摘要:

ObjectiveTo identify the relationship between maternal cigarette smoking and ultrasound-confirmed placenta previa.MethodsA matched case-control design was used. Cases were drawn from the New England Medical Center and Cambridge Hospital from July 1992 through March 1994. Each case was delivered by cesarean after 24 weeks' gestation and had an antenatal ultrasound examination cnfirming placenta previa. Matched controls were obtained by requesting records on the first three deliveries by the referring provider the same month as the index case. Data on potential risk factors were drawn from the records of the initial prenatal visit, before previa was diagnosed. The data were analyzed with conditional logistic regression.ResultsThirty-two cases of ultrasound-documented planceta previa were identified. A number of potential confounders were associated with previa: age (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.05–1.26), gravidity (OR 1.4, 95% CI 1.1–1.7), parity (OR 1.4, 95% CI 1.1–1.9), prior spontaneous abortion (OR 3.1, 95% CI 1.3–7.4), prior elective abortion (OR 3.0, 95% CI 1.2–7.6), and prior cesarean delivery (OR 3.5, 95% CI 1.3–9.9). The crude OR for current smoking was 3.0 (95% CI 1.1–8.6). The OR for smoking ranged from 2.6–4.4, despite controlling for confounders.ConclusionCurrent cigarette smoking is associated with a 2.6–4.4-fold incresed risk of placenta previa.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo evaluate the variations in physician behavior leeding to performance of gynecologic surgical procedures related to fee-for-service and capitation reimbursement systems.MethodsThis study compared the physician practice utilization of surgical services for free-for-service and capitated contract reimbursement systems within a gynecology clicnic. Attending gynecologists were reimbursed on a fee-for-service basis for all surgical services performed during a 6-month interval; subsequently, the same physicians were reimbursed on a capitated basis for 6 months and received a fixed payment for the clinical and surgical services provided.ResultsThree thousand seven hundred eighty consecutive outpatient gynecology visits were evaluated at the university gynecology visits were evaluated at the university gynecology clinic during 1994. We found a 15% overall decrease in the number of surgical procedures that were performed during the capitated reimbursement period compared with the fee-for-service time interval. The procedure most responsible for the reduction of surgical services was elective sterilization by laparoscopy, which underwent a statistically significant decrease (P< .01).ConclusionThe remuneration system in our review seemed to affect physician decision making for only the most elective procedures, whereas physicians maintained similar practice patterns for more severe conditions, fee-for-service seems to encourage, whereas capitation seems to discourage, gynecologists, from performing elective procedures.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo determine the effect of increasing vesical volume on the Valsalva leak-point pressure, examine the relationships between leakage at a given volume and clinical incontinence severity, and evaluate the relationship between leakage at a given volume and other measures of urethral resistance.MethodsOne hundred twenty women with genuine stress urinary incontinence (GSI) underwent serial Vlsalva leak-point pressure determinations at vesical volumes of 100, 200 and 300 mL, and at maximum cystometric capacity. Urinary diary data, quantitative pad testing, and passive and dynamic urethral profilometry were also performed.ResultsThirty-three women had leakage starting at a vesical volume of 100 mL, 18 at 200 mL, and 19 at 300 mL, and 17 had leakage only at maximum cystometric capacity. The mean first positive Valsalva leak-point pressures were significantly higher than Valsalva leak-point pressures were significantly higher than Valsalva leak-point pressures at maximum capacity in all groups: in women who began to leak at 100 mL, 57 versus 36 cm H2O (P< .001); at 200 mL, 59 versus 45 cm H2O (P< .001); and at 300 mL, 61 versus 47 cm H2O (P= .01). Women who had leakage at lower vesical volumes had worse measures of clinical incontinence severity and lower maximum urethral closure pressures (P< .001 to .002). The presence of leakage at a vesical volume of 300 mL was 100% sensitive for the presence of both low urethral pressure (maximum urethral closure pressure less than or equal to 20 cm H2O) and pure intrinsic sphincteric