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An effective osteoporosis screening and patient education program for gynecology office practice
Accuracy of Fundal Height Measurements in an Academic Center Ana M. Vidal, MD University of Miami/Jackson Memorial Hospital, Miami, FL
Victor Hugo Gonzalez-Quintero, MD, Orlando Gomez-Marin, PhD, and Dibe Martin, MD OBJECTIVE: To determine the accuracy of fundal height measurement by different practitioners in an academic center. MATERIAL AND METHODS: This is a prospective study of women between 18 and 36 weeks of gestation who attended clinic in a tertiary care center. Fundal height was measured in the supine position with a nonelastic tape and after bladder emptying. Participants had had various levels of training; they included medical students, nurses, midwives, and attending physicians. All were blinded to the gestational age of the patient. Variables of interest included body mass index, parity, and maternal age. Kappa statistics were used as measure of agreement between rates. A kappa coefficient of greater than or equal to 0.75 equaled optimal agreement, 0.60 – 0.75 was acceptable, 0.40 – 0.60 was suboptimal, and less than 0.40 was poor. Logistic regression was also used for statistical analysis. RESULTS: A total of 229 fundal height measurements were performed on 25 different patients. The overall accuracy of fundal height was found to be 60%. When applying kappa analysis, the accuracy between different levels of training was found to be poor to suboptimal (kappa coefficient 0.46 – 0.14). No association was found between the accuracy of fundal height and body mass index, parity, maternal age, and gestational age. CONCLUSION: Serial fundal height measurements performed by multiple practitioners may not provide useful clinical information with respect to fetal growth because of this unacceptable interobserver variability.
Accuracy of the Diagnosis of Trichomonas vaginalis on Liquid-Based Pap Test Eduardo Lara-Torre, MD University Hospitals of Cleveland, Cleveland, OH
Jay Pinkerton, MD OBJECTIVE: To determine the accuracy of the liquid-based Pap test in the diagnosis of Trichomonas vaginalis in women. MATERIALS AND METHODS: Two hundred and three consecutive patients who required a liquid-based Pap test also had a culture for T vaginalis. Cultures were placed at 37° C and
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observed under direct microscopy daily for 5 consecutive days or until they were positive. Sample calculation was done using the chi-square test with a power of more than 90% to detect a 15% difference compared to traditional Pap test. Results were analyzed for sensitivity, specificity, and positive and negative predictive values as calculated by a 2 ⫻ 2 table. RESULTS: Forty-four patients (21.6%) were positive, most by day one. Liquid-based Pap test results included 28 patients (13.8%) positive for T vaginalis. The liquid-based Pap test showed a sensitivity of 61.4%, specificity of 99.4%, positive predictive value of 96.4%, and negative predictive value of 90.8. Comparing wet mount and culture, a sensitivity of 50%, specificity of 93%, positive predictive value of 77%, and negative predictive value of 80% was obtained. Patients with positive culture were more likely to have a wet mount performed (P ⫽ 0.027) and to have inflammation on liquid-based Pap test (P ⬍ 0.001); they were less likely to have a normal Pap test result (P ⬍ 0.001) and to have clue cells on wet mount (P ⫽ 0.028). CONCLUSION: The liquid-based Pap test is an accurate method for detection of T vaginalis infection. The presence of the organism should warrant treatment without the need for further testing.
An Effective Osteoporosis Screening and Patient Education Program for Gynecology Office Practice Joseph F. Sclafani, MD Seven Hills Women’s Health Centers, Cincinnati, OH
Randolph C. Stinger, MD, Z. Tom Grapes, PhD, Jonathan J. Ijaz, MPA, and William McBride, MD The purpose of this study was to modify office practices to better document, detect, and treat osteoporosis. A chart review was conducted on women 50 years of age and older to assess demographics, use of dual-energy X-ray absorptiometry (DXA) scan, menopause risk factors, menopause counseling, and prescription and over-the-counter medication usage. Office practices were modified by having patients complete a form assessing the above factors. This form was attached to the front of the chart and reviewed by the physician. Additionally, educational materials regarding osteoporosis were distributed at that visit. One year later, a second chart review was conducted. Four hundred thirty-five and 507 charts were included, pretest and posttest, respectively. Physician compliance with the form was 83%. A significant increase was seen in the following: patients willing to undergo a DXA scan, use of nonprescription and over-the-counter drugs such as calcium, counseling on hormone replacement therapy, evaluation of modifiable risk factors, and total number of DXA scans conducted. No significant difference was seen in the use of hor-
OBSTETRICS & GYNECOLOGY
mone replacement therapy or prescription medications. Based on these results, it would appear that the office practice modification was well accepted and extremely effective in improving the documentation, detection, and treatment of osteoporosis.
