Primary care update for Ob/Gyns最新文献

Approximately 3–5% of patients diagnosed with endometrial cancer in the United States are under the age of 40. For these patients, fertility preservation is often of paramount importance. Patients with endometrial cancer and other medical co-morbidities are not ideal surgical candidates and may also be candidates for medical therapy. After careful selection and counseling, certain patients with Grade 1 endometrial cancer may be offered treatment with progesterone therapy.

Technological advances in the diagnosis of human immunodeficiency virus (HIV) infection provide the clinician with greater opportunities to reduce HIV transmission rates. The main drawback of conventional methods of HIV testing is a potential delay of 1–2 weeks for obtaining results, making routine screening a two-step method. Many of those tested never return to learn of their results, limiting our efforts to notify seropositive individuals and their contacts. Consequently, our ability to educate them on strategies for optimizing their health and reducing their risk for transmitting the disease is impaired. For pregnant women who present to Labor and Delivery with late prenatal care, having unknown HIV serological status reduces our ability to prevent transmission to neonates. Two new rapid HIV tests have become available commercially. These tests are just as accurate as conventional methods and offer the advantage of producing preliminary results within hours rather than days. As a result, case- finding and prevention counseling can be completed in a single visit, making the process more efficient and, hopefully, more effective. Additionally, faster identification of seropositive pregnant women who present later for prenatal care allows us to more precisely target intrapartum antiretroviral therapy for prevention of vertical HIV transmission.

Jonas Salk began his career in microbiology working with the inactivated influenza vaccine. He would later use the formalin inactivation process to create the poliomyelitis vaccine. Using a newly created modern cell culture technique, Salk was able to mass produce vaccines for the large-scale polio vaccine field trial. Under the direction of Thomas Francis, Jr., the field trial utilized both a double-blinded placebo-controlled trial and an observational study, and included almost 2 million American schoolchildren as subjects. The vaccine proved to be both safe and effective. Although later replaced by the Sabin oral vaccine, the Salk inactivated vaccine played a large part in the eventual eradication of polio from the Western Hemisphere. After his work on the polio vaccine, he created the Salk Institute, a private institution dedicated to research. Subsequently, until his death in 1995, Salk conducted research on an HIV vaccine.

The basic, accepted tenet of every physician and every obstetrician-gynecologist’s treatment philosophy is to provide the highest quality, cost effective medical care to each and every woman in their practice. Given this fact, our direction, response, and therapeutic goals for all patients at each and every branch of the medical algorithm decision tree should be no less than that expected or desired for one of our beloved family members. All aspects of our daily practice, including but not limited to decisions regarding appropriate spacing of appointment times, careful correct prescribing practices, thorough history taking, appropriate and complete physical examination, a resolve to relieve pain, thoughtful preoperative preparation, and successful safe completion of every surgical procedure should by governed by these “standards.” While every decision regarding women’s health care carries potential value and possible consequences, few carry as much psychologic or physiologic impact on short- or long-term patient well being as the correct diagnosis and appropriate management of a suspected gynecologic malignancy.

In our era of advanced medical technology, it is difficult to imagine a time when clinical treatment was absent or largely ineffective. Patients of the early 20th century had few options when it came to medical therapy. Many of the people admitted to hospitals at that time suffered from bacterial infections, which caused major morbidity and mortality, as antibiotics were not yet present. Dr. Alexander Fleming’s discovery of penicillin and the subsequent development of antibiotics were the most significant advances that revolutionized the practice of medicine. The details of Fleming’s life and work reveal a story combining his grand achievements with the accomplishments of others, intermixed with some measure of luck, arbitrariness, and serendipity.

Anorexia nervosa is a serious systemic disease affecting virtually all major organ systems. It is frequently undiagnosed, or there is a significant delay in the diagnosis. Anorexia nervosa is one of the few major medical diseases where patients frequently do not seek help and may actively hide their symptoms, making it especially hard for physicians to diagnose and treat. Anorexia has many endocrine and reproductive complications, including amennorhea or irregular menses, delayed puberty, changes in ovarian morphology, and infertility. Women with anorexia have worse pregnancy outcomes; pregnancy itself may also worsen their symptoms of anorexia. Anorexia nervosa is a disease with high morbidity and mortality; patients may die, especially from cardiovascular complications. Anorexia also can cause gastrointestinal, renal, biochemical, hematologic, dermatologic, and metabolic complications. Comorbid psychiatric illnesses occur in greater than 50% of patients with anorexia. Ob/Gyn physicians must know how to adequately assess patients for the presence of anorexia and understand basic treatment principles.

