Items in AFP with MESH term: Patient Selection
Initiating Hormonal Contraception - Article
ABSTRACT: Most women can safely begin taking hormonal birth control products immediately after an office visit, at any point in the menstrual cycle. Because hormonal contraceptives do not accelerate cervical neoplasia or interfere with cervical cytology, women who have not had a recent Papanicolaou smear can begin using hormonal contraceptives before the test is performed. After childbirth, most women can begin using progestin-only contraceptives immediately. Estrogen-containing methods can safely be initiated six weeks to six months postpartum for women who are breastfeeding their infants and three weeks postpartum for women who are not breastfeeding. Women can begin any appropriate contraceptive method immediately following an early abortion. Delaying contraception may decrease adherence. Physicians can help patients improve their use of birth control by providing anticipatory guidance about the most common side effects, giving comprehensive information about available choices, and honoring women's preferences. An evidence-based, flexible, patient-centered approach to initiating contraception may help to lower the high rate of unintended pregnancy in the United States.
Vasectomy: An Update - Article
ABSTRACT: Vasectomy remains an important option for contraception. Research findings have clarified many questions regarding patient selection, optimal technique, postsurgical follow-up, and risk of long-term complications. Men who receive vasectomies tend to be non-Hispanic whites, well educated, married or cