Mediation Analysis of Maternal Smoking, Gestational Age, and Birth Weight on the Texas-Mexico Border.

OBJECTIVES: Published data on the indirect effect of maternal smoking on birth weight as mediated by gestational age in Hispanic populations are lacking. Our goal was to conduct such a mediation analysis using data from El Paso County, Texas. METHODS: El Paso County is located on the US-Mexico border. A simple mediation analysis was conducted using year 2010 El Paso County birth certificate data. The SAS macro PROCESS 3.5.3 was used to estimate the direct and indirect effects of active maternal smoking (by trimester) on birth weight (in grams) in the setting of linear regression. The single mediator was gestational age in weeks. A direct or indirect effect was deemed to be present if the 95% confidence limits (CLs) excluded 0. Analyses were adjusted for multiple variables, including maternal prepregnancy body mass index. The indirect effect was reported along with a 95% bootstrap CL. RESULTS: A total of 16,654 singleton births were included in the cohort. The majority of the mothers were White Hispanic (87.2%). The mean (standard deviation) birth weight was 3198.6 g (517.2). A direct effect of maternal smoking during each trimester on birth weight was detected. An indirect effect of maternal smoking on birth weight was not detected in any of the trimesters. In adjusted analyses for the third trimester, the indirect effect for every 1-U increase in the mean number of cigarettes smoked per day was -4.18 (95% bootstrap CL -10.64 to 1.99). CONCLUSIONS: In our large, predominantly Hispanic cohort, it appears that gestational age is not a mediator of the effect of maternal smoking on birth weight. Future studies in our population should explore other possible mediators of this association.

Ethnic and border differences on blood cancer presentation and outcomes: A Texas population-based study.

BACKGROUND: The Texas/Chihuahua (US/Mexico) border is a medically underserved region with many reported barriers for health care access. Although Hispanic ethnicity is associated with health disparities for many different diseases, the population-based estimates of incidence and survival for patients with blood cancer along the border are unknown. The authors hypothesized that Hispanic ethnicity and border proximity is associated with poor blood cancer outcomes. METHODS: Data from the Texas Cancer Registry (1995-2016) were used to investigate the primary exposures of patient ethnicity (Hispanic vs non-Hispanic) and geographic location (border vs non-border). Other confounders and covariates included sex, age, year of diagnosis, rurality, insurance status, poverty indicators, and comorbidities. The Mantel-Haenszel method and Cox regression analyses were used to determine adjusted effects of ethnicity and border proximity on the relative risk (RR) and survival of patients with different blood cancer types. RESULTS: Hispanic patients were diagnosed at a younger age than non-Hispanic patients and presented with increased comorbidities. Whereas non-Hispanics had a higher incidence of developing blood cancer compared with Hispanics overall, Hispanics demonstrated a higher incidence of acute lymphoblastic leukemia (RR, 1.92; 95% CI, 1.79-2.08; P < .001) with worse outcomes. Hispanics from the Texas/Chihuahua border demonstrated a higher incidence of chronic myeloid leukemia (RR, 1.28; 95% CI, 1.07-1.51; P = .02) and acute myeloid leukemia (RR, 1.17; 95% CI, 1.04-1.33; P = .0009) compared with Hispanics living elsewhere in Texas. CONCLUSIONS: Hispanic ethnicity and border proximity were associated with a poor presentation and an adverse prognosis despite the younger age of diagnosis. Future studies should explore differences in disease biology and treatment strategies that could drive these regional disparities.

Predictors of timely diagnostic follow-up after an abnormal Pap test among Hispanic women seeking care in El Paso, Texas.