Sexual History-Taking: Standards of Physician Practice
Comparing Tissue Quality by Removing the End of the Endometrial Suction Pipelle
Nicole S. Nevadunsky
K. R. Justus, MD
OBJECTIVE: To examine standards of practice and the impact of physician and patient age, sex, religion, marital status, sexual preference, and level of academic achievement on sexual history-taking.
St. Luke’s Hospital, Bethlehem, PA
D. M. Steinberg, MD, T. L. Gaydos, MD, and J. N. Anasti, MD OBJECTIVE: Cutting the tip of an endometrial biopsy (EMB) Pipelle prior to passing the tissue into fixative has been suggested to improve sample quality. However, no prospective study has been done to validate this technique. The authors designed a prospective randomized masked trial to determine if cutting the tip prior to expelling EMB tissue from the Pipelle into the fixative improves histologic integrity. METHODS: Consecutive Pipelle EMBs were randomized to each arm prior to biopsy. One pathologist compared three microscopic sections from each sample in a blinded fashion. A tissue integrity score from 0 to 3 (0 ⫽ poor, 3 ⫽ best) was employed to grade each of the samples. The scores were compared for each group using the Mann–Whitney rank sum test. RESULTS: Fifty-five EMBs were available for evaluation. The average age of patients was 46.3 years. Biopsies were performed for the following indications: postmenopausal bleeding, 18; premenopausal irregular bleeding, 34; and other, 3. Indications for the biopsy were similar in each group. Eight were excluded because of lack of tissue, leaving 25 cut and 22 uncut samples for analysis. No difference was noted in the histologic integrity between cut and uncut samples (P ⫽ 0.974). CONCLUSION: Based on light microscopy findings, the authors could not demonstrate a benefit in cutting the tips of the EMB Pipelle prior to collecting the tissue. Although the sample size was limited, the authors see no clinical value in performing this additional step when obtaining an EMB.
VOL. 99, NO. 4 (SUPPLEMENT), APRIL 2002
University of Medicine and Dentistry of New Jersey, New Brunswick, NJ
Ngoc Quynh T. Tran, MD, and Gloria A. Bachmann, MD
METHODS: Physicians of a multispecialty academic group were mailed a six-page study questionnaire regarding practice styles on sexual history-taking. RESULTS: Sixty-one questionnaires (47%) were returned, 43 were completed (n ⫽ 34), and 18 were returned because of address change. Of the 43 responders, 34 reported taking sexual histories, and nine reported not taking sexual histories. Twenty-eight percent of physicians taking a sexual history reported finding sexual dysfunction. Although a large percentage (48%) of physicians reported dissatisfaction with their training in obtaining a sexual history, the majority (79%) felt comfortable discussing sexual dysfunction. In all categories, physicians perceived that their patients experienced more discomfort than the physicians themselves during sexual inquiry. Characteristics identified as causing physician discomfort included patient age younger than 18 years and greater than 65 years, academic achievement below college level, and divorced or single marital status. Of note, 44% of physicians believed that sexual history-taking caused great discomfort among homosexual patients. CONCLUSION: Even at a large academic medical center, many practitioners do not take sexual histories and are dissatisfied with their training on this subject. It is of concern that patients at the extremes of age, who are at greatest risk for sexual dysfunction, are identified as causing physician discomfort. These data suggest that there are still many barriers to the identification of sexual dysfunction in patients.
