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Background: Chlamydial infection is associated with tubal factor infertility (TFI); however, assessment of prior chlamydial infection and TFI is imperfect. We previously evaluated a combination of serological assays for association with TFI. We now describe the chlamydial contribution to TFI using a newer Chlamydia trachomatis Pgp3-enhanced serological (Pgp3) assay., Methods: In our case-control study of women 19 to 42 years old with hysterosalpingogram-diagnosed TFI (cases) and non-TFI (controls) in 2 US infertility clinics, we assessed possible associations and effect modifiers between Pgp3 seropositivity and TFI using adjusted odds ratios with 95% confidence intervals (CIs) stratified by race. We then estimated the adjusted chlamydia population-attributable fraction with 95% CI of TFI., Results: All Black (n = 107) and 618 of 620 non-Black women had Pgp3 results. Pgp3 seropositivity was 25.9% (95% CI, 19.3%-33.8%) for non-Black cases, 15.2% (95% CI, 12.3%-18.7%) for non-Black controls, 66.0% (95% CI, 51.7%-77.8%) for Black cases, and 71.7% (95% CI, 59.2%-81.5%) for Black controls. Among 476 non-Black women without endometriosis (n = 476), Pgp3 was associated with TFI (adjusted odds ratio, 2.6 [95% CI, 1.5-4.4]), adjusting for clinic, age, and income; chlamydia TFI-adjusted population-attributable fraction was 19.8% (95% CI, 7.7%-32.2%) in these women. Pgp3 positivity was not associated with TFI among non-Black women with endometriosis or among Black women (regardless of endometriosis)., Conclusions: Among non-Black infertile women without endometriosis in these clinics, 20% of TFI was attributed to chlamydia. Better biomarkers are needed to estimate chlamydia TFI PAF, especially in Black women., Competing Interests: Conflict of Interest and Sources of Funding: The authors have no conflict of interest. This study was supported by Centers for Disease Control and Prevention, Prevention Research Centers grants (5U48DP001915 and 5U48DP001918) and National Institutes of Health, Sexually Transmitted Infections Clinical Trials group (contract HHSN27220130012I)., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Nearly 14% of US women report any lifetime infertility which is associated with health care costs and psychosocial consequences. Tubal factor infertility (TFI) often occurs as a result of sexually transmitted diseases and subsequent pelvic inflammatory disease. We sought to evaluate for and describe potential racial disparities in TFI and in vitro fertilization (IVF) prevalence., Methods: Records of women aged 19 to 42 years in our retrospective cohort from 2 US infertility clinics were reviewed. We calculated TFI prevalence, IVF initiation prevalence, and prevalence ratios (PRs), with 95% confidence intervals (CIs) for each estimate, overall and by race., Results: Among 660 infertile women, 110 (16.7%; 95% CI, 13.8-19.5%) had TFI which was higher in Black compared with White women (30.3% [33/109] vs 13.9% [68/489]; PR, 2.2 [95% CI, 1.5-3.1]). For women with TFI, IVF was offered to similar proportions of women by race (51.5% [17/33] vs 52.9% [36/68] for Black vs White women); however, fewer Black than White women with TFI started IVF (6.7% [1/15] vs 31.0% [9/29]; PR, 0.2 [95% CI, 0-1.0]), although the difference was not statistically different., Conclusions: Tubal factor infertility prevalence was 2-fold higher among Black than White women seeking care for infertility. Among women with TFI, data suggested a lower likelihood of Black women starting IVF than White women. Improved sexually transmitted disease prevention and treatment might ameliorate disparities in TFI., Competing Interests: Conflicts of Interest: K.R.H. is on the Speakers bureau for AbbVie, and W.M.G. has received research funds and consulting fees from Hologic and consulting fees from Roche. The other authors declare no conflicts of interest., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Chlamydia trachomatis (Ct) infection ascending to the upper genital tract can cause infertility. Direct association of genetic variants as contributors is challenging because infertility may not be diagnosed until years after infection. Investigating the intermediate trait of ascension bridges this gap., Methods: We identified infertility genome-wide association study (GWAS) loci using deoxyribonucleic acid from Ct-seropositive cisgender women in a tubal factor infertility study and Ct-infected cisgender women from a longitudinal pelvic inflammatory disease cohort with known fertility status. Deoxyribonucleic acid and blood messenger ribonucleic acid from 2 additional female cohorts with active Ct infection and known endometrial infection status were used to investigate the impact of infertility single-nucleotide polymorphisms (SNPs) on Ct ascension. A statistical mediation test examined whether multiple infertility SNPs jointly influenced ascension risk by modulating expression of mediator genes., Results: We identified 112 candidate infertility GWAS loci, and 31 associated with Ct ascension. The SNPs altered chlamydial ascension by modulating expression of 40 mediator genes. Mediator genes identified are involved in innate immune responses including type I interferon production, T-cell function, fibrosis, female reproductive tract health, and protein synthesis and degradation., Conclusions: We identified Ct-related infertility loci and their potential functional effects on Ct ascension., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Chlamydia trachomatis infection is highly prevalent among young women in the United States. Prevention of long-term sequelae of infection, including tubal factor infertility, is a primary goal of chlamydia screening and treatment activities. However, the population-attributable fraction of tubal factor infertility associated with chlamydia is unclear, and optimal measures for assessing tubal factor infertility and prior chlamydia in epidemiological studies have not been established. Black women have increased rates of chlamydia and tubal factor infertility compared with White women but have been underrepresented in prior studies of the association of chlamydia and tubal factor infertility., Objectives: The objectives of the study were to estimate the population-attributable fraction of tubal factor infertility associated with Chlamydia trachomatis infection by race (Black, non-Black) and assess how different definitions of Chlamydia trachomatis seropositivity and tubal factor infertility affect population-attributable fraction estimates., Study Design: We conducted a case-control study, enrolling infertile women attending infertility practices in Birmingham, AL, and Pittsburgh, PA, during October 2012 through June 2015. Tubal factor infertility case status was primarily defined by unilateral or bilateral fallopian tube occlusion (cases) or bilateral fallopian tube patency (controls) on hysterosalpingogram. Alternate tubal factor infertility definitions incorporated history suggestive of tubal damage or were based on laparoscopic evidence of tubal damage. We aimed to enroll all eligible women, with an expected ratio of 1 and 3 controls per case for Black and non-Black women, respectively. We assessed Chlamydia trachomatis seropositivity with a commercial assay and a more sensitive research assay; our primary measure of seropositivity was defined as positivity on either assay. We estimated Chlamydia trachomatis seropositivity and calculated Chlamydia trachomatis-tubal factor infertility odds ratios and population-attributable fraction, stratified by race., Results: We enrolled 107 Black women (47 cases, 60 controls) and 620 non-Black women (140 cases, 480 controls). Chlamydia trachomatis seropositivity by either assay was 81% (95% confidence interval, 73-89%) among Black and 31% (95% confidence interval, 28-35%) among non-Black participants (P < .001). Using the primary Chlamydia trachomatis seropositivity and tubal factor infertility definitions, no significant association was detected between chlamydia and tubal factor infertility among Blacks (odds ratio, 1.22, 95% confidence interval, 0.45-3.28) or non-Blacks (odds ratio, 1.41, 95% confidence interval, 0.95-2.09), and the estimated population-attributable fraction was 15% (95% confidence interval, -97% to 68%) among Blacks and 11% (95% confidence interval, -3% to 23%) among non-Blacks. Use of alternate serological measures and tubal factor infertility definitions had an impact on the magnitude of the chlamydia-tubal factor infertility association and resulted in a significant association among non-Blacks., Conclusion: Low population-attributable fraction estimates suggest factors in addition to chlamydia contribute to tubal factor infertility in the study population. However, high background Chlamydia trachomatis seropositivity among controls, most striking among Black participants, could have obscured an association with tubal factor infertility and resulted in a population-attributable fraction that underestimates the true etiological role of chlamydia. Choice of chlamydia and tubal factor infertility definitions also has an impact on the odds ratio and population-attributable fraction estimates., (Published by Elsevier Inc.)