BACKGROUND: Diagnostic follow-up of women with an abnormal Pap test is necessary to resolve the risk developing cervical cancer. The purpose of this study is to describe patient characteristics associated with timely receipt of a diagnostic colposcopy after an abnormal Pap test among Hispanic women in El Paso, a Texas-Mexico border city. METHODS: We conducted a retrospective chart review of Hispanic patients seen at an academic colposcopy clinic following an abnormal Pap test. An optimal diagnostic interval to colposcopy was based on a National Breast and Cervical Cancer Early Detection Program (NBCCEDP) quality indicator and was defined as receipt of colposcopy within 90 days or less from the date of an abnormal Pap test. Risk ratios (RR) were calculated by building a generalized linear model fit using a Poisson distribution, log link, and robust variance. RESULTS: Overall, 177 of the 270 women (65.6%) received follow-up within an optimal diagnostic interval. After adjusting for other variables in the model, women who were 30 years of age or older were 32% more likely to have an optimal interval than younger women (adjusted RR = 1.32, P < 0.01). High school graduates were less likely than more educated women to have an optimal interval (adjusted RR = 0.68, P < 0.01). Participation in the NBCCEDP was not associated with receipt of follow-up within an optimal diagnostic interval. CONCLUSIONS: Compared with women with greater educational attainment, high school graduates were less likely to receive follow-up within an optimal diagnostic interval, as were younger (≤ 30 years) women compared with older women. Participation in the NBCCEDP was not associated with receipt of care within an optimal diagnostic interval.

Evaluating the performance of a low-cost mobile phone attachable microscope in cervical cytology.

BACKGROUND: Cervical cancer remains a global health problem especially in remote areas of developing countries which have limited resources for cervical cancer screening. In this study, we evaluated the performance of a low-cost, smartphone attachable paper-based microscope when used for classifying images of cervical cytology. METHODS: Cervical cytology samples included: 10 Normal, 10 Low-grade squamous intraepithelial lesion (LSIL), 10 High-grade squamous intraepithelial lesion (HSIL), and 10 Malignant Pap Smears. The agreement between conventional microscopy vs. Foldscope imaging was calculated using a weighted kappa coefficient. A confusion matrix was created with three classes: Normal, LSIL, and HSIL/malignant, to evaluate the performance of the Foldscope by calculating the accuracy, sensitivity, and specificity. RESULTS: We observed a kappa statistic of 0.68 for the agreement. This translates into a substantial agreement between the cytological classifications by the Foldscope vs. conventional microscopy. The accuracy of the Foldscope was 80%, with a sensitivity and specificity of 85 and 90% for the HSIL/Mal category, 80 and 83.3%, for LSIL, and 70 and 96.7% for Normal. CONCLUSIONS: This study highlights the usefulness of the Foldscope in cervical cytology, demonstrating it has substantial agreement with conventional microscopy. Its use could improve cytologic interpretations in underserved areas and, thus, improve the quality of cervical cancer screening. Improvements in existing limitations of the device, such as ability to focus, could potentially increase its accuracy.

Novel coronavirus, novel faculty development programs: rapid transition to eLearning during the pandemic.

The novel coronavirus disease 2019 (COVID-19) has caused a rapid and massive transition to online education. We describe the response of our Office of Faculty Development at Texas Tech University Health Sciences Center El Paso (TTUHSC EP) to this unprecedented challenge during and after this post-pandemic crisis. The initiatives for emergency transition to eLearning and faculty development described in this paper may serve as a model for other academic health centers, schools, colleges and universities.

HIV-1 Env Glycoprotein Phenotype along with Immune Activation Determines CD4 T Cell Loss in HIV Patients.

