Intrapartum Epidural Anesthesia May Affect Breast Feeding

(26th Annual Meeting of the North American Primary Care Research Group) The use of intrapartum epidural anesthesia may be associated with increased rates of breast-feeding cessation soon after birth, according to a pilot study of 124 mothers of healthy infants admitted to a normal newborn nursery. All of the mothers had begun breast-feeding their infants after delivery, and infant feeding was assessed during hospitalization and the two-week postpartum period. Other predictive factors known to be associated with breast-feeding success were also assessed. Follow-up information was available for 95 (76.6 percent) of the mothers. Twenty-seven (21.8 percent) of the mothers discontinued or decreased breast-feeding in the two weeks after delivery. Overall, the mothers who used epidural anesthesia had a higher risk of discontinuing breast-feeding, compared with women who had not used epidural anesthesia (relative risk: 1.7). Black and single women who used epidural anesthesia had a significantly higher risk of discontinuing breast-feeding (relative risk: 8.0 and 3.7, respectively). Other factors, such as maternal educational status, source of prenatal care, and infant birth weight, also were associated with the discontinuation of breast-feeding but did not appear to change the fundamental relationship between epidural use and breast-feeding success.—claire e. hollan d, University of North Carolina, Chapel Hill, and valerie j. king, m.d., m.p.h., Radcliffe Infirmary, Oxford, England.

Factors Related to Underreferral of Older Women for Mammography

(North American Primary Care Research Group) Survey data from a study sponsored by the National Institutes of Health reveal a number of reasons why physicians do not refer all women over age 50 for annual screening mammograms even though physicians overwhelmingly agree with mammography screening guidelines and know that encouraging use of mammography is important to increase compliance. Eighty-five primary care physicians from 61 nonacademic community practices completed several surveys over a three-year period. Referrals for mammograms fell short of screening guidelines from the National Cancer Institute because of the following factors: (1) concerns about patient comorbidity and age; (2) physician habits that limit referrals to certain types of patient/physician encounters, such as the annual physical examination; (3) beliefs of physicians that patients see other physicians who will handle referrals; (4) anticipated patient resistance; and (5) lack of practice reminder systems to cue referral. Physicians also overestimated their referral rates by 100 percent. The investigators note that these data point out several areas of intervention for addressing underreferral for screening mammography in women over age 50.—jeanne parr lemkau, ph.d., Wright State University School of Medicine, Dayton, Ohio, and kathleen e. grady, ph.d., Massachusettes Institute of Behavioral Medicine, Springfield.

Children's Drawings Have Limited Value in Detecting Child Abuse

(North American Primary Care Research Group) Results of a study conducted to evaluate the use of children's drawings in the detection of child abuse indicate that drawing techniques appear to have limited value in highlighting abuse. In the study, 33 mental health professionals and 29 other professionals (persons without health training but with similar personal and professional experience with child abuse, such as teachers and probation workers) attended a seminar on children's drawings and afterward attempted to correctly identify 12 drawings by abused children from a sample of 36 drawings that were created during a matched control study (each abused child was matched with two children who had not been abused). None of the participants were able to identify the drawings of the abused children with an accuracy above the level expected by chance. However, the mental health professionals did significantly better than the other professionals in identifying drawings of abused children. The investigator believes that family physicians and other health care professionals should not use such drawings as the only evidence that abuse has taken place when confronted with children's drawing in case conferences.—m. w. m. veltman, University of Cambridge, England.

Leg Strengthening Programs Can Reduce Knee Injury Rate in Athletes

(North American Primary Care Research Group) Effective lower extremity strengthening programs can significantly reduce the rate of knee injuries in high school athletes, according to a study that included all varsity football players at seven high schools in San Antonio (298 athletes). Baseline data were collected on height, weight, 40-yd sprint speed, lower extremity strength (ability to perform a maximal squat), school size and socioeconomic status of the school population. Injury surveillance data were obtained weekly throughout the football season. Performance measures were repeated at the end of the season. The injury rate was inversely correlated with the mean squat strength. The athletes at schools with overall strength gains through the season showed a strong trend toward lower knee injury rates than athletes at schools with strength losses (6.1 percent versus 11.1 percent). Among schools with lower socioeconomic status, the athletes at schools with strength gains demonstrated significantly lower knee injury rates than athletes at schools with strength losses (5.7 percent versus 18.7 percent). The athletes at schools with strength losses through the season were four times more likely to sustain a knee injury than athletes at schools with strength gains. The investigators believe that family physicians who are team physicians should educate coaches, athletes and athletic trainers about the importance of programs to maintain and increase lower extremity strength in preventing knee injuries.—walter l. calmbach, m.d., et al., University of Texas Health Science Center, San Antonio.

Study Evaluates Dosing Schedule of Vaccine Against Lyme Disease

(36th Annual Meeting of the Infectious Diseases Society of America) Three doses of the vaccine against Lyme disease (Lymerix), when given to adults (15 to 70 years of age) on an accelerated dosing schedule of zero, one and two months, provide an antibody response comparable to that obtained with the dosing schedule of zero, one and 12 months recently approved by the U.S. Food and Drug Administration (FDA), according to a new randomized, double-blind study of the vaccine. The FDA-approved dosing schedule demonstrated vaccine efficacy rates of 79 percent against definite Lyme disease and 100 percent against asymptomatic infection. In the new study of accelerated dosing, all of the subjects received injections of the vaccine at zero and one month. Subjects were then randomized to receive an additional dose at either month 2 or month 12. Clinical signs and symptoms were recorded for four days after each dose. Blood was collected one month after the second and third doses. Subjects receiving the accelerated dosing schedule had comparable antibody titers to those receiving the third dose at 12 months. In all of the studies of the vaccine, most local and general side effects were mild to moderate in severity and self-limited.—vijay sikand, m.d., et al., Tufts University School of Medicine, Boston.