Operative vaginal delivery has been maligned since the days of W.J. Little with the word &amp... more Operative vaginal delivery has been maligned since the days of W.J. Little with the word "forceps" becoming nearly synonymous with "Birth Injury" and "Cerebral Palsy." However in his presentation to the Obstetrical Society of London in 1861, Little's emphasis was on difficult labors being the culprit in subsequent disabilities in the offspring. Instrumented deliveries in that era were the end result of a long, obstructed labor performed for maternal benefit and to avoid a destructive procedure to the fetus thus allowing a chance at life. If there had been a normal progress in labor, operative assistance for delivery would not have been needed. Thus, was it the instrument or the obstructed labor that led to fetal injury? In this article, we will review what injuries to the fetus and the mother can be directly attributable to the instrument. We will explore the processes of labor, conduct of labor management, and concurrent fetal factors that can modulate the occurrence of birth trauma. Evidence regarding inexperience and improper use as contributing to injury will also be explored.
There are several issues inherent in the question of the adequacy of gynecologic and colorectal s... more There are several issues inherent in the question of the adequacy of gynecologic and colorectal screening: 1) are the available screening tests effective; 2) are they appropriate to use in women over 65; and if so, 3) are they being used in this group of women? The incidence of gynecologic and colorectal cancers increases with age. Additionally, gynecologic cancers are diagnosed at more advanced stages in older women. Older women are at greatest risk for these cancers but are often less likely to be screened than younger women. The following is a review of the incidences of individual cancers, their effects on women aged 65 and older, available screening methods, and their use in older women. CERVICAL CANCER The incidence of cervical cancer increases with age) It is estimated that in 1991 there will have been 13,000 newly diagnosed cervical cancers, and 4500 women will die from this disease. 2 Twenty-seven percent of these cases and 41% of the deaths will occur in women over the age of 65. The relative 5-year survival rate decreases with age: 62% for women under the age of 65 and 50% for those age 65 and older. 3 The incidence of cervical cancer is greater in black women, and the relative 5-year survival rate in blacks is dramatically lower at 37%.~ When the data from several cancer registries are reviewed, there is a definite relationship between the stage at which cervical cancer is diagnosed and a patient's age, with older women being diagnosed at more advanced stages of cervical cancer. 4~ The Pap smear is the most commonly used method of screening for cervical cancer. It allows the clinician to detect and treat preinvasive cervical neoplasia. Although the efficacy of the Pap smear has never been tested in a prospective study, 7 there have been several epidemiologic studies that show a decrease in invasive cervical cancer when the Pap smear has been introduced as a screening test. 8-H Concomitantly, the incidence of cervical cancer has increased in unscreened populations, n If the Pap smear is an effective screening test, why do women still die of invasive cervical cancer? Using the Pap smear as a screening tool involves
Because primary care physicians (PCPs) are the initial health care contact for most patients with... more Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal. To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders. A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked a...
Operative vaginal delivery has been maligned since the days of W.J. Little with the word &amp... more Operative vaginal delivery has been maligned since the days of W.J. Little with the word "forceps" becoming nearly synonymous with "Birth Injury" and "Cerebral Palsy." However in his presentation to the Obstetrical Society of London in 1861, Little's emphasis was on difficult labors being the culprit in subsequent disabilities in the offspring. Instrumented deliveries in that era were the end result of a long, obstructed labor performed for maternal benefit and to avoid a destructive procedure to the fetus thus allowing a chance at life. If there had been a normal progress in labor, operative assistance for delivery would not have been needed. Thus, was it the instrument or the obstructed labor that led to fetal injury? In this article, we will review what injuries to the fetus and the mother can be directly attributable to the instrument. We will explore the processes of labor, conduct of labor management, and concurrent fetal factors that can modulate the occurrence of birth trauma. Evidence regarding inexperience and improper use as contributing to injury will also be explored.
Operative vaginal delivery has been maligned since the days of W.J. Little with the word &amp... more Operative vaginal delivery has been maligned since the days of W.J. Little with the word "forceps" becoming nearly synonymous with "Birth Injury" and "Cerebral Palsy." However in his presentation to the Obstetrical Society of London in 1861, Little's emphasis was on difficult labors being the culprit in subsequent disabilities in the offspring. Instrumented deliveries in that era were the end result of a long, obstructed labor performed for maternal benefit and to avoid a destructive procedure to the fetus thus allowing a chance at life. If there had been a normal progress in labor, operative assistance for delivery would not have been needed. Thus, was it the instrument or the obstructed labor that led to fetal injury? In this article, we will review what injuries to the fetus and the mother can be directly attributable to the instrument. We will explore the processes of labor, conduct of labor management, and concurrent fetal factors that can modulate the occurrence of birth trauma. Evidence regarding inexperience and improper use as contributing to injury will also be explored.
There are several issues inherent in the question of the adequacy of gynecologic and colorectal s... more There are several issues inherent in the question of the adequacy of gynecologic and colorectal screening: 1) are the available screening tests effective; 2) are they appropriate to use in women over 65; and if so, 3) are they being used in this group of women? The incidence of gynecologic and colorectal cancers increases with age. Additionally, gynecologic cancers are diagnosed at more advanced stages in older women. Older women are at greatest risk for these cancers but are often less likely to be screened than younger women. The following is a review of the incidences of individual cancers, their effects on women aged 65 and older, available screening methods, and their use in older women. CERVICAL CANCER The incidence of cervical cancer increases with age) It is estimated that in 1991 there will have been 13,000 newly diagnosed cervical cancers, and 4500 women will die from this disease. 2 Twenty-seven percent of these cases and 41% of the deaths will occur in women over the age of 65. The relative 5-year survival rate decreases with age: 62% for women under the age of 65 and 50% for those age 65 and older. 3 The incidence of cervical cancer is greater in black women, and the relative 5-year survival rate in blacks is dramatically lower at 37%.~ When the data from several cancer registries are reviewed, there is a definite relationship between the stage at which cervical cancer is diagnosed and a patient's age, with older women being diagnosed at more advanced stages of cervical cancer. 4~ The Pap smear is the most commonly used method of screening for cervical cancer. It allows the clinician to detect and treat preinvasive cervical neoplasia. Although the efficacy of the Pap smear has never been tested in a prospective study, 7 there have been several epidemiologic studies that show a decrease in invasive cervical cancer when the Pap smear has been introduced as a screening test. 8-H Concomitantly, the incidence of cervical cancer has increased in unscreened populations, n If the Pap smear is an effective screening test, why do women still die of invasive cervical cancer? Using the Pap smear as a screening tool involves
Because primary care physicians (PCPs) are the initial health care contact for most patients with... more Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal. To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders. A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked a...
Operative vaginal delivery has been maligned since the days of W.J. Little with the word &amp... more Operative vaginal delivery has been maligned since the days of W.J. Little with the word "forceps" becoming nearly synonymous with "Birth Injury" and "Cerebral Palsy." However in his presentation to the Obstetrical Society of London in 1861, Little's emphasis was on difficult labors being the culprit in subsequent disabilities in the offspring. Instrumented deliveries in that era were the end result of a long, obstructed labor performed for maternal benefit and to avoid a destructive procedure to the fetus thus allowing a chance at life. If there had been a normal progress in labor, operative assistance for delivery would not have been needed. Thus, was it the instrument or the obstructed labor that led to fetal injury? In this article, we will review what injuries to the fetus and the mother can be directly attributable to the instrument. We will explore the processes of labor, conduct of labor management, and concurrent fetal factors that can modulate the occurrence of birth trauma. Evidence regarding inexperience and improper use as contributing to injury will also be explored.
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Papers by Mary Ciotti