BACKGROUND: A growing number of reproductive-age women in the U.S. have chronic medical conditions, increasing their risk of perinatal morbidity and mortality. Still, they experience unintended pregnancies at similar rates to low-risk mothers. We have limited understanding of how these individuals consider decisions about pregnancy and contraceptive use. The purpose of this study was to understand factors that influence reproductive decision-making among pregnant women with chronic medical conditions. METHODS: We conducted 28 semi-structured interviews with pregnant women with pre-existing medical conditions admitted to a tertiary maternal hospital to examine factors influencing reproductive decision making. Maternal demographic characteristics, medical history, and pregnancy outcome data were obtained through participant surveys and abstraction from electronic health records. Interview transcripts were coded and analyzed using Dedoose® with both deductive and inductive content analysis. RESULTS: Out of 33 eligible participants, 30 consented to participate and 28 completed interviews. The majority of participants identified as black, Christian, made less than $23,000 yearly, and had a variety of preexisting medical conditions. Overarching themes included: 1) Perceived risks-benefits of pregnancy, 2) Perceived risks-benefits of birth control, 3) Determinants of contraceptive utilization, and 4) Perceived reproductive self-agency. Contraception was viewed as acceptable, but with concerning physical and psychological side effects. Although some considered pregnancy as a health threat, more experienced pregnancy as positive and empowering. Few planned their pregnancies. CONCLUSIONS: Preexisting health conditions did not significantly influence reproductive decision-making. Barriers to birth control use were generally based in patient value-systems instead of external factors. Interventions to improve uptake and use of birth control in this cohort should focus on improving care for chronic health conditions and influencing patient knowledge and attitudes toward contraception.
Contraception , Pregnancy, Unplanned , Pregnancy , Humans , Female , Contraceptive Agents , Pregnancy Outcome , Decision Making , Contraception Behavior
PURPOSE: Environmental aspects and sustainability are becoming increasingly important. In addition to energy consumption, the consumption and environmental discharge of contrast agents pose a particular challenge. Because of their desired stability, X-ray contrast agents (XCAs) are deposited in surface water at a rate of up to 400 tons per year. MATERIALS AND METHODS: In a pilot project, a set of measures (installation of specific separation toilets, the establishment of feedback systems, interviews, questionnaires, and observation) was implemented to sensitize patients and staff to the problem of XCAs during outpatient CT examinations and a retention and recovery system for XCAs was evaluated. RESULTS: In the initial baseline phase, a separation toilet with an additional collection system and a feedback/button system was installed. The built-in feedback system indicated that the separation toilets were used by approx. 16â% of patients without measures. In two subsequent intervention phases, accompanying measures significantly (pâ<â0.01) increased the use of these separation toilets to 21â% and 25â%, respectively. The measures to reduce the discharge of XCAs were positively assessed by both staff and patients. CONCLUSION: Measures to reduce the discharge of XCAs into the environment have a high acceptance among staff and patients. The subsequent installation of separation toilets is one possibility to achieve on-site retention of XCAs. However, this measure is likely to be of high value only if patients stay on site for a correspondingly long time, as is the case in cardiology, for example. KEY POINTS: · The input of X-ray contrast agents into the environment is relevant in light of the quantity. · Measures to reduce the discharge of X-ray contrast agents into the environment have been investigated in pilot projects. · The (subsequent) installation of separation toilets is possible and allows retention of X-ray contrast agents. · This measure is considered useful by patients and staff. · The financing of these measures needs to be clarified. CITATION FORMAT: · Beer M, Schuler J, Kraus E etâal. Discharge of iodine-containing contrast media into the environment - problem analysis and implementation of measures to reduce discharge by means of separation toilets - experience from a pilot project. Fortschr Röntgenstr 2023; 195: 1122â-â1127.
Bathroom Equipment , Iodine , Humans , Contrast Media , Pilot Projects , Toilet Facilities
INTRODUCTION: Prenatally diagnosed Ebstein's anomaly with tricuspid valve dysplasia (EA/TVD) is a rare and high-risk congenital heart malformation with limited effective treatments. We report a case of severe fetal EA with hydrops treated with modest doses of nonsteroidal anti-inflammatory drug (NSAID) therapy, resulting in reversal of hydrops and a favorable fetal outcome. CASE PRESENTATION: Fetal heart defects included an inferiorly displaced tricuspid valve, severe tricuspid regurgitation, significantly dilated right atrium, and hypoplastic pulmonary valve with moderate regurgitation resulting in a circular shunt across the ductus arteriosus. Maternal indomethacin therapy was initiated at 31+5 weeks gestation due to the development of fetal hydrops as demonstrated by the presence of a pericardial effusion and ascites. Indomethacin therapy resulted in the desired restriction of the ductus arteriosus and resolution of fetal hydrops. Maternal therapy was transitioned to ibuprofen and serial fetal echocardiograms ensured continued ductal restriction. Delivery occurred via cesarean at 36+3 weeks. The neonate did not require immediate cardiac surgical intervention and was discharged home with close follow-up. DISCUSSION/CONCLUSION: A lower dose of prenatal NSAID therapy effected successful ductal restriction and hemodynamic mitigation of the circular shunt, resulting in reversal of hydrops and avoidance of postnatal cardiac surgical intervention.