In the second part of the 19th century, maternal mortality following classical cesarean section was nearly 100%. In 1876, the Italian obstetrician, Eduardo Porro, developed a cesarean section technique consisting of uterine corpus amputation and suturing of the cervical stump into the abdominal wall incision in an attempt to prevent life-threatening hemorrhage and infection. The successful outcome in Porro’s test case was due to his adherence to surgical principles that are well recognized today, but were not firmly established in 1876. He achieved hemostasis by use of the occluding snare of Cintrat. He irrigated the peritoneal cavity with carbolized sponges, drained the operative bed, and exteriorized the cervical stump in an effort to prevent access of bacteria from the lower genital tract into the peritoneal cavity. Despite the lack of blood products, intravenous fluids, and antibiotics, the Porro operative technique subsequently decreased maternal mortality to 58%. His innovative, carefully planned approach for cesarean hysterectomy was a major innovation in obstetric surgery.

The objective of this study was to determine whether requiring students to intensively prepare for clinical lectures resulted in improved scores on the National Board of Medical Examiners (NBME) Subject Examination in Obstetrics and Gynecology (subject examination). A new curriculum was developed for the class of 2000/2001 at the Medical College of Ohio. The curriculum required that students, prior to attending clinical lectures, do required reading tested by a take-home test and an in-class quiz. The performances on the subject examination for the classes of 1998/1999 and 2000/2001 were compared. This was done as a cohort study controlling for previous NBME Step I performance, educational site, and timing of the clerkship in the academic year. The 2000/01 class had raw scores 5.7 points higher on average (71.3 versus 65.6). For students in Area Health Education Centers (AHEC) off campus, who attended only half the lectures, the average score was 3 points lower in 1999, p < 0.020. In 2000, these students were required to prepare for take-home examinations and quizzes the same as in-town students, and there was no significant difference between AHEC and in-town students who attended all of the lecture series. We conclude that students have better retention and understanding of clinical information if they prepare prior to lectures. Timely self-directed learning throughout the clerkship offers an advantage over cramming in the final weeks. The timely preparation was more important than the lecture exposure for these sophisticated adult learners.

Robert Koch was one of the founding fathers of biology. His contributions to the field of infectious disease are rivaled only by those of Pasteur and Lister. Koch rose from humble beginnings, working as a country doctor, and catapulted to the pinnacle of a scientific career to receive the Nobel Prize for Medicine in 1905. Confirming Pasteur’s germ theory, describing the entire life cycle of Bacillus anthracis, formulating his famous postulates, isolating the tubercle bacillus, isolating the cholera vibrio, inventing new methods for microscopy, and taking the first photomicrograph of a bacterium are just a few of the tremendous accomplishments that Robert Koch achieved in his lifetime.

Cryptosporidiosis, the leading cause of endemic and epidemic diarrheal disease worldwide, has been increasingly recognized within the immunosuppressed population of the United States since the AIDS epidemic began in 1982. Cryptosporidium parvum, the causative agent, is an intestinal, spore-forming protozoan that invades enterocytes, where it replicates to produce highly infectious and resistant oocysts. Transmission of these oocysts is by the fecal–oral route, and the incubation period is 2–14 days. Although healthy hosts may be asymptomatic or experience mild, self-limited symptoms, the immunocompromised host often presents with continuous, copious, watery diarrhea for an extended period. In such patients, infection with C. parvum may lead to dehydration, malabsorption, and nutritional deficiencies. C. parvum is usually confined to the gastrointestinal tract; however, depending on the degree of immunosuppression and strain of protozoan, extraintestinal infections can occur. The most common method of diagnosis is microscopic identification of the 4-μm to 6-μm oocysts in stool using a modified acid-fast staining technique. Direct immunofluoresence with monoclonal and polyclonal antibodies to the oocyst wall and a specific C. parvum enzyme–linked immunosorbent assay also are available; however, these tests most often are used in research settings and water treatment plants. To date, there is no effective cure or treatment for cryptosporidiosis. In healthy patients, antidiarrheal agents may provide temporary relief, whereas combination antibiotic therapy with paromomycin and azithromycin has been most effective in the immunosuppressed patient. Although treatment remains limited, new research that may prevent attachment and invasion of the parasite currently is being explored.