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

Coronary artery disease (CAD) is a leading cause of morbidity and mortality among men and women. Although substantial research efforts have refined diagnosis and treatment strategies for patients at risk, the detection of CAD in women can be problematic. Atypical chest pain is not only more common among women than men, but the predictive value of traditional risk factors is also different for women and men. Moreover, sex-specific issues in the selection of an appropriate noninvasive diagnostic test must be considered. This article reviews the challenges inherent in the evaluation of chest pain in women as well as the strengths and limitations of the diagnostic stress-testing modalities commonly used.

Objective: To explore women's perspectives about how to enhance services for those who experience intimate partner violence (IPV) and how to improve the links between such services and the health care setting.

Methods: We conducted 6 focus groups involving 67 women in both rural and urban settings in North Carolina. A standardized interview guide was used to investigate the women's perspectives on the study objectives. Coding and theme analyses were conducted to assess new ideas and/or common themes among the groups.

Results: Participants identified currently available services for women experiencing IPV, including health care providers, police and the legal system, domestic violence shelters, and churches. Participants discussed existing barriers to addressing violence within the health care system, including cost of medical services, risk of having social services remove their children, violence being too personal to discuss, and doctors' inability to provide what they thought victims really needed. Participants agreed that the most important role for providers would be referrals to useful services (advocacy, job training, and financial support). Participants also emphasized the need for community-based prevention efforts.

Conclusion: We found a striking lack of support among women participants in our study for using the health care setting as part of the service response to IPV. Participants believed that the health care system is not set up to allow providers to provide the level of individual assistance that they thought would be most useful. Participants did have hope that women's risk of future IPV would decrease if they were provided with useful community-based services and if community-wide prevention efforts were implemented.

Clinics that provide assisted reproductive technology (ART) are guided by general guidelines set forth by the American Society for Reproductive Medicine and its Ethics Committee and are free to set their own policies within those guidelines. This article presents a case in which a university clinic was presented with a novel request. A same-sex male couple, both positive for the human immunodeficiency virus (HIV), asked to use one of the couple's sperm to establish a pregnancy in an unrelated gestational surrogate through in vitro fertilization, intracytoplasmic sperm injection, and embryo transfer. The couple's argument in favor of such a plan was that no documented case of HIV seroconversion had so far occurred in recipients of gametes from HIV-positive donors. Since gestational surrogates routinely accept the risks inherent in pregnancy and childbearing, an informed surrogate should be allowed to accept the risks of such an arrangement. They further argued that if no clinic were willing to provide such services, data regarding seroconversion would never be obtained. The university ethics committee examined the fertility clinic's policies and found the clinic's refusal to provide such services to be completely consistent with its policy that allows providing services to HIV-discordant couples, same-sex couples, and gestational surrogates, but that always acts to protect the surrogate from exposure to infectious risk.

Objective: To examine temporal associations between obstetrics/gynecology (ob/gyn) care, substance abuse treatment (SAT), and antiretroviral therapy (ART) during and after pregnancy among HIV-infected women on Medicaid.

Method: We identified 345 women, representing 378 deliveries, from merged New Jersey AIDS/HIV surveillance data and paid Medicaid claims data between 1992 and 1998. T-tests were used to analyze person-level differences in service use before and after delivery. Data were converted to person-months to predict SAT and receipt of ART in multivariate regressions that corrected for correlations among repeated observations.

Results: Compared to antepartum months there were significant reductions in ART and ob/gyn care in postpartum months and a significant increase in substance abuse. Multivariate analyses showed that compared to other months, women were more likely to obtain SAT during the postpartum period (odds ratio [OR] 1.51, 95% confidence interval [CI], 1.31-1.74); conversely, women were more likely to receive ART in the antepartum period (OR 1.77, 95% CI, 1.43-2.17). Ob/gyn care predicted ART and SAT, regardless of the timing of care relative to delivery. African American women were least likely to receive SAT and ART.

Conclusion: Our findings underscore that ob/gyn providers have a central position in pathways to care for a vulnerable population of women with multiple health care needs and that patterns of ART use and SAT shift markedly during the months before and after delivery. However, receipt of ob/gyn care during these months is not associated with the changes, suggesting that ob/gyn providers may have untapped opportunities during the ante- and postpartum months to educate women with HIV/AIDS about the importance of consistent use of ART and to provide SAT referrals as needed. These results may have implications for policy makers interested in promoting adherence to ART and decreasing substance abuse among women with HIV/AIDS.

Objectives: Psychosocial factors, including depression, anger, and social isolation, have been associated with increased morbidity and mortality from coronary heart disease (CHD), but predictors of psychosocial burden among women with CHD are poorly defined. The purpose of this study was to determine whether readily measured demographic and risk factors could identify women with psychosocial risk factors that are more difficult to assess in a clinical setting.

Methods: Baseline data on 304 women (mean age 62 years, 52% minority) hospitalized with CHD at 3 academic medical centers participating in a clinical study of adherence to prevention guidelines were evaluated. Standardized questionnaires were used to measure depression (4-item self-report tool from the Primary Care Evaluation of Mental Disorders questionnaire) and anger (Spielberger Trait Anger Scale). One self-report question was used to assess social isolation.

Results: Thirty-seven percent of women with CHD reported depression, 50% reported anger, and 41% reported social isolation. In a logistical model controlling for confounders, independent predictors of depression were having dependents (odds ratio [OR] = 2.27, p = .006), age (< or = 65 years) (OR = 1.91, p = .02), and exercise (< 3 days/week) (OR = 3.92, p < .001). Anger was associated with having dependents (OR = 3.16, p < .001), age (< or = 65 years) (OR = 1.95, p = .02), and smoking (OR = 2.05, p = .04). Subjects who had dependents (OR = 2.24, p = .005), were unemployed (OR = 1.93, p = .03), and who did not get enough exercise (< 3 days/week) (OR = 2.07, p = .03) reported higher isolation in adjusted models. Differences in prevalence of psychosocial factors by ethnicity were not statistically significant. However, there was a trend toward increased prevalence of psychosocial risk factors among white women, possibly reflecting the need for more culturally sensitive screening tools.

Conclusion: These data may be helpful in identifying women who are at risk of increased CHD morbidity and mortality because of psychosocial burden.

Medical ethics evolved over the past half-century. This brought close reexamination and scrutiny of medical education and the "hands-on training" of future medical practitioners. Likewise societal opinions have intensified regarding the rights of patients, especially those deemed less likely to express their humiliation if they should discover themselves in compromising positions during treatment. Informed consent is modern medico-legal terminology; if the public felt that all patients were treated with the self-determination and dignity required by current HIPAA regulations, then there would be no reason to legislate such requirements. Law professor Robin Fretwell Wilson, Esq., and obstetrics and gynecology professor Nancy G. Chescheir, MD, present evidence and opinions from the legal and medical perspectives regarding conducting pelvic exams on anesthetized women without or with vague consent.

Objective: To investigate breast cancer outcomes in a group of African American and white patients offered the same access to mammography screening in a health maintenance organization located in suburban Philadelphia, Pennsylvania.

Methods: We used medical chart reviews and retrospective tumor tissue studies to investigate disparities in the mode of diagnosis and breast cancer outcomes among African American and white patients in a health maintenance organization.

Results: African American women were more likely to have detected their breast cancers accidentally and to have breast tumors larger than 2 cm than were whites. Invasive breast cancers with both lymph node involvement and systemic metastases were more prevalent in African American than in white women.

Conclusion: These results suggest that even in health care settings that provide access to routine screening, African American women are more likely to have their breast cancers diagnosed accidentally and at more advanced stages than their white counterparts.