WEDNESDAY POSTERS
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Victor Hugo Gonzalez-Quintero, MD, Orlando Gomez-Marin, PhD, and Dibe Martin, MD OBJECTIVE: To determine the accuracy of fundal height measurement by different practitioners in an academic center. MATERIAL AND METHODS: This is a prospective study of women between 18 and 36 weeks of gestation who attended clinic in a tertiary care center. Fundal height was measured in the supine position with a nonelastic tape and after bladder emptying. Participants had had various levels of training; they included medical students, nurses, midwives, and attending physicians. All were blinded to the gestational age of the patient. Variables of interest included body mass index, parity, and maternal age. Kappa statistics were used as measure of agreement between rates. A kappa coefficient of greater than or equal to 0.75 equaled optimal agreement, 0.60 – 0.75 was acceptable, 0.40 – 0.60 was suboptimal, and less than 0.40 was poor. Logistic regression was also used for statistical analysis. RESULTS: A total of 229 fundal height measurements were performed on 25 different patients. The overall accuracy of fundal height was found to be 60%. When applying kappa analysis, the accuracy between different levels of training was found to be poor to suboptimal (kappa coefficient 0.46 – 0.14). No association was found between the accuracy of fundal height and body mass index, parity, maternal age, and gestational age. CONCLUSION: Serial fundal height measurements performed by multiple practitioners may not provide useful clinical information with respect to fetal growth because of this unacceptable interobserver variability.
Accuracy of the Diagnosis of Trichomonas vaginalis on Liquid-Based Pap Test Eduardo Lara-Torre, MD University Hospitals of Cleveland, Cleveland, OH
Jay Pinkerton, MD OBJECTIVE: To determine the accuracy of the liquid-based Pap test in the diagnosis of Trichomonas vaginalis in women. MATERIALS AND METHODS: Two hundred and three consecutive patients who required a liquid-based Pap test also had a culture for T vaginalis. Cultures were placed at 37° C and
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WEDNESDAY POSTERS
observed under direct microscopy daily for 5 consecutive days or until they were positive. Sample calculation was done using the chi-square test with a power of more than 90% to detect a 15% difference compared to traditional Pap test. Results were analyzed for sensitivity, specificity, and positive and negative predictive values as calculated by a 2 ⫻ 2 table. RESULTS: Forty-four patients (21.6%) were positive, most by day one. Liquid-based Pap test results included 28 patients (13.8%) positive for T vaginalis. The liquid-based Pap test showed a sensitivity of 61.4%, specificity of 99.4%, positive predictive value of 96.4%, and negative predictive value of 90.8. Comparing wet mount and culture, a sensitivity of 50%, specificity of 93%, positive predictive value of 77%, and negative predictive value of 80% was obtained. Patients with positive culture were more likely to have a wet mount performed (P ⫽ 0.027) and to have inflammation on liquid-based Pap test (P ⬍ 0.001); they were less likely to have a normal Pap test result (P ⬍ 0.001) and to have clue cells on wet mount (P ⫽ 0.028). CONCLUSION: The liquid-based Pap test is an accurate method for detection of T vaginalis infection. The presence of the organism should warrant treatment without the need for further testing.
An Effective Osteoporosis Screening and Patient Education Program for Gynecology Office Practice Joseph F. Sclafani, MD Seven Hills Women’s Health Centers, Cincinnati, OH
Randolph C. Stinger, MD, Z. Tom Grapes, PhD, Jonathan J. Ijaz, MPA, and William McBride, MD The purpose of this study was to modify office practices to better document, detect, and treat osteoporosis. A chart review was conducted on women 50 years of age and older to assess demographics, use of dual-energy X-ray absorptiometry (DXA) scan, menopause risk factors, menopause counseling, and prescription and over-the-counter medication usage. Office practices were modified by having patients complete a form assessing the above factors. This form was attached to the front of the chart and reviewed by the physician. Additionally, educational materials regarding osteoporosis were distributed at that visit. One year later, a second chart review was conducted. Four hundred thirty-five and 507 charts were included, pretest and posttest, respectively. Physician compliance with the form was 83%. A significant increase was seen in the following: patients willing to undergo a DXA scan, use of nonprescription and over-the-counter drugs such as calcium, counseling on hormone replacement therapy, evaluation of modifiable risk factors, and total number of DXA scans conducted. No significant difference was seen in the use of hor-
OBSTETRICS & GYNECOLOGY
mone replacement therapy or prescription medications. Based on these results, it would appear that the office practice modification was well accepted and extremely effective in improving the documentation, detection, and treatment of osteoporosis.
