Screening the vasectomy applicant: reassessing the importance of eligibility criteria

All family planning clinics and a random sample of private physicians throughout the US were surveyed in 1972 and 1984 by questionnaire to discern the importance of eligibility criteria in the process of screening vasectomy applicants. In general, age and parity expectations have become significantly more flexible and liberal over a decade of waning vasectomy popularity. Physicians in the 2 surveys tend to ascribe greater importance than clinical staff to marital status, religious conflicts, marital stability, and spousal consent. Both groups currently place less emphasis on eligibility criteria than they did 12 years ago. A common measure has been age of the applicant; in 1972 nearly 20% of clinics expected applicants to be between 27-34 years old, but in 1984 this expectation had declined to 5% of clinic services. In the 1984 survey significantly more clinics than physicians reported acceptance of younger men. More clinic respondents (27% compared to 13%) noted that age-parity criteria were not specifically appropriate to or compatible with overall eligibility criteria; unsolicited remarks indicate that eligibility decisions rested more on other criteria than age or parity.     

Consultant Surgeons and Vasectomy

In late 1971 410 consultant general surgeons and urologists—74% of a national random sample—responded to a postal survey about vasectomy. Probably about 50,000 vasectomies were performed by surgeons in England and Wales in 1970. The service was largely a private one: 60% of consultants'' hospital vasectomies were not done under the National Health Service, and, in addition, 26% of the consultants who worked in relevant specialties performed vasectomies elsewhere than in hospital (usually in private nursing homes). Based again on consultants'' estimates, probably 6,000 men in 1970 had their requests for vasectomy turned down by surgeons, or more than one turned down for every 10 done. The most common reason was that patients were “too young.”About 90% of the consultants thought vasectomy could normally be performed safely and adequately as an outpatient procedure, yet only 64% said that 90% or more of their hospital vasectomies were done on this basis. While 69% regarded services in their areas as adequate, most were in favour of more special vasectomy clinics.     

Languages of labor: negotiating the "real" and the relational in Indo-Fijian women's expressions of physical pain

Medical personnel in public clinics in Fiji routinely contend that state-funded medical resources are misallocated on patients who complain of, but do not actually experience, physical pain. Frequently, these patients are identified as being Indo-Fijian women (i.e., women of South Asian origin in Fiji). In this article, I examine clinical interactions between medical staff and female Indo-Fijian patients to demonstrate how "real" and 'unreal' pain are distinguished in the clinical setting and to indicate some of the roles clinical encounters play in community processes that ascribe alternative meanings to physical pain. Focusing on how both physicians and women patients foster certain interpretations of physical pain over others, I argue that the category of 'unreal' pain, as employed by Fiji's physicians, consists of pain that medical professionals consider to be induced by psychological or physical, work-related stresses. I then show how Indo-Fijian women engage in a complementary but distinct discourse that emphasizes links between physical labor and pain and suggests that, in some cases, expressions of physical pain are as much an idiom of pride as an idiom of distress.     

Risk of testicular cancer after vasectomy: cohort study of over 73,000 men.

OBJECTIVE--To confirm or refute reports that vasectomy may increase the risk of cancers of the testis and prostate. DESIGN--Computerised record linkage study of cohort of men with vasectomy and comparison of cancer rates with those in the whole Danish population; manual check of all records of patients with testicular and prostate cancer diagnosed within the first year of follow up. SETTING--Denmark 1977-89. SUBJECTS--Cohort of 73,917 men identified in hospital discharge and pathology registers as having had a vasectomy for any reason during 1977-89. MAIN OUTCOME MEASURES--Observed incidences of testicular, prostate, and other cancers up to the end of 1989. RESULTS--The overall pattern of cancer incidence in the study cohort was similar to that expected nationally. No increased incidence in testicular cancer was observed (70 cases; standardised morbidity ratio 1.01 (95% confidence interval 0.79 to 1.28)). The incidence during the first year of follow up was also close to that expected (nine cases; standardised morbidity ratio 0.80 (0.36 to 1.51)). The incidence of prostate cancer was not increased (165 cases; standardised morbidity ratio 0.98 (0.84 to 1.14)). CONCLUSIONS--The incidence of testicular cancer in men with vasectomy is no higher than in other men. Vasectomy does not cause testicular cancer and does not accelerate the growth or diagnosis of pre-existing testicular neoplasms. Data concerning a causal relation between vasectomy and prostate cancer were inconclusive.     