The mechanism behind the selective depletion of CD4(+) cells in HIV infections remains undetermined. Although HIV selectively infects CD4(+) cells, the relatively few infected cells in vivo cannot account for the extent of CD4(+) T cell depletion, suggesting indirect or bystander mechanisms. The role of virus replication, Env glycoprotein phenotype, and immune activation (IA) in this bystander phenomenon remains controversial. Using samples derived from HIV-infected patients, we demonstrate that, although IA in both CD4(+) and CD8(+) subsets correlates with CD4 decline, apoptosis in CD4(+) and not CD8(+) cells is associated with disease progression. Because HIV-1 Env glycoprotein has been implicated in bystander apoptosis, we cloned full-length Envs from plasma of viremic patients and tested their apoptosis-inducing potential (AIP). Interestingly, AIP of HIV-1 Env glycoproteins were found to correlate inversely with CD4:CD8 ratios, suggesting a role of Env phenotype in disease progression. In vitro mitogenic stimulation of PBMCs resulted in upregulation of IA markers but failed to alter the CD4:CD8 ratio. However, coculture of normal PBMCs with Env-expressing cells resulted in selective CD4 loss that was significantly enhanced by IA. Our study demonstrates that AIP of HIV-1 Env and IA collectively determine CD4 loss in HIV infection.

Barriers to seeking care for urinary incontinence in Mexican American women.

INTRODUCTION AND HYPOTHESIS: The majority of epidemiologic studies of urinary incontinence (UI) have been conducted in non-Hispanic populations. We conducted a case-control study to identify factors associated with delayed care-seeking behavior in adult Mexican American women with UI. METHODS: Cases were women with UI who sought care >2 years after the onset of symptoms (delayed care group). Controls were women with UI who sought care ≤2 years after the onset of symptoms. Participants were women who self-identified as Mexican American, Hispanic, Chicana or Latina, and were 18 years of age or older. RESULTS: A total of 209 records (107 cases and 102 controls) were available for analysis. Of the women in the delayed care and control groups, 32% and 23%, respectively, were ≥66 years of age (P = 0.12). Women in the delayed care group were less likely than those in the control group to report that the following item was a barrier (adjusted OR = 0.54, P = 0.06): "The wait is too long to the appointment". Women in the delayed care group were twice as likely as those in the control group (adjusted OR = 2.17, P = 0.03) to agree that lack of interest on the part of the health-care practitioner and staff was a barrier. In addition to standardized responses, open-ended responses were solicited and the most frequent barrier was lack of knowledge. CONCLUSIONS: Among Mexican American women with UI, those who delayed seeking care for their UI were more likely than those who sought care promptly to cite lack of interest on the part of a health-care provider as a barrier to seeking care in a timely fashion.

Parental Age and the Risk of Gestational Hypertension and Preeclampsia.

OBJECTIVES: To determine the effect of maternal age (MA) and paternal age (PA) on the risk of gestational hypertension, preeclampsia, and eclampsia in women who delivered on the Texas-Mexico border. METHODS: A cohort study using birth certificate data (singleton pregnancies, years 2005-2010) from El Paso County, Texas, was conducted. Six parental age-exposure categories were created with MA 20 to 34 years and PA younger than 35 years serving as the referent. A directed acyclic graph was created. Adjusted risk ratios for the composite outcome of gestational hypertension, preeclampsia, or eclampsia were calculated using Poisson regression. RESULTS: A total of 85,114 records were identified, with a majority of the mothers being of Hispanic ethnicity (89.2%). The incidence of the composite outcome ranged from 2.8% in the MA 20 to 34 years old and PA 35 years and older group to 4.4% in the MA younger than 20 years old and PA 35 years and older group. Compared to the MA 20 to 34 years old and PA younger than 35 years group, women in the MA 35 years and older and PA 35 years and older groups were more likely to experience the outcome (adjusted risk ratio 1.57, 95% confidence interval 1.39-1.77, P < 0.0001). CONCLUSIONS: Couples in which both parents are 35 years old and older should be counseled on the increased risk of gestational hypertension or preeclampsia/eclampsia.

A Comparison of Outcomes Between Robotic-Assisted, Single-Site Laparoscopy Versus Laparoendoscopic Single Site for Benign Hysterectomy.