We know little about how forest bats, which are cryptic and mobile, use roosts on a landscape scale. For widely distributed species like the endangered Indiana bat Myotis sodalis, identifying landscape-scale roost habitat associations will be important for managing the species in different regions where it occurs. For example, in the southern Appalachian Mountains, USA, M. sodalis roosts are scattered across a heavily forested landscape, which makes protecting individual roosts impractical during large-scale management activities. We created a predictive spatial model of summer roosting habitat to identify important predictors using the presence-only modeling program MaxEnt and an information theoretic approach for model comparison. Two of 26 candidate models together accounted for >0.93 of AICc weights. Elevation and forest type were top predictors of presence; aspect north/south and distance-to-ridge were also important. The final average best model indicated that 5% of the study area was suitable habitat and 0.5% was optimal. This model matched our field observations that, in the southern Appalachian Mountains, optimal roosting habitat for M. sodalis is near the ridge top in south-facing mixed pine-hardwood forests at elevations from 260-575 m. Our findings, coupled with data from other studies, suggest M. sodalis is flexible in roost habitat selection across different ecoregions with varying topography and land use patterns. We caution that, while mature pine-hardwood forests are important now, specific areas of suitable and optimal habitat will change over time. Combining the information theoretic approach with presence-only models makes it possible to develop landscape-scale habitat suitability maps for forest bats.

