Cervical cancer: epidemiology, prevention and the role of human papillomavirus infection.

Organized screening has contributed to a decline in cervical cancer incidence and mortality over the past 50 years. However, women in developing countries are yet to profit extensively from the benefits of screening programs, and recent trends show a resurgence of the disease in developed countries. The past 2 decades have witnessed substantial progress in our understanding of the natural history of cervical cancer and in major treatment advances. Human papillomavirus (HPV) infection is now recognized as the main cause of cervical cancer, the role of coexisting factors is better understood, a new cytology reporting terminology has improved diagnosis and management of precursor lesions, and specific treatment protocols have increased survival among patients with early or advanced disease. Current research has focused on the determinants of infection with oncogenic HPV types, the assessment of prophylactic and therapeutic vaccines and the development of screening strategies incorporating HPV testing and other methods as adjunct to cytology. These are fundamental stepping stones for the implementation of effective public health programs aimed at the control of cervical cancer.

Human papillomaviruses: into the new millennium.

Human papillomaviruses (HPV) are newsworthy in this new millennium. Numerous articles have appeared in the lay press ranging in style and quality from informative essays to sensationalized exposes. Women, sensitized by confusing information, are asking obstetricians hard questions about HPV transmission and prevention, partner notification, the need for HPV testing, and methods of treatment. These questions are difficult because none of the answers are clear cut. This article provides the practicing gynecologist and obstetrician a concise and accurate summary of clinically important issues surrounding HPV. Current knowledge about HPV virology, epidemiology, testing, and the prospects for vaccination and other prevention measures is summarized.

Persistent human papillomavirus infection as a predictor of cervical intraepithelial neoplasia.

CONTEXT: Human papillomavirus (HPV) infection is believed to be the central cause of cervical cancer, although most of the epidemiological evidence has come from retrospective, case-control studies, which do not provide information on the dynamics of cumulative or persistent exposure to HPV infection. OBJECTIVE: To assess the risks of cervical neoplasia related to prior persistent HPV infections. DESIGN AND SETTING: Longitudinal study of the natural history of HPV infection and cervical neoplasia in women residing in the city of São Paulo, Brazil, which was conducted between November 1993 and March 1997 and involved repeated measurements of HPV and lesions with follow-up until June 2000. PARTICIPANTS: A total of 1611 women with no cytological lesions at enrollment and HPV test results available from the first 2 visits. MAIN OUTCOME MEASURE: Cervical specimens taken for Papanicolaou cytology and HPV testing every 4 months in the first year and twice yearly thereafter. Incident cervical cancer precursor lesions ascertained by expert review of all cytology smears. RESULTS: The incidence rate of squamous intraepithelial lesions (SILs) was 0.73 per 1000 women-months (95% confidence interval [CI], 0.5-0.9) among women free of HPV at the 2 initial visits and 8.68 (95% CI, 2.3-15.1) among women with HPV type 16 or 18 infections persisting over both visits. Relative to those negative for HPV oncogenic types at both initial visits, the relative risk (RR) of incident SIL was 10.19 (95% CI, 5.9-17.6) for persistent infections with any known oncogenic HPV types. The equivalent RR of incident high-grade SIL was 11.67 (95% CI, 4.1-33.3). The RRs of lesions were considerably higher for persistent infections with HPV type 16 or 18. CONCLUSION: A strong relationship exists between persistent HPV infections and SIL incidence, particularly for HPV types 16 and 18.

Continuing educational needs in computers and informatics. McGill survey of family physicians.

OBJECTIVE: To describe family physicians' perceived educational needs in computers and informatics. DESIGN: Mailed survey. SETTING: General or family practices in Canada. PARTICIPANTS: Physicians (489 responded to a mailing sent to 2,500 physicians) who might attend sessions at the McGill Centre for CME. Two duplicate questionnaires were excluded from the analysis. METHOD: Four domains were addressed: practice profile, clinical CME needs, professional CME needs, and preferred learning formats. Data were entered on dBASE IV; analyses were performed on SPSS. MAIN FINDINGS: In the 487 questionnaires retained for analysis, "informatics and computers" was mentioned more than any other clinical diagnostic area, any other professional area, and all but three patient groups and service areas as a topic where improvement in knowledge and skills was needed in the coming year. Most physicians had no access to computer support for practice (62.6%); physicians caring for neonates, toddlers, or hospital inpatients were more likely to report some type of computer support. CONCLUSIONS: Family physicians selected knowledge and skills for computers and informatics as an area for improvement in the coming year more frequently than they selected most traditional clinical CME topics. This educational need is particularly great in small towns and in settings where some computerized hospital data are already available.

Medical conditions and the risk of motor vehicle crashes in men.

