Menopause Management Knowledge in Postgraduate Family Medicine, Internal Medicine, and Obstetrics and Gynecology Residents: A Cross-Sectional Survey

OBJECTIVE

To evaluate the knowledge of and nature of training for menopause management in postgraduate residents.

PARTICIPANTS AND METHODS

A cross-sectional, anonymous survey was e-mailed to trainees at all postgraduate levels in family medicine, internal medicine, and obstetrics and gynecology at US residency programs between January 11, and July 4, 2017. The survey was adapted from an existing instrument and included questions regarding knowledge of hormone therapy (HT) and other menopause management strategies, availability and type of training in menopause medicine, and demographic information.

RESULTS

Of the 703 surveys sent, a total of 183 residents representing 20 US residency programs responded (26.0% response rate). Most trainees were between 26 and 30 years of age (133 of 172 [77.3%]), female (114 of 173 [65.9%]), and believed it was important or very important to be trained to manage menopause (165 of 176 [93.8%]). Although most respondents answered some of the menopause competency questions correctly, important gaps were identified. Of 183 participants, 63 (34.4%) indicated they would not offer HT to a symptomatic, newly menopausal woman without contraindications, and only 71 (38.7%) indicated they would prescribe HT until the natural age of menopause to a prematurely menopausal woman. Of 177 respondents, 36 (20.3%) reported not receiving any menopause lectures during residency, and only 12 of 177 (6.8%) reported feeling adequately prepared to manage women experiencing menopause.

CONCLUSION

Family medicine, internal medicine, and obstetrics and gynecology residency trainees recognize the importance of training in menopause management, but important knowledge gaps exist. Investing in the education of future clinicians to provide evidence-based, comprehensive menopause management for the growing population of midlife women is a priority.

Drain Usage in Head and Neck Surgery: A National Survey of Thirty-five Surgeons across Ten Units

Introduction Drain usage is commonplace in head and neck surgery. There is an increasing body of literature disputing their routine placement in certain procedures. The aim of this study is to explore modern-day practice in terms of drain usage and the use of haemostatic agents. Methods A simple questionnaire was devised and sent to 35 ENT Surgeons across 10 units nationally. Results There was an overall response rate of 77.1% (n=27). There was considerable heterogeneity amongst surgeons in terms of indication for insertion, how the decision is made to remove the drain and if any alternative/adjunctive haemostatic agents are being used. Discussion The management of drains is poorly defined and guidelines are lacking. With increased pressure on resources, the risk of infection and discomfort to the patient, further reflection is required to evaluate if careful patient selection rather than habitual drain insertion in every case is more appropriate.

Sexual Problems of Sexual Assault Survivors

Attempts to downplay the sexual component of sexual assault may actually result in an injustice to sexual assault survivors as it may desensitize professionals working with sexual assault survivors to the possible development of sexual problems. Of 371 sexual assault survivors evaluated, more than 40% reported that they were experiencing sexual problems as a result of their assaults. In addition, these assault-related sexual problems can be chronic, enduring for many years. The need to screen for and provide treatment when necessary for such sexual problems is apparent.

Parapharyngeal abscess in an insulin dependant diabetic patient following an elective tonsillectomy

OBJECTIVES

To demonstrate a potentially life-threatening complication following tonsillectomy in a diabetic patient and discuss the possible pathogenesis.

METHODS

Case report and review of the world literature concerning parapharyngeal abscess post-tonsillectomy.

CASE REPORT

A 20-year-old female patient underwent an uneventful tonsillectomy following a history of recurrent tonsillitis. She re-presented 14 days post-surgery with a large erythematous tender right mid cervical neck swelling. Clinical and radiological evaluation confirmed a parapharyngeal abscess. She proceeded to have an incision and drainage of the abscess through a horizontal skin crease incision and subsequent intravenous antibiotic therapy. She was discharged home well three days post-surgery.

CONCLUSION

Diabetes mellitus is a well-recognised systemic disease that may leave an individual more susceptible to infection. We report the first case in a young healthy diabetic patient and highlight a potential serious complication following a routine tonsillectomy.