Objective: To determine the proportion of euthyroid women attending a fertility practice who develop hypothyroidism in very early pregnancy (gestational hypothyroidism [GHT]), and to examine the association of GHT with exogenous gonadotropin treatment., Design: Retrospective cohort study., Setting: A private reproductive medicine practice., Patient(s): All healthy women (N = 94) with infertility or recurrent pregnancy loss, TSH level <2.5 mIU/L, negative thyroid peroxidase antibodies at initial evaluation, and not taking thyroid medication, who conceived during an 18-month period., Intervention(s): Usual fertility care; 30 women who had received exogenous gonadotropins., Main Outcome Measure(s): Serum TSH level at the time of pregnancy detection., Result(s): Gestational hypothyroidism (TSH ≥ 2.5 mIU/L) developed in 23 of 94 women (24%). The mean increase in serum TSH level from initial evaluation to early pregnancy was 0.45 ± 0.08 [SE] mIU/L. There was a trend toward the association of GHT with use of exogenous gonadotropins. Gestational hypothyroidism was positively associated with initial prepregnancy TSH level., Conclusion(s): Euthyroid women may develop mild hypothyroidism in early pregnancy, especially after exogenous gonadotropin treatment. Appropriate vigilance will allow for timely levothyroxine treatment., (Copyright © 2015 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine if obstetric outcome is compromised in pregnancies in which a spontaneous pregnancy reduction (SPR) occurred in the first trimester., Study Design: Case-control study., Results: First-trimester SPR was diagnosed in 29 (27.8%) of 104 twin pregnancies, 14 (28.6%) of 49 triplet pregnancies and 10 (28.6%) of 35 quadruplet pregnancies. Of these 53 patients, 15 were excluded from the analysis. In the remaining 38 women with SPR, vaginal bleeding occurred in 2 (5.3%) as compared to 7 (8.3%) of the controls. Pregnancy-induced hypertension occurred in 4 (10.5%) of SPR pregnancies as compared to 9 (10.7%) of control pregnancies. When compared to respective controls, there were no significant differences in the birth weights or gestational age at delivery of pregnancies spontaneously reduced to singletons (SPR, 38.5 weeks; controls, 38.2 weeks), twins (SPR, 36.2 weeks; controls, 34.4 weeks) or triplets (SPR, 31.0 weeks; controls, 32.0 weeks)., Conclusion: SPR can be recognized in >25% of multiple pregnancies diagnosed in the early first trimester. Our data suggests that SPR is not associated with decreased gestational age at delivery, reduced birth weight or increased incidence of pregnancy-induced hypertension.

Objective: To determine whether recombinant follicle-stimulating hormone (rFSH) should be administered intramuscularly (i.m.) or subcutaneously (s.c.) to obese women., Design: Randomized, single-center, two-way crossover study., Setting: Academic clinical research center., Subject(s): Nineteen healthy women of reproductive age with body mass indices of 19.9 kg/m(2)-42.8 kg/m(2)., Intervention(s): Leuprolide acetate 3.75 mg i.m. to achieve pituitary down-regulation as determined by serum E(2) levels. Subjects were then given a single dose of 300 IU rFSH either i.m. or s.c.. Multiple blood sampling was performed over the next two weeks, and after retreatment with leuprolide, a second 300 IU rFSH dose was given via the other administration route., Main Outcome Measure(s): Serum samples were analyzed in duplicate for follicle-stimulating hormone (FSH) using a standard radioimmunoassay in a single run. Maximum concentrations (C(max)), times to C(max) (T(max)), and extent of absorption (area under curve [AUC]) with i.m. vs. s.c. administration were compared using paired analysis., Result(s): Maximal concentrations were achieved within 24 hours with both s.c. and i.m. routes. No significant differences were found in C(max), T(max), or AUC with s.c. vs. i.m. administration. A decline of AUC occurred among subjects of higher body mass index (BMI) with rFSH given either s.c. or i.m.. Subcutaneous administration achieved AUCs comparable to i.m. administration in both normal-weight and obese subjects., Conclusion(s): Our data indicate that the s.c. administration of rFSH is appropriate for women regardless of body mass.