STUDY OBJECTIVE: To compare the perioperative outcomes, including estimated blood loss, conversion to open laparotomy, length of stay, and total operative time of hysterectomies using robotic-assisted, single-site laparoscopy with laparoendoscopic single site (LESS) for benign indications. DESIGN: A retrospective cohort study (Canadian Task Force classification Level II-2. SETTING: Multicenter (private hospitals). PATIENTS: Gynecologic patients who underwent a hysterectomy for benign indications via robotic-assisted, single-site laparoscopy (n = 50) versus LESS (n = 50). INTERVENTIONS: Observational study. MEASUREMENTS AND MAIN RESULTS: Continuous outcomes were analyzed using multiple linear regression, whereas the dichotomous outcome of conversion was analyzed using a multiple log-binomial regression model. Linear and log-binomial regression coefficients were adjusted for the ages of the patients and other clinical factors. A total of 100 consecutive patient records were available for analysis: 50 for robotic-assisted, single-site laparoscopy and 50 for LESS. Univariate analyses revealed that both groups were similar in mean age (robotic, 46.0 years; LESS, 45.4 years; p = .75), but not mean body mass index (robotic, 25.9 kg/m(2); LESS, 28.8 kg/m(2); p = .02). There was no difference in the unadjusted (crude) risk of conversion to a multiport procedure between the robotic and laparoscopic groups (p = .37). There were only 2 major complications (cystotomy and vaginal dehiscence) in the LESS arm and 1 vaginal dehiscence in the robotic-assisted, single-site arm. After adjusting for 7 potential confounders, no relationship was detected between the type of approach (robotic vs laparoscopic) and the outcome of a major complication (exact odds ratio, 0.55; exact p = 1.0). A multivariate linear regression analysis that compared the 2 groups (robotic-assisted single site vs LESS) revealed no differences in estimated blood loss. On average, the robotic-assisted, single-site group had a length of stay that was 8.12 hours shorter than the LESS group (p = .003) after adjusting for patient characteristics. Total operative time was an average of 24.9 min longer in the robotic-assisted, single-site group (p = .002) after adjustment. A plot of total operative time in minutes by chronological case number and procedural approach was analyzed to estimate a learning curve. This plot showed a steeper learning curve with the robotic-assisted, single-site approach. CONCLUSIONS: This preliminary observational study found that the robotic-assisted, single-site group had a statistically significant decrease in length of hospital stay, but also experienced an increase in total operative time. There were no conversions to open laparotomies.

Predictors of a Prolonged Length of Stay in Children with Perforated Appendicitis.

OBJECTIVES: Little is known about the factors that affect the length of stay (LOS) of children hospitalized for perforated appendicitis. The objective of this study was to identify clinical and demographic factors associated with a prolonged LOS (PLOS) in children with perforated appendicitis. METHODS: A retrospective cohort study was conducted using the records of 197 children 0 to 17 years old with perforated appendicitis. The children were hospitalized at one of two teaching hospitals located in El Paso, Texas, and were discharged between January 2008 and January 2014. PLOS was defined as an LOS greater than the 75th percentile value in our patient cohort, which was 7 days. An initial log-binomial regression model failed to converge, and hence logistic regression was used to calculate adjusted incidence odds ratios (OR) for PLOS, 95% confidence intervals, P values, and a receiver operating characteristic curve. The best subset method was used to identify predictors for inclusion in the final model. RESULTS: The overall risk of PLOS was 23.4% (46/197). Approximately 76% of the children who experienced PLOS and 94% of those who did not have PLOS were Hispanic. After adjusting for insurance status, presence of an abscess, asthma, consulting interventional radiology, and various antibiotics, Hispanics were less likely than non-Hispanics to experience PLOS (adjusted OR 0.20; P = 0.003). Children whose providers consulted the interventional radiologist had an increased odds of PLOS (adjusted OR 3.64; P = 0.01). CONCLUSIONS: Hispanic ethnicity was associated with a lower odds of PLOS, whereas children who required the services of an interventional radiologist were more likely to experience PLOS.

Risk factors for ureteral occlusion during transvaginal uterosacral ligament suspension.

