摘要:

ObjectiveTo determine the potential effects on costs and outcomes of changes in sensitivity and specificity with new screening methods for cervical cancer.MethodsUsing a Markov model of the natural history of cervical cancer, we estimated the effects of sensitivity, specificity, and screening frequency on cost-effectiveness. Our estimates of conventional Papanicolaou test sensitivity of 51% and specificity of 97% were obtained from a meta-analysis. We estimated the effect of reducing false-negative rates from 40–90% and increasing false-positive rates by up to 20%, independently and jointly. We varied the marginal cost of improving sensitivity from $0 to $15.ResultsWhen specificity was held constant, increasing sensitivity of the Papanicolaou test increased life expectancy and costs. When sensitivity was held constant, decreasing specificity of the Papanicolaou test increased costs, an effect that was more dramatic at more frequent intervals. Decreased specificity had a substantial effect on cost-effectiveness estimates of improved Papanicolaou test sensitivity. Most of those effects are related to the cost of evaluation and treatment of low-grade lesions.ConclusionPolicies or technologies that increased sensitivity of cervical cytologic screening increased overall costs, even if the cost of the technology was identical to that of conventional Papanicolaou smears. These effects appear to be caused by relatively high prevalence of low-grade lesions and are magnified at frequent screening intervals. Efficient cervical cancer screening requires methods with greater ability to detect lesions that are most likely to become cancerous.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo assess knowledge of human papillomavirus (HPV) among high school–aged adolescents.MethodsWe administered written surveys to 523 inner-city high school students in Toronto, Canada, that asked about HPV, other sexually transmitted diseases (STDs), and Papanicolaou testing. We also asked them to report doctor or clinic visits and whether they received sexual health information at those visits. The predictor variables used in analysis were gender and sexual experience.ResultsEighty-seven percent of our population [95% confidence interval (CI) 84%, 89%] had not heard of HPV. Although adolescent women were more knowledgeable about Papanicolaou testing than adolescent men, only 39% of sexually experienced adolescent women knew who should get a Papanicolaou test. Sexually experienced and inexperienced adolescents failed to identify correctly their STD risk. Both genders showed greater knowledge about human immunodeficiency virus (HIV) than other diseases. Among adolescent women, 85% had visited a doctor or clinic within the past year, but only 29% had talked about sexual health.ConclusionKnowledge of HPV infection and cervical cancer screening was low in this urban adolescent population. Improved efforts are needed for prevention of HPV infection and HPV-related cervical changes. Programs modeled after HIV-education programs might be effective. Doctors' offices and clinics providing health care to adolescents should take greater responsibility in sexual health education.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo assess frequency of and identify risk factors for the development of cervical stenosis after loop electrosurgical excision procedure.MethodsWe reviewed outpatient charts of women treated by loop excision for cervical dysplasia between August 1996 and January 1998 in the colposcopy clinic at Massachusetts General Hospital. One hundred sixty-four women were evaluated for cervical stenosis during follow-up. Stenosis was considered present if manual dilation was required to allow endocervical sampling with an endocervical currette 3 mm wide. Multivariable analysis with stepwise logistic regression was used to evaluate age, parity, tobacco use, hormonal status, use of oral contraceptives, pathology, previous loop excision, performance of additional endocervical excision, and dimensions of excision specimens as predictors of cervical stenosis.ResultsThe average age was 32 years. Cervical stenosis occurred in ten of 164 women (6%, 95% CI 3%, 11%). Among factors analyzed, previous loop excision and volume of excision specimen were the only independent predictors of stenosis.ConclusionCervical stenosis correlated with history of loop excision and volume of tissue removed, suggesting that women who have second excisions or large excisions should be counseled that their risk of stenosis might be higher.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo assess the efficacy of lidocaine spray during outpatient hysteroscopy for reducing procedure-related pain and to identify risk factors for discomfort.MethodsOne hundred twenty-one women were assigned randomly to have application of lidocaine spray or placebo to the uterine cervix during outpatient hysteroscopy. The main outcome measure was pain during hysteroscopy, assessed on a visual analog scale.ResultsThere was no statistically significant difference between study and control groups in mean age, rate of nulliparity, postmenopausal state, need for cervical dilation, or percentage of women who used hormone replacement therapy. Indications for diagnostic hysteroscopy were similar between groups. Women in the lidocaine group had statistically significantly less pain during the procedure than women in the placebo group (2.2 ± 1.9 and 3.7 ± 2.5, respectively;P< .001). Women with abnormal uterine findings (submucous myoma, endometrial polyps, or intrauterine adhesions) had significantly higher pain scores than women with normal cavities (2.2 ± 1.9 and 3.2 ± 2.4, respectively;P< .002). Aerosol anesthesia and normal uterine findings were independently associated with less pain. No procedure had to be abandoned because of excessive pain or complications, and no women required hospitalization.ConclusionWomen treated with lidocaine spray had significantly less pain. Uterine cavity abnormality might be associated with a higher degree of pain during hysteroscopy.