The objective of this study was to assess how characteristics of the intercourse and the couple relate to semen exposure during use of the female condom. From 1996 to 1998, 210 women in Birmingham, Alabama, were trained to use the female condom and follow study procedures during a group session and individually practiced inserting the device. The outcome was semen exposure as defined by comparing pre- and postcoital prostate-specific antigen levels in vaginal fluid. Women who had high income levels had lower rates of semen exposure (odds ratio (OR) = 0.3, 95% confidence interval (CI): 0.2, 0.7), while those in a relationship of less than 2 years were at greater risk (OR = 2.4, 95% CI: 1.3, 4.1). Couples with a large disparity in vaginal fundus size and penis size were at increased risk of semen exposure (OR = 2.7, 95% CI: 1.2, 6.0). Engaging in very active intercourse also increased the risk (OR = 1.7, 95% CI: 1.1, 2.6). Thus, the protective effect of the female condom appears to be a function of user- and intercourse-specific characteristics. Future studies of male condom efficacy should focus on collecting detailed data about the users and characteristics of intercourse to predict failure accurately.

In 1996-1998, the authors measured prostate-specific antigen (PSA) in vaginal fluid to assess the frequency of female condom failure and to evaluate the association of self-reported failure with semen exposure. Women at low risk of sexually transmitted diseases (n = 210) were recruited in Birmingham, Alabama. They were trained to use the female condom, sample vaginal fluid before and after condom use, and complete forms to report problems during each use. Semen exposure was assessed by comparing pre- and postcoital PSA levels in vaginal fluid. A total of 175 women used 2,232 condoms. The rate of semen exposure ranged from 7% to 21% of condom uses, depending on the exposure criterion. Exposure was more likely (21-34%) and more intense (mean postcoital PSA, 24.7 ng/ml) if participants reported a mechanical problem versus other problems or no problems (exposure rate, 5-20% in both instances; mean postcoital PSA, 9.6 and 7.8 ng/ml, respectively). In logistic regression analyses for repeated measurements, user-reported problems accounted for less than 59% of the instances of semen exposure. The female condom prevented semen exposure in 79-93% of condom uses. Exposure was associated with user-reported problems but also occurred in their absence. Reported problems and semen exposure decreased with user experience.

Objective: To report on a one-year experience participating in a capitated healthcare plan for infertility., Design: Prospective study., Setting: University population., Patient(s): Reproductive-age women 15 to 50 years., Intervention(s): The first-generation Lewin infertility algorithm and CATHI software were used to negotiate infertility services under a capitated arrangement for $0.50 per member per month. The following reports our experience for the fiscal year 1997., Main Outcome Measure(s): Infertility services rendered, pregnancy rate, cost of services, collection rates., Result(s): Five thousand forty-six women representing 39,689 member months generated 39 new and 198 return visits. Thirty-two percent of the patients required three visits or less; six patients generated 22% of the visits. Fifty-one percent listed infertility as one of their chief complaints; 31% had mixed diagnoses. Eight (7.6%) patients required surgery, 11 (10.5%) patients underwent either IVF or GIFT cycles. Total charges submitted were $176,636; the amount assigned to specialty care was $135,277, and to IVF/GIFT, $33,433. Total capitated payments, including copayments, was $126,256 under the reproductive medicine agreement and $32,891 under the infertility rider. This resulted in a 71% gross collections rate., Conclusion(s): This study indicates that entering into a capitated health care plan to provide an infertility benefit can produce a successful result.

Background: Studies of condom efficacy rely on self-reported behavior. Objective markers of exposure to semen may provide a more valid assessment of condom failure and failure to use condoms., Goals of This Study: To compare three semen biomarkers: acid phosphatase (AP) activity, prostate specific antigen (PSA), and the human seminal plasma antigen (MHS-5)., Study Design: Twenty women were intravaginally inoculated with six measured, increasingly larger amounts of their partners' semen. Vaginal fluid was collected by the participant using swabs and tested., Results: Background levels of PSA were low (0.00-1.25 ng/ml), background levels of AP were variable (0-350 U/l), and all preinoculation samples were negative for MHS-5. All postinoculation samples were positive for PSA, 64 of 117 (55%) for AP, and 14 of 120 (12%) for MHS-5., Conclusion: The PSA immunoassay was the best semen biomarker under these sampling and testing conditions.

