Improving adherence to screening follow-up among women with abnormal Pap smears: results from a large clinic-based trial of three intervention strategies.

In a large randomized trial involving over 2,000 women with abnormal cervical cytology (pap smear), three clinic-based interventions were tested as strategies to increase return rates for screening follow-up: 1) a personalized follow-up letter and pamphlet; 2) a slide-tape program on pap smears; and 3) transportation incentives (bus passes/parking permits). The three interventions were evaluated using a 2 x 2 x 2 factorial design. Results of this study confirm a high rate of loss to screening follow-up (i.e., no return visits) among women with abnormal pap smears (29% overall), with substantial variability among the 12 participating clinics (13% to 42/%). For the sample as a whole, both transportation incentives and the combined intervention condition of personalized follow-up and slide-tape program had a significant positive impact on screening follow-up. However, transportation incentives emerged as the dominant intervention condition among patient subgroups that can be characterized as more disadvantaged socioeconomically and at higher risk of developing cervical cancer, including patients receiving care from the county health department (odds ratio (OR) = 1.51; P less than .05); patients without health insurance (OR = 1.77; P less than .01); and patients with more severe pap smear results (OR = 1.71; P less than .05). In contrast, among patient subgroups that can be characterized as relatively more advantaged and at lower risk of developing cervical cancer, only the combined intervention condition of personalized follow-up and slide-tape program was associated with a higher patient return rate. Subgroups reflecting this pattern included patients seen in noncounty clinics (OR = 4.54; P less than .05) and patients with less severe pap smear results (OR = 5.16; P less than .01). The implications of these findings are discussed in terms of designing clinic-based interventions to improve screening follow-up.

Tryptophan and neutral amino acids in premenstrual syndrome.

An abnormality of the serotonin system may play a role in the genesis of the symptoms of premenstrual syndrome, especially those related to mood and appetite. Whole blood and platelet uptake of serotonin are decreased during the luteal phase in women with premenstrual syndrome. The ratio of L-tryptophan (the amino acid precursor of serotonin) to the sum of the other neutral amino acids that compete for the same protein carrier cerebral uptake mechanism has been suggested to reflect central L-tryptophan levels and resultant serotonin levels in the brain. We evaluated the ratio of plasma L-tryptophan to the sum of five competing neutral amino acids in women with premenstrual syndrome and in controls. There were no significant differences between groups or across time, suggesting that it is unlikely that the aberrations of the serotonergic system in women with premenstrual syndrome are due to saturation of the tryptophan-carrying protein.

Psychologic aspects of providing infertility services.

Psychologic issues enter into all aspects of providing infertility services. At the onset the infertile are faced with decisions regarding treatment options. Treatment involves uncertainty and lack of control and exposes the couple to the possibility of failure. The introduction of in vitro fertilization and gamete intrafallopian transfer exposes a proportion of couples to successive experiences of failure. These treatments have implications for emotional processing; some factors can increase the likelihood of impaired coping. Specific ways of dealing with the psychologic needs of infertile couples at all stages of their treatment can be helpful.

Mood and cognitive style in premenstrual syndrome.

Women with premenstrual syndrome (PMS) report symptoms that resemble those of affective disorder. In depression, there is an alteration in cognitive processing and performance such that dysphoric material is retrieved more readily and the ability to concentrate and sustain attention and motivation is impaired. To determine whether PMS leads to changes in information processing similar to those accompanying depression, ten subjects with PMS and nine controls were subjected to psychological testing, selective and incidental recall tests, and measures of cognitive performance during the follicular and luteal phases of the menstrual cycle. Women with PMS failed to show the characteristic cognitive changes that usually accompany depression. Despite substantial symptomatology, there were no significant differences in cognitive functioning between PMS subjects and controls.

Attitudes and anxiety levels in women conceiving through in vitro fertilization and gamete intrafallopian transfer.

Anxiety and attitudes have been examined in a series of women conceiving through in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). Women were assessed before and after their first ultrasound examination conducted between 6 and 8 weeks' gestation. A comparison group of women attending for genetic counseling for advanced maternal age also was assessed. The results showed the two patient groups to be comparable on psychological testing. The IVF-GIFT group tended to be more concerned about a problem developing but were not more anxious. Attitude ratings showed the IVF-GIFT women to have greater investment in the pregnancy and the fetus. A comparison of scores before and after the ultrasound showed anxiety reduction for women seeing the fetal heartbeat. Attitude ratings were more positive for the women seeing the fetal heartbeat, with change less pronounced in women denied this feedback. These results confirm the effects of diagnostic testing on emotional state. Women with IVF-GIFT pregnancies show both higher concern than documented elsewhere in low-risk pregnancies, as well as greater emotional investment in the fetus.

Platelet monoamine oxidase B activity in women with premenstrual syndrome.

Several lines of evidence suggest a strong association between premenstrual syndrome and affective disorder. Similar psychological symptoms, behavioral manifestations, and biochemical etiologies have been reported. We attempted to evaluate the biologic interconnection between premenstrual syndrome and psychiatric disorder by investigating the platelet enzyme, monoamine oxidase B. The activity of this enzyme has been noted to be decreased in affective disorder, alcoholism, and psychiatric vulnerability. Platelet monoamine oxidase B activity, estradiol, and progesterone were assessed throughout one menstrual cycle in 13 women with premenstrual syndrome and 19 control subjects. No significant differences were noted between groups using these parameters. The study indicates that well-screened subjects with premenstrual syndrome are, as evidenced by the parameter of monoamine oxidase B, biochemically similar to normal control subjects.

Whole-blood serotonin in premenstrual syndrome.