Ebstein Anomaly , Fetal Diseases , Heart Defects, Congenital , Tricuspid Valve Insufficiency , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Ebstein Anomaly/complications , Ebstein Anomaly/diagnostic imaging , Ebstein Anomaly/drug therapy , Female , Fetal Diseases/diagnostic imaging , Fetal Diseases/drug therapy , Humans , Hydrops Fetalis/diagnostic imaging , Hydrops Fetalis/drug therapy , Indomethacin/therapeutic use , Infant, Newborn , Pregnancy , Tricuspid Valve Insufficiency/diagnostic imaging , Tricuspid Valve Insufficiency/drug therapy
The experience of pregnancy loss is a relatively common, but seldom discussed event in many families' reproductive years. Accordingly, this occurrence is one of the most common poor outcomes treated in healthcare. The narratives in this issue present several themes shared widely despite a diversity of circumstances in how women and their families experience pregnancy loss. Unfortunately, negative experiences within the healthcare system-with both providers and the process of medical treatment, surfaced as a common theme. These articulated experiences prompt a reflection on how pregnancy loss is perceived, described, and communicated about in medicine. Notably, the stories reflect the outcome of several patterns in medicine that can introduce bias and harm in the patient-physician interaction. First, there are inconsistencies within healthcare of how pregnancy loss is named and defined, and second, there is a sharp distinction in how early and later losses are considered medically. These medical considerations affect the vocabulary medical providers use to describe and discuss pregnancy, pregnancy loss, and its related management. This language, in turn, conveys values, and thus potential depersonalization and bias. These stories echoed a need for acknowledgement of the individual's specific situation through open listening and affirmation of the life lost, however that is defined by the parent. The narratives also prompt a consideration of the need for streamlined and individualized processes for acquiring information, receiving treatment, and memorializing a child after a pregnancy loss.
This symposium includes 12 narratives from people who have experienced pregnancy loss at any stage of pregnancy or during labor and delivery. Stories of pregnancy loss are seldom shared, and bereaved parents must navigate their grief, anger, confusion, guilt, shame, or other feelings alone. They may be left wondering, "Did I do something wrong?", "Will this happen again?" or "How do I grieve this loss?" Other people who experience a fetal death may feel relieved or conflicted by the loss, causing stress on their relationships. Family members, friends, and healthcare professionals may be unsure about how to respond to or support people who have experienced pregnancy loss. These narratives foster a better understanding of the emotions people experiencing pregnancy loss may feel. The authors describe what was helpful and what was lacking in their interactions with healthcare providers and loved ones in the time following a fetal death. This issue also includes 4 expert commentaries written by Tammara Ruiz Ziegler, Kathryn R. Grauerholz, Raymond De Vries, and Elena Kraus.
Primary care is crucial as a foundation to healthcare in the United States, and has benefited from the increasing use of mid-level providers to achieve universal and quality primary healthcare. We investigated nurse pracitioners (NPs) as independent providers in primary care through a grounded theory study including interviews with both NPs and physicians. Subsequent content analysis revealed a spontaneous theme among NPs: a focus on current trends in advanced practice nurse education. Nurse practitioner (NP) participants voiced concerns regarding the amount of clinical training required for the NP degree in two areas: clinical experience requirements for applying to graduate nursing programs, and clinical experience in graduate programs before practicing as advanced practice nurses. Nursing education organizations should make as a priority gathering information on the perceptions and clinical needs of NPs in practice. This will aid in creating educational programs that graduate NPs ready to practice as independent primary care providers.
