Primary care update for Ob/Gyns最新文献

Thanks to the efforts of Pasteur and Jenner, the widespread use of immunization has had a dramatic effect on public health in the 20th century. As the 21st century begins, public health advocates, researchers, and health practitioners alike are continuing the work of these pioneers. However, many barriers remain that prevent access and delivery of vaccinations. Obstetrician/gynecologists are at the forefront of delivering quality primary care services to a diverse population of women, and are in a unique position to impact this important public health issue. This article will provide an overview of the most common immunizations used in clinical practice today. Target populations, indications, and side effects will be addressed as well as suggestions for promoting this service in an obstetrics and gynecology primary care setting.

The purpose of this study was to assess obstetrician knowledge and behavior as it relates to paternity establishment for unwed mothers in the state of Michigan. Masked questionnaires were sent to 1328 obstetricians. Statistics were based on the binomial distribution, with significance reported at P < .05. Ordinal logistic regression was performed evaluating the relationship between physician attitudes and paternity establishment success rates. The response rate was 44%. Respondents were more likely male (56%), married (82%), white (80%), and with children (78%). Few (13%) provided their unwed gravidas with paternity establishment information. Only 37% knew that their hospital had a paternity establishment program. Forty-four percent knew the State unwed rate for live births; 20% knew the average hospital paternity establishment rate; 13% correctly answered when federal sanctioning occurred. Knowledge regarding statewide unwed delivery rates and paternity establishment was correlated to rates within the respondent’s own institution (P < .05). Physician attitudes were significantly associated with individual hospital paternity establishment rates. Most obstetricians agreed that it was important to have a legal father (91%) and that paternity establishment is important for the child (76%). Few thought that it was an invasion of privacy (10%) or that it was primarily for child support (40%). Only 21% thought that the paternity establishment process was clearly defined. In our survey, the obstetricians were generally poorly informed regarding data related to unwed deliveries, paternity establishment regulations, and current government mandates. Attitudinal responses suggested that clinicians are supportive of paternity establishment goals. Physician behavior correlates with hospital paternity establishment success rates.

The American Diabetes Association and the American College of Obstetricians and Gynecologists recommend reclassification of maternal glycemic status at-least 6 weeks after delivery in pregnancies complicated by gestational diabetes mellitus. The purpose of this study is to investigate the adherence to this recommendation. A cohort of gestational diabetic patients was identified through a diabetic care management database. These patients received coordinated diabetic management by a team of diabetic nurse managers, registered nutritionists, maternal-fetal medicine specialists, and their obstetrical providers. A retrospective review of their records was conducted. The recommendation for postpartum testing, the number of women undergoing this testing, and the type of postpartum testing performed were analyzed. From January 2000 to July 2001, 158 gestational diabetics received care through the diabetic care management program. One hundred fifty-two patients (96%) returned for their 6-week postpartum office visit. Ninety-two of the 152 patients (60.5%) were offered postpartum diabetic testing. Thirty-four percent of the patients (52 of 152) actually underwent diabetic testing. No uniform testing method was used in these 52 patients. We conclude that despite a comprehensive care program, the utilization of postpartum diabetic testing was poor. The result of this study is in agreement with the current literature, which showed postpartum testing rates varying from 17–69%. This indicates a need for further education and emphasis on postpartum screening for the obstetric care providers and the patients.

Aortic dissection is a catastrophic illness that is estimated to occur at a rate of >2,000 new cases per year. It is two times more common in males, and occurs most commonly between the ages of 50 and 70 years. Early mortality can be as high as 1% per hour if left untreated. Aortic dissection results when blood separates the layers of the aortic media, usually through a tear in the intima. The tear most commonly occurs in the ascending aorta but can occur in the descending aorta or aortic arch. Hypertension is the single most important risk factor for thoracic aortic dissection. Aortic dissections are classified as either ascending or descending, depending on the location of the tear relative to the ligamentum arteriosum. The rationale for the classification of aortic dissections into ascending and descending is based on the management. Aortic dissections involving the ascending aorta require surgical management, whereas those limited to the descending aorta are managed medically. Chest pain is the most common presenting symptom and classically is described as tearing, knifelike, and ripping, with abrupt onset. Patients may also present with syncope, stroke, paraplegia or paraparesis, congestive heart failure, myocardial infarction, upper airway obstruction, dysphagia, gastrointestinal bleeding, superior vena cava syndrome, pleural effusion, new aortic regurgitation murmur and cardiac arrest. There is an unexplained relationship between pregnancy and aortic dissection. The diagnosis is made by maintaining a high index of suspicion. Once suspected, aggressive medical management of the blood pressure and pulse as well as obtaining confirmatory exams (computed tomography, magnetic resonance imaging, or transesophageal echocardiogram) and early cardiothoracic consultation can be life saving.

