A blueprint for academic obstetrics and gynecology

A consensus conference sponsored by the Council of University Chairs of Obstetrics and Gynecology in February 1997 formulated the organization's response to the many external issues affecting academic medicine and obstetrics and gynecology including 1) a new practice model based on "wellness," 2) reimbursement changes that have jeopardized traditional revenue sources, 3) an emphasis on quality assurance based on outcomes research and evidence-based medicine, 4) the concept of lifelong learning dictated by an expanding knowledge base and new technology, 5) insufficient resources for basic and clinical investigation in obstetrics and gynecology, 6) workforce statistics indicating stabilization in the number of subspecialists, 7) the increasing diversity of the United States population. Recommendations were developed that are intended to foster change and contribute to the design of academic programs. These include appropriate training for residents as providers of primary care, with an emphasis on continuity clinics, an interdisciplinary curriculum in women's health for medical students; promotion of gender, racial, and ethnic diversity at all levels of medical education and academic leadership; creation of clinical trials research units; and the development of expanded opportunities for research in obstetrics and gynecology supported by the National Institutes of Health.     

Gas embolism in obstetrics and gynecology. A review

Recent data suggest that the clinical course of reactional states in leprosy is closely related to the cytokine profile released locally or systemically by the patients. In the present study, patients with erythema nodosum leprosum (ENL) were grouped according to the intensity of their clinical symptoms. Clinical and immunological aspects of ENL and the impact of these parameters on bacterial load were assessed in conjunction with patients' in vitro immune response to mycobacterial antigens. In 10 out of the 17 patients tested, BI (bacterial index) was reduced by at least 1 log from leprosy diagnosis to the onset of their first reactional episode (ENL), as compared to an expected 0.3 log reduction in the unreactional group for the same MDT (multidrug therapy) period. However, no difference in the rate of BI reduction was noted at the end of MDT among ENL and unreactional lepromatous patients. Accordingly, although TNF-alpha (tumor necrosis factor) levels were enhanced in the sera of 70.6% of the ENL patients tested, no relationship was noted between circulating TNF-alpha levels and the decrease in BI detected at the onset of the reactional episode. Evaluation of bacterial viability of M. leprae isolated from the reactional lesions showed no growth in the mouse footpads. Only 20% of the patients demonstrated specific immune response to M. leprae during ENL. Moreover, high levels of soluble IL-2R (interleukin-2 receptor) were present in 78% of the patients. Circulating anti-neural (anti-ceramide and anti-galactocerebroside antibodies) and anti-mycobacterial antibodies were detected in ENL patients' sera as well, which were not related to the clinical course of disease. Our data suggest that bacterial killing is enhanced during reactions. Emergence of specific immune response to M. leprae and the effective role of TNF-alpha in mediating fragmentation of bacteria still need to be clarified.     

Uses of nitric oxide in obstetrics and gynecology

A cDNA clone encoding a human ribosomal protein L39 (hRPL39) was isolated through a random cDNA sequencing approach to a cDNA library constructed from a human colon carcinoma cell line of COLO 205. Although levels of hRPL39 mRNA were different in several cell lines including carcinoma cell lines from different tissues, they were shown not to be cell cycle-dependent in a human fibroblast cell line of TIG-1.     

Manpower for obstetrics and gynecology. II. Characteristics of patients; their diagnoses and care

A further report from the cooperative manpower study of the University of Southern California American College of Obstetricians and Gynecologists has identified characteristics of patients and their diagnoses and classified types of patient-physician encounters. Obstetrician-gynecologists care for women mainly between the ages of 20 and 44, deal two thirds of the time with only five diagnostic categories in the office and 10 in the hospital, and provide primary care in 78.2% of all patient encounters.     