Clinical Competence/standards , Credentialing , Education, Nursing/standards , Nurse Practitioners/education , Nurse Practitioners/psychology , Primary Health Care , Adult , Aged , Female , Grounded Theory , Humans , Middle Aged , Professional Autonomy
STUDY OBJECTIVE: To report on the presence and rate of endometriosis in hydatid cysts of Morgagni found at the time of excision surgery for endometriosis and to describe any association of endometriosis in hydatid cysts of Morgagni with preoperative or operative factors. DESIGN: A retrospective cohort study (Canadian Task Force Classification II-2). SETTING: The Center for Endometriosis at Saint Louis University, a tertiary referral center for endometriosis. PATIENTS: Women who underwent optimal excision surgery for suspected endometriosis because of chronic pelvic pain and/or infertility and who also had hydatid cysts of Morgagni removed at the time of surgery when found. INTERVENTIONS: Preoperative and operative data were collected prospectively. MAIN OUTCOME MEASURES: The rate of endometriosis in hydatid cysts of Morgagni. Secondary measures included are the rate of hydatid cysts of Morgagni in patients with pelvic pain or infertility with and without endometriosis in the cysts. RESULTS: The overall prevalence of endometriosis in hydatid cysts of Morgagni was 11.3%. Patients with pelvic pain had a higher rate (although not statistically significant) of hydatid cysts of Morgagni compared with those without pain (21.1% vs 12.5 %, p = .54). Patients with infertility had a higher rate of hydatid cysts of Morgagni compared with those without infertility (38.1% vs 16.7%, p < .001), and there was a higher rate of endometriosis in the hydatid cysts of Morgagni in patients with infertility compared with those without (11.1% vs 0.0%, p < .001). CONCLUSIONS: This study is the first known report of endometriosis found within hydatid cysts of Morgagni. With a rate of 11.3% of cysts of Morgagni having endometriosis within them, this study supports a practice of removing hydatid cysts of Morgagni at the time of surgery in order to achieve optimal excision of endometriosis. The rates of hydatid cysts of Morgagni and of endometriosis found within hydatid cysts of Morgagni were higher in patients with infertility. Further studies are needed to evaluate whether excising cysts of Morgagni affects clinical outcomes.
Endometriosis/complications , Parovarian Cyst/complications , Adult , Female , Humans , Infertility, Female/etiology , Middle Aged , Pelvic Pain/etiology , Retrospective Studies
BACKGROUND: The shortage of primary care providers and the provisions of the Affordable Care Act (ACA) have spurred discussion about expanding the number, scope of practice (SOP), and independence of primary care nurse practitioners (NPs). Such discussions in the media and among professional organizations may insinuate that changes to the laws governing NP practice will engender acrimony between practicing physicians and NPs. However, we lack empirical, descriptive data on how practicing professionals view NP independence in primary care. OBJECTIVE: The aim of the present study was to explore and describe the attitudes about NP independence among physicians and NPs working in primary care. DESIGN: A qualitative study based on the principles of grounded theory. PARTICIPANTS: Thirty primary care professionals in Missouri, USA, including 15 primary care physicians and 15 primary care NPs. APPROACH: Semi-structured, in-depth interviews, with data analysis guided by grounded theory. KEY RESULTS: Participants had perspectives that were not well represented by professional organizations or the media. Physicians were supportive of a wide variety of NP roles and comfortable with high levels of NP independence and autonomy. Physicians and NPs described prerequisites to NP independence that were complementary. Physicians generally believed that NPs needed some association with physicians for patient safety, and NPs preferred having a physician readily accessible as needed. The theme "knowing your limits" was important to both NPs and physicians regarding NP independence, and has not been described previously in the literature. CONCLUSIONS: NP and physician views about NP practice in primary care are not as divergent as their representative professional organizations and the news media would suggest. The significant agreement among NPs and physicians, and some of the nuances of their perspectives, supports recommendations that may reduce the perceived acrimony surrounding discussions of NP independent practice in primary care.
Attitude of Health Personnel , Nurse Practitioners/psychology , Nurse's Role , Physicians, Primary Care/psychology , Professional Autonomy , Adult , Aged , Cooperative Behavior , Female , Humans , Male , Middle Aged , Nurse Practitioners/legislation & jurisprudence , Patient Protection and Affordable Care Act , Practice Patterns, Nurses' , Primary Health Care/organization & administration , Qualitative Research , Quality of Health Care , Young Adult
BACKGROUND: No published curricula in the area of medical business ethics exist. This is surprising given that physicians wrestle daily with business decisions and that professional associations, the Institute of Medicine, Health and Human Services, Congress, and industry have issued related guidelines over the past 5 years. To fill this gap, the authors aimed (1) to identify the full range of medical business ethics topics that experts consider important to teach, and (2) to establish curricular priorities through expert consensus. METHODS: In spring 2012, the authors conducted an online Delphi survey with two heterogeneous panels of experts recruited in the United States. One panel focused on business ethics in medical practice (n = 14), and 1 focused on business ethics in medical research (n = 12). RESULTS: Panel 1 generated an initial list of 14 major topics related to business ethics in medical practice, and subsequently rated 6 topics as very important or essential to teach. Panel 2 generated an initial list of 10 major topics related to business ethics in medical research, and subsequently rated 5 as very important or essential. In both domains, the panel strongly recommended addressing problems that conflicts of interest can cause, legal guidelines, and the goals or ideals of the profession. CONCLUSIONS: The Bander Center for Medical Business Ethics at Saint Louis University will use the results of the Delphi panel to develop online curricular resources for each of the highest rated topics.