West Nile virus was discovered in 1937 in the West Nile region of Uganda. The virus was found only in the Eastern Hemisphere until 1999. In 1999, West Nile virus was first identified in the Western Hemisphere in New York City. Since 1999, viremic birds have continued to spread the disease across the United States. West Nile virus is an arbovirus and is transmitted as part of a bird-mosquito-bird cycle. During 2002, newly recognized mechanisms of West Nile virus transmission were described. Epidemiologists have documented transmission of the West Nile virus to recipients of transplanted organs and blood transfusions, to laboratory workers, to fetuses, and to breast-fed infants. Approximately 20% of infected individuals will develop a mild febrile illness with symptoms lasting from 3–6 days. Roughly 1 in 150 infected persons will develop severe neurological disease. Recent outbreaks have been associated with meningoencephalitis and case fatality rates of 4–13%. Also, West Nile virus infection has been linked with acute flaccid paralysis. Acute flaccid paralysis is a polio-like syndrome with involvement of the anterior horn cells of the spinal cord and motor axons. The most efficient way to diagnose West Nile virus is to detect IgM antibody in serum or cerebral spinal fluid within 8 days of onset of illness using IgM MAC-ELISA. Treatment of severe neurological disease requires hospitalization and intense supportive care. Effective prevention of West Nile virus infections is dependent on integrated arboviral surveillance and vector mosquito control programs, as well as public education.

Lung cancer is the most common cause of cancer deaths in the world. In the U.S., approximately 170,000 cases and 155,000 deaths are predicted for 2002.1 Lung cancer accounts for 29% of all cancer deaths and causes more deaths than breast, colorectal and prostate cancer combined. While the prognosis of patients with lung cancer has improved over the past 20 years, overall it remains poor. Fewer than 15% of patients survive for more than 5 years. The poor prognosis is largely attributable to the fact that approximately 70% of lung cancer patients are diagnosed with mediastinal lymph node involvement, malignant effusion or distant metastases. In the US approximately 45 million people are current smokers and another 40–50 million are former smokers. Elimination of tobacco use as primary prevention of lung cancer should remain a priority for teenagers and young adults. However, considering the large pool of individuals at risk, lung cancer will undoubtedly remain a significant public health problem in the coming decades. Given our current inability to cure patients with metastatic disease, intensive efforts should be aimed at early identification and intervention. While screening and, more recently, chemoprevention have significantly impacted the incidence and survival of other cancers, such as breast, cervical and colorectal cancer, chemopreventive strategies for lung cancer have not shown clear benefits. In addition, radiographic screening is still controversial. In this review, we will provide a summary of the recent developments in the areas of molecular epidemiology, screening and chemoprevention with special emphasis on women.

Dr. Albert Bruce Sabin is best known for his research in poliomyelitis. He developed the trivalent oral polio vaccine that has made the global eradication of polio a realistic goal. He also developed vaccines for dengue fever and Japanese encephalitis.

The majority of older women are diagnosed with several medical conditions. These conditions are treated with multiple medications, often including combinations of prescription, over-the-counter, and possibly holistic therapies. As women age, organ system functions change, which leads to differences in the response to therapies introduced to their system. An ob/gyn providing care for an older patient must be cognizent of effects the physiological changes and medications can have on their patients.

In 2000, the Surgeon General of the United States issued the first-ever report on oral health, to alert Americans on its importance to general health and well-being. Women, due to gender, display oral disease differentially. The most common oral diseases are dental caries and periodontal disease. Both of the diseases are infectious in nature, and are responsive to a variety of interventions including: community wide, professional care and self-care. Eating disorders, which are prevalent in adolescent women, have oral manifestations that need to be addressed by the dentist as well as the primary care Ob/Gyn. Oral health in women is markedly affected by hormonal fluctuations. Specific oral conditions are associated with puberty, adolescence, menses, pregnancy, and menopause. These conditions are discussed along with available effective preventive modalities that can optimize oral health.

Compliance stands between the physician and the successful treatment of the patient. The physician labors to accumulate, update, master, and apply a vast and growing store of medical knowledge and to communicate well-founded diagnostic and treatment recommendations to patients. Patients come to physicians with physical and psychological pain and disability. If recommendations are not utilized, pain and disability persist. The rates of compliance with the whole range of medical recommendations, from smoking cessation to medication, is surprisingly low. Non-compliance with medical advice is enormously frustrating to physicians. Careful analysis of the reasons for non-compliance—cognitive deficits, miscommunications, language barriers, unvoiced fears, financial difficulties—turns non-compliance into a treatable problem.