OBJECTIVE: To determine whether men aged 45 to 70 years with any medical condition are at an increased risk of involvement as drivers in police-reported motor vehicle crashes. DESIGN: Case-control study. SETTING: Province-wide population-based sampling. PARTICIPANTS: A total of 2504 drivers randomly selected from those involved as a driver in a motor vehicle crash (cases) and 2520 men not involved in a crash (controls) during a 6-month period. DATA COLLECTION: The Societé de l'assurance automobile du Quebec (SAAQ) computerized files provided data on crashes, age, and medical conditions. A mailed questionnaire elicited information on usual mileage and driving conditions. RESULTS: Data from the SAAQ files were obtained for all 5024 drivers. The overall response rate to the mailed survey was 35.5% with no statistically significant differences in the distribution of characteristics between respondents and nonrespondents. There was no increase in crude (odds ratio, 0.99; 95% confidence interval, 0.85-1.17) or age-adjusted risk of crashes for men with a medical condition in the entire sample of subjects (N = 5024). Among respondents to the mailed questionnaire only, men with a medical condition showed no increased crude risk of crashes (odds ratio, 0.99; 95% confidence interval, 0.76-1.27); no difference was observed after adjustment for age, mileage driven, driver behaviors, and sociodemographic characteristics (odds ratio, 0.91; 95% confidence interval, 0.64-1.31). CONCLUSIONS: Unlike previous studies, the risk estimate was derived from a population-based sample of drivers and adjusted for age, mileage driven, driver behaviors, and sociodemographic characteristics in multivariate analyses. The adjusted estimates failed to show an increased risk of motor vehicle crashes for drivers with a medical condition.

Knowledge of and attitude toward patient confidentiality within three family medicine teaching units.

PURPOSE: To describe the knowledge and attitudes about confidentiality issues within family medicine teaching units (FMUs) at McGill University. METHOD: The authors surveyed McGill University FMU staff (physicians, nurses, and support staff) on their knowledge of and attitudes toward confidentiality issues. RESULTS: The response rate was 84%. Only one of nine questions on confidentiality laws was correctly answered by more than 80% of the respondents. Only 55% of the support staff knew that police are not permitted free access to charts, although the majority of those who answered incorrectly held attitudes that were consistent with the law. Only approximately 25% knew that physicians and nurses are not permitted free access to any medical record within the center. There were minimal differences between the professions or between the FMUs. CONCLUSION: These findings suggest that FMU staff do not fully understand their obligations towards patient confidentiality.

Attitudes toward obstetrics training. Residents surveyed at McGill University and University of Montreal.

OBJECTIVE: To determine family medicine residents' attitudes toward family practice training in obstetrics and neonatology before and after implementation of a modified obstetrics curriculum at McGill University (MG). DESIGN: Two-group pretest and posttest. Fifty-seven respondents, 31 at MG, 26 at University of Montreal (UM), were case matched as first-year and second-year residents. SETTING: Departments of Family Medicine at MG and UM. PARTICIPANTS: Family medicine residents at MG and UM. INTERVENTION: A modified obstetrics curriculum was introduced at MG (study group); no modifications were introduced at UM (control group). First- and second-year residents' attitudes toward the adequacy of training were assessed through responses to a questionnaire administered in July 1992 and July 1994. MAIN OUTCOME MEASURES: Changes in response scores before and after implementation of the modified curriculum. RESULTS: Repeated multivariate analysis of variance (MANOVA) showed respondents believed family practice obstetrics training was adequate in general, but that family practitioners were inadequately trained in emergency obstetric skills. Scores for items assessing neonatology skills increased significantly in the MG group after the intervention. CONCLUSIONS: Residents' overall confidence in their obstetrics training did not appear to improve, but this might be due to a time lag between curriculum modification and attitudinal change. McGill residents' confidence in neonatology skills improved significantly after curriculum modification.

Complementary health care services: a survey of general practitioners' views.

OBJECTIVE: To determine the referral practices, perceived usefulness, knowledge, prior training and desire for training of general practitioners (GPs) in Quebec with regard to complementary health care services such as acupuncture, chiropractic and hypnosis. DESIGN: Cross-sectional mail survey. SETTING: Province of Quebec. PARTICIPANTS: Random sample of 200 GPs. Of the 146 who responded, 25 were excluded because they were no longer in practice; this left 121 (83%). OUTCOME MEASURES: Self-reported referral practices for complementary health care services, perceived usefulness and self-assessed knowledge of such services, and prior training and desire for training in these services. RESULTS: Sixty percent (72/121) of the GPs knew at least one practitioner of a complementary health care service for referral; 59% (70/119) reported referring patients to physicians who practise such services and 68% (80/118) to nonmedical practitioners. At least one of the three services studied were regarded as having some use by 83% (101/121). Overall, self-reported knowledge was poor: the proportions of GPs who reported knowing a lot about acupuncture, chiropractic and hypnosis were 11% (13/121), 10% (12/121) and 8% (10/121) respectively. Prior training was also lacking: only 8% (9/118) of the GPs had received previous training in acupuncture, 2% (2/111) in chiropractic and 3% (3/103) in hypnosis. In all, 48% (57/118) indicated that they would like further training in at least one of the services studied, and 13% (16/121) indicated that they currently provided one service. CONCLUSIONS: Referral of patients by GPs to practitioners of complementary health care services is common in Quebec. Although self-assessed knowledge about such services is relatively poor, interest in learning more about them is high. These findings identify a demand for future educational initiatives.

Tubal sterilization in women 15-24 years of age: demographic trends in the United States, 1970-1980.

Between 1970-1980, approximately 942,000 women 15-24 years of age underwent tubal sterilization in the United States. These women represented about 17 per cent of all women ages 15-44 years who underwent tubal sterilization in the United States during this 11-year period. During 1970-1980, sterilization rates rose steadily from three per 1,000 to 11 per 1,000 for women in the 20- to 24-year age group, but remained stable at less than one per 1,000 for women in the 15- to 19-year age group. For each year, rates for Black women were greater than those for White women. Sterilization rates increased over the time period for both currently and previously married women, but remained low for never-married women. Most tubal sterilizations were performed after delivery of an infant.