Biomedical Research/education , Clinical Medicine/education , Curriculum , Ethics, Business/education , Practice Management, Medical/ethics , Biomedical Research/ethics , Consensus , Delphi Technique , Educational Measurement , Female , Humans , Male , Practice Patterns, Physicians'/ethics , United States
BACKGROUND: In recent years, issues in medical business ethics (MBE), such as conflicts of interest (COI), Medicare fraud and abuse, and the structure and functioning of reimbursement systems, have received significant attention from the media and professional associations in the United States. As a result of highly publicized instances of financial interests altering physician decision-making, major professional organizations and government bodies have produced reports and guidelines to encourage self-regulation and impose rules to limit physician relationships with for-profit entities. Nevertheless, no published curricula exist in the area of MBE. This study aimed to establish a baseline level of knowledge and the educational goals medical students and residents prioritize in the area of MBE. METHODS: 732 medical students and 380 residents at two academic medical centers in the state of Missouri, USA, completed a brief survey indicating their awareness of major MBE guidance documents, knowledge of key MBE research, beliefs about the goals of an education in MBE, and the areas of MBE they were most interested in learning more about. RESULTS: Medical students and residents had little awareness of recent and major reports on MBE topics, and had minimal knowledge of basic MBE facts. Residents scored statistically better than medical students in both of these areas. Medical students and residents were in close agreement regarding the goals of an MBE curriculum. Both groups showed significant interest in learning more about MBE topics with an emphasis on background topics such as "the business aspects of medicine" and "health care delivery systems". CONCLUSIONS: The content of major reports by professional associations and expert bodies has not trickled down to medical students and residents, yet both groups are interested in learning more about MBE topics. Our survey suggests potentially beneficial ways to frame and embed MBE topics into the larger framework of medical education.
Academic Medical Centers/organization & administration , Curriculum , Ethics, Professional , Organizational Objectives , Missouri , Surveys and Questionnaires
Virtues define how we behave when no one else is watching; accordingly, they serve as a bedrock for professional self-regulation, particularly at the level of the individual physician. From the time of William Osler through the end of the 20th century, physician virtue was viewed as an important safeguard for patients and research participants. However, the Institute of Medicine, Association of American Medical Colleges, and other policy groups-relying on social science data indicating that ethical decisions often result from unconscious and biased processes, particularly in the face of financial conflicts of interest-have increasingly rejected physician virtue as an important safeguard for patients.The authors argue that virtue is still needed in medicine-at least as a supplement to regulatory solutions (such as mandatory disclosures). For example, although rarely treated as a reportable conflict of interest, standard fee-for-service medicine can present motives to prioritize self-interest or institutional interests over patient interests. Because conflicts of interest broadly construed are ubiquitous, physician self-regulation (or professional virtue) is still needed. Therefore, the authors explore three strategies that physicians can adopt to minimize the influence of self-serving biases when making medical business ethics decisions. They further argue that humility must serve as a crowning virtue-not a meek humility but, rather, a courageous willingness to recognize one's own limitations and one's need to use "compensating strategies," such as time-outs and consultation with more objective others, when making decisions in the face of conflicting interests.
Conflict of Interest , Physicians/ethics , Virtues , Disclosure/ethics , Drug Industry/ethics , Humans , Interprofessional Relations
In this paper we describe our approach to understanding wrongdoing in medical research and practice, which involves the statistical analysis of coded data from a large set of published cases. We focus on understanding the environmental factors that predict the kind and the severity of wrongdoing in medicine. Through review of empirical and theoretical literature, consultation with experts, the application of criminological theory, and ongoing analysis of our first 60 cases, we hypothesize that 10 contextual features of the medical environment (including financial rewards, oversight failures, and patients belonging to vulnerable groups) may contribute to professional wrongdoing. We define each variable, examine data supporting our hypothesis, and present a brief case synopsis from our study that illustrates the potential influence of the variable. Finally, we discuss limitations of the resulting framework and directions for future research.
"Ethical disasters" or egregious violations of professional ethics in medicine often receive substantial amounts of publicity, leading to mistrust of the medical system. Efforts to understand wrongdoing in medical practice and research are hampered by the absence of a clear taxonomy. This article describes the authors' process of developing a taxonomy based on (1) reviews of academic literature, ethics codes, government regulations, and cases of wrongdoing; (2) consultation with experts in health law and healthcare ethics; and (3) application of the taxonomy to published cases of wrongdoing in medical research and practice. The resulting taxonomy includes 14 categories of wrongdoing in medical practice and 15 categories of wrongdoing in medical research. This taxonomy may be useful to oversight bodies, researchers who seek to understand and reduce the prevalence of wrongdoing in medicine, and librarians who index literature on wrongdoing.
Biomedical Research/ethics , Ethics, Medical , Ethics, Research , Codes of Ethics/classification , Humans
