCIS or microinvasive cancers. This trend toward earlier stage appears entirely due to an increasing use of mammography.Conclusion.The potential benefit of regular mammography to healthy women aged 70 and older may equal that observed in their younger counterparts.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.We used dynamic magnetic resonance imaging (MRI) to study breast lesions in 13 women.Methods.We observed differences in contrast uptake between benignancy and malignancy in 14 suspicious breast lesions. Three-dimensional (3D) gradient echo sequences were obtained before and after administration of gadolinium-based contrast medium (0.16 mmol/kg). The percentage of signal increase in lesions was measured in a series of five 90- second sequences, and time-enhancement patterns were correlated with pathologic diagnoses.Results.Seven benign lesions and three breast cancer recurrences showed less than 185% signal increase at 90 seconds after contrast administration. Three new breast cancers and one recently biopsied benign lesion showed more than 185% signal increase at 90 seconds.Conclusion.Using this MRI technique, we can discriminate between new breast cancers (more than 185% early signal increase) and breast cancer recurrence and/or benign lesions (less than 185% early signal increase) but cannot distinguish recurrent from benign lesions.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.Older women are considered at risk for hip fracture; fracture rates are highest in the southern region of the United States. The purpose of this study was to develop a predictive model for osteoporotic hip fracture among a national sample of southern women aged 50 years and older.Methods.Subjects were participants in the Third National Health and Nutritional Examination Survey, Phase 1. Data were collected by the National Center for Health Statistics. Predictors examined included age, race, heredity, body mass index, physical activity, smoking status, alcohol use, and dairy product use.Results.The sample consisted of 953 women aged 50 years and older. The predictive model included older age, black race, Hispanic race, and low body mass index.Conclusions.Recommendations emphasize weight gain for underweight women and promotion of healthy body weights for women of all ages.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.Short-stay obstetric stays have been the recent focus of many social and medical debates. We did a retrospective study of a large community teaching hospital's experience in making a safe transition to short-stay obstetrics.Methods.Over a 10-month period, a multidisciplinary committee developed an intrapartum and postpartum education program to allow short hospital stays after uncomplicated vaginal deliveries. Computerized data were then retrieved on all uncomplicated spontaneous vaginal deliveries (DRG 373) from January 1994 to March 1995.Results.During the study period, 554 women were discharged on the first postpartum day, resulting in three maternal readmissions and nine pediatric readmissions (combined readmission rate of 2.2%). This low readmission rate compared favorably with our experience with 2,563 uncomplicated vaginal deliveries from January 1991 to December 1993, immediately before the institution of the short-stay obstetrics program (combined readmission rate of 3.9%). The average hospital cost for a 1-day stay was $1,714 compared with $2,477 for a 2- to 3-day stay, representing a saving of only 31%.Conclusions.Early obstetric discharges after an uncomplicated spontaneous vaginal delivery can be safe and effective with appropriate patient selection and support.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.Kaposi's sarcoma (KS) associated with human immunodeficiency virus type 1 (HIV-1) is the most common malignancy in patients with AIDS. It has been most commonly reported in white homosexual men, though a few cases have been reported in blacks.Methods.We conducted a retrospective analysis of all HIV-1 seropositive patients with biopsy-proven KS seen at Howard University Hospital between February 1985 and June 1995.Results.Of the 73 patients identified, 66 (90%), 4 were white, 2 were Hispanic, and 1 was of unidentified race. The median age was 32 years. Forty-eight (66%) were homosexual or bisexual men, and 10 (14%) were homosexual or bisexual with a history of intravenous drug use (IDU). A history of IDU or blood transfusion was the only risk factor in 7 (9%) and 2 (3%), respectively. The other 6 (8)% were heterosexual. The median survival was 2.2 years. A CD4 count <200 and the presence of an opportunistic infection were associated with shortened survival.Conclusions.The predominant risk factor for HIV-1–associated KS was homosexual or bisexual activity. Only a few women with KS were identified, and they also reported sexual transmission from male bisexuals and/or drug users. Poor survival was associated with CD4 <200, stage III and IV KS at presentation, and opportunistic infections.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.Clinical prevention is a critical component of primary care residency training. How well residents do preventive services is one measure of the adequacy of their training.Methods.To assess the level of preventive health care in a university internal medicine residency clinic, we conducted a randomized retrospective review of 225 patient records.Results.We documented preventive services in only 39% of potentially appropriate instances. Cholesterol screening occurred in 53% of eligible cases, breast examination in 41%, mammogram in 69%, Papanicolaou's smear in 53%, estrogen replacement therapy (ERT) in 41%, fecal occult blood testing in 30%, flexible sigmoidoscopy in 18%, influenza vaccination in 65%, pneumococcal vaccination in 44%, and tetanus immunization in only 9%. Male residents were significantly less likely than females to order mammograms or offer ERT.Conclusions.Compared to earlier studies of similar design, we found that the level of preventive health care has improved during residency training, but remains unacceptably low.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.Nationwide, 32% of residency-trained family physicians deliver babies compared with 73% to 90% in the military. This study describes and defines issues that could ultimately help revive family practice maternity care.Method.We surveyed 112 family physicians who had left the navy.Results.Ninety-one percent had delivered babies in the navy, 45% since leaving the military, and 25% currently. Principal maternity care incentives both in and out of the military were personal and professional satisfaction. Reasons for not providing civilian maternity care included malpractice risks, insurance costs, and lifestyle issues. The decision for providing maternity care was usually made before or during residency, whereas the decision against was most often made upon leaving the military. Among more recent graduates (1990-1995), 48% continued to deliver babies in civilian practice. (This is about 20% more than recent civilian graduates.) Malpractice concerns were less important to this group than to earlier graduates.Conclusions.Factors discouraging family physicians from providing maternity care arise from their practice environment and are not easily overcome with improved training and experience. Recent navy residency graduates are not as easily discouraged.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background.We studied the feasibility of using patient-controlled anesthesia (PCA) for conscious sedation during colonoscopy.Methods.Patients having elective colonoscopy had medications delivered in bolus fashion by PCA pump (Abbot Lifecare Provider 5500 Infusion System). Four patients received propofol as 20 mg/dose boluses, and four patients received propofol in a 0.3 mg/kg/dose. Twelve patients received propofol at 0.2 mg/kg/dose with alfentanil at 4 µg/kg/dose.Results.There were no clinically unacceptable changes in continuously monitored blood pressure, pulse rate, ECG, or respiratory rate. There were no adverse effects from the sedation and no complications due to colonoscopy. Recovery time was rapid, but recall persisted in most subjects. Pain and overall discomfort in patients given propofol only were rated as moderate by most subjects.Conclusion.Patient-controlled anesthesia is feasible for use in endoscopic sedation. Propofol alone did not allow adequate pain relief, but propofol and alfentanil together seemed to provide good control of pain.

ISSN:0038-4348    

出版商:OVID    

年代:1998

数据来源: OVID