Whole-blood serotonin levels in 14 subjects with well documented premenstrual syndrome and 13 age-matched controls were compared. Serotonin levels of premenstrual syndrome subjects were significantly lower during the last ten days of the menstrual cycle. No significant differences were noted in levels of serum estradiol and progesterone. Decreased serotonin is known to be associated with depression in humans, and nonhuman primates have exhibited abnormal behavioral profiles when given serotonin antagonists. The present observation suggests that the physiologic basis of premenstrual syndrome involves an alteration in serotonin metabolism.

Pain assessment methods in mechanical dysfunction.

This paper considers the reliability and validity of pain assessment methods in mechanical dysfunction. A distinction is drawn between measures of subjective report and those of pain behaviour. The latter is observable and therefore more amenable to direct study than subjective report. Measures of subjective report include rating scales, the McGill Pain Questionnaire, and diary cards. Consideration is also given to personality assessment in this context. It is concluded that measurement needs to proceed from a number of standpoints, with the importance of each of these dependent upon the context. For chronic pain, emphasis on pain behaviours is appropriate.

Impact of fetal testing on maternal anxiety.

We evaluated the impact of fetal testing on maternal anxiety. A consecutive series of high-risk women attending during the third trimester for fetal assessment were each randomly assigned to one of four conditions: (1) high-feedback ultrasonography (n = 11), in which the monitor screen was visible; (2) low-feedback ultrasonography (n = 8), in which specific visual and verbal feedback was denied; (3) fetal heart rate monitoring (n = 11); or (4) a video control (n = 7), in which the women viewed a videotape of an ultrasonographic recording. Assessments were conducted before and after each procedure. No change was found in attitude ratings towards the fetus, although there was a significant reduction in state anxiety from before to after, with the reduction most pronounced in women undergoing high-feedback ultrasonography.

Pain measurement: an overview.

The practice and theoretical basis of pain measurement is reviewed and critically examined in the areas of animal research, human subjects laboratory investigation and clinical study. The advantages and limitations of both physiological and behavioral methods are discussed in each area, and subjective report procedures are evaluated in human laboratory and clinical areas. The need for procedures that bridge these areas is emphasized and specific issues are identified. Progress in the technology of pain measurement over recent decades is reviewed and directions for future work are suggested.

An analysis of self-reported sexual behavior in a sample of normal males.

Ninety-eight presumably normal London men, age 20-35 and sexually active in a stable relationship, responded to an invitation at their work place to participate in a detailed sexuality interview. The interview was developed by a group of WHO collaborators to measure possible effects on sexual functioning resulting from various medical regimens (for example, a male contraceptive pill). It assessed frequency of coitus and masturbation during the previous 4 weeks, a variety of subjective ratings of sexual interest, satisfaction, and quality of relationships, as well as reports of the nature and incidence of various sexual problems. The study sample's responses displayed internal consistency and in general supported the inference that the sample was not atypical. The data appear to support Westoff's (1974) notion that the frequency of coitus has increased since the early normative reports by Kinsey et al. (1948). Most importantly, the results of principal components analyses point to the fact that overall sexual drive or "libido" (e.g., frequency of sexual behavior) is independent of several other possibly significant dimensions, including latency to orgasm, quality of sexual experience, autoeroticism, and the incidence of erectile difficulties. It is concluded that the sexuality interview provides potentially useful baseline data against which to evaluate effects of sexual therapy or drug regimens.

Psychological changes over the course of pregnancy: a study of attitudes toward the fetus/neonate.

Pregnant women's attitudes towards their fetus over the course of the pregnancy were studied in relation to physiological events of pregnancy, namely seeing the fetus via ultrasound and experiencing fetal movement. A consecutive series of primiparae (n = 129) was randomly assigned, at recruitment between 10 and 14 weeks menstrual age, to conditions of high (n = 67) or low (n = 62) feedback real time ultrasound. Thereafter, women were assessed at 16 and 32 weeks gestation, within 24 hours of delivery and by questionnaire at 3 months postpartum. On each occasion women completed attitude rating scales concerning their pregnancy and their fetus or neonate. These scales were subjected to principal components analysis and two main dimensions were derived for ratings of both attitudes towards the pregnancy and the fetus/neonate. No relationship was found between factor scores and ultrasound feedback condition, although scores on the fetal attachment dimension showed a significant linear increase over the pregnancy. Women reporting fetal movement at 16 weeks displayed significantly higher scores on the fetal-attachment dimension at all three assessment points. Multiple regression analyses were utilized to identify predictors of initial reactions to the neonate and attachment ratings at 3 months postpartum. At delivery, ratings of attachment to the neonate were related to drug requirements in labor and attachment ratings at 32 weeks. Reactions to the neonate at delivery and ratings of postpartum mood emerged as significant predictors of maternal attachment at 3 months postpartum. These results are discussed in the context of research attempting to establish the importance of postpartum bonding.

A controlled trial of naproxen sodium for relief of pain associated with Vabra suction curettage.

In a double-blind study naproxen sodium (550 mg), or placebo was administered 1 h before Vabra curettage and pain associated with the procedure was assessed immediately after operation and 30, 60 and 120 min later by visual analogue and verbal rating scales, and the McGill pain questionnaire. The pre-curettage anxiety of the patients was assessed by the Spielberger state anxiety inventory. Of the 58 patients, 51 (87.9%) reported pain during the procedure; there was no relation between the level of pain experienced and the pre-curettage anxiety score. Compared with the placebo group, the pain experienced by the naproxen group was significantly less as measured by the McGill pain questionnaire immediately after curettage, and by visual analogue scales 30 and 60 min after the procedure. The verbal rating scales showed that naproxen significantly reduced backache 30 min after curettage, and cramp immediately after the procedure and 30 and 60 min later but did not reduce the severity of the pain associated with the procedure.