Daniel W. Gorenflo

Rapid repeat pregnancy and experiences of interpersonal violence among low-income adolescents

CONTEXT Rapid repeat pregnancy (RRP) among adolescents, usually defined as pregnancy onset within 12-24 months of the previous pregnancy outcome, has frequently been the target of public health interventions, due to the exacerbation of negative consequences associated with recurrent adolescent pregnancy (and more specifically with childbearing). OBJECTIVE To examine what, if any, relationship exists between RRP and the experience of interpersonal violence and abuse among low-income adolescents at one semi-urban health center. DESIGN Case-control study using retrospective chart review. PARTICIPANTS AND SETTING 100 women aged 13-21 who received prenatal care at one independent nonprofit health center that serves adolescents and their children from June 1994 through June 1996. MAIN OUTCOME MEASURES Number and timing of pregnancies, occurrence of physical or sexual abuse; other psychosocial risk factors were evaluated. RESULTS In this population, the experience of any form of physical or sexual violence during the study interval was associated with RRP within 12 months (p = 0.01, OR = 3.46) and 18 months (p = 0.013, OR = 4.29). Other previously reported predictors of RRP, including family stress, financial stress, and other environmental stressors did not reach statistical significance at either 12 months or 18 months in this sample. Of additional note, young women who experienced any form of abuse during the 12-month study interval were substantially more likely to miscarry than were their nonabused peers, and spontaneous abortion was also very strongly associated with RRP (p < 0.00001; OR = 22.6). CONCLUSIONS The experience of interpersonal violence is correlated with rapid repeat pregnancy among low-income adolescents. This study strongly suggests a need for both extensive screening for partner and family violence among pregnant and postpartum adolescents, and follow-up safety planning support in combination with family planning interventions.

Predictors of Screening for Breast, Cervical, Colorectal, and Prostatic Cancer Among Community-Based Primary Care Practices

Background: As we enter the year 2000, it is worth looking at whether primary care practices are reaching the goals established in Healthy People 2000 for breast, cervical, colorectal, and prostatic cancer screening. The objectives of this study were (1) to determine the current rates of cancer screening; and (2) to determine which factors predict completion of a single screening test, of all tests for each cancer, and of all procedures for age and sex. Methods: Medical records of 200 eligible patients (100 men and 100 women) from each of 24 community-based primary care practices were abstracted for cancer-screening events. Results: We audited 5125 charts. A Papanicolaou smear was documented for 63.8% of women with an intact cervix within 3 years of the audit .. We found that 46.8% of women had documentation of ever having a discussion of breast self-examination. For breast cancer screening, 41.8% of the women had a clinical breast examination within 1 year, 48.2% aged 40 to 49 years had a mammogram within 2 years, and 38.5% aged 50 years and older had a mammogram within 1 year. Only 29% of women aged 40 to 49 years and 17% of women 50 years and older were current for all breast cancer-screening tests. Among patients 50 years and older, 33% of men and 38% of women had a digital rectal examination within 1 year, 26% of men and 28% of women had a fecal occult blood test within 1 year, and 22% of men and 16.8% of women had a Oexible sigmoidoscopy within 5 years. Of all men 28.7% had a prostate-specific antigen test within 1 year. Completion of all tests relevant for age and sex were documented for 8.6% of women aged 40 to 49 years, 3% of women 50 years and older, and 5% of men 50 years and older. The single most Significant predictor of documented cancer screening was a health maintenance visit. Conclusions: This sample of primary care clinicians has not reached the goals set in Healthy People 2000 for cancer screening. Interventions aimed at increasing the percentage of patients who schedule a health maintenance visit could serve to increase cancer screening and help us reach goals set for the year 2010.

Weight loss methods of high school wrestlers.

KININGHAM, R. B., and D. W. GORENFLO. Weight loss methods of high school wrestlers. Med. Sci. Sports Exerc., Vol. 33, No. 5, 2001, pp. 810–813. Purpose:The purpose of this investigation was to assess the weight loss practices of Michigan high school wrestlers at all levels of competition. Methods:A

