Erin E. Tracy

Updated Parental Viewpoints on Male Neonatal Circumcision in the United States

Through a questionnaire, the authors sought to elicit information about initial attitudes concerning circumcision after reading a summary of the American Academy of Pediatrics (AAP) Policy Statement and, again, after reading a description of recent HIV/HPV studies. Predictors of increased support for circumcision included having a prior circumcised boy and being US born. Predictors of decreased support included being of Hispanic ethnicity and believing that the uncircumcised penis was more culturally normal. After reading the AAP statement, 86% of respondents remained favorable of elective circumcision, whereas 13% viewed it less favorably. After reading the passage about the HIV/HPV studies, the majority maintained their initial level of support. Certain characteristics were associated with an individual’s desire to perform circumcision on his/her infant. Despite a slight decrease in support to perform circumcision after reading the AAP policy summary, respondents’ initial attitudes toward circumcision were unchanged after subsequent review of recent HIV/HPV research.

Human Trafficking: A Call for Heightened Awareness and Advocacy by Obstetrician–gynecologists

A a recent labor floor sign-out round, the resident presented a laboring patient with a complicated social history. The patient was a homeless teenager who had just arrived from Texas and was having an unplanned, undesired pregnancy. I somewhat sheepishly asked, “Any possibility of human trafficking here?” I realized that, despite having recently become educated about this topic, I still did not feel fully prepared to educate my peers about trafficking or identify and assist victims of trafficking. As obstetrician–gynecologists (ob-gyns), we need to educate ourselves and feel empowered to help these patients. Years ago, the physician’s role in identifying and assisting victims of intimate partner violence was not recognized. After decades of advocacy and education, intimate partner violence became a topic of formal instruction in medical schools and residency programs, and the same should be true regarding human trafficking. The extent of human trafficking is staggering. Barrows and Finger note that the “practice of slavery is alive and well around the globe.”1 According to the U.S. Department of State, there are many kinds of human trafficking, including forced labor, bonded labor, involuntary domestic servitude, sex trafficking, forced child labor, child soldiers, and child sex trafficking.2 The United Nations Office on Drugs and Crime reports that human trafficking is one of the top three most profitable crimes crossing national borders.3 By some estimates, nearly 1 million people in the world are trafficked across international borders each year, and approximately 14,500–17,500 people are trafficked into the United States each year.4 According to the most recent U.S. Department of State’s Trafficking in Persons report, trafficking is widespread across this nation and the year 2010 saw an increase in the number of female, foreign-born trafficking victims receiving services in the United States.5 This U.S. report identifies Thailand, India, Mexico, the Philippines, Haiti, Honduras, El Salvador, and the Dominican Republic as the most common countries of origin of persons trafficked into the United States. However, human trafficking does not require the crossing of international borders, and the aforementioned figures do not include the larger number of individuals estimated to be trafficked domestically within their own countries. According to one report, the United States is second only to Germany with regard to the rate at which women and children are trafficked into sex work.6 One author notes that there are currently at least 100,000 victims of domestic minor sex trafficking in the United States and that there are as many as 325,000 additional youth at risk of being trafficked.7 Although there are many challenges in determining accurate prevalence estimates, the United States enacted the Victims of Trafficking and Violence Prevention Act in 2000 in response to this seeming epidemic.8 The Act subsequently was amended and reauthorized in 2003, 2005, and 2008. Additionally, the United States ratified the United Nations’ “Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children” in November 2005.9 Encounters with health care providers can be windows of opportunity to intervene on behalf of these victims. Given the many medical problems associated with trafficking, health care providers are uniquely positioned to identify and assist these vicFrom Massachusetts General Hospital, Boston, Massachusetts.

Elective vulvoplasty: a bandage that might hurt.

I recently saw a patient who made me think about financial temptations physicians might face. A 110pound teen-age girl came to see me asking for a “vulvoplasty.” She and her friend went to see an “expert” in another city because they didn’t like “the way skin hangs there when wearing a bathing suit.” This patient’s pelvic examination was within normal limits. She had entirely normal vulvar anatomy. Her vulva were not abnormally enlarged or protruding. I spent a lot of time counseling this patient. I told her there was no medical rationale for doing this procedure. I reviewed my concerns that she might have long-term dyspareunia or pelvic pain as a result. We also discussed the risk of wound breakdown and infection. My fear was this was more related to her body image or a potential eating disorder than to actual gynecologic pathology. She asked me if I could “figure out a way” to have insurance cover such a procedure for her. She said she had found an “expert” who would do this procedure for cash. Anecdotally, a number of my colleagues have recently had similar requests for this procedure. One patient reported the need to have this done because her husband mocks her in a bathing suit, regardless of the fact she has normal anatomy. I’m afraid that doing this surgical procedure isn’t going to correct the former patient’s selfimage, or assist the latter patient in her relationship with her husband. I suspect more appropriate therapies might include social services or psychiatric intervention.