Application of DNA fingerprinting to obstetrics and gynecology

Restriction fragment length polymorphisms (RFLP) are variations in the size of restriction fragments of genomic DNA that hybridize to specific probes. They are the consequence of changes in primary DNA sequences, most of which result from small-scale changes in DNA. Recently minisatellite DNA probes that detect many regions of great variability within the human genome have been described. Minisatellite probes consist of multiple repeated copies of a common 10-15 base pair core sequence. On hybridization to restriction enzyme digests of human DNA, they simultaneously detect many highly polymorphic minisatellites at different loci in the genome, and produce band patterns that are individual specific. The band patterns are called "DNA fingerprints" or "DNA barcode" which can be used for individual identification on forensic and legal medicine. In addition to forensic and legal medicine, DNA fingerprinting can be used in both basic research and clinical examination of obstetrics and gynecology. The RFLP bands in DNA fingerprinting are inherited as single Mendelian co-dominants and we can use such minisatellite DNA probe for the determination of zygosity in multiple pregnancy. This probe can be used for the determination of androgenesis as a cause of complete hydatidiform mole. Each polymorphic band in molar tissues could be identified as being of paternal but not maternal origin. Some polymorphic bands of paternal origin were not observed in molar tissues, indicating that endoreduplication of a normal haploid sperm or fertilization by dispermy to an anuclear oocyte with no effective genome could be the cause of complete hydatidiform mole (androgenesis).(ABSTRACT TRUNCATED AT 250 WORDS)     

Three-dimensional ultrasonography in obstetrics and gynecology: preliminary experience

OBJECTIVE: Technologic advances in ultrasonographic imaging have revolutionized the management of women's health care. We recently began to evaluate the clinical applications of three-dimensional ultrasonography. STUDY DESIGN: This study prospectively evaluated 161 obstetric and gynecologic patients. Both two- and three-dimensional imaging data were acquired from real-time ultrasonography. Three orthogonal planes were displayed on a monitor and were used to create the rendered three-dimensional images. RESULTS: To date, 201 three-dimensional ultrasonographic studies have been performed, 165 transabdominally and 36 transvaginally. Transabdominally, an average of eight acquisitions per patient were obtained. Of the clinically suspected abnormalities, 29 of 32 (91%) were confirmed by three-dimensional imaging. Three of 32 (9%) improved the diagnostic capabilities or changed the diagnosis. Of the 36 transvaginal studies, an average of four acquisitions per patient were done. Thirty (83%) of these patients had suspected abnormalities and all were confirmed. CONCLUSIONS: Three-dimensional ultrasonographic imaging appears to be highly promising in the clinical setting.     

Evaluation of current practices in routine preoperative crossmatching for transurethral resection of the prostate

Increasing demand for blood during elective surgery has led to attempts to rationalize routine preoperative crossmatching to those operations when there is a reasonable (greater than 30%) chance of it being required. Results of a questionnaire returned by 86% of the urology units in Great Britain show that 41% continue to crossmatch 2 units of blood before transurethral prostatectomy. A review of 301 transurethral prostatectomies performed with preoperative grouping and saving of blood showed that only 11% of the patients required transfusion. The need for transfusion was significantly associated with presentation in chronic or acute on chronic retention (p < 0.01), and the operative factors of weight of resection (p < 0.0001) and degree of hemostasis (p < 0.001). Therefore, a policy of routine preoperative blood grouping and saving is safe, and could be widely adopted, leading to financial saving and a decrease in wastage of blood that becomes too old to use.     

Quality assurance and risk management in gynecology and obstetrics]

The predominance of medical experts in hearings on so-called professional malpractice has frequently been bemoaned, but is indispensable since lawyers lack the necessary knowledge and requisite expertise. Court decisions are therefore essentially dependent on the quality of expert medical opinions, which in turn are dependent on the professional competence of the expert and on whether the expert is aware of the judicial demands made of him, i.e. whether the expert correctly understands his status and function within the scope of the civil or criminal proceedings. For example,the fact that court practice allows for differing standards (i.e. that medical standards can vary within limits) is important for the expert's appraisal, as is also knowing to what extent he is bound by the assignment and which requirements apply for proving causality (i.e. of an error leading up to damage) in civil and criminal proceedings. Strict objectivity, comprehensible language, restriction to one's own special field, preparation of the report within a reasonable time, intellectual integrity, no dealing with legal issues, ex ante assessment of the case and personal responsibility for the opinion are other important precepts that must be adhered to in order to avoid a miscarriage of justice. Quality control as exercised by specialised experts is therefore of vital significance.     

Ethical challenges in the managed practice of obstetrics and gynecology

Obstetrics and gynecology has been transformed from a fee-for-service, unmanaged system to a prepaid managed system. This change poses significant ethical challenges, which we address. We show that obstetrician-gynecologists and medical institutions are moral co-fiduciaries of female and pregnant patients, that the obstetrician-gynecologist should be economically disciplined without capitulating to managed care, and that managed care organizations have an obligation to support the medical education and research from which they benefit.     