Prevalence of antibody to human T lymphotropic virus type III by risk group and area,United Kingdom 1978-84.

Antibody to human T lymphotropic virus type III (anti-HTLV-III) was sought in 2150 patients in three groups at risk with a radioimmunoassay and an immunofluorescence test. Results by the two methods were closely concordant. Anti-HTLV-III was already present in some British homosexuals in 1980 and in some British haemophiliacs in 1981, and since then its prevalence has increased. Of homosexual patients needing laboratory tests for hepatitis B virus infection in 1984, 34% of 282 in London and 5% of 955 in five centres outside London were positive for anti-HTLV-III. Of haemophiliacs sampled in 1984, 38% of 81 were anti-HTLV-III positive. Most of the seropositive haemophiliacs were regular recipients of commercial factor VIII concentrates. Few British intravenous drug abusers sampled in 1984 (2.5% of 203) were positive for anti-HTLV-III. These results show that infection with HTLV-III has rapidly become widespread among homosexuals attending sexually transmitted disease clinics and among haemophiliacs receiving pooled blood products. Thus, while many anti-HTLV-III positive individuals may remain asymptomatic, there may soon be a considerable increase in the incidence of the acquired immune deficiency syndrome and related disease in Britain.     

Current status of the endocrinological effects of vasectomy

The relevant literature which has appeared, primarily within the last several years, in regard to the endoncrinological effects of vasectomy is reviewed. Focus is on early animal studies, examinations of interstitial tissue, short-term endocrine studies in animals and man, and long-term endocrine studies in man. Suspicion that vasectomy may influence androgen and gonadotropin status has reappeared recently because of experimental investigations of vasectomized rats and human vasectomy follow-up studies. The possibility that vasectomy is accompanied by untoward consequences to the endocrine system, which might become manifest shortly after the procedure or later in life, received support from recent animal investigations. During the 1972-1975 period, several reports appeared which attempted to clarify what effect vasectomy had upon the human pituitary-gonadal axis. Recently, there have been several prospective long-term studies on the pituitary-testicular axis in vasectomized men. Several areas where additional research is necessary are identified.     

Psychiatric and Social Factors in the Abortion Decision

A total of 132 consecutive referrals for psychiatric opinion on termination of pregnancy were examined and followed up at nine months. Of these, 48 (36%) were refused and 44 of the 84 terminated were sterilized. Those recommended for abortion tended to be older, married, and to have children. They had used contraception more often and they showed more clinical psychiatric abnormalities. The group had numerous social problems, but these did not distinguish those terminated from those refused, nor were there differences in religious affiliation or duration of pregnancy. Most of those refused obtained an abortion elsewhere and only 25 of the original 132 had a live child. General practitioners were more likely to disagree with a refusal decision than with termination. Psychiatric, physical, and social sequelae were infrequent in both groups. Contraception before and after was inadequate in most patients.     

Sterilization: Canadian choices.

Significant differences in cost and safety between vasectomy and tubal ligation have been reported. For this reason the incidence of these two procedures between 1976 and 1986 was studied to obtain information upon which future policy decisions might be based. Although tubal ligation predominated in almost every province and year its rate declined by 27.6% over the study period, whereas the rate of vasectomy increased by 39.1%. When projected to 1988 the national rates for the two procedures became nearly equal; those for Quebec had become equal by 1986. Provincial differences were most marked in eastern Canada, where neighbouring provinces had the highest and the lowest rates of sterilization in the country. Given the relative economic and surgical disadvantages of tubal ligation, policymakers may wish to consider fostering an increased acceptance of vasectomy, particularly in areas where such acceptance continues to be slow.     