Higher-order multiple pregnancy is associated with significant maternal and fetal complications. Multifetal pregnancy reduction is one option for women with a higher-order multiple pregnancy. Various aspects of multifetal pregnancy reduction are discussed, including the background, options, risks, benefits, techniques, results, and appropriate physical and psychosocial support.

Objective: To assess the feasibility of logistic regression analysis for determining the gestational ages at which detection of early pregnancy landmarks first can be observed., Design: Retrospective analysis., Setting: University-based tertiary care clinic., Patient(s): Eighty-two women with viable singleton pregnancies in whom ovulation had been achieved by an injection of hCG., Intervention(s): Two hundred fifteen transvaginal sonographic scans., Main Outcome Measure(s): Logistic regression was used to estimate the probability of detection of sonographic findings as a function of gestational age., Result(s): We found that the likelihood of visualization of a gestational sac or fetal heart motion could be represented accurately by logistic equations. Gestational age at which there was 95% probability of visualization was 35.5 days for the gestational sac and 44.5 days for fetal cardiac activity. The probability of detecting fetal cardiac activity was 95% when the mean gestational sac diameter was 1.6 cm and was 99% at 1.9 cm., Conclusion(s): The sonographic appearances of developmental landmarks in early pregnancy occurs within well-defined gestational time periods, and the probabilities for visualization can be closely approximated using a logistic model. Our results suggest that the number of sonographic examinations required to document infertility treatment success can be minimized by surveillance at standardized gestational ages.

The author's purpose is to urge the constructive convergence of two current judgment and decision-making research paradigms. He shows why the heuristics-and-biases approach and the lens-model approach should be placed in the context of two very different metatheories, the coherence metatheory and the correspondence metatheory. The differences between the two research paradigms thus become apparent; they speak to different problems and appeal to different criteria for evaluating performance. Bringing the two into a constructive relationship to one another, however, will not only double the store of knowledge regarding diagnostic judgment and decision making, but also enhance efforts to achieve a cumulative discipline. Isolating these research paradigms from one another--as is done now--stifles theoretical generality, fragments knowledge, and confuses medical decision makers. An example of how convergence can be achieved is provided.

The quantity and subclass distribution of IgA produced by the human uterine cervix may have a significant impact on the defence against sexually transmitted diseases as well as the regulation of fertility. Cervical mucus was obtained from 15 normal ovulating women around the time of ovulation. The total amounts of secreted IgA (including IgA1 and IgA2), IgG, and IgM were determined by ELISA. IgA was detected at high levels in all samples of cervical mucus. When ovulation was ascertained by daily urinary luteinizing hormone testing, IgA production was maximal 2-3 days before ovulation. Equal proportions of IgA1 and IgA2 were detected in cervical mucus, and 80% of the IgA occurred in the polymeric forms. The increased levels of IgA, the ratios of IgA1 to IgA2, and the predominance of polymeric IgA indicate that much of the IgA in human uterine cervical fluid originates from local production.

Objective: To evaluate the effect of a routine breast examination on serum PRL levels., Design: Prospective clinical study., Setting: University-based reproductive endocrinology unit., Patients: Eleven nonlactating, euprolactinemic women of reproductive age with a history of regular menstrual cycles and currently taking no medications., Interventions: Breast examination using standard technique., Main Outcome Measure: Changes in serum PRL levels after breast examination., Results: Baseline PRL levels ranged from 3.64 to 19.23 ng/mL (mean 7.17 ng/mL; conversion factor to SI unit, 1.00). There were no significant increases in PRL levels after breast examination, with mean PRL levels after 15, 30, and 45 minutes of 6.59, 6.84, and 6.45 ng/mL, respectively., Conclusion: Routine breast examination does not alter acutely serum PRL levels in normal women.

