Primary care update for Ob/Gyns最新文献

As the population ages, increasing numbers of older women will undergo gynecologic surgical procedures. Optimizing the perioperative care of older women requires an understanding of and attention to usual perioperative issues such as cardiac risk assessment and venous thromboembolism prophylaxis, as well as geriatric-specific issues such as functional status, dementia, delirium, polypharmacy, pressure sores, geriatric physiology, and bowel and bladder management.

Urinary incontinence is an important health problem with a significant effect on the quality of life of its sufferers. Despite the prevalence and impact of the condition, incontinent patients seem to accept their symptoms for years before they consult their physician. When they do finally consult their physician, an unnecessarily high proportion is referred to a specialist. However, though the pathophysiology is complex, urinary incontinence can be effectively treated in primary care practice with a basic knowledge of the anatomy and function of the lower urinary tract. This review presents updated findings on the neurophysiology of the lower urinary tract (LUT), focusing on the role of the central and peripheral autonomic and somatic nervous systems during urinary storage and voiding.

Hans Christian Joachim Gram, who pioneered the method of the Gram stain, was born on September 13, 1853, in Copenhagen, Denmark. His early interests involved plants, pharmacology, and microscopes. He obtained his M.D. from the University of Copenhagen and ultimately became a resident physician at the Municipal Hospital of Copenhagen. Gram's early work concerned the study of red corpuscles in humans. Gram traveled throughout Europe studying pharmacology and bacteriology and worked in the Berlin laboratory of the well-respected microbiologist, Karl Friedländer. It was here that Gram developed and perfected his new method for staining and identifying bacteria. Throughout his career he showed a keen interest in the clinical education of students. In 1923, Gram retired from his medical practice position and lived inconspicuously, resuming his former interest in the history of medicine. He died in 1938 at the age of 85.

Paternity establishment for 90% of births to unwed mothers is a recent federal mandate designed to optimize parental rights and childhood benefits. Using a statewide database, this study examines the relationship between selected demographic and clinical variables and in-hospital paternity establishment. Vital statistics for the year 2000 were obtained pertaining to live birth deliveries in the state of Michigan. Data were developed by the Michigan Department of Community Health through linkage of state birth data files with a central paternity registry. Statistical comparisons were made of the frequency distributions of the study variables, using a normal approximation of binomial distribution. There were a total of 134,917 live births in Michigan during 2000. Of these, 46,057 (34.1%) were to unmarried women. The overall rate of in-hospital paternity establishment for these cases was 56% in 2000. A review of selected characteristics indicated a wide range of variability in the proportion of cases for which paternity is established. The following characteristics were significantly different (P<0.05) from the overall average rate (56%) of paternity establishment in 2000: African American, 37.3%; less than high school education, 48.3%; birth weight under 1500 g, 44.8%; birth weight 1500–2499 g, 48.4%; no prenatal care, 30.1%; third trimester care, 37.9%; second trimester care, 47.3%; abnormal newborn, 53.2%; gestational age ≤37 weeks, 50.7%; age less than 20, 52.8%. A greater than average rate of paternity establishment was noted with first trimester care (61.3%), high school or greater education (60.7%), and non–African-American race (71.3%). In conclusion, key demographic and clinical variables limiting the successful establishment of paternity are readily identifiable. In order to achieve the legislative mandate of 90% success, strategies must be developed to improve overall paternity establishment, with special emphasis on these target populations. In addition, these data suggest that racial and ethnic factors are important determinants of paternity establishment in the state of Michigan.

N. gonorrhoeae is an infection found only in humans. In the United States, an estimated 600,000 new cases occur each year, with the peak incidence occurring in the summer months. Adolescents and young adults are at the highest risk of infection. N. gonorrhoeae affects both men and women. Infection in men typically produces symptoms that lead patients to seek treatment. On the other hand, N. gonorrhoeae infection in women often is asymptomatic and can lead to sterility or ectopic gestation. N. gonorrhoeae becomes disseminated in 1–3% of all gonococcal infections. Disseminated gonococcal infection (DGI) usually presents as an arthritis-dermatitis syndrome; patients experience migrating polyarthalgias usually affecting the knees, elbows, and distal joints. Approximately 75% of patients have a characteristic dermatitis consisting of discrete papules and pustules with a hemorrhagic component. If untreated, the arthritis tends to progress in one to two joints, usually the knee, ankle, elbow, or wrist. Treatment consists of hospitalization, evaluation for serious sequelae such as endocarditis and meningitis, and antibiotic therapy. Additionally, the patient's partner also should be treated. Disseminated gonococcal infection can cause serious complications during pregnancy such as septic abortion or chorioamnionitis, as well as preterm labor and preterm premature rupture of membranes.