The Sequelae of Acute Purulent Meningitis in Childhood

Of a series of 122 children suffering from acute purulent meningitis at the Children''s Hospital, Winnipeg, in the years 1952-56, 12 (9.8%) succumbed, all deaths occurring in those 12 months of age or less. Fortyone of the survivors were re-studied 2.5 to 7.5 years after their acute illness to assess the nature and incidence of sequelae, the relationship of sequelae to the severity of the acute illness, and the correlation between the various methods of identifying sequelae. Five children exhibited psychiatric evidence of organic brain damage; seven, neurological abnormality; 11, electroencephalographic abnormality. Three had defective intelligence and nine psychological test evidence of organic brain damage. Children with sequelae tended to have several abnormal test results, the total number with neuropsychiatric and/or psychological sequelae being 11 (26%). There was a positive correlation between the severity of the acute illness and the presence of neuropsychiatric sequelae; also between neuropsychiatric sequelae, defective intelligence and psychological evidence of brain damage. No correlation existed between the electroencephalographic abnormality and neuropsychiatric defect.     

Psychological aspects of vasectomy in Malaysia

246 men, aged 21-59, living on rubber estates on the outskirts of Kuala Lumpur, Malaysia, were interviewed 1-4 years after vasectomy in a study conducted by the International Institute for the Study of Human Reproduction of Columbia University and the National Family Planning Board of Malaysia. Most of the men were of Indian origin; 223 were Hindus. The incidence and nature of psychological and medical complications were investigated, but this article treats only the psychological effects. The basic interviews consisted of verbal questionnaires; care was taken to avoid drawing attention to the researchers' interest in psychosexual effects. Men claiming regrets, fears, ill effects, and problems in married life after the operation were 9%, 11%, 54%, and 4%, respectively, of the total population. 11.8% of the men claimed to have a loss of libido. The percentages of men expressing regrets and fears decreased with increasing age, parity, and pregnancies of wife; age here is probably the overriding variable. When the vasectomy decision was joint, rather than the individual decision of either husband or wife, regrets and fears were significantly less (p.05 for both regrets and fears). No couple in the sample was without at least 1 living son, this suggesting that men without heirs will refrain from vasectomy in Malaysia. Higher proportions of men who had lost children reported anxiety. Men reporting psychosexual complications were reinterviewed in depth. In these depth interviews a variety of fantasies associated with the operation was revealed.     

Illness after measles-mumps-rubella vaccination.

OBJECTIVES: To provide accurate information on the common sequelae of measles-mumps-rubella (MMR) vaccination and to compare post-vaccine symptoms in children vaccinated at 13 and 15 months. DESIGN: Prospective cluster randomized controlled trial. SETTING: Twenty-two family practices in southwestern Ontario. PATIENTS: All 376 infants who were due to receive MMR vaccine in the next year, 253 (67.3%) successfully completed the study. INTERVENTION: MMR vaccine administered at 13 months by half of the family physicians and at 15 months by the remaining half. OUTCOME MEASURES: Family physician''s physical findings in children 7 days and 30 days after vaccine; reported illnesses by mothers in a daily diary in the month before and after vaccination and medical records of visits to family physicians and hospital admissions in the month before and after vaccination. RESULTS: Compared with the incidence rates in the corresponding weeks before vaccination, the rates of lymphadenopathy (23.8%) and fever (16.8%) were higher 1 week afterward and the rate of rash (26.9%) was higher 7 to 14 days afterward. Fewer health problems were reported in the third and fourth weeks after vaccination than in the corresponding weeks beforehand. Hospital admissions after vaccination were no more frequent than those before once cause and time of admission were taken into account. The two age groups did not differ in any of the outcomes. CONCLUSIONS: Mothers should be informed about the possibility of increased physical findings in the weeks after MMR vaccination, especially lymphadenopathy, nasal discharge and rash. Since the occurrence of sequelae does not seem to differ significantly between 13-month-old recipients and 15-month-old recipients, it should not influence the decision of when to administer the vaccine.     

Childhood leukaemia in the West Berkshire and Basingstoke and North Hampshire District Health Authorities in relation to nuclear establishments in the vicinity.

