Narrative medicine in a hectic schedule.

The move to patient-centered medical practice is important for providing relevant and sustainable health care. Narrative medicine, for example, suggests that patients should be involved significantly in diagnosis and treatment. In order to understand the meaning of symptoms and interventions, therefore, physicians must enter the life worlds of patients. But physicians face high patient loads and limited time for extended consultations. In current medical practice, then, is narrative medicine possible? We argue that engaging patient perspectives in the medical visit does not necessarily require a lengthy interview. Instead, a new orientation to this process that emphasizes dialogue between practitioners and patients should be considered. In this new model, the purpose of the visit is to communicate successfully and develop a mutual understanding of illness and care.

Ethics in Narrative Health Interventions.

The thrust of narrative medicine is that patients and communities construct stories that guide their lives and give meaning to both health and illness. The responsibility of health care practitioners, therefore, is to learn how to read these local narratives to provide care that is relevant to an individual or community. Given the recognition that interaction must be tailored to the subjective experiences of patients and their communities, can there be universal ethical standards in the treatment of illness? We argue that the constructed nature of patient experiences does not pose a threat to making ethical clinical judgments. The solution to this dilemma requires that the traditional distinction between objectivity and subjectivity be eschewed by clinicians in favor of establishing dialogue with patients. Narratives are never created alone and are therefore not esoteric. Listening carefully to patients' stories is an ethical practice that can be fostered in health care settings. Subjectivity can be embraced by clinicians without jeopardizing ethical or evidence-based patient care.

The Role of Reflection in Narrative Medicine.

Reflection has become an important tool for physicians and other medical practitioners. However, many forms of reflection exist in the health care literature, with each having particular implications for successful clinical practice. Very little attention has been given to whether reflection is a vital part of narrative medicine and which forms of reflection might be compatible with this approach to patient care. In this article, the most common types of reflection are compared and discussed, specifically regarding their potential role in narrative medicine. Reflection that encourages practitioners to focus on the various perspectives shared within a medical encounter is both in line with the tenets of narrative medicine and has important consequences for patient empowerment.

The Patient-Centered Medical Home as a Community-based Strategy.

Increasing attention has been devoted to the important role that primary care will play in improving population health. One innovation, the patient-centered medical home (PCMH), aims to unite a variety of professionals with patients in the prevention and treatment of illness. Although patient perspectives are critical to this model, this article questions whether the PCMH in practice is truly community-based. That is, do physicians, planners, and other health care professionals take seriously the value of integrating local knowledge into medical care? The argument presented is that community-based philosophy contains a foundational principle that the perspectives of health care practitioners and community members must be integrated. Although many proponents of the PCMH aim to offer patient-centered and sustainable health care, focusing on this philosophical shift will ensure that services are organized by communities in collaboration with health care professionals.

Group Maturity in a Community-Based Project.

Community-based projects have become popular as a method to address various community problems. Specifically important is that community members take an active role in these interventions resulting in sustainable social change. Although considerable literature exists on the dynamics of small group interaction, this article addresses how group processes differ in community-based projects. Instead of constructing a static model for group interaction, this discussion focuses on experiences from a recent community-based health project on the island of Grenada. Because community-based projects are directed by a diverse group of community members, maturity is described as a process of negotiation rather than consensus.

Changing medical relationships after the ACA: Transforming perspectives for population health.

American health care has undergone significant organizational change in recent decades. But what is the state of core medical relationships in the wake of these changes? Throughout ACA-era health care reform, the doctor-patient relationship was targeted as a particularly important focus for improving communication and health outcomes. Recent developments however have shifted the focus from individual-level outcomes to the wellbeing of populations. This, we argue, requires a fundamental rethinking of health care reform as an opportunity to renegotiate relationships. For example, the move to population medicine requires that the very concept of a patient be resituated and the scope of relevant relationships expanded. Medical relationships in this era of health care are likely to include partnerships between various types of clinicians and the communities in which patients reside, as well as a host of new actors, from social workers and navigators to scribes and community health workers. To address the upstream determinants of population health, providers must be increasingly willing and trained to collaborate with community stakeholders to address both medical and non-medical issues. These community-based partnerships are critical to providing health care that is both relevant and appropriate for addressing problems, and sustainable. Approaching health care reform, and the focus on population health, as a fundamental reworking of relationships provides scholars with a sharper theoretical lens for understanding 21st century American health care.