Otogenic pneumocephalus: case report and review of the literature

We report a case of a 70 year old lady who presented to the accident and emergency department with a three day history of left sided otalgia, drowsiness and confusion. On admission her temperature was 39 degrees C, glascow coma scale was 14/15 and otoscopy revealed a left sided otitis media. There was no sign of CSF otorrhoea or mastoiditis. Neuro-otological examination was normal. High resolution CT scan of temporal bones and brain showed evidence of pneumocephalus near the left cerebello-pontine angle and posterior to the left petrous bone. No focal parenchymal pathology, intra-cranial bleed or defect in the tegmen was noted. The patient responded very well to conservative management in the form of high dose intravenous antibiotics. We would like to emphasise that this complication of otitis media should be borne in mind when an elderly patient presents with otalgia and confusion.

Technique to prevent post-operative CSF leak in the translabyrinthine excision of vestibular schwannoma

Cerebrospinal fluid (CSF) leak following VS removal is a challenging complication. With experience, it can be seen that anatomical factors such as the extent of pneumatization of the petrous temporal bone and posterior wall of the internal auditory canal play animportant role in contributing to CSF leak. Nevertheless, the risk of post-operative CSF leak remains a major concern for both the surgeon and patient. This paper describes a technique, which we have used since 1994, and which has helped us to achieve the lowest reported rate of post-operative CSF leak in translabyrinthine excision of vestibular schwannoma in the world literature.

Ectopic ossification in the parotid gland

We present a unique report of ectopic ossification with dystrophic calcification within an otherwise histologically normal parotid gland. The histopathological features of the case are discussed and general pathogenetic explanations for the lesion are explored.

Helicobacter pylori and tonsillectomy

Tonsillar tissue is a component of mucosa-associated lymphoid tissue (MALT), which has evolved to protect vulnerable mucosal surfaces. Helicobacter pylori, implicated as an aetiological factor in duodenal ulcers and gastritis, induces the appearance of lymphoid aggregates (MALT) in the stomach. This organism is cytotoxic via a nitric oxide synthase cascade. The possibility that tonsillar tissue processes Helicobacter pylori or that Helicobacter pylori can colonize the palatine tonsils is explored. The study design was that of a prospective study. We determined if Helicobacter pylori (i) forms part of the normal microenvironment of the tonsil, (ii) plays a role in the pathogenesis of tonsillitis and (iii) is associated with increased expression of inducible nitric oxide synthase (iNOS) in macrophages of the tonsil. Serology for Helicobacter pylori was performed on 50 patients undergoing tonsillectomy. Tonsillar specimens were monitored for urease activity by CLO test (a sealed plastic slide holding an agar gel, which contains urea and detects the urease enzyme of Helicobacter pylori), and immunocytochemically probed for Helicobacter pylori and iNOS expression. The mean age of this patient group was 17.2 years (3-36 years). Fourteen (28%) were sero-positive for Helicobacter pylori but no evidence of this pathogen was found in any tonsillar specimen. The number of macrophages staining for iNOS, per field, under a magnification of x40, was increased in sero-positive patients (13.3 +/- 1.3 versus 9.9 +/- 0.7; P = 0.01). Helicobacter pylori does not appear to colonize the tonsil. We believe that Helicobacter pylori primes the tonsils by inducing macrophage iNOS expression. The higher expression in sero-positive patients is a reflection of a pro-inflammatory reaction to Helicobacter pylori that is both local and systemic.

Causes of the acute abdomen: add thrombophilia to your list

A47-year-old male was admitted with a 2-week history of periumbilical discomfort. For 48 hours before admission, the patient suffered from associated vomiting and anorexia. Upon admission the abdominal pain had become more severe and began to radiate to both flanks.

His past medical history included a deep vein thrombosis 18 months previously. He was taking Tegretol for epilepsy (seizure free for many years) and regular inhalers for asthma. He had no recent episode of prolonged immobility. He was a non-smoker and did not drink alcohol.

On examination, he was obese (96 kg). He had a low grade pyrexia with a sinus tachycardia (120 beats per minute). He was normotensive. Abdominal examination revealed tenderness over the umbilical and epigastric areas. At this stage, there was no evidence of guarding or rigidity and bowel sounds were present.

Investigations including serum bioprofile, amylase, coagulation screen, chest X-ray, plain film of abdomen and ultrasound of abdomen were all reported as normal. Full blood count revealed a moderate leucocytosis (13.2 × 109/litre).