During the years 1972-85, 89 children aged 0-14 were registered with leukaemia in the West Berkshire and Basingstoke and North Hampshire District Health Authorities. Two nuclear establishments are located within the health authorities, and a third is situated nearby. Fifty of the 143 electoral wards in the two district health authorities lie wholly within, or have at least half their area lying within, a circle of radius 10 km around the establishments. In those 50 electoral wards 41 children aged 0-14 were registered with leukaemia, 28.6 registrations being expected on the basis of leukaemia registration rates in England and Wales (incidence ratio = 1.4, p less than 0.05). This excess was confined to children aged 0-4, among whom there were 29 registrations of leukaemia, 14.4 being expected (incidence ratio = 2.0, p less than 0.001). In the remaining 93 electoral wards there was a small and non-significant increase in the number of registrations of leukaemia at age 0-14 (48 observed, 40.8 expected; incidence ratio = 1.2). There was no obvious trend in the incidence of childhood leukaemia over the 14 years and the overall occurrence of the malignancy in the 143 electoral wards was consistent with a random distribution. In the surrounding Oxford and Wessex Regional Health Authorities the number of registrations of leukaemia at age 0-14 was virtually identical with that expected on the basis of registration rates in England and Wales (362 observed, 372.5 expected; incidence ratio = 1.0). These data indicate that in the two district health authorities studied there was an excess incidence of childhood leukaemia during 1972-85 in the vicinity of the nuclear establishments. In the West Berkshire and Basingstoke and North Hampshire District Health Authorities an average of 60,000 children aged 0-14 lived within a 10 km radius of a nuclear establishment each year. The normal expectation of leukaemia in these children was two cases a year, whereas the recorded incidence was three cases per year, representing one extra case of leukaemia each year among these 60,000 children.     

The effects of vasectomy on health

The study of possible adverse effects of vasectomy have been mainly focussed on hormonal balance, spermatogenesis, the induction. of auto-immune reactions and cardiovascular changes including the non-fatal myocardial infarction. The review of literature, including our own work on the immunological sequelae of vasectomy, indicates that there is no health hazard following vasectomy. The presence of antibodies to spermatozoa in some individuals, however, may effect future fertility, if reversal is requested.     

Systematic position of some nearctic Heligmosomoidea (Nematoda: Trichostrongylina) from the U.S. National Parasite collection and their description

The systematic position of some heligmosomoid nematodes from rodents, deposited in the U.S. National Parasite Collection (USNPC), is revised, mainly through the study of their synlophe, which in all cases was unknown or insufficiently described. The material was registered as different species of Longistriata Schulz, 1926, a genus whose representatives are only parasitic in Holarctic insectivores. Longistriata norvegica Dikmans, 1935, parasitic in Rattus sp. becomes a synonym of Hassalstrongylus aduncus (Chandler, 1932). Specimens registered as Longistriata dalrymplei Dikmans, 1935, from Ondatra zibethicus, are confirmed to belong to Carolinensis (Travassos, 1937). Specimens registered as Longistriata noviberiae Dikmans, 1935, parasitic in Sylvilagus floridanus alacer, were found to belong to Vexillata, and Vexillata noviberiae n. comb. is here proposed. This is the first record of a species of Vexillata in a lagomorph. Other specimens registered as Longistriata norvegica, parasitic in Geomys floridanus austrinus, were also found to be an undescribed species of Vexillata (Hall, 1916), which is named Vexillata chitwoodi n. sp. This is similar to Vexillata chabaudi Yoyotte-Vado, 1972, Vexillata petteri Durette-Desset, 1970, Vexillata scorzai Guerrero, 1984 and Vexillata tejerai Guerrero, 1984, all having the same number of cuticular ridges (4 dorsal, 5 ventral) and the division of the dorsal ray at its apex. The most related species is V. chabaudi, which is differentiated from the new species by rays 4 not curved distally, by thick rays 8, and by a dorsal ray enlarged at the level of the arising of rays 8.     

Clinic-based primary care of frail older patients in California.

We surveyed medical directors of primary care clinics in California to learn how those clinics cared for their frail older patients. Of 143 questionnaires sent, 127 (89%) were returned. A median of 30% of all patient encounters were with persons aged 65 or older, and a median of 20% of older patients were considered frail. A total of 20% of the clinics routinely provided house calls to homebound elderly patients. Of clinics involved in training medical students of physicians (teaching clinics), 70% had at least one physician with an interest in geriatrics, compared with 42% of nonteaching clinics (P less than .005). For frail patients, 40% of the clinics routinely performed functional assessment, while 20% routinely did an interdisciplinary evaluation. Continuing education in geriatrics emerged as a significant independent correlate of both functional assessment and interdisciplinary evaluation. Among the 94 clinics with a standard appointment length for the history and physical examination, only 11 (12%) allotted more than 60 minutes for frail patients. The data suggest that certain geriatric approaches are being incorporated into clinic-based primary care in California but do not provide insight into their content or clinical effects.     

