Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants.

OBJECTIVE: The available data on antidepressant levels in nursing infants were analyzed in order to calculate average infant drug levels and determine what factors influence plasma drug levels in breast-feeding infants of mothers treated with antidepressants. METHOD: Electronic searches of MEDLINE, PreMEDLINE, Current Contents, Biological Abstracts, and PsycINFO from 1966 through July 2002 followed by bibliographic searches identified 67 relevant studies (two unpublished). By consensus the authors identified 57 studies of maternal plasma, breast milk, and/or infant plasma antidepressant levels from nursing mother-infant pairs, measured by liquid chromatography. RESULTS: Infants with recent prenatal exposure and symptomatic infants included in case reports were analyzed separately. Infant plasma levels were standardized against the average maternal level for each drug. The average infant-maternal plasma ratio was calculated for each drug, and correlations of infant plasma level to maternal dose, maternal plasma level, and breast milk level were calculated. Nortriptyline, paroxetine, and sertraline usually produce undetectable infant levels. Of drugs currently used, fluoxetine produces the highest proportion (22%) of infant levels that are elevated above 10% of the average maternal level. Based on smaller numbers, the data on citalopram indicate that it produces elevated levels in 17% of infants. The milk-to-plasma ratios for 11 antidepressants had a statistically significant negative association with the percentage of the drug bound to protein. CONCLUSIONS: Nortriptyline, paroxetine, and sertraline may be preferred choices in breast-feeding women. Minimizing the maternal dose may be helpful with citalopram. Current data do not support monitoring breast milk levels in individual patients. Future researchers should report maternal, breast milk, and infant antidepressant levels along with other appropriate variables.

Non-evidence-based use of Rho(D) immune globulin for threatened abortion by family practice and obstetric faculty physicians.

OBJECTIVE: To examine the practice patterns and differences between faculty members in obstetrics and gynecology (OB/G) and family practice (FP) residency programs in administering Rho(D) immune globulin (RhIG) for threatened abortion. STUDY DESIGN: A questionnaire was mailed to 50% (222) of all FP residencies and 100% (267) of OB/G programs in the United States. The obstetric curriculum coordinator at each FP residency and the director of obstetrics or maternal-fetal medicine at each OB/G residency were asked to respond. A total of 156 (70%) FP questionnaires and 186 (70%) OB/G questionnaires were returned after two mailings. RESULTS: Seventy-six percent of FP faculty and 85% of OB/G faculty reported giving RhIG in threatened abortion. Physicians with advanced training were more likely to recommend giving RhIG. CONCLUSION: Most FP and OB/G residency faculty report using RhIG in threatened abortion. The practice has become part of the medical culture despite the lack of supporting evidence and should be revaluated in that light.

Community characteristics associated with child abuse in Iowa.

PROBLEM: Various demographic and community characteristics are associated with child abuse rates in national and urban samples, but similar analyses have not been done within rural areas. This study analyzes the relationships between reported and substantiated rates of child abuse and county demographic, health care resource and social services factors in a predominantly rural state in the US. METHODS: County-level data from Iowa between 1984-1993 were analyzed for associations between county characteristics and rates of child abuse using univariate correlations and multivariate stagewise regression analysis. Population-adjusted rates of reported and substantiated child abuse were correlated with rates of children in poverty, single-parent families, marriage and divorce, unemployment, high-school dropouts, median family income, elder abuse, birth and death rates, numbers of physicians and other healthcare providers, hospital, social workers, and number of caseworkers in the Department of Human Services. RESULTS: Rates of single-parent families, divorce and elder abuse were significantly associated with reported and substantiated child abuse in multivariate analysis, while economic and most health care factors were not. Reporting and substantiation rates differed across districts after adjustment for multiple factors including caseworker workload. CONCLUSIONS: In this rural state, family structure is more significantly associated with child abuse report and substantiation rates than are socioeconomic factors. The level of health care resources in a county does not appear to affect these rates.

Effectiveness of a dynamic breast examination training model to improve clinical breast examination (CBE) skills.

Despite the potential utility of clinical breast examination (CBE), doctors' palpation skills are often inadequate and difficult to train. CBE sensitivity ranges from 39-59%, in part because current training does not effectively teach tactile skills. To address CBE training limitations, we developed a breast examination training model with 15 dynamically controlled lumps, set to desired hardness within underlying rib and muscle structures, in a silicone breast. In an experiment of 48 medical students, training with the dynamic model increased lump detection by 1.35 lumps compared to 0.60 lumps for a traditional breast model (P=0.008), reduced false positives by -0.70 lumps compared to +0.42 lumps (P=0.0277), and demonstrated skill transfer with a 1.17 lump detection improvement on the traditional device compared to only a 0.17 lump detection improvement by traditional device trainees on the dynamic device (P<0.001). Findings demonstrate the advantage of the dynamic model over conventional models in training CBE tactile skills.

The natural history of primary dysmenorrhoea: a longitudinal study.

OBJECTIVE: To describe the prevalence, severity, course and predictive factors of primary dysmenorrhoea in women of all reproductive ages. DESIGN: Prospective mailed surveys in 1985 and 1991. SETTING: University of Iowa, College of Nursing. POPULATION: We began with a stratified sample of 996 nurses who graduated between 1963 and 1984. We analysed data from 404 women who responded to both surveys, but denied endometriosis, pelvic inflammatory disease or uterine fibroids. METHODS: Participants were surveyed twice at an interval of six years (response rates 73% and 78%) regarding menstrual cycle characteristics. For analysis, dysmenorrhoea was dichotomised as none/mild or moderate/severe. We analysed predictive factors using chi2 tests and stepwise logistic regression. MAIN OUTCOME MEASURE: Severity of dysmenorrhoea. Menstrual cramps as experienced when not taking medication to prevent discomfort were rated on a four-point scale: 0 = no dysmenorrhoea, 1 = minimal (can work, somewhat uncomfortable), 2 = moderate (can work, but quite uncomfortable) or 3 = severe dysmenorrhoea (miss work, have to be in bed). RESULTS: In 1985, 80% of respondents were >25 years old and 60% were parous. There were few changes over six years in the prevalence of mild (51% to 53%), moderate (22% to 20%) or severe dysmenorrhoea (4% to 2%). After adjusting for dysmenorrhoea in 1985, each live birth during follow up (OR = 0.20, 95% CI = 0.08 to 0.53) and older age (OR = 0.92, 95% CI = 0.86 to 0.98) were associated with less dysmenorrhoea in 1991. CONCLUSIONS: Primary dysmenorrhoea affects most women throughout the menstrual years. Dysmenorrhoea severe enough to cause absence from work occurs in less than 5% of women. Although improvement and worsening are equally likely for all women, improvement is more likely in women who bear children.