Objective: To compare the obstetric outcomes of twin pregnancies obtained as a result of multifetal pregnancy reduction to those in which pregnancy reduction had not been used., Design: Retrospective analysis., Setting: University-based tertiary care infertility clinic., Patients: Seventy-four twin pregnancies continuing beyond 10 weeks. Of these, 32 gestations had undergone reduction to twins at 10 weeks., Main Outcome Measures: Gestational age at delivery, birth weights, pregnancy complications., Results: All pregnancies advanced beyond 20 weeks gestation. The mean gestational age at delivery of the reduction group was 33.8 versus 35.7 weeks in the nonreduced group; only 25% of reduced pregnancies reached 37 weeks compared with 57.9% of nonreduced twins. The mean fetal birth weights of the two groups differed significantly (reduced: 2,038 g, nonreduced: 2512 g). The gestational age at delivery in patients reduced from triplets was significantly greater than in pregnancies reduced from quadruplets or higher. Multiple regression analysis revealed that for a given gestational age at delivery, a history of pregnancy reduction was associated with decreased birth weight., Conclusion: These data suggest that multifetal pregnancy reduction does not reverse completely the decreased gestational age and impaired fetal growth associated with high-order multiple pregnancy. Furthermore, fetal growth of reduced pregnancies seems to be impaired independent of the gestational age at which delivery occurs.

The findings of our study indicate that women pretreated with E/progestin demonstrate increased gonadotropin requirements when undergoing ovulation induction. Whether this treatment has a significant effect on the outcome of ovulation induction in patients receiving gonadotropins remains to be established.

Estrogen (E)/progestin therapy for functional ovarian cysts is widely used in clinical practice, but the efficacy of this treatment has not been determined in controlled trials. In this study, we examined the effect of E/progestin administration in a group of infertility patients enrolled in a program of ovulation induction who had cysts identified by transvaginal sonography. Patients were randomized to receive either norethindrone 1 mg/mestranol 0.05 mg/d (group A, n = 24) or no treatment (group B, n = 24) for up to 6 weeks. Patients were re-evaluated by sonography at 3, 6, and 9 weeks after entry into the protocol. The ages, mean cyst diameters, and proportions of patients having received gonadotropins in the previous menstrual cycle were not significantly different among the two groups. All patients who had a sonographic abnormality persisting for 9 weeks were surgically explored and found to have pathological cysts. The rate of disappearance of functional ovarian cysts was not affected by E/progestin treatment.

The requirement to obtain a semen sample at a specific time for an infertility treatment procedure has potential to produce considerable performance anxiety. This study was designed to evaluate the semen quality of men participating in infertility treatments associated with heightened performance anxiety. The most recent pretreatment semen analysis and the infertility treatment semen analysis, as well as the first and last procedure semen analyses, were compared using paired t-tests for 77 patients undergoing assisted reproductive technology procedures and 121 patients undergoing intrauterine insemination. No significant differences were noted in either of these groups of patients. However, in men with total motile sperm counts of less than 40 million, semen parameters improved significantly in the procedure semen analyses. Thus, participation in infertility treatments associated with performance anxiety does not appear to be detrimental to semen quality, and in certain groups of patients semen quality may improve.

Before carrying out any action, whether it is concerned with professional life or with humdrum everyday routine, one has always to choose between at least two alternatives: to act or not to act. Decisions are always based upon information, and it is clear that this information should be of the best quality possible and that it should also be used in the most efficient way possible. Judgement analysis helps to improve the reliability of clinical decisions, in practice as well as in the management of clinical trials.

This study extends earlier work on the evaluation of depression by general physicians, and compares the results obtained with that group with those from a group of experienced psychiatrists. Differences within each group were larger than those between them. In neither group were individuals able to describe their own diagnostic processes with great accuracy, but psychiatrists were, as expected, somewhat more consistent than general physicians. They became even more so when allowed to select their own cues; of which, however, they made use of a smaller number. These tended to be of a specific rather than (as with the physicians) of a general nature.

Fifteen general physicians were given profiles of symptom combinations representing 80 depressed patients. They were asked to judge the severity of the disorder and to prescribe. There were two phases to the experiment, the formal structure of both being the same. In the first phase, all physicians based their judgments only on the cues of the Hamilton Depression scale; in the second, each physician defined his own cues. Multivariate regression analysis was applied to the observations. Agreement between the judges was low. Most had a more complex policy, in regard to both judgment of the severity of the depression and prescribing, when selecting their own cues than when restricted to textbook variables, but used it more consistently. The observations have important implications for training and research in psychiatry and in psychopharmacology.

Departing from the traditional model for teaching and learning, this article deals with the problem of teaching and learning the effective application of knowledge already acquired. To this end, a model for the process of exercising judgment was outlined, and the results of an empirical study of judgmental learning were employed to show the inadequacy of the traditional outcome feedback procedures. Computer graphics techniques were used to provide new forms of information to the learner; the results are promising for the rapid learning of a task that would otherwise be difficult to learn.