Credentialing based on surgical volume, physician workforce challenges, and patient access.

Advances within the medical profession have resulted in an increase in available medical therapeutic options and minimally invasive surgical techniques for common gynecologic conditions. In many circumstances, this has led to a reduction in surgical volume for many common conditions in benign gynecology. There is also some evidence that a threshold number of cases may exist, below which surgical competence may be affected. Although the practice of medicine continues to evolve, there is broad recognition of a projected workforce shortage of physicians. If credentialing or privileging bodies establish criteria based solely on the number of procedures performed by an individual physician, patient access may be greatly affected. From a public health perspective, these issues cannot be considered in isolation. Thoughtful analysis of existing data and recognition of patient access issues should be carefully weighed before any dramatic changes in hospital privileging or hiring practices. Consideration for ongoing maintenance of credentialing should be carefully balanced and strategies for ongoing assurance of competency may require creative alternatives to simple numerical documentation. Differential approaches to regions with different densities of physicians may also be necessary.

Newborn care and safety: the black box of obstetric practices and residency training.

Certain causes of newborn mortality such as sudden unexpected infant death, which includes sleep-related infant death and sudden unexplained infant death syndrome, are potentially preventable. Obstetricians are uniquely positioned to counsel new parents about safe practices regarding newborn sleep, feeding, and transportation. Patients often do not develop a relationship with their pediatricians until the neonate has been discharged, and the newborn period is a time of particular vulnerability. Newborn safety should be routinely taught in obstetric curricula, and the American College/Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics (AAP) should partner to disseminate updated literature and guidelines to health care providers regarding newborn safety. Current guidelines from the Academy of Pediatrics Task Force on Sudden Infant Syndrome are summarized in this article.

The Role of Social Networks, Medical-Legal Climate, and Patient Advocacy on Surgical Options: A New Era.

The dissemination of information online and resultant public discourse through social media and other online channels has influenced the practice of medicine in dramatic ways. Physicians have historically worked to develop new techniques and devices for the benefit of their patients. It is only a more recent phenomenon, however, that these tools are either removed or their use is curtailed largely driven by anecdotal reports; passionate, vocal, often media-savvy advocates; and plaintiff attorneys. The use of power morcellation, hysteroscopic tubal sterilization, and mesh in urogynecologic procedures all have been victims of these societal pressures. It is important for health care professionals to be involved in the debate to ensure that public outcry does not unduly influence what we, as clinicians, are able to safely offer our patients. By being better advocates for our field, our instruments, and our patients, we can ensure medical decision-making is driven by good science and not public fervor.

Confessions of an Electronic Medical Record User

T advent of electronic medical records has extraordinary implications for the practice of medicine. In 1997 the Institute of Medicine pointed out that “in spite of more than 30 years of exploratory work and millions of dollars in research and implementation of computer systems in health care provider institutions, patient records today are still predominantly paper records.”1 Due to the many complexities of implementation of such a system, and the significant potential benefits, the Institute of Medicine subsequently, just four years later, advocated a “renewed national commitment to building an information infrastructure [that will] lead to the elimination of most handwritten clinical data by the end of the decade.”2 That same year, 2001, only 17% of primary care physicians in the United States, compared with 29% of their European counterparts, were routinely using electronic medical records in their practices.3 There are many potential benefits of electronic medical records from a patient quality perspective. Electronic prescribing has significant benefits regarding the improved legibility of prescriptions, electronic submission to pharmacies, and online reminders regarding drug interactions, contraindications, dosages, and therapeutic guidelines. Bates et al4 demonstrated that computerized physician order entry reduced medication errors by 55%. Indeed, 14 of 19 computerized reminder systems for

