Faculty Bibliography

The growth of managed care is changing the practice of medicine; it has a direct impact on the quality of care offered to women and may erode gains made in the field of women's health. Graduate medical education must be transformed if women's health is to be effectively represented in the evolving health care system. An interdisciplinary primary care specialty in women's health is the best strategy for preparing physicians to deliver cost-effective comprehensive care to women in a changing health care marketplace

In the medical evaluation of older female patients with sexual problems, you need to assess the woman's psychological state, as well as her physical condition. An important question to ask is whether her level of sexual activity is satisfactory to her. Women's early sexual experiences, in some cases including childhood sexual abuse, impact greatly on their sexuality in later life. When sexual problems are related to the menopause, customized hormone replacement therapy is the treatment of choice. Other clinical factors that impact on older women's sexuality include urinary incontinence, breast surgery, and hysterectomy

In the medical evaluation of older men with erectile dysfunction, obtain a detailed history to determine whether the dysfunction is organic or psychogenic. Determine if there are underlying pathologic processes--most notably vascular diseases--or other factors responsible for the dysfunction, such as medications or nerve or arterial damage from surgery. Lifestyle changes in mid-life (regular exercise, a low-fat diet, and smoking cessation) increase a man's chances of remaining potent as he grows older. Treatments for impotence include injection therapy, vacuum devices, and implants. Each therapy has advantages and disadvantages, and the informed patient plays an important role in choosing the therapy that is right for him

Contemporary physicians who wish to specialize formally in the care of women have inherited a surgical postgraduate program that focuses primarily on reproductive health. Mounting evidence suggests a broader perspective is needed. This article describes the role obstetrics-gynecology might play in this advancement

Monocyte-specific monoclonal antibodies (7) were used to compare the efficacy of monocytes and dendritic cells as accessory or stimulator cells for human T cell replication. Both unfractionated and plastic-adherent mononuclear cells were first treated with a cytolytic antimonocyte antibody that kills greater than 95% of monocytes but not dendritic cells. When tested as stimulators of the mixed leukocyte reaction (MLR) and of oxidative mitogenesis (the proliferation of T cells modified with sodium periodate), the monocyte-depleted cells had normal or enhanced stimulatory capacity. Monocyte-depleted mononuclear cells also proliferated normally to soluble antigens (Candida albicans, tetanus toxoid), even under limiting conditions of cell dose, antigen dose, and culture time. Adherent blood mononuclear cells were next separated into monocyte-enriched and -depleted components using fluoresceinated antimonocyte antibody and the cell sorter. The depleted fraction (less than 2% monocytes by esterase staining and by cytology) contained the dendritic cells and exhibited at least 75% of the accessory activity. The monocyte-rich fraction (approximately 97% esterase positive) stimulated the MLR and oxidative mitogenesis weakly, and was comparable in potency to nonadherent cells. Cell-specific antibodies and complement were also used to prepare dendritic cells that were thoroughly depleted of monocytes and lymphocytes. The dendritic cells (70-80% pure) were potent stimulators of the allogeneic MLR, syngeneic MLR, and tetanus toxoid response, being active at stimulator to responder ratios of 1:100 or less. Taken together with previous studies (1, 2), these experiments indicate that the dendritic cell is the major stimulator of T cell replication in man. The contribution of class II products of the major histocompatibility complex (7) was then evaluated with a new monoclonal, 9.3F10. Accessory function was dramatically inhibited if cells bearing class II antigens were killed with 9.3F10 and complement, or if class II molecules were blocked by the addition of 9.3F10 Fab to the culture medium. The expression of 9.3F10 class II products was therefore studied on purified monocytes and dendritic cells. Most if not all cells in both populations reacted with 9.3F10, and each population exhibited approximately 150,000 125I-Fab 9.3F10 binding sites per cell. Since Ia+ dendritic cells are active accessory cells, but Ia+ monocytes are not, class II products are necessary but not sufficient for the stimulation of T cell proliferation in man.