deficiency (low urethral pressure and the lack of urethral hypermobility), but the specificities were 63 and 50%, respectively.ConclusionsWomen with GSI are more likely to leak during Valsalva with increasing vesical volume. Valsalva leak-point pressures decrease significantly with bladder filling. The volume at which leakage occurs correlates inversely with clinical severity and directly with maximum urethral closure pressure. A negative Valsalva leak-point pressure at 300 mL excludes the presence of low urethral pressure and pure intrinsic sphincteric deficiency; however, the specificity and positive predictive value are inadequate for making a clinical diagnosis of either condition.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo estimate prevalence of and identify factors associated with urinary incontinence in older women.MethodsA cross-sectional study involved 7949 community-dwelling women, with a mean (± standard deviation) age of 76.9 ± 5.0 years, recruited from population-based listings to participate in the Study of osteoporotic Fractures. The prevalence and severity of urinary incontinence during the previous 12 months were assessed by questionnaire. Factors potentially associated with urinary incontinence were assessed by questionnaire, interview, and physical examination. Multivariate logistic regression analysis was sused to determine the independent associations between these factors and the primary outcome of daily incontinence.ResultsForty-one percent (3285) of the women reported urinary incontinence, with 14% (1130) reporting daily incontinence. In multivariate analysis, the prevalence of daily urinary incontinence increased significantly with age (odds ratio [OR] 1.3 per 5 years, 95% confidence interval [CI] 1.2–1.5), prior hysterectomy (OR 1.4 95% CI 1.1–1.6), higher body mass index (OR 1.6 per 5 units. 95% CI 1.4–1.7), history of stroke (OR 1.9, 95% CI 1.3–2.7), diabetes (OR 1.7, 95% CI 1.2–2.4), chronic obstructive pulmonary disease (OR 1.4, 95% CI 1.1–1.9), and poor overall health (OR 1.6, 95% CI 1.3–2.0). Faster gait speed (OR 0.8 per 0.2 units, 95% CI 0.6–1.0) was associated with decreased incontinence.ConclusionUrinary incontinence is a common problem in older women, more common than most chronic medical conditions. Of the associated factors that are preventable or modifiable, obesity and hysterectomy may have the greatest impact on the prevalence of daily incontinence.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo determine whether the response to the progestin challenge test can be predicted from the endometrial thickness measured sonographically.MethodsProgestin challenge tests were performed on 44 women with secondary amenorrhea, each of whom also had her endometrial thickness measured by transvaginal ultra-sonography and her serum estradiol (E2) levels determined. The relationships between the response to the challenge test, endometrial thickness, and serum E2 levels were studied, as well as whether the presence or absence of withdrawal bleeding could be predicted from the endometrial thickness and serum E2 levels.ResultsThe endometrium was significantly thicker in 32 women who had withdrawal bleeding (10.3 ± 4.1 mm) than in the 12 who did not bleed (5.0 ± 1.3 mm) (P< .001). The serum E2 level was also significantly higher in the positive group: 45.3 ± 19.4 versus 18.6 ± 8.0 pg/mL (P< .001). Endometrial thickness of 6.0 mm or more predicted the occurrence of withdrawal bleeding with an accuracy of 95.5%. Endometrial thickness was superior to the serum E2 level in predicting withdrawal bleeding.ConclusionProgestin-induced withdrawal bleeding can be predicted from the endometrial thickness measured sonographically.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo quantify the cervical dilation achieved from multiple medium-thick laminaria tents used for 16–26 hours in single applications before abortion.MethodsIn a practice setting, cervical dilation was studeied from all abortions done at greater than 8 weeks in which one or more medium-thick laminaria tents were used a single application for 16–26 hours. Multiple regreesion analysis was used to quantify results.ResultsThere was a positive linear regression of dilation against weeks of gestation for all numbers of tents. The more tents, the greater the dilation; the more weeks, the greater the dilation.ConclusionApproximate cervical circumferential dilation from medium-thick laminaria tents under the constraints listed is provided by the formula: Pratt dilation = 12.36+(2.35 × tents) + (1.79 × weeks).