Cancer disclosure in Japan: Historical comparisons, current practices

Although Japanese physicians historically have not disclosed cancer diagnoses to patients, pressures upon physicians to disclose have increased in recent years. We questioned physicians practicing at a private medical hospital in rural Japan about their current approach to cancer disclosure. We compared their responses with responses of physicians in a 1991 study conducted in Japan, and two studies conducted in the United States, in 1961 and in 1977. Seventy-seven clinically active physicians with experience treating cancer patients responded (73% response rate). Forty percent of respondents reported usually telling patients of a cancer diagnosis, over three times more than the 13% who reported such a policy in Japan in 1991. Physicians were significantly more likely (P < 0.001) to make exceptions than physicians in the previous Japanese study, and physicians in the previous U.S. studies. Respondents reported considering more factors in deciding whether to tell than participants in the 1977 U.S. study. Factors predicting an increased probability of disclosure included age (in a hyperbolic relationship), improved prognosis, breast or cervical cancer, and social status and religion (by a minority of respondents). Increase in a substitute decision makers age was predictive for physicians not to involve the person in decision-making. Most respondents reported their disclosure policy is based on clinical experience. More respondents indicated a likelihood of changing in the future than respondents in the previous U.S. studies. These data suggest Japanese physicians are moving away from a rigid policy of nondisclosure to a policy of selective disclosure, but they have not adopted universal cancer disclosure as practiced in many Western countries. Since young age and advanced age predicted self-reports of not disclosing cancer diagnoses, these data raise the question of whether nondisclosure by age groups represents age discrimination or compassionate medical care tailored to individual patient needs.

Physician experience with family presence during cardiopulmonary resuscitation in children.

Objective: Family presence during cardiopulmonary resuscitation in children is an emerging practice. Although many hospitals allow this practice, there is scant research on physician attitudes and opinions and on physician views about training for resident physicians. Design: Survey method. Setting: University and community settings. Patients: We randomly selected 1,200 pediatric critical care and emergency medicine providers from professional association mailing lists. Intervention: The providers were mailed up to two written surveys and two reminder cards. The survey consisted of 40 multiple-choice and short-answer questions about demographics, past experiences, and opinions on pediatric family presence. Measurements and Results: Of 1,200 surveys mailed, 521 were completed (43.4%) and 73 (6.1%) respondents returned the form declining to participate. More than 99% of respondents were physicians. Four hundred and thirty-three respondents (83%) reported participation in pediatric resuscitation with family members present, with a mean of 15 episodes ever and three episodes within the last year. Of those who had ever participated, more than half thought it was helpful for the family, and two thirds believed that parents wanted the option. Ninety-three percent would allow family presence in some situations. Seventy-four percent believed family presence would be stressful for a resident physician, but nearly 80% believed that residents working with children should be educated in this area. Conclusions: Family presence during cardiopulmonary resuscitation in children is not an uncommon experience for health care providers. Most respondents had resuscitated a child with family members present. The majority thought that presence was helpful to parents and that residents should be trained in this practice.

Reliability and validity of self-reported symptoms for predicting vulvodynia.

OBJECTIVE: To evaluate the reliability and validity of self-reported symptoms to predict vulvodynia, compared with examination-based confirmation. METHODS: Between August 5, 2004, and December 13, 2004, 1,046 members of the University of Michigan Women’s Health Registry were surveyed regarding the presence of symptoms suggestive of vulvodynia. Diagnoses of vulvodynia and of control status based on survey responses were made, and a subset of these respondents was evaluated in the office. RESULTS: One thousand forty-six of 1,447 (72.3%) eligible women, aged 19 to 92 years, completed the survey. Seventy-nine (7.6%) of the survey respondents who reported ongoing vulvar pain lasting more than 3 months were predicted to have vulvodynia, while women reporting no current pain with intercourse and no history of prolonged vulvar pain were predicted to be controls (N=543). Agreement between the history taken at the office and that reported on the survey was very good (reliability: Cohen’s &kgr;=0.86, 95% confidence interval 0.73–0.99). Of the 28 women predicted to have vulvodynia who were examined in the office, 27 (96.4%) were confirmed to have vulvodynia, and 28 of the 34 (82.4%) asymptomatic women examined did not have increased vulvar sensitivity (Cohen’s &kgr;=0.78, 95% confidence interval 0.64–0.92). CONCLUSION: Excellent reliability and validity of survey responses for predicting vulvodynia were demonstrated. LEVEL OF EVIDENCE: II-2

Treatment of vulvodynia with tricyclic antidepressants: efficacy and associated factors.

Objective. To determine the efficacy of tricyclic antidepressants (TCAs) as treatment for vulvodynia, and to identify demographic factors and pain characteristics associated with improvement. Materials and Methods. Between January 2001 and April 2004, women diagnosed with vulvodynia were offered TCA therapy. The patients rated their worst recent pain on a 10-point scale at baseline and at follow-up; improvement was classified as at least 50% reduction in reported pain from baseline. Results. Of 271 women diagnosed with vulvodynia, 209 (77.1%) were treated initially with a TCA (amitriptyline [n = 183], desipramine [n = 23], and other tricyclic medications [n = 3]). One hundred sixty-two (59.8%) of the women were followed up at a median period of 3.2 months after their initial visit, including 122 women who had started on a TCA. Of 83 women taking a TCA at the first follow-up, 49 (59.3%) improved by more than 50%, compared with 30 of 79 women not taking TCA at follow-up (improvement rate = 38.0%; p =.007; odds ratio = 2.35; 95% CI = 1.23-4.42). Multivariate analysis indicated that age, severity of pain, diagnosis (localized vs generalized vulvar pain), length of time with pain before treatment, age at menarche, use of oral contraceptives, and the number of previous pregnancies were not associated with the outcome; however, taking a TCA at the time of the first follow-up was strongly associated with improvement (p <.001; odds ratio = 4.23; 95% CI = 1.98-9.01). Repeated analysis including only those women prescribed with amitriptyline rather than any tricyclic revealed similar results. Conclusions. Women with vulvodynia who were prescribed a TCA in general (or amitriptyline, specifically) were more likely to have pain improvement compared with those women not taking these medications at follow-up. Randomized, controlled studies of TCAs versus other treatments are needed to clarify the overall effectiveness of these drugs.