A two-term MEDLINE search strategy for identifying randomized trials in obstetrics and gynecology

In this study, we examined whether endothelin (ET) plays a role in the short-term increase in mean arterial pressure (MAP) after nitric oxide synthase (NOS) inhibition with N(omega)-nitro-L-arginine methyl ester (L-NAME) in stroke-prone spontaneously hypertensive rats (SHRSPs). Experiments were performed by using Inactin-anesthetized male SHRSPs that were pretreated with chlorisondamine to block reflex autonomic cardiovascular effects. Injection of L-NAME (10 mg/kg, i.v.), but not D-NAME, produced rapid and marked increases (74 +/- 3 mm Hg) in MAP that were sustained for >1 h. In SHRSPs that were treated with the ET(A/B) receptor antagonist, L-754,142 (15 mg/kg + 15 mg/kg/h), L-NAME increased MAP by 45 +/- 4 mm Hg (p < 0.0001 compared with L-NAME alone). L-754,142 blocked pressor responses to big ET-1 by >90% but was without effect on pressor responses to norepinephrine. Plasma levels of ET-1 averaged 5 +/- 1 pg/ml in animals given vehicle and were slightly increased in animals given either L-NAME alone (7 +/- 2 pg/ml) or L-754,142 alone (7 +/- 2 pg/ml) but increased markedly when L-NAME and L-754,142 were given together (114 +/- 18 pg/ml). This may relate to an effect of L-754,142 to block ET-receptor-mediated clearance of ET-1. We conclude that ET plays a role in the short-term pressor response after NOS inhibition in SHRSPs.     

Improving the processes of care and outcomes in obstetrics/gynecology

BACKGROUND: The obstetrics/gynecology department of York Hospital (York Health System, York, Pennsylvania) initiated a program to improve the processes of care and control costs for common women's and newborns' health care services. Twelve clinical policies were established between June 1993 and February 1995. CONDUCTING THE QUALITY IMPROVEMENT (QI) PROJECTS: Using the plan-do-check-act (PDCA) improvement cycle method, the QI group established clinical pathways for high-volume conditions or procedures known to have low rates of complications and clinical guidelines for those conditions or procedures not requiring coordinated efforts of a group of health care professionals. EXAMPLE--PYELONEPHRITIS IN PREGNANCY: The literature had indicated that the prevalence of pyelonephritis can be decreased by identifying and treating asymptomatic bacteriuria early in prenatal care. After the validity of the clinical policy was demonstrated in the resident service, the policy was extended to all private obstetric practices. Dissemination of the finding that most of the admissions for pyelonephritis were for referred patients (for whom we had no control over prenatal care) or for patients referred by private physicians who were not yet following the guidelines quickly led to complete compliance by our obstetricians and other health care providers referring patients to the York Health System. RESULTS: The 12 clinical policies resulted in the elimination of 113 admissions and 5,595 inpatient days and in the reduction of the cost of patient care by $1,306,214 for the years 1994-1995 and 1995-1996 combined, without apparent adverse effects on patient health. CONCLUSION: A voluntary clinical policies program can change the culture of a department and lead to cost-effectiveness and better quality of patient care.     

The use of once-daily dosing of gentamicin in obstetrics and gynecology

Gentamicin is a widely-used antimicrobial agent for obstetric and gynecologic infections. Renewed excitement in this antibiotic has arisen from recent information supporting less frequent dosing. In this symposium, we will describe the pharmacokinetics of gentamicin and review new information advocating the use of once-daily administration of gentamicin.     

The quality of citations in major international obstetrics and gynecology journals

OBJECTIVE: Our goal was to determine the error rate in references in articles published in three major international journals in obstetrics and gynecology. STUDY DESIGN: All issues (excluding supplements) for the year 1995 of the American Journal of Obstetrics and Gynecology, the Australian and New Zealand Journal of Obstetrics and Gynaecology, and the British Journal of Obstetrics and Gynaecology were examined. References were numbered sequentially, and 50 randomly selected references from each journal were checked against the original for accuracy. RESULTS: Errors were found in the majority of references. The lowest error rate was 55.6% from the Australian and New Zealand Journal of Obstetrics and Gynaecology, and the highest was 66.7% from the British Journal of Obstetrics and Gynaecology. The difference between journals was not statistically significant. The most frequent types of error were in the title of the article or in the authors' names. CONCLUSIONS: Error rates in major international journals in obstetrics and gynecology are high, and care must be taken by authors and journal staff to improve the quality of published articles.