Diverticular disease is thought to be related to dietary fiber deficiency and has a higher incidence in developed countries and in older patients, especially women. Diverticulitis is an inflammatory process of colonic diverticula that commonly presents with lower abdominal pain, fever, and leukocytosis. The differential diagnosis of diverticulitis includes ruptured ovarian cyst, ovarian torsion, tubo-ovarian abscess, ectopic pregnancy, pelvic inflammatory disease, appendicitis, Crohn's disease, colon cancer, ischemic colitis, pseudomembranous colitis, complicated ulcer disease, and urologic disease. Treatment may be medical or surgical, depending upon the severity of the episode and the presence or absence of complications.

Pelvic malignancy complicating pregnancy poses a difficult management problem. Survival of the patient is the foremost concern, but fetal viability and well-being are also factors that have to be addressed in these cases. Cervical cancer is rarely diagnosed during pregnancy, but is still the most commonly diagnosed malignancy in pregnancy. Because of the relative infrequency of this condition, guidelines for management are not clearly defined. The basis of treatment for cervical malignancy in a pregnant patient is similar to that of a nonpregnant patient, with variations done to achieve the best possible outcome for the fetus without compromising the mother. Over the last decade, investigators have reported and advocated a more conservative approach to the management of this disease. This article will review the literature on the management of invasive cervical cancer in pregnancy and suggest a treatment scheme.

The maternity blues are a group of symptoms of overemotionalism and overreactivity that appear very often in the early puerperium. The blues seem not to be part of a continuum with postpartum depression and puerperal psychosis. Causation is mostly biological, mainly the massive fluctuation of hormones in that period. There are no clear relationships with demographic or psychosocial factors. The clinical picture appears very similar in all the different settings in which it has been examined. As some women suffering from the blues will go on to develop postpartum depression, requiring medication and psychological interventions, it is very important to recognize the symptoms and to educate the patient and her partner, if there is one, so they will know what to expect and when to notify the obstetrician/gynecologist in case psychiatric referral is necessary. The time spent listening to the patient discuss her emotions and giving her pertinent education is very valuable, because the establishment of a good therapeutic alliance is crucial in the event that depression (a serious condition that puts both mother and child at risk) develops.

A high index of suspicion is critical in the prevention of serious complications of gonorrheal infection. This article reviews published information regarding the pathophysiology, epidemiology, clinical characteristics, diagnosis, and treatment of gonorrhea. MEDLINE was used to search the literature for articles and studies that have a bearing on these issues. Keywords used were disseminated gonococcal infection; septic arthritis; gonorrhea and pregnancy; and gonorrhea and pathophysiology. We conclude that disseminated gonococcal infection (DGI) should be in the differential diagnosis of any sexually active patient who presents with arthritis, dermatitis, and/or tenosynovitis. Although the incidence of DGI has declined in recent years, it still is the most common cause of newly diagnosed arthritis requiring hospitalization. Careful culturing of every site that could be infected is imperative to aid in diagnosis and treatment. Prompt therapy with appropriate antibiotics such as ceftriaxone will prevent the more serious complications of DGI.

Anemia represents a common problem encountered in daily clinical practice, affecting 3.4 million Americans. Hence, a structured approach to evaluating anemia is highly relevant in primary care. Multichannel automated analyzers have revolutionized the work of performing complete blood counts (CBCs). However, when interpreting results, clinicians must be aware of limitations encountered with these technologies, which can yield spurious red blood cell (RBC) values in certain clinical circumstances. Automated analyzers identify subpopulations of RBCs that are unexpectedly small or large or have unexpectedly low or high hemoglobin concentrations, thereby signifying aberrant RBC morphologies for review on peripheral blood smear. Results of various blood chemistries help to refine or confirm diagnostic considerations suggested by the CBC, reticulocyte count, and peripheral blood smear. Although tempo of anemia development may strongly support bleeding or hemolysis as the cause of anemia, kinetic changes in RBC mass, even due to these mechanisms, are often more subtle, suggesting possible underproduction causes of anemia. Abnormalities in white blood cell (WBC) counts, platelet counts, and WBC differentials may suggest disorders of trilineage hematopoiesis, although multiple competing factors may coexist, with certain factors affecting RBCs independent of those affecting WBCs and/or platelets. To focus diagnostic considerations, clinicians should consider anemia etiologies categorized by RBC size (mean cell volume, MCV) and morphology (eg, spherocytes, bite cells, schistocytes, target cells, teardrops). These categories include the microcytic, normocytic, and macrocytic anemias. Each of these categories are briefly reviewed, and case presentations are provided to illustrate specific points.