Vulvodynia incidence and remission rates among adult women: a 2-year follow-up study.

OBJECTIVE: To estimate the incidence and remission rates of vulvodynia over a 2-year period. METHODS: A 2-year follow-up survey was sent to the University of Michigan Women’s Health Registry members who had participated in a previously reported, validated survey. Changes in clinical status, incidence, and remission rates for vulvodynia were estimated, as were factors associated with new onset or remission of symptoms, using univariable and multivariable analyses. RESULTS: Of 1,037 women enrolled in the initial study, 744 women (71.7%) completed an online or written follow-up survey between September 2006 and March 2007. Of the 372 asymptomatic women controls at initial enrollment, 13 (3.5%, 95% confidence interval 1.6–5.4%) had developed vulvodynia during the 2-year follow-up period; nine (2.2%) of these had ongoing symptoms. Of 45 women with vulvodynia at initial enrollment, 10 (22.2%, 95% confidence interval 10.1–34.4%) indicated their symptoms had resolved. Factors at enrollment that were associated with incidence of vulvodynia were younger age and history of pain after intercourse. Remission was more common in women who did not have pain after intercourse and in those who reported less severe pain at enrollment. CONCLUSION: Based on 2-year follow-up, each year approximately one in 50 women develop symptoms of vulvodynia, and one in 10 women with vulvodynia report remission of symptoms. LEVEL OF EVIDENCE: II

Knowledge and attitudes about AIDS among deaf and hard of hearing persons

We investigated whether the public information being dispensed about Acquired Immunodeficiency Syndrome (AIDS) reaches Deaf and Hard of Hearing (D&HH) persons to the same extent as the rest of the American population. Using a self-administered written survey, modified so that D&HH persons whose primary language is American Sign Language (ASL) could understand the questions, we studied 40 D&HH and 37 hearing persons in southeast Michigan. There were no significant demographic differences between the two populations, but there were differences regarding attitudes towards and knowledge about AIDS. D&HH persons were less likely to associate sexual contact with drug users and number of sexual partners as high risk sexual behaviours, were more likely to believe that storing blood for future personal use lowers their chances of contracting AIDS, and believed that using public restrooms, kisses on the cheek and visiting an AIDS patients increased their chance of contracting AIDS. Furthermore, they were more likely to believe they did not need to change their sexual behaviour as a result of the AIDS epidemic. D&HH persons also reported different attitudes towards AIDS patients, such as they were not important to their community, dentists with AIDS should not be allowed to continue working, and landlords should be able to evict people with AIDS. Our findings suggest differences in receiving, trusting, and/or being exposed to current information about AIDS by the Deaf community, consistent with the fact that they are a minority population with distinct knowledge and cultural traditions.

Sexual activities and attitudes of women with vulvar dysesthesia.

OBJECTIVE To assess the relationship between sexual activities and attitudes of women with and without vulvar dysesthesia. METHODS Women with vulvar dysesthesia, 18–60 years old, and ethnically matched women without this disorder were enrolled in this cross-sectional study, completed a 27-page questionnaire, and had a physical examination. We compared sexual activities and attitudes between patients and controls using univariate and multivariable analyses. RESULTS Between January 21, 2001, and December 12, 2002, we enrolled 63 women with vulvar dysesthesia and 62 controls who reported having a current sexual partner. Women with vulvar dysesthesia were less likely than controls to have had, during the previous month, intercourse (66.7% versus 83.9%, P = .03) and orgasms (57.6% versus 78.7%, P = .02), although the association with intercourse was no longer statistically significant after controlling for age, education, and smoking status (P = .07). Of those having had intercourse in the past month, the frequency of this activity was less among patients (3.0 ± 2.7 versus 6.2 ± 4.5 episodes, P < .001). Frequencies of orgasms, fellatio, cunnilingus, and masturbation did not significantly differ between patients and controls. Patients rated sex less important and rated themselves more negatively as sexual people than did controls (P < .001). CONCLUSION Women with vulvar dysesthesia are similar to those without in many sexual activities but are less likely to have had an orgasm in the past month or to have had intercourse at the same frequency as controls. Although some attitudes were similar, sexual interest and self-concept were decreased among those with this disorder