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo determine whether hormone replacement therapy (HRT) alters glucose metabolism.MethodsCross-sectional data from the third National Health and Nutrition Examination Survey (1988–1994) included levels of hemoglobin A1cin women with diagnosed diabetes and levels of hemoglobin A1c, fasting and 2-hour glucose, and fasting insulin and C-peptide in women without diagnosed diabetes. We compared mean values for these measures among never, current, and past users of HRT with adjustment for confounders. Types of hormones were not studied.ResultsHormone replacement therapy was used by 8.6% of diabetic women and 16.7% of women without diagnosed diabetes; 19.3% and 18.5%, respectively, had used HRT in the past. Current use approximately doubled among diabetic women between 1988–1991 and 1991–1994. Current users had lower hemoglobin A1cand fasting plasma glucose levels but higher 2-hour glucose levels compared with never and past users. After adjustment for confounding factors, hemoglobin A1clevels were 0.1% lower, fasting glucose levels were 3 mg/dL lower, and 2-hour glucose levels were 15 mg/dL higher in current users. Fasting serum insulin and C-peptide levels were not associated with HRT use. Duration of HRT use among current users and time since cessation among former users were not associated with measures of glucose metabolism.ConclusionThe prevalence of HRT in the United States among diabetic women is approximately half that of women without diabetes diagnoses, although it appears to be increasing. Postmenopausal hormones appear to have no adverse effect on basal glucose metabolism but are associated with slightly elevated postchallenge glucose levels.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo assess the safety and efficacy of a protocol that mandated at least 12 hours of oxytocin administration after membrane rupture before cesarean delivery for failed labor induction in the latent phase.MethodsGravidas at or beyond 36 weeks' gestation undergoing indicated induction with cervical dilatation up to 2 cm were studied prospectively. Prior cesarean was an exclusion criterion. If the fetal heart rate pattern was reassuring, cesarean was not permitted before the active phase of labor (4-cm dilatation and at least 90% effacement or 5-cm dilatation regardless of effacement) unless the membranes had been ruptured and oxytocin administered for at least 12 hours.ResultsFive hundred nine women were treated according to protocol; 360 (71%) were nulliparas and 149 (29%) were parous. Twenty-five percent of nulliparas and 9% of parous women were delivered by cesarean. After 6 hours of ruptured membranes and oxytocin, 14% of nulliparas were still in the latent phase; 39% of whom delivered vaginally, compared with 7% still in the latent phase after 9 hours (vaginal delivery rate 28%), and 4% after 12 hours (vaginal delivery rate 13%). In contrast, after 6 hours of ruptured membranes and oxytocin, only five (3%) parous women were still in the latent phase. Among those, none remained in the latent phase for 12 hours and all were delivered vaginally. No women had serious complications. Severe neonatal morbidities were infrequent and not related to duration of the latent phase.ConclusionBy requiring a minimum of 12 hours of oxytocin after membrane rupture before failed labor induction could be diagnosed, many nulliparas who remained in the latent phase at 6 and 9 hours had safe vaginal deliveries, and failed labor induction was eliminated as an indication for cesarean in parous women.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo describe a second-stage partogram based on a system of scoring the descent and position of the fetal head and to use this system for studying progress in the second stage of labor and predicting mode of delivery and obstetric outcome.MethodsA prospective observational study of 1413 women at term with a singleton, cephalic presentation. The position and station of the fetal head were observed and scored at diagnosis of the second stage of labor, 1 hour later, and then at 30 minute intervals until delivery was achieved. The score at diagnosis of the second stage of labor was assessed for its ability to predict eventual mode of delivery and duration of labor. A normogram was defined for nulliparas and multiparas and was used to define normal and abnormal progress in the second stage, associated factors in the first stage of labor, and mode of delivery.ResultsIncreasing total score at the start of the second stage of labor is associated with increasing chance of spontaneous vaginal delivery (odds ratio [OR] 1.68 for nulliparas, 1.59 for multiparas), decreasing chance of instrumental vaginal delivery (OR 0.67 for nulliparas, 0.64 for multiparas), and emergency cesarean delivery (OR 0.39 for nulliparas). Abnormal progress as defined by the normogram is associated with use of epidural anesthesia, induction of labor, augmentation, dystocia, and increased incidence of operative delivery. No significant difference is found between normal and abnormal second stages of labor in fetal outcome as determined by Apgar scores.ConclusionThe second-stage partogram offers an objective basis for management of the second stage of labor.