Primary care update for Ob/Gyns最新文献

Twenty-seven years into the malpractice “crisis” in the United States, physicians continue to be subject to the threat of litigation. They know that they can be sued even when they meet the standard of care. This threat gives rise to a range of specific fears that represent an ongoing emotional burden for practitioners and contribute to work dissatisfaction. This article identifies a range of these fears and suggests ways to cope with them.

Considered one of the greatest biologists of the 19th century, Louis Pasteur began his important work as a humble French chemist. His scientific genius allowed him to debunk previously held theories such as that of the spontaneous generation of life, and to produce the most important discovery in medical history, the germ theory of disease. Although he did not make the initial discovery of microbes, he identified many microorganisms (staphylococci, streptococci, pneumococci) and, even more important, determined the role of these microbes in causing disease. Pasteur’s scientific achievements have been cornerstones of modern medicine, and have laid the foundations for branches of science such as stereochemistry, microbiology, bacteriology, virology, immunology, and molecular biology. As a result of the practical application of his knowledge, Pasteur made some of the greatest contributions of any research scientist to the welfare of humanity.

Joseph Lister was an English surgeon and founder of modern antiseptic surgery. Using carbolic acid as the antiseptic agent, he developed techniques of applying it that, when combined with heat sterilization of instruments, brought about a dramatic decrease in postoperative mortality. His contributions to medicine also included the development of absorbable sutures and the drainage tube.

Handwashing is a staple of modern medical practice. However, this has not always been the case. Before the germ theory of disease was well known, it was common practice to examine patient after patient without the use of gloves or a strong disinfectant. When an obstetrician/gynecologist named Semmelweis started to examine why his maternity ward had such a high mortality rate, he made a discovery that later became the foundation for aseptic practice.

Melanoma is a serious public health issue. More than 53,000 individuals will be diagnosed with this potentially devastating disease in 2002, making it one of the fastest-growing cancer risks in the country. Diagnosis and management at an early stage result in an excellent outcome in most patients, but more advanced stages of this disease can portend a dire prognosis. In this review, melanoma pathology, risk factors, staging, and treatment are reviewed. Screening, prevention, and early detection are discussed. Diagnosis and management of melanoma before, during, and after pregnancy is a controversial topic that is covered in this review, as is the safety of hormone replacement therapy in patients with melanoma. A combination of preventive behavior, vigilance, and appropriate management before, during, and after pregnancy can result in decreased risk and improved outcomes.

Viral hemorrhagic fever (VHF) is a severe, often fatal disease in humans and nonhuman primates (e.g., monkeys and chimpanzees). The two main causes of VHF are Marburg and Ebola virus infection. Lassa fever and Crimean-Congo hemorrhagic fever occur less commonly. Marburg and Ebola viruses are RNA filoviruses. Filoviruses first emerged as the cause of significant clinical outbreaks of VHF in Marburg, Germany in 1967 and later at multiple sites in Africa in 1976. Pathogenesis appears to involve initial infection of the mononuclear phagocytic system, resulting in a generalized cytopathic effect of other cell types and eventual disruption of the coagulation system, hemorrhage, and shock. The typical fulminant disease course is attributed to an immunosuppressive effect caused by the virus. Viral transmission occurs with close, personal contact and exposure to body fluids, especially in caregivers. The risk for person-to-person transmission of VHF is highest during late-stage disease. Contact with cadavers at the time of funerals is considered an independent risk factor for exposure because of the high levels of viral antigens and particles in skin tissues. The incubation period ranges from 2 to 21 days (average 1 week). Clinical manifestations include an abrupt onset of influenza-like symptoms, sore throat, diarrhea, and abdominal pain. Other common symptoms include high fever, headaches, arthralgias, myalgias, abdominal pain, asthenia, fatigue, and hiccups. A transient morbilliform rash develops and eventually desquamates by the end of the first week of illness. Other physical findings include an exudative pharyngitis and, less commonly, conjunctivitis, jaundice, and edema. Hemorrhagic complications appear as petechiae or frank bleeding from any location, but most commonly the gastrointestinal tract. Within 1 week of infection, symptoms may progress into retrosternal pain, fulminant shock, and death. Diagnosis is based on clinical symptomatology, serologic tests, and virus isolation. Isolation must be performed in a biosafety level four facility. There is no antiviral agent or vaccine for EHF. Supportive therapy is the mainstay of treatment. Case fatality rates range from 50 to 90%.

One in 180 American girls has precocious puberty. Accordingly, as a primary care physician, the obstetrician/gynecologist must be knowledgeable about the clinical evaluation and management of this disorder. Pubertal precocity has numerous causes and may be classified broadly as being central or peripheral in etiology. A meticulous history and physical examination, the judicious choice and interpretation of laboratory tests, and the selective use of radiological studies are the cornerstones of the evaluation. The initial approach should focus on identifying life-threatening tumors of the brain, adrenal gland, or ovary. The management goals include reducing the gonadotropin secretion and sex steroid effects and maximizing the eventual adult height. Because the child and her parents are frequently extremely distressed, the treating physician’s sensitivity and reassurance are paramount. The obstetrician/gynecologist, as both primary care physician and consultant, is in an ideal position to investigate, diagnose, and treat female precocious puberty.

Gout results from the deposition of urate crystals in a variety of soft tissues throughout the body. Currently over half a million American women suffer from the disorder. Disease manifestations include painful attacks of acute arthritis as well as chronic arthritis with deposition of uric acid crystals known as tophi. The disorder is often overlooked and misdiagnosed as another form of arthritis. Multiple drugs are now available to treat the acute pain of gouty arthritis, as well as to help reduce the long-term complications of gout and chronic hyperuricemia.

Sexual dysfunction is an extremely common problem in the gynecologic patient population, affecting over 40% of women. There is little consensus, however, as to the appropriate treatment of women with sexual dysfunction. This review will evaluate the epidemiology and etiology of sexual dysfunction including menopause, aging, hormone deficiency, and vascular insufficiency. It will then evaluate some potential medical therapies for female sexual dysfunction in terms of their risks and benefits. It will specifically address the use of estrogen and androgen supplementation, dehydroepiandrosterone, tibolone, and sildenafil. All of these therapies have shown some benefit in select patient populations. However, large-scale, randomized placebo-controlled double-blind trials remain to be done to establish the true long-term efficacy and side effects of these interventions.