Journal of the American Medical Women's Association (1972)最新文献

Background: The protocol for shoulder dystocia assumes an anterior shoulder entrapped above the pubic symphysis. If the shoulders lie in a different position, a different strategy is required. Such a situation can occur in shoulder dystocia with an occipito-posterior position.

Case: An operative vaginal delivery in a nulliparous woman resulted in a shoulder dystocia with the head in the occipito-posterior position, and the usual maneuvers were unsuccessful. The shoulders were transverse and after being manipulated into the oblique plane, an atraumatic vaginal delivery resulted.

Conclusion: In the rare situation of an occipito-posterior shoulder dystocia, the shoulders may be in the transverse position. This situation can be addressed by manipulating the shoulders and by making an episiotomy to facilitate the maneuver. If unsuccessful, cephalic replacement may be an option.

Studies have shown that lack of confidentiality is a barrier to adolescents use of needed health care services. Professional medical organizations support confidential care for adolescents as a matter of individual and public health. Confidentiality is governed by both state and federal law, and physicians must be aware of both. Physicians must facilitate communication between teens and parents while guaranteeing confidential care to their adolescent patients.

Despite international efforts to halt the practice of female genital mutilation (FGM), the number of African girls and women undergoing the procedure is not declining as rapidly as international observers had hoped when the World Health Organization began focusing attention on the practice in the 1960s. This article focuses on the psychological effects of FGM through the example of a patient who had undergone the procedure in childhood and now felt that her closed appearance was "normal" and that to be opened would be "abnormal." Western advocates must educate themselves about the various cultural forces that lead to FGM in order to help women who have undergone the procedure heal psychologically, thereby breaking the pattern of abuse from generation to generation.

Objective: To compare women who use Department of Veterans Affairs (VA) health care providers only with women who use VA and non-VA providers (dual users).

Methods: An anonymous survey was mailed to women veterans randomly sampled from 10 VA medical centers in 3 states. We measured reports of dual use of VA and non-VA providers according to the VA provider's gender, provision of routine gynecological care by VA provider, use of VA women's clinic, and overall satisfaction with VA care. Multiple logistic regression analyses were performed with adjustment for patient demographics, health status, VA service connection status, and clustering by site to determine what factors influenced dual use of providers.

Results: In the fully adjusted logistic regression model, provision of routine gynecological care by VA providers (odds ratios [OR] 0.37; 95% confidence intervals [CI] 0.22, 0.60) and use of VA women's clinics (OR 0.56; CI 0.35, 0.90) were strongly associated with a lower likelihood of dual use. Dissatisfaction with care (OR 1.88; CI 1.04,3.41) and higher income (OR 1.89; CI 1.32, 2.71) were also associated with an increased likelihood of dual use. Having a female VA provider was not associated with dual use.

Conclusions: Women veterans' use of VA and non-VA providers is influenced by the scope of clinical services and dissatisfaction with those services. VA clinics should either promote routine gynecological care within primary care clinic settings or pair traditional primary care with VA women's clinics to enhance coordination and comprehensiveness and, thus, reduce fragmentation of care for veteran women.

This article provides practical advice about foods and dietary supplements that are beneficial for the health of older people. Overweight and obesity are among the most common nutrition-related disorders in older people. A plant-based diet is associated with reduced risk of chronic diseases such as obesity, cardiovascular disease, cancer, and diabetes. Vitamin B12 deficiency is prevalent in older adults, but there are misconceptions about the causes, consequences, and treatments. Diminished synthesis of vitamin D in the skin that occurs with aging and poor dietary intake contribute to the high prevalence of poor vitamin D status in older adults. Vitamin D deficiency is associated with chronic disorders beyond poor bone health. Supplements containing vitamin B12 and vitamin D will help older adults meet their needs for these key nutrients.

The end of life is a difficult time for individuals and their families; some families find it devastating. Although the majority of Americans express a desire to die at home, only 25% achieve this goal. This finding and others from the landmark Last Acts state-by-state report card suggest we can do more to help ease the end-of-life transition. Report card results are reported, highlighting the need for better communication between physicians and patients. Physicians have a key role to play in helping individuals and their families understand their choices and deal with end-of-life care issues. Resources and recommendations are offered to help facilitate planning discussions. Information about hospice use and eligibility is also outlined.

Objectives: To compare male and female medical students by age, level of education before admission to medical school, race/ethnicity, parental education level, socioeconomic status, and attitudes toward public health care.

Methods: In 2001, we conducted an Internet-based survey of all students enrolled in the 16 medical schools across Canada. Based on the high response rate, first-year medical students at Canadian medical schools outside of Quebec were included in this analysis. The interactions between sex and age, years of premedical education, race/ethnicity, parental occupation, education and household income, impact of finances on choice of medical school, future specialty and practice location, attitudes toward private funding in the Canadian health care system were examined using descriptive statistics and chi2 tests.

Results: There were no significant differences between male and female medical students in age, level of education before admission, and race/ethnicity. Female students' fathers (p=.046) and mothers (p=.061) were more likely to hold positions of higher occupational status than were those of male students. There was no significant difference between the parental household incomes of male and female students. Male students were more likely than female students to state that financial considerations would affect their choice of specialty (p=.002) and practice location (p=.002). Male students were more likely to express a positive attitude toward private funding in the health care system, both with respect to increasing the amount of private funding (p=.007) and the addition of private paying patients (p=.002).

Conclusion: Although women have almost reached equity with men in undergraduate medical education, female students are more likely than male students to have highly educated parents, suggesting that some barriers to access may still exist. The differences in attitudes of female and male medical students to finances and the public health care system become increasingly important as more women practice medicine. These sex differences need to be investigated further, as they could have implications for health policy.

A case is presented in which an uninsured woman sought care at a medical clinic and then an emergency room, where she was ultimately diagnosed with early cervical cancer. Although cervical cancer at this stage carries an excellent prognosis, the patient was unable to pay for the diagnostic testing, surgery, and additional treatment that she needed and was therefore told that she would be treated in an emergency situation only. The ethics of providing care in a health care system that makes no provision for care of the indigent is discussed, with consideration of obligations of individual physicians as well as of institutions to care for the sick. A single-payer system is advocated as a solution to the problem of providing care to the under- and uninsured.