Intimate partner violence: not just a concern of the reproductive ages

T he Centers for Disease Control and Prevention defines intimate partner violence (IPV) as the Bphysical, sexual or psychological harm by a current or former partner or spouse.[ IPV is pervasive both nationally and internationally. The recent National Violence Against Women Survey of 16,000 US adults revealed that approximately 25% of women had experienced either physical assault or rape by their partner at some point in their life. This number can be extrapolated to estimate that 1.5 million women are raped and/or physically assaulted by an intimate partner each year in this country. International lifetime prevalence rates range from 10% to 58%. Although a significant amount of literature exists about IPV in general, information about women past their reproductive years is more limited. A recent study involving a random sample of 370 women at least 65 years old revealed that 26.5% of them had a lifetime IPV prevalence. This abuse also occurred during their postmenopausal years because 3.5% of them had suffered from IPV in the past 5 years, and 2.2% of them had been involved in IPV within the past year. Nelson et al recently noted that the Babuse of elderly persons takes many forms, including physical, sexual, psychological, and financial exploitation as well as neglectIthe highest rates of elder abuse are among women and those 80 years of age and older. In 90% of cases, the perpetrator is a family member, most often an adult child or spouse.[ The link between IPV and psychiatric diagnoses is well known. An analysis of the Women’s Health Initiative Observational Study involving 93,676 women aged 50 to 79 years revealed that female IPV victims had significant increases in Bdepressive symptomatology.[ This was true for those incurring Bverbal abuse only[ in addition to those living with Bphysical and verbal abuse.[ Another study of 1,024 women revealed that those who experienced IPV had statistically significant higher rates of physical symptoms, depression, and alcohol use and decreased social support. The myriad of health consequences of IPV should prompt physicians to incorporate domestic violence screening into their practices. The recent statement by the US Preventive Services Task Force (USPSTF) concluding that there is Binsufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse of neglect of children, or women for intimate partner violence, or of older adults or their caregivers for elder abuse[ engendered significant controversy. The American Medical Association, the American Academy of Pediatrics, and the Family Violence Prevention Fund (now called Futures without Violence) all published editorials opposing the USPSTF statement. The latter group noted the BTask Force made serious mistakes in reaching its conclusion. It used an overly narrow approach by assessing screening for abuse as a medical screen rather than a behavioral assessment toolIit dismissed more than 750 studies on screening and 650 studies on intervention.[ The American Medical Association and American Academy of Pediatrics editorial advised, BNo provider should stop inquiring about family violence as a result of the USPSTF recommendation. We believe that a Fwait and see_ approach is ill-advised and will leave thousands of women without information that could help prevent further violence and save lives.[ In 2011, the Institute of Medicine published Clinical Preventive Services for Women: Closing the Gaps, which concluded that Bthe evidence provided to support a recommendation related to increasing detection of and counseling for domestic violence and abuse is based on peer-review studies and federal and international policies, in addition to clinical professional guidelines.[ The Institute of Medicine recommendation prompted the US Department of Health and Human Services to require new health insurance plans to cover domestic violence screening without charging a copayment, coinsurance, or a deductible. The article by Teixeira de Araujo Moraes et al in this issue of Menopause involves a questionnaire administered to 124 women 40 to 65 years old who have experienced IPV. This cohort was further subdivided into three groups: those who had experienced violence exclusively during their childhood/adolescence (16.1%), exclusively during adulthood (41.9%), or throughout their lives (41.9%). The control group included an additional 120 postmenopausal women who had not experienced IPV. The survey instrument incorporated specific aspects of the violence, information regarding obtaining help in healthcare settings, associated medical comorbidities and the Menopausal Kupperman Index. An analysis of results revealed the consistency of the 34-item questionnaire after it was administered to 33 women on two dates, by two different interviewers, 45 to 90 days apart. Statistical analysis indicated that the survey was well validated and appeared to be reproducible. The types of violence incurred were physical (75.8%), sexual (59.7%), and psychological (97%); physical neglect (75.8%); and emotional neglect (31.4%). The vast majority of perpetrators were husbands/partners or biological parents. Of the 36 women who had an active sex life, only 10 found their sex life to be satisfactory. The control group had a statistically significant lower rate of medical comorbidities compared with the IPV groups (mean of 2.2 comorbidities vs 5.1 comorbidities, respectively, P 9 0.01). The most commonly associated

Prospects and problems of direct-to-public genetic tests

Direct-to-consumer advertising of genetic tests is prevalent, poorly regulated and fraught with potential negative public-health ramifications. While some genetic tests are available through means that safeguard patient understanding of the implications of having genetic tests performed, others are available to anyone who has a credit card, without any individualized counseling, assessment of whether such tests are indicated, or interpretation of test results. While the US FDA, the Centers for Medicare and Medicaid Services and the Federal Trade Commission all have a regulatory role, most experts agree that the industry is not adequately being reigned in to best protect the public it serves.

Fibroepithelial bladder polyp and renal tubular dysgenesis: an unusual cause of third-trimester oligohydramnios.

The fetal genitourinary tract is evaluated sonographically by visualizing the kidneys, identifying fluid within the bladder, and assessing amniotic fluid volume. Most renal abnormalities associated with oligohydramnios are obstructive uropathies or cystic renal anomalies. Rarely does one consider renal failure as a cause of oligohydramnios and nonvisualization of the bladder in the third trimester. We present an unusual case of a fetus who appeared to have no structural abnormalities on sonography in the midtrimester and who had late-onset oligohydramnios as well as slightly enlarged kidneys and an abnormal-appearing bladder.