INTRODUCTION AND HYPOTHESIS: To determine any risk factors associated with ureteral occlusion during transvaginal uterosacral ligament suspension (USLS). METHODS: A retrospective query to identify patients that underwent transvaginal USLS at a teaching hospital from 2008 to 2013 was performed. Patients in which ureteral occlusion was identified by cystoscopy were identified (cases), and compared with those without occlusion (controls). Medical records were reviewed for data abstraction. Variables compared between cases and controls included demographics, medical history/examination, concomitant procedures, number of suspension sutures placed, estimated blood loss and length of hospital stay. Univariate analyses were performed to identify potential risk factors for ureteral occlusion, followed by multivariate regression analysis to estimate odds ratios for identified predictors. RESULTS: A total of 144 USLS procedures were performed. Thirteen cases of ureteral occlusion were identified (9%). Baseline prolapse stage, body mass index, parity, previous hysterectomy or pelvic surgery of the groups were similar (all P > 0.05). Univariate analysis identified age (P = 0.04), concomitant anterior colporrhaphy (P = 0.01), and use of a suture-capturing device for suture placement (P = 0.04) as significant factors. On multivariate logistic regression analysis, concomitant anterior colporrhaphy increased ureteral occlusion risk (OR 10.5, 95%CI 2.37-74.99, P = 0.001), while use of a suture-capturing device decreased it (OR 0.1, 95%CI 0-0.41, P = 0.01). The mean number of suspension sutures placed per side was similar in the two groups (2.6 [range 2-4] for cases and 2.4 [range 1-4] for controls, P = 0.15). CONCLUSIONS: During transvaginal USLS, performance of a concomitant anterior colporrhaphy increased the risk of ureteral occlusion, while the use of a suture-capturing device for suspension suture placement was associated with decreased risk.

Is maternal colonization with group B streptococci a risk factor for preeclampsia?

OBJECTIVE: To explore the association between maternal rectovaginal colonization with group B Streptococcus (GBS) and the outcome of preeclampsia, and to identify other factors such as maternal chocolate consumption that may be associated with preeclampsia on the Texas-Mexico border. STUDY DESIGN: A case-control study was conducted among 330 women who delivered at a teaching hospital in El Paso, Texas, during the time period April 2010 to April 2012. Preeclamptic cases (n = 165) and controls free of preeclampsia (n = 165) were matched by gestational age and date of delivery. Conditional logistic regression (with multiple imputation for missing data) was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) that were adjusted for maternal age and other factors. RESULTS: Cases (94.6%) and controls (97.0%) were predominantly Hispanic. GBS colonization was not associated with preeclampsia: adjusted OR = 1.73 (95% CI 0.63-4.74, p = 0.29). Maternal consumption of chocolate desserts once daily or more frequently as compared to < 7 times weekly was associated with a 76% reduction in the odds of preeclampsia: adjusted OR = 0.24 (95% CI 0.09-0.63, p = 0.004). CONCLUSION: Our study did not confirm the protective association between GBS and preeclampsia that was found in 2 existing state hospital datasets. Chocolate consumption during pregnancy was inversely associated with preeclampsia.

Effect of bromhexine in hospitalized patients with COVID-19.

BACKGROUND: Bromhexine is a potent inhibitor of transmembrane serine protease 2 and appears to have an antiviral effect in controlling influenza and parainfluenza infection; however, its efficacy in COVID-19 is controversial. METHODS: A group of hospitalized patients with confirmed COVID-19 pneumonia were randomized using 1:1 allocation to either standard treatment lopinavir/ritonavir and interferon beta-1a or bromhexine 8 mg four times a day in addition to standard therapy. The primary outcome was clinical improvement within 28 days, and the secondary outcome measures were time to hospital discharge, all-cause mortality, duration of mechanical ventilation, the temporal trend in 2019-nCoV reverse transcription-polymerase chain reaction positivity and the frequency of adverse drug events within 28 days from the start of medication. RESULTS: A total of 111 patients were enrolled in this randomized clinical trial and data from 100 patients (48 patients in the treatment arm and 52 patients in the control arm) were analyzed. There was no significant difference in the primary outcome of this study, which was clinical improvement. There was no significant difference in the average time to hospital discharge between the two arms. There were also no differences observed in the mean intensive care unit stay, frequency of intermittent mandatory ventilation, duration of supplemental oxygenation or risk of death by day 28 noted between the two arms. CONCLUSION: Bromhexine is not an effective treatment for hospitalized patients with COVID-19. The potential prevention benefits of bromhexine in asymptomatic postexposure or with mild infection managed in the community remain to be determined.