At this stage he was managed conservatively with intravenous fluids and antibiotics. However, over the next 12 hours, the patient's condition deteriorated and he developed diffuse peritonism with guarding and rebound tenderness. He was prepared for theatre. Laparoscopy demonstrated haemosanguinous fluid and gangrenous loops of small bowel. Laparotomy confirmed the presence of a 24” gangrenous segment of distal jejenum and proximal ileum. Perioperatively, this segment was noted to have good arterial pulsation with obvious clot in the venous arcades. Formal resection with end to end anastomosis was completed. Postoperative recovery was uneventful. After surgery he was anticoagulated with unfractionated heparin.

Histology confirmed mesenteric venous infarction. In view of the past history of deep vein thrombosis, a thrombophilia screen was performed. Our patient was heterozygous positive for the factor V leiden mutation. He was anticoagulated and discharged on warfarin indefinitely (under ongoing review).

Panendoscopy and bronchial washings: role and efficacy in detection of simultaneous primary head and neck cancers

The phenomenon of multicentricity in head and neck squamous cell carcinoma affects survival rates. We evaluated the use of panendoscopy/triple endoscopy and, in particular, the place of bronchial washings in the initial staging assessment of head and neck tumours. In a prospective panendoscopic study, a second primary rate of 4.8 per cent was discovered. All four bronchial tumours--both index and simultaneous primary cases--were obvious on bronchoscopy and chest X-ray, despite 50 per cent of them being clinically silent. A self-limiting complication rate of 2.4 per cent was encountered. The issue of bronchial washings was debated and our sensitivity (50 per cent) and specificity (97 per cent) results assessed. We advocate the inclusion of bronchoscopy as part of a panendoscopic work-up of head and neck tumours. The rationale for this is discussed. Bronchial washings, although cheap and easy to process, did not change the management of any patient in the study group and contamination could complicate assessment. Overall, panendoscopy is a safe worthwhile procedure.

Paraganglioma of the external auditory canal: an unusual case

Primary paraganglioma of the external auditory canal is a rare otological finding. To date, only three cases have been reported in the world-wide literature. Such a tumour is now described in a 42-year-old female. The clinical and histopathological features of the case are discussed. The role of immunocytochemistry in defining diagnosis, from a large list of differentials, is illustrated. We present the first magnetic resonance images of this rare tumour and highlight the benefit of intra-operative frozen section in limiting surgery to canal excision.

Assumptions and beliefs about the role of AD dolls in child sexual abuse validation interviews: are they supported empirically?

The use of anatomically detailed dolls in child sexual abuse validation interviews is based on a number of underlying assumptions and beliefs. However, only over the last 12 years have researchers begun to evaluate the validity of these assumptions and beliefs systematically. This consideration of the existing AD doll empirical literature reveals that the support for some of the assumptions underlying the use of the dolls, as well as the surrounding beliefs, is available. However, for other assumptions and beliefs support is less firm, frequently contradictory, and sometimes absent. The evidence of support for these assumptions and beliefs is discussed and future research needs are identified.

Comparison of relative uses of commercial assays for Toxoplasma gondii IgM antibodies

AIMS

To compare the sensitivity and user friendliness of seven commercially available enzyme linked immunoabsorbent assay (ELISA) kits for toxoplasma specific IgM.

METHODS

Five antibody capture assays supplied by Abbott, Mercia, Northumbria, Organon and Sorin, and two indirect ELISA assays from Biostat and Mast, were assessed. Using defined dilutions of Toxoplasma gondii specific IgM, the performance and sensitivity of each assay was established. They were further assessed on a panel of 27 sera with a range of dye test and IgM results (as determined by the Scottish Toxoplasma Reference Laboratory). All of the assays were performed by three experienced operators and assessed for user satisfaction.

RESULTS

The Mast, Organon, and Abbott assays were of low sensitivity; the Mercia and Northumbria were of high sensitivity; and the Biostat and Sorin assays produced too many false positive results. The Mercia kit provided most user satisfaction; the Mast and Abbott assays were most difficult to use.

CONCLUSIONS

Local laboratories investigating toxoplasma infection should have three tests: one IgG and two IgM (high and low sensitivity) to help in the timing of infection. Alternatively, one sensitive IgM assay, such as that of Mercia, could be used by selecting appropriate high and low thresholds.

