Baron J., Holzman G.B., Schulkin J. Attitudes of Obstetricians and Gynecologists Toward Hormone Replacement Therapy. Medical Decision Making. 18:406-411, 1998.
Objective. To determine the attitudes of obstetricians and gynecologists toward hormone replacement therapy (HRT), and the beliefs and intuitions that affect those attitudes. Design. A questionnaire was sent to 1,000 gynecologists in the United States; 328 replies were received. The questionnaire asked about the effects of HRT, practices concerning HRT, and decisions in hypothetical scenarios. Results. The respondents strongly favored HRT, and they were well informed about its effects on osteoporosis, cardiovascular disease, and breast cancer. They were aware of conflicting findings concerning breast cancer. The strength of their recommendation of HRT was sensitive to patient differences in risk factors. The respondents also showed four biases hypothesized to cause resistance to HRT: omission bias (more concern about harmful acts than harmful omissions); proportionality bias (attention to relative risk rather than risk difference); naturalness bias (preference for the natural); and ambiguity (avoiding options with missing information). Proportion bias, naturalness bias, and (weakly) omission bias were related to less favorable attitudes toward HRT in general. Some negativity toward HRT may result from decision biases.
Plouffe L., & Schulkin J. The Clinical Relevance of Estrogen in Cognition, Memory, and Mood. JSOG 20:929-941, 1998.
There is accumulating scientific evidence to support a role for estrogen in brain function. The data come from animal and human studies. Specifically, estrogen receptors are found in most functional areas of the brain. Estrogens demonstrate discrete effects on components of memory and cognition. Estrogens may also play a role in modulation of mood states. Finally, recent evidence points to the potential benefits of estrogens in preventing or lessening the severity of Alzheimer's disease. While exciting and encouraging, the current body of evidence must be viewed as preliminary, and much more work is required in the field to confirm the effects described up to now.
Schulkin J., Gold P.W., McEwen B.S. Induction of Cortocotropin-Releasing Hormone Gene Expression by Glucocorticoids. Psychoneuroendocrinology 23:219-243, 1998.
One endocrine mechanism underlying the body's sense of adversity is the activation of corticotropin releasing gene expression. Glucocorticoids in several extrahypothalamic sites (including the placenta) upregulate corticotropin gene expression, in contrast to the inhibition of corticotropin releasing hormone in the paraventricular nucleus of the hypothalamus. The positive induction of CRH gene expression underlies the continued sense of adversity or danger to biological systems.
Horan D.L., Chapin J., Klein L., Schmidt L., Schulkin J. Domestic Violence Screening Practices of Obstetrician-Gynecologists. Obstetrics and Gynecology 92:785-789, 1998.
Objective: To ascertain the current knowledge base and screening practices of obstetrician-gynecologists in the area of domestic violence. Method: We mailed a survey to 189 ACOG Fellows who are members of the Collaborative Ambulatory Research Network. Questionnaires were also mailed to a random sample of 1250 nonmember Fellows. Results: Obstetrician-gynecologists are aware of the nature of domestic violence and familiar with common symptomatology that may be associated with domestic violence. For pregnant patients, 39% of respondents routinely screen at the first prenatal visit; 27% of respondents routinely screen nonpregnant patients at the initial visit. Screening is most likely to occur when the obstetrician-gynecologist suspects a patient is being abused, both during pregnancy (68%) and when the patient is not pregnant (72%). Only 30% of obstetrician-gynecologists received training on domestic violence during medical school; 37% received such instruction during residency training. The majority (67%) have received continuing education on the subject. Years since training and personal experience with intimate-partner violence were associated with increased screening practices. Conclusion: Routine screening of all women for domestic violence has been recommended by ACOG for more than a decade. The majority of obstetrician-gynecologists screen both pregnant and nonpregnant patients when they suspect abuse. However, with universal screening, more victims of violence can be identified and can receive needed services.