Sex and diet-dependent gene alterations in human and rat brains with a history of nicotine exposure.

Introduction: Chronic nicotine exposure induces changes in the expression of key regulatory genes associated with metabolic function and neuronal alterations in the brain. Many bioregulatory genes have been associated with exposure to nicotine, but the modulating effects of sex and diet on gene expression in nicotine-exposed brains have been largely unexplored. Both humans and rodents display motivation for nicotine use and the emergence of withdrawal symptoms during abstinence. Research comparing pre-clinical models with human subjects provides an important opportunity to understand common biomarkers of the harmful effects of nicotine as well as information that may help guide the development of more effective interventions for nicotine cessation. Methods: Human postmortem dorsolateral prefrontal cortex (dLPFC) tissue BA9 was collected from female and male subjects, smokers and non-smokers (N = 12 per group). Rat frontal lobes were collected from female and male rats that received a regular diet (RD) or a high-fat diet (HFD) (N = 12 per group) for 14 days following implantation of a osmotic mini-pump (Alzet) that delivered nicotine continuously. Controls (control-s) received a sham surgical procedure. RNA was extracted from tissue from human and rat samples and reversed-transcribed to cDNA. Gene expression of CHRNA10 (Cholinergic receptor nicotinic alpha 10), CERKL (Ceramide Kinase-Like), SMYD1 (SET and MYD Domin Containing 1), and FA2H (Fatty Acid 2-Hydrolase) in humans was compared to rats in each subset of groups and quantified by qPCR methods. Additionally, protein expression of FA2H was analyzed by immunohistochemistry (IHC) in human dLPFC. Results: Humans with a history of smoking displayed decreased CHRNA10 (p = 0.0005), CERKL (p ≤ 0.0001), and SMYD1 (p = 0.0005) expression and increased FA2H (p = 0.0097) expression compared to non-smokers (p < 0.05). Similar patterns of results were observed in nicotine exposed vs. control rats. Interestingly, sex-related differences in gene expression for CERKL and FA2H were observed. In addition, ANCOVA analysis showed a significant effect of nicotine in a sex-different manner, including an increase in CERKL in male and female rats with RD or HFD. In rats exposed to an HFD, FA2H gene expression was lower in nicotine-treated rats compared to RD rats treated with nicotine. Protein expression of FA2H (p = 0.001) by IHC was significantly higher in smokers compared to non-smokers. Conclusion: These results suggest that a history of long-term nicotine exposure in humans alters the expression of sphingolipid metabolism-related (CERKL, SMYD1, and FA2H) and neuronal (CHRNA10) marker genes similarly as compared to rats. Sex- and diet-dependent differences appear in nicotine-exposed rats, critical in regulating sphingolipid metabolism and nicotinic acetylcholine receptors. This research enhances the construct validity of rat models of nicotine usage by showing a similar pattern of changes in gene expression in human subjects with a smoking history.

Descriptive epidemiology of gastric adenocarcinoma in the state of Texas by ethnicity: Hispanic versus White non-Hispanic.