Imipenem/cilastatin in the treatment of obstetric and gynecologic infections.

Fifty-five patients with soft tissue pelvic infections were treated with imipenem/cilastatin 500 mg intravenously every six hours for a minimum of four days. Six patients were unevaluable, one because of protocol non-compliance and five because no pathogen was isolated. At enrollment, mean temperature was 39.5 degrees C and the mean white blood cell count was 14,700. Of 49 evaluable patients, 43 (87.8 percent) had complete clinical cures. In three of the six patients with clinical failures, subsequent alternative antibiotic treatment also failed and they required operative intervention for pelvic abscess. In two of the patients with failures, antibiotic-associated pseudomembranous colitis developed after three days of imipenem/cilastatin therapy, requiring discontinuation of the medication. At the time of discontinuation, both patients had clinical failures. All microbiologic isolates were susceptible to imipenem/cilastatin, although at least one pathogenic organism persisted in two patients with clinical failures despite apparent in vitro susceptibility of the organism to imipenem/cilastatin. Imipenem/cilastatin is a promising agent for the empiric treatment of serious obstetric and gynecologic infections although surgery often remains a necessary treatment for pelvic abscess regardless of initial antibiotic choice.

The potential of digitally inserted tampons to induce vaginal lesions.

To determine the incidence of vaginal mucosal alterations associated with the use of digitally inserted tampons, 100 women were prospectively evaluated colposcopically for three consecutive menstrual cycles. Three groups of 20 women each used the regular, super, and super-plus sizes of a digitally inserted rayon and cotton tampon; two additional groups of 20 each used external sanitary protection or an applicator-inserted rayon polyacrylate tampon. Vaginal mucosal drying and layering were significantly more common in all tampon users than in pad users; vaginal mucosal ulceration was a more rare event, seen only in tampon users, and statistically more commonly in the rayon polyacrylate group. The incidence of these alterations was not related to the presence of Staphylococcus aureus. All ulcerations healed without treatment. The common occurrence and relatively benign nature of these changes are discussed in view of the concern that these changes might predispose a woman to developing toxic shock syndrome.

Both midluteal serum progesterone levels and late luteal endometrial histology should be assessed in all infertile women.

Criteria for diagnosis of luteal phase deficiency vary among specialists. Adequacy of corpus luteum function usually is based on a midluteal serum progesterone (P) concentration or a late luteal biopsy. To compare these two methods of determining luteal phase adequacy, 42 midluteal P levels were compared with late luteal endometrial biopsies from the same cycles in 34 women undergoing evaluation for infertility. Eleven cycles contained both hormonal and histologic evidence of luteal phase inadequacy; 12 contained only hormonal evidence of inadequacy; 9 contained only histologic evidence of inadequacy; and 10 contained both hormonal and histologic evidence of adequate luteal function. These data suggest that both midluteal phase P levels and late luteal endometrial biopsies should be assessed in infertile women, because neither can be used to predict the other.

Late luteal estradiol patterns are a better prognosticator of pregnancy outcome than serial beta-human chorionic gonadotropin concentrations.

OBJECTIVE: Since the corpus luteum (CL) is known to play an important role in early pregnancy, its activity could possibly be a marker for pregnancy outcome. DESIGN: The late estradiol (E2) concentration in 48 viable pregnancies and 39 pregnancies which resulted in spontaneous abortions after in vitro fertilization and embryo transfer were used to evaluate such predictability. SETTING: All patients studied were of the Center for Reproductive Medicine at Cornell University Medical College. PATIENTS, PARTICIPANTS: Eighty-seven patients. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Serum E2 and human chorionic gonadotropin (hCG) concentrations on day +11, +13, +15 (day +1 = day of ovum pick-up) were measured and studied. RESULTS: The late luteal CL activity after rescue had a positive correlation with the number and quality of the implanted embryos. Reduced CL activity was indicative of abortion. The late luteal E2 pattern when compared with hCG doubling time had a better abortion predictability (37.8% versus 63.9%, respectively). CONCLUSION: Corpus luteum activity demonstrated to be a better prognosticator of abortion than serial beta-hCG titers.