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo evaluate the diagnostic test charactersitic of common tests used to diagnose upper genital tract infection.MethodsSubjects included women who either met the Centers for Disease Control and Prevention's minimal criteria for acute pelvic inflammatory disease or who had other signs of upper genital tract infection (ie, atypical pelvic pain, abnormal uterine bleeding, or cervicitis). The subjects were evaluated with a baseline interview, comprehensive laboratory testing, and either an endometrial biopsy of laparoscopy for definitive diagnosis or upper genital tract infection. Patients were considered positive for upper genital tract infection if they had any of the following findings: 1) histologic evidence of acute endometritis or salpingitis, 2) laparoscopic visualization of purulent exudate in the pelvis without another source, or 3) positive testing forNeisseria gonorrhoeaeorChlamydia trachomatisfrom the endometrium, fallopian tubes, or pelvis.ResultsOne hundred twenty women with adequate endometrial samples were evaluated between August 1993 and September 1995. The median age of the study population was 24 years; 38% were white, 52% were smokers, 81% were insured by medicaid or were uninsured, and 67% were single. Sensitivities for elevated white blood cell count (WBC), erythrocyte sedimentation rate, C-reactive protein, and increased vaginal white blood cells are 57, 70, 71 and 78%, respectively. If any one test is abnormal, the sensitivity is 100% and specificity is 18%. If all four tests are abnormal, sensitivity, is 29% and specificity is 95%.ConclusionTesting for incresaed vaginal white blood cells was found to be the most sensitive laboratory indicator for upper genital tract infection, whereas serum WBC was the most specific. NO one diagnostic laboratory test is pathognomonic for upper genital tract infection. Combinations of positive tests can improve diagnostic specificity and positive predictive value, but with a diminution of sensitivity and negative predictive value. Combinations of negative tests can reliably exclude upper genital tract infection.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo assess the findings and complications laparotomies for completely staging presumed early-stage ovarian cancer in patients whose initial surgery was inadequate.MethodsRecords of 45 patients surgically restaged at our institution, after having been incompletely staged elsewhere, were reviewed for original operative, reports, pathologic diagnoses, restaging procedures, operative results, and perioperative complications.ResultsInitial clinical staging was IA, 28; IB, three; IC 12; II A, one; IIB, one. Histologic distribution was as follows: invasive epithelial, 19 (42%); borderline epithelial, 16(36%); germ cell tumor, seven (16%); and stromal tumor, three (6%). Seven of the 45 patients (16%) had their disease reclassified to a more advanced stage. Of patients with borderline ovarian tumors, two initially staged as IA, were restaged to IB and IC, and one was restaged from IIB to IIIA. Three patients with invasive epithelial adenocarcinoma were reclassified to a higher stage: one, with a presumed stage IC, poorly differentiated adenocarcinoma, to IIB; and a third, with a IIA, poorly differentiated adenocarcinoma, to IIIC. A patient with granulosa cell tumor, initially staged as IC, was restaged to IIB; Fifteen patients (33%) had complications after restaging laparotomy for presumed early ovarian cancer were reclassified to a higher stage, resulting in alteration of treatment for only one patient. In 18 patients with invasive cancer, the second operation confirmed the presence of low-risk stage IA/B disease, allowing adjuvant chemotherapy to be withheld.ConclusionAlthough restaging laparotomies provide important prognostic information with minimal morbidity, they provide little benefit to those patients already requiring chemotherapy based on the original operative findings.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo evaluate the effect of resection of central disease when the parametria are involved by tumor in high-risk stage I cervical cancer patients.MethodsThirty-two patients with high-risk stage I cervical cancer who underwent radical hysterectomy and had pathologic findings of positive lymph nodes (N= 13), positive parametria (N= 7), or both (N= 12) were identified retrospectively. The effects of various histopathologic findings on disease-free interval and survival were evaluated, including the effect of resection of central disease with and without positive nodal disease. Kaplan-Meier survival curves were compared with the log-rank test. Multivariate analyses nusing a stepwise regression model were performed.ResultsCompared with other histologies, adenocarcinoma was associated with a significantly shorter disease-free interval (P= .037). Among patients with parametrial involvement, lymph node status did not affect disease-free interval or survival. However, when patients with positive lymph nodes were examined, the additional finding of parameterial positivity significantly worsened both diseasefree interval (P= .039) and survival (P= .036). When the 19 patients with positive parametria, regardless of lymph node status, were compared with those with positive lumph nodes alone, the former group had a significantly shorter disease-free interval (P= .038). The tumor recurred in 12 of these 19 patients; all cases involved the pelvis, with a median time to recurrence of 15 months. Multivariate analysis showed that adenocarcinoma histology (P= .038) and parametrial involvement (P= .043) were independent, poor prognostic indicators for disease-free interval.ConclusionInvolvement of the parametria, regardless of lumph node status, and adenocarcinoma histology confer a poor prognosis in high-risk patients undergoing radical hysterectomy. Caution should be used when contemplating resection of bulky tumors as part of primary therapy if the parametria appear to be involved by tumor.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo determine the effectiveness and toxicity of ifosfamide chemotherapy in women with metastatic or recurrent endometrial stromal sarcomas unexposed to other chemotherapy.MethodsIn a prospective, multi-institutional phase II study conducted by the Gynecologic Oncology Group, the starting dose of ifosfamide was 1.5 g/m2given daily intravenously (IV) for 5 days (reduced to 1.2 g/m2daily in patients who had previously received radiotherapy). Mesna (2-mercaptoethane sodium sulfonate) was given IV immediatley and at 4 and 8 hours after the administration of ifosfamide. EAch dose of mesna was 20% of the total daily dose of ifosfamide. Patients were treated every 3 weeks if blood counts permitted. Therapy was discontinued if there was progression of the cancer or unacceptable toxicity.ResultsTwenty-two patients were entered into this study. One was excluded from analysis because of the wrong histologic type, leaving 21 evaluable for response and toxicity. Gynecologic Oncology Group grade 3 or 4 granulocytopenia occurred in four patients (19%), and one patient each experienced Gynecologic Oncology Group grade 4 anemia and genitourinary toxicity. Three patients experienced complete tumor responses and four had partial responses, for an overall response rate of 33.3%.ConclusionIfosfamide is active in the therapy of women with chemotherapy-naive metastatic or recurrent endometrial stromal sarcomas.

ISSN:0029-7844    

出版商:OVID    

年代:1996

数据来源: OVID