McGregor J.A., Hager W.D., Gibbs R.S., Schmidt L., Schulkin J. Assessment of Office-Based Care of Sexually Transmitted Diseases and Vaginitis and Antibiotic Decision-Making by Obstetrician-Gynecologists. Infect Dis Obstet Gynecol 6:247-251, 1998.
Objective: Survey office-based obstetric-gynecologic practitioners regarding their knowledge of infectious disease care and antibiotic use. Methods: A survey questionnaire of multiple-choice questions was mailed to Fellows of the American College of Obstetricians and Gynecologists about clinical entities for which recommendations have undergone recent changes or about which there was a lack of consensus in a prior similar survey. Results: Respondents indicated that oral metronidazole was their most frequent choice to treat bacterial vaginosis. Ampicillin (57%) was used more often than penicillin (39%) for intrapartum group B streptococcus prophylaxis. Azithromycin was preferred (61%) over erythromycin-base (38%) for chlamydia treatment during pregnancy. There were several modes of practice that deviated from accepted care: 27% and 29% did not screen for chlamydia and gonorrhea, respectively, in pregnancy; 17% used cultures for Gardnerella vaginalis to diagnose bacterial vaginosis; 25% considered quinolones to be safe in pregnancy; 93% felt metronidazole should never be used in pregnancy; and the majority (66%) would send a patient, treated successfully for pelvic cellulitis, home with an oral antibiotic. Conclusion: Respondents' infectious disease knowledge and practices in obstetrics and gynecology is appropriate in treating sexually transmitted diseases, bacterial vaginosis, and group B streptococcus. Numerous deficiencies still exist in screening for sexually transmitted diseases in pregnancy and diagnosing bacterial vaginosis, as well as in the choice of antibiotics to use or avoid for certain infections.
Schulkin J. & Holzman G.B. Post-Partum Length of Stay: Obstetrician-Gynecologist Perspective. ACOG Clinical Review 1:1-4, 1998.
Average hospital length of stay following delivery has markedly decreased over the last 25 years. We found that the average length of stay estimated by physicians for their patients was 31.10 hours following vaginal delivery. Seventy-six percent of the physicians who estimated that their patients length of stay after vaginal delivery was less than 32 hours thought that it was not long enough, and none thought that it was ever too long. Most physicians reported that they were not satisfied when their patients were discharged in less than 32 hours (p = .001). Both medical (eg, unstable maternal vital signs) and social factors (eg, maternal support at home) were rated as important in determining obstetrician recommendations regarding patient length of stay.
Gabbe S., Hill L., Schmidt L., Schulkin J. Management of Diabetes by Obstetrician-Gynecologists. Obstet Gynecol 91:643-647, 1998.
Objective: To examine the rates of diagnosis and treatment of diabetes mellitus by AGOG Fellows in pregnant and nonpregnant patients. Methods: We sent a questionnaire to 1250 ACOG Fellows. Thirty-nine percent responded. Responses were examined for potential differences between recently and less recently trained obstetrician-gynecologists. Results: Ninety-six percent of obstetricians routinely screened for gestational diabetes mellitus (GDM). Fifty-five percent of obstetrician-gynecologists screen for diabetes in nonpregnant patients if there is a history of diabetes in the patient's family. Moreover, 33% care for nonpregnant women with type-1 diabetes mellitus, and 39% care for nonpregnant women with type-2 diabetes mellitus. Sixty-two percent believed that their patients with GDM are at increased risk for developing nongestational diabetes later in life, and 71% will recommend an evaluation of glucose tolerance in the future for these women. Finally, 99% are willing to perscribe oral contraceptives to women diagnosed previously with GDM. Conclusion: Obstetrician-gynecologists are aware of the need to screen for GDM and the importance of postpartum follow-up in GDM patients to detect type-2 diabetes mellitus. This practice is important because half of the 14 milllion people with type-2 diabetes mellitus are unaware they have this disorder, and may learn about it only after a serious complication has occurred.