Physicians' private clinics in a Northern Thai Town — Patient-healer “Collaboration” and the shape of biomedical practice

Physicians' private clinics in small Northern Thai towns offer the patient the services of official biomedicine's most sophisticated clinical talent, and the physicians themselves an opportunity to significantly supplement their incomes. The clinic form, while familiar to Westerners and Japanese, has been adapted to the Northern Thai medical environment and Northern Thai notions of the therapeutic process. Because of sociocultural constraints and the pressure of the plural medical environment, physicians' private clinics result in a collaboration between patient and practitioner in which some prerogatives of each are compromised and others upheld to shape a clinical institution that satisfies the needs of each. This paper discusses three private clinics in a small Northern Thai town from the perspectives of the physicians and the patients, and then describes the collaboration that shapes practices within the clinics.     

Comparison of immunisation rates in general practice and child health clinics.

OBJECTIVE--To compare immunisation uptake rates in general practice surgeries and community child health clinics. DESIGN--Cohort study using data from a computerised child health system. SETTING--Four health districts of North East Thames Regional Health Authority. SUBJECTS--3616 children born January to March 1990 and resident in the four districts at the end of January 1991. MAIN OUTCOME MEASURES--Immunisation uptake rates at 10-12 months of age, age at immunisation, scheduling performance at the two locations, and odds ratios of outstanding immunisations. RESULTS--80% of children registered at general practices had completed their third dose of pertussis immunisation compared with 68% of those at health clinics. Median ages at the third dose were 24 weeks and 29 weeks at the two locations respectively. Scheduling was more effective at general practice surgeries. Unscheduled immunisations were more likely to be given after the recommended age. Overall, children resident in rural and suburban areas had greater uptakes than those in inner cities. Odds ratios for not being fully immunised among children registered at health clinics were 1.4 times those among children immunised in general practice and 3.0 times greater among children resident in inner cities than among those in rural and suburban districts. Children who moved into a district, however, were no less likely to be fully immunised than children who were born there. CONCLUSIONS--The immunisation uptake rate was better in general practices than in child health clinics in both inner city and rural and suburban areas. Uptake may be increased with additional support to enable general practitioners to undertake immunisations, especially in inner cities.     

Psychological Sequelae of the Station Nightclub Fire: Comparing Survivors with and without Physical Injuries Using a Mixed-Methods Analysis

Background

Surveying survivors from a large fire provides an opportunity to explore the impact of emotional trauma on psychological outcomes.

Methods

This is a cross-sectional survey of survivors of The Station Fire. Primary outcomes were post-traumatic stress (Impact of Event Scale – Revised) and depressive (Beck Depression Inventory) symptoms. Linear regression was used to examine differences in symptom profiles between those with and without physical injuries. The free-response section of the survey was analyzed qualitatively to compare psychological sequelae of survivors with and without physical injuries.

Results

104 participants completed the study survey; 47% experienced a burn injury. There was a 42% to 72% response rate range. The mean age of respondents was 32 years, 62% were male, and 47% experienced a physical injury. No significant relationships were found between physical injury and depressive or post-traumatic stress symptom profiles. In the qualitative analysis, the emotional trauma that survivors experienced was a major, common theme regardless of physical injury. Survivors without physical injuries were more likely to experience survivor guilt, helplessness, self-blame, and bitterness. Despite the post-fire challenges described, most survivors wrote about themes of recovery and renewal.

Conclusions

All survivors of this large fire experienced significant psychological sequelae. These findings reinforce the importance of mental health care for all survivors and suggest a need to understand factors influencing positive outcomes.     

Psychological Aspects of Vasectomy

In a study to assess the psychosocial and sexual effects of contraceptive vasectomy by questionnaire and personal interview, 10 out of 82 respondents indicated some psychological problem arising from the operation. Five out of seven couples interviewed had histories of marital, sexual, or psychological instability. Screening of applicants for vasectomy is therefore recommended, pre-existing instability being a contraindication to the operation.