Simultaneous diagnosis of toxoplasmosis in goats and goatowner's family

Four out of 6 goats from a small British goat herd gave birth to weak or stillborn kids. All were seropositive for Toxoplasma gondii. The parasite was isolated from the tissues of one kid and the milk of one goat. Concurrently, one of the goatowner's sons developed a mononucleosis-like illness with serological evidence of current toxoplasma infection. Investigation of the family showed past infection in the other son, but both parents were seronegative. The source of infection for both boys appeared to be the consumption of unpasteurized goat's milk.

Diagnosis of congenital toxoplasmosis in Scotland

During a period of 10 years (1976-1986) 853 cases of toxoplasmosis were identified serologically in the Toxoplasma Reference Laboratory in Scotland. Suspected cases of infection in pregnancy (29 cases) and of congenital infection (27 cases) were rare but ophthalmic disease was common (224 cases). In two of the congenital cases, maternal infection was identified during pregnancy. The other 25 babies were investigated because of suspected congenital infection. Toxoplasmosis was confirmed retrospectively in 11/25 babies and excluded in two of them. The other 12 cases remain unclassified. Diagnosis of infection in babies was difficult although the introduction of an IgM capture ELISA was of some help. IgM was detected by ELISA in 3/13 congenitally infected babies but by immunofluorescence tests in only one of these. In two antenatal studies, involving 16,000 women, an additional 32 women were identified whose babies might have benefited from treatment or the availability of fetoscopy for early detection of congenital infection.

Toxoplasmosis: effectiveness of enzyme immunoassay screening

The effectiveness of IgG enzyme-linked immunosorbent assays as serological screening tests for Toxoplasma gondii infection was investigated in three Scottish hospital laboratories. Three assays--two commercial and one produced by the Scottish Toxoplasma Reference Laboratory--were investigated. There was little difference in the sensitivity of the three tests (86-91%), but one of the commercial tests was markedly less specific. The performance of the more specific assays was improved by adjustment to an eight international unit per ml threshold.

Biotin-labelled antigen screening test for toxoplasma IgM antibody

A method for the simple preparation of biotin-labelled toxoplasma antigen was used with avidin peroxidase in an IgM-capture enzyme linked immunosorbent assay (BAM-ELISA). Although the overall predictive value of a positive result was only 38%, its low cost and 100% sensitivity makes it a very suitable screening test. Positive results can be confirmed by an alternative assay, thus providing a more economical and effective diagnostic service than either screening all sera by a commercial test or selecting sera for IgM testing.

The use of an IgM immunosorbent agglutination assay to diagnose congenital toxoplasmosis

An IgM immunosorbent agglutination assay (ISAGA) was compared with a standard ELISA IgM test for the diagnosis of congenital toxoplasmosis. It was more sensitive, detecting all of five mothers of infected babies whereas the IgM ELISA was positive in two of three mothers tested at delivery and neither of two mothers referred 10-12 months after delivery. Five women infected in a previous pregnancy had IgM detectable by ISAGA in a subsequent pregnancy. The assays were comparable when sera from patients with past infection were tested or following toxoplasma-associated miscarriage or abortion. Four cord sera from congenitally-infected babies were positive by the ISAGA but only three of these were positive by ELISA for IgM. The ISAGA also detected IgM in another four sera from congenitally-infected babies referred late (10-18 months old); none were IgM positive by ELISA. The increased sensitivity of the ISAGA is an improvement in the diagnosis of congenital toxoplasmosis.

Depressive symptoms associated with sexual assault

The Beck Depression Inventory was used to assess depressive symptoms in 178 sexual assault survivors and 50 control subjects who had never been sexually assaulted. The sexual assault survivors reported significantly more depressive symptoms than the control subjects, and further analyses strongly suggested that the depressive symptoms were caused by the sexual assault. Investigation of the relationships between depression scores and survivor and assault characteristics indicates that the nonspecifics of the assault and the use of a weapon by the assailant were most highly correlated with development of depressive symptoms.

Incidence and types of sexual dysfunctions in rape and incest victims

Many authors have commented on the impact of sexual assault on the sexual lives of the victims. Eighty-three victims were interviewed with regard to their sexual histories, and completed the Sexual Arousal Inventory, to determine the incidence and types of sexual dysfunctions in rape and incest victims: 56% of these victims experienced sexual dysfunctions postassault; 71% of these subjects reported that the sexual assault precipitated the dysfunction. Fear of sex, arousal or desire dysfunctions were the most common sexual problems presented within this victim sample. The Sexual Arousal Inventory was not successful in discriminating dysfunctional and nondysfunctional rape and incest victims.