A two- versus three-embryo transfer: the oocyte donation model.

OBJECTIVE: To compare implantation and pregnancy rates in oocyte recipients undergoing a two-embryo versus three-embryo transfer, 3 days after retrieval. DESIGN: Retrospective comparative analysis. SETTING: University-based in vitro fertilization center. PATIENT(S): All oocyte recipients undergoing embryo transfer from January 1, 1997 through August 31, 1999. INTERVENTION(S): Recipients received two or three embryos. MAIN OUTCOME MEASURE(S): Implantation, and clinical and multiple pregnancy rates. RESULT(S): Seventy-three recipients underwent a two-embryo transfer, and 376 had three embryos replaced. The numbers of oocytes retrieved (12.7 +/- 0.89 vs. 13.1 +/- 0.36) and embryos obtained (8.05 +/- 0.65 vs. 8.77 +/- 0.27) did not differ between the two-embryo and three-embryo transfer groups, nor did the proportion of patients with embryo cryopreservation (54.3% vs. 42.6%, respectively). There was no significant difference in pregnancy or implantation rates when comparing those patients with a two-embryo transfer to those with a three-embryo transfer. Significantly, 13.8% of the pregnancies in the three-embryo transfer group were triplet. CONCLUSION(S): Reducing the number of embryos transferred in an oocyte donation cycle can lower the incidence of triplet pregnancies without significantly lowering the overall pregnancy rate.

In vitro fertilization outcome relative to embryo transfer difficulty: a novel approach to the forbidding cervix.

OBJECTIVE: To assess the impact of ET difficulty on IVF outcome and to optimize the ET procedure. DESIGN: Retrospective analysis of IVF outcome by ET catheter type and ET difficulty. Prospective treatment and follow-up of patients with a history of extremely difficult cervical passage. SETTING: Large university-based IVF program. PATIENT(S): All patients < 40 years of age undergoing IVF-ET from September 1995 to May 1998. INTERVENTION(S): Surgical correction of cervical stenosis. MAIN OUTCOME MEASURE(S): Pregnancy and embryo implantation rates. RESULT(S): Only 0.6% of ETs were "extremely difficult." Pregnancy rates were not statistically significantly different among ETs graded easy, moderate, and difficult. In contrast, no pregnancies occurred in the rare "extremely difficult" ET group. Eight patients with a history of extremely difficult cervical passage underwent surgical correction of their cervical stenosis. Twelve postoperative IVF-ET in these women resulted in eight clinical pregnancies, six of which were multiple gestations. The embryo implantation rate of these cycles was 42.2%. CONCLUSION(S): Patients with a history of extremely difficult ET may benefit from hysteroscopic evaluation and possible modification of their cervical canal before a future IVF attempt.

Evaluation of leuprolide acetate and gonadotropins versus clomiphene citrate and gonadotropins for in vitro fertilization or gamete intrafallopian transfer.

A prospective randomized trial was conducted to compare the efficiency of two ovarian stimulation protocols for in vitro fertilization-embryo transfer or gamete intrafallopian transfer. Protocol 1 consisted of clomiphene citrate and human menopausal gonadotropin (hMG) with 55 cycles of 42 patients being evaluated. Protocol 2 had 38 cycles of 34 patients receiving a gonadotropin-releasing hormone agonist (GnRH-a) and hMG. The incidence of a spontaneous luteinizing hormone surge was 38.2% in protocol 1 and 0% in protocol 2. Both protocols had a similar cancellation rate. The total clinical pregnancy rates per oocyte retrieval for patients receiving protocol 1 and protocol 2 were 19.5% and 10.3%, respectively. The difference was not statistically significant. Therefore, as first-line ovulation induction agents, it cannot be concluded that either protocol demonstrates a clear superiority over the other and further trials of the GnRH-a/hMG combination are indicated.

The incidence of luteal phase defect in normal, fertile women, determined by serial endometrial biopsies.