BACKGROUND: We aimed to evaluate the clinicopathological and demographic characteristics of gastric adenocarcinoma in Hispanics and compare these trends with those found in non-Hispanic Whites in Texas. METHODS: Records of patients with gastric adenocarcinoma found in the Texas Cancer Registry from 1995 to 2006 were reviewed. Four ethnic-geographic groups were formed: Hispanics residing in El Paso County (a county on the Texas-Mexico border), White non-Hispanics in El Paso County, Hispanics from the remaining counties of Texas combined, and White non-Hispanics from the remaining counties of Texas combined. Adjusted prevalence ratios (PRs) for the outcome of late stage at diagnosis were calculated. RESULTS: Of 9949 patients, 561 patients were El Paso County residents, of whom 83% were Hispanics. Among the four ethnic-geographic groups, the age-adjusted incidence was the highest in Hispanics in El Paso County (15.5 cases/100000). Tumor pathobiology varied by ethnicity. White non-Hispanics were more likely than Hispanics to have a proximal tumor and less likely to have a poorly differentiated or undifferentiated tumor. In El Paso County, patients in each of the eight age groups under 75 years compared to patients aged ≥85 years were significantly more likely to be at late stage (adjusted PRs 1.44-1.71). CONCLUSION: The incidence of gastric adenocarcinoma is higher in Hispanics than in Whites in both El Paso County and the remaining portion of Texas. Hispanics have a higher grade of gastric adenocarcinoma. The prevalence of late stage at the time of diagnosis is higher in younger patients than in older patients.

Association between increased yolk sac diameter and abnormal karyotypes.

AIMS: To investigate the association between increased yolk sac diameter and abnormal karyotype. METHODS: Retrospective analysis of 42 patients with no history of diabetes between 6 and 12 weeks of gestation with increased yolk sac diameter measuring ≥6 mm was evaluated by transvaginal ultrasound. Sonographic findings were correlated with karyotype. The Fisher's exact test and exact conditional logistic regression analysis were used for statistical analysis. RESULTS: Chromosome abnormalities were found in 76.2% of chorionic villi samples. A statistically significant relationship between karyotype and missed abortion was detected (P=0.001). None of the patients with a yolk size diameter ≥8 mm and viable pregnancy had a normal karyotype. Trisomy 15 or 16 was strongly associated with missed abortion (unadjusted odds ratio=14.97, P=0.01). Nine patients with viable pregnancy had a yolk sac ≥6 mm (six patients with normal karyotype, one patient with monosomy X, one patient with trisomy 16, and one patient with trisomy 21). CONCLUSION: Our data indicate that enlarged yolk sac may also be visualized in viable pregnancies. Patients with an enlarged yolk sac and normal karyotype require detailed ultrasound evaluation in the second and third trimester.

Pediatricians', obstetricians', gynecologists', and family medicine physicians' experiences with and attitudes about breast-feeding.

OBJECTIVES: Investigate physicians' breast-feeding experiences and attitudes using a survey based on two behavioral theories: theory of reasoned action (TRA) and the health belief model (HBM). METHODS: There were 73 participants included in the investigation. These participants were resident and faculty physicians from pediatrics, obstetrics/gynecology, and family medicine at a university campus, located on the US-Mexico border. The sample was reduced to 53 and 56 records for the attitude and confidence variables, respectively. Physicians answered a survey about their breast-feeding experiences and attitudes to learn about intention and ability applying constructs from TRA and HBM. An attitude scale, confidence variable (from self-efficacy items), and a lactation training index were created for the analysis. RESULTS: Analysis of the association between physicians' breastfeeding experiences and their attitudes revealed physicians are knowledgeable about breast-feeding and have positive attitudes towards breast-feeding. They did not seem to remember how long they breast-fed their children or whether they enjoyed breast-feeding, but they wanted to continue breast-feeding. Physicians cite work as a main reason for not continuing to breast-feed. CONCLUSIONS: Physicians' attitudes toward breast-feeding are positive. They are expected to practice health-promotion behavior including breast-feeding; however, physicians' breast-feeding rates are low and although they are knowledgeable about breast-feeding their training lacks on didactic depth and hands-on experience. If physicians learn more about breast-feeding and breast-feed exclusively and successfully, the rates in the United States would increase naturally.