Sexual History-Taking: Standards of Physician Practice
Comparing Tissue Quality by Removing the End of the Endometrial Suction Pipelle
Nicole S. Nevadunsky
K. R. Justus, MD
OBJECTIVE: To examine standards of practice and the impact of physician and patient age, sex, religion, marital status, sexual preference, and level of academic achievement on sexual history-taking.
St. Luke’s Hospital, Bethlehem, PA
D. M. Steinberg, MD, T. L. Gaydos, MD, and J. N. Anasti, MD OBJECTIVE: Cutting the tip of an endometrial biopsy (EMB) Pipelle prior to passing the tissue into fixative has been suggested to improve sample quality. However, no prospective study has been done to validate this technique. The authors designed a prospective randomized masked trial to determine if cutting the tip prior to expelling EMB tissue from the Pipelle into the fixative improves histologic integrity. METHODS: Consecutive Pipelle EMBs were randomized to each arm prior to biopsy. One pathologist compared three microscopic sections from each sample in a blinded fashion. A tissue integrity score from 0 to 3 (0 ⫽ poor, 3 ⫽ best) was employed to grade each of the samples. The scores were compared for each group using the Mann–Whitney rank sum test. RESULTS: Fifty-five EMBs were available for evaluation. The average age of patients was 46.3 years. Biopsies were performed for the following indications: postmenopausal bleeding, 18; premenopausal irregular bleeding, 34; and other, 3. Indications for the biopsy were similar in each group. Eight were excluded because of lack of tissue, leaving 25 cut and 22 uncut samples for analysis. No difference was noted in the histologic integrity between cut and uncut samples (P ⫽ 0.974). CONCLUSION: Based on light microscopy findings, the authors could not demonstrate a benefit in cutting the tips of the EMB Pipelle prior to collecting the tissue. Although the sample size was limited, the authors see no clinical value in performing this additional step when obtaining an EMB.
VOL. 99, NO. 4 (SUPPLEMENT), APRIL 2002
University of Medicine and Dentistry of New Jersey, New Brunswick, NJ
Ngoc Quynh T. Tran, MD, and Gloria A. Bachmann, MD
METHODS: Physicians of a multispecialty academic group were mailed a six-page study questionnaire regarding practice styles on sexual history-taking. RESULTS: Sixty-one questionnaires (47%) were returned, 43 were completed (n ⫽ 34), and 18 were returned because of address change. Of the 43 responders, 34 reported taking sexual histories, and nine reported not taking sexual histories. Twenty-eight percent of physicians taking a sexual history reported finding sexual dysfunction. Although a large percentage (48%) of physicians reported dissatisfaction with their training in obtaining a sexual history, the majority (79%) felt comfortable discussing sexual dysfunction. In all categories, physicians perceived that their patients experienced more discomfort than the physicians themselves during sexual inquiry. Characteristics identified as causing physician discomfort included patient age younger than 18 years and greater than 65 years, academic achievement below college level, and divorced or single marital status. Of note, 44% of physicians believed that sexual history-taking caused great discomfort among homosexual patients. CONCLUSION: Even at a large academic medical center, many practitioners do not take sexual histories and are dissatisfied with their training on this subject. It is of concern that patients at the extremes of age, who are at greatest risk for sexual dysfunction, are identified as causing physician discomfort. These data suggest that there are still many barriers to the identification of sexual dysfunction in patients.
WEDNESDAY POSTERS
89S