Five regularly menstruating women of proven fertility, with normal prolactin and thyroid function studies, underwent a total of 39 endometrial biopsies (EMBs). The slides were dated in blinded fashion, and the cycle date determined by considering the date of the next menstrual period as day 28 and counting backward. Using a 2-day or greater lag in endometrial maturity to define a luteal phase defect (LPD), the incidence of single and sequential out-of-phase EMBs was 51.4% and 26.7%, respectively. Using a 3-day or greater lag to define a LPD, the incidence of single and sequential out-of-phase EMBs was 31.4% and 6.6%, respectively. These incidences in normal, fertile women are as high as the rates quoted for infertile populations, and call into question the standard criteria for defining this condition and evaluating therapies to correct it.

Detection and characterization of immune complexes in the circulation of infertile women.

The incidence of circulating immune complexes (CICs) was evaluated in sera from 39 female partners of infertile marriages and from 38 fertile women. Fifteen (38%) of the infertile women had CICs, as determined by the Raji cell assay, in levels ranging from 300 to 8000 micrograms/ml; whereas only 1 (3%) of the fertile women displayed CICs (P less than 0.001). Analysis of the CICs from nine of the women following polyethylene glycol precipitation and acid dissociation revealed that four contained C1q and three contained an antigen reactive with rabbit antibody to human spermatozoa. These latter three women all lacked free sperm antibody, as determined by enzyme-linked immunosorbent assay and agglutination. Thus, CICs are not uncommon as a manifestation of infertility in females. Their presence may lead to an underestimation of sperm antibody levels and may be indicative of underlying infection or autoimmunity.

Midfollicular anticardiolipin and antiphosphatidylserine antibody titers do not correlate with in vitro fertilization outcome.

OBJECTIVE: To determine the prevalence of anticardiolipin and antiphophatidylserine antibodies in an IVF population and to correlate their presence and specific isotype with IVF cycle outcome. DESIGN: Retrospective clinical study using stored midfollicular sera for determination of antibody status. SETTING: University hospital infertility clinic. PATIENT(S): Women who underwent IVF treatment in 1991. INTERVENTION(S): Midfollicular sera were used to assess antibody status during the time of stimulation for IVF. MAIN OUTCOME MEASURE(S): Anticardiolipin and antiphosphatidylserine antibody titers and biochemical or sonographic documentation of IVF cycle outcome. RESULT(S): The overall prevalence of anticardiolipin and antiphosphatidylserine antibodies in IVF patients was 7.0% and 11.2%, respectively. There was no statistically significant difference in the prevalence of these antibodies in the groups of patients with a biochemical pregnancy (0 for anticardiolipin and 2.8% for antiphosphatidylserine), spontaneous miscarriage (11.4% for anticardiolipin and 20% for antiphosphatidylserine), ongoing pregnancy (7.3% for anticardiolipin and 11.6% for antiphosphatidylserine), and patients who failed to conceive (7.2% for anticardiolipin and 10.8% for antiphosphatidylserine). There was no correlation between outcome and the antibody isotype expressed. CONCLUSION(S): Anticardiolipin and antiphosphatidylserine antibodies are poorly predictive of the IVF cycle outcome. Routine testing of IVF patients for the presence of these antibodies is of limited clinical utility.

Genetic screening of prospective oocyte donors.

OBJECTIVE: To report our experience with genetic screening of oocyte donor candidates and to determine the frequency with which significant genetic issues are identified. DESIGN: Prospective genetic screening of oocyte donor candidates. SETTING: University hospital oocyte donation program. PATIENT(S): Women presenting consecutively as volunteer oocyte donors. INTERVENTION(S): Genetic screening was performed by pedigree analysis and laboratory studies. MAIN OUTCOME MEASURE(S): Inclusion in the oocyte donor pool based on the results of clinical evaluation and laboratory tests consisting of polymerase chain reaction based mutational analysis for cystic fibrosis carrier status, cytogenetic analysis for karyotype, enzymatic assay for Tay-Sachs disease carrier status, and complete blood count and hemoglobin electrophoresis. RESULT(S): Eight (11%) of 73 oocyte donor candidates were excluded from the donor pool because of a potentially serious genetic finding. Cystic fibrosis mutations were identified in 5 candidates (7%), abnormal karyotypes were found in 2 (3.5%), and an autosomal dominant skeletal dysplasia was identified in 1 (1.4%). CONCLUSION(S): A significant proportion of women who present as candidates for oocyte donation are inappropriate for donation because of their genetic history or genetic testing results. A thorough genetic evaluation, including a history and laboratory screening, is essential to any oocyte donation program to maximize positive outcomes in pregnancies achieved through assisted means.