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo determine if outpatient cervical ripening using misoprostol can initiate labor within 48 hours of medication administration and to determine if time from medication administration to time of delivery is decreased using outpatient cervical ripening.MethodsUncomplicated singleton, vertex pregnancies at 41 weeks' gestation or later with Bishop score of 4 or less were eligible for enrollment. Other inclusion criteria included intact membranes, less than eight uterine contractions per hour, a reactive nonstress test, and amniotic fluid index (AFI) over 5 cm. After randomization, 25 μcg of misoprostol or placebo was placed within the posterior vaginal fornix. Patients were continuously monitored for 4 hours, then discharged if not in active labor. Patients returned in 24 hours for a repeat administration of the respective medication. Patients not delivered within 48 hours were admitted for inpatient induction of labor. Statistical analysis was performed with the Fisher, Studentt, χ2, and Mann-WhitneyUtests, withP< .05 considered statistically significant.ResultsAmong the 60 patients enrolled, 27 (45%) received misoprostol and 33 (55%) received placebo. The majority (24 of 27, 88.9%) of study group patients entered active labor within 48 hours after dosing, compared with 16.7% (five of 33) of placebo group patients (P< .001). The time from initial dose to delivery was significantly shorter in the misoprostol group (36.9 ± 3.8 compared with 61.3 ± 3.8 hours,P< .001).ConclusionIntravaginal misoprostol is effective for outpatient cervical ripening. No adverse effects were encountered, although further study is required to determine the safety of this treatment regimen.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo determine the extent to which meteorologic factors explain seasonality in birth weight in a developed country.MethodsRecorded birth weights were collected for all singleton live births after 36 weeks of pregnancy in Northern Ireland between 1971 and 1986. Data on daily maximum and minimum temperatures, rainfall, and hours of bright sunshine were obtained from a local climatologic station for the same period. For each birth, mean daily maximum and minimum temperatures, rainfall, and hours of bright sunshine were calculated for the trimesters of the pregnancy. Linear regression models were constructed with birth weight as the dependent variable and month of birth as a predictor variable. Months of birth were entered in the models as dummy variables. Adjustment was made for year of birth, duration of gestation, maternal age, number of previous pregnancies, sex, and social class of infants at birth and for meteorologic variables relating to each trimester.ResultsA clear seasonal pattern in birth weight was observed, with lowest mean birth weight in late spring and summer. Adjusted mean birth weights were 25.5 g, 29.6 g, and 31.6 g lower in May, June, and July, respectively, than in January. This seasonal variation occurred in both sexes, and in female births, it disappeared almost entirely after adjustment for mean daily maximum temperature during the second trimester of pregnancy.ConclusionInfants born during late spring and summer are lighter than those born in winter, which might be the result of exposure to low winter temperatures during midgestation. Pregnant women should keep themselves warm during midpregnancy.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo evaluate the effect of low birth weight adjusted for gestational age in first pregnancies on preeclampsia in second pregnancies and to estimate the proportion of preeclampsia in second pregnancies attributable to histories of LBW for gestational age.MethodsWe conducted a cohort study based on linked data from the Medical Birth Registry of Norway, which covered all births in 1967–1992.ResultsWomen who delivered infants under the third percentile birth weight were three times more likely to have initial or recurrent preeclampsia in second pregnancies than those who delivered infants at or above the tenth percentile. After adjusting for maternal age, year of birth, interpregnancy interval, education, chronic hypertension, diabetes mellitus, and change of partner, the increased risk persisted. Birth weight below the tenth percentile in the first delivery accounted for 10% of the total cases of preeclampsia in the second pregnancy and 30% of recurrent cases.ConclusionA history of low birth weight adjusted for gestational age is associated significantly with subsequent occurrence as well as recurrence of preeclampsia. These findings are consistent with the hypothesis of a shared etiologic factor or recurrent pathophysiologic mechanism for preeclampsia and fetal growth restriction. A history of fetal smallness for gestational age is found in a substantial proportion of all cases of preeclampsia and thus seems to be important in the etiology of preeclampsia.

ISSN:0029-7844    

出版商:OVID    

年代:2000

数据来源: OVID