Factors useful in predicting the success of oocyte donation: a 3-year retrospective analysis.

OBJECTIVE: To establish prognostic relevance of parameters assessed in oocyte donation cycles. DESIGN: Retrospective analysis. SETTING: Large university-based donor oocyte program. PATIENT(S): All oocyte recipient cycles achieving embryo transfer from September 1995 to October 1998. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pregnancy. RESULT(S): Recipient age and reproductive status, day 9 and 12 serum estradiol (E(2)) levels and a progesterone (P) level obtained 2 days after initiation of hormonal therapy did not correlate with pregnancy. Endometrial thickness, but not endometrial pattern, was useful in predicting pregnancy outcome. The clinical pregnancy and live-birth rate in cycles where the endometrial thickness was less than 8 mm was significantly lower when compared to cycles with an endometrial thickness > or =9 mm. Cycles where optimal quality embryos were transferred had the highest implantation (36%), clinical pregnancy (63%) and live birth (54%) rates and these rates were significantly higher than those of cycles where only poor quality embryos were available for transfer (10% implantation, 17% clinical pregnancy, and 8% live birth rates, respectively; P<.05). CONCLUSION(S): The most reliable predictive factors for pregnancy in oocyte donation cycles are the quality of the embryos transferred and the recipient's mid-cycle endometrial thickness. Recipient monitoring should minimally include ultrasound assessment of endometrial thickness.

Epididymal micropuncture with in vitro fertilization and oocyte micromanipulation for the treatment of unreconstructable obstructive azoospermia.

OBJECTIVE: To provide fertility to couples in whom the man has surgically unreconstructable obstructive azoospermia. DESIGN: Prospective. SETTING: Hospital-based IVF unit, including associated division of urologic microsurgery. PATIENTS: Couples referred to our fertility unit for treatment of men with surgically unreconstructable reproductive tract obstruction, including congenital absence of the vas deferens. MAIN OUTCOME MEASURES: Fertilization, pregnancies, and live births. RESULTS: Of 51 cycles in which sperm and eggs were retrieved, 67% (34/51) resulted in fertilization and 27.5% (14/51) developed clinical pregnancy. Clinical pregnancy rate per couple was 33% (14/43). A total of 15 live births have been obtained in 11 couples with one ongoing pregnancy. Epididymal length was the best predictor of sperm quality and pregnancy results. For couples with at least the corpus epididymis present, 41% (9/22) of cycles resulted in clinical pregnancies. CONCLUSIONS: Pregnancy rates are optimized using sperm retrieved from the epididymis by micropuncture and when micromanipulation is available for use during IVF.

Oral versus intramuscular progesterone for in vitro fertilization: a prospective randomized study.

OBJECTIVE: To evaluate the efficacy of oral micronized progesterone compared with IM progesterone in oil for luteal support in patients undergoing IVF who are treated with a GnRH agonist. DESIGN: Randomized prospective clinical trial. SETTING: University-based IVF center. PATIENT(S): Women <40 years of age who were undergoing IVF with luteal GnRH pituitary down-regulation. INTERVENTION(S): Patients were randomized to receive either oral micronized progesterone (200 mg three times daily) or IM progesterone (50 mg daily). MAIN OUTCOME MEASURE(S): Progesterone levels at standardized days 21 and 28, and pregnancy and embryo implantation rates. RESULT(S): Day 21 progesterone levels were 77.6+/-13.2 ng/mL in the IM group and 81.5+/-16.2 ng/mL in the oral group. Day 28 progesterone levels were 76.3+/-15.0 ng/mL in the IM group and 53.6+/-10.1 ng/mL in the oral group. The clinical pregnancy rates were 57.9% and 45.8% for the IM and oral groups, respectively. The implantation rate per embryo was significantly higher in the IM group (40.9%) than in the oral group (18.1%). CONCLUSION(S): When used according to our protocols, oral progesterone and IM progesterone result in comparable levels of circulating progesterone. However, oral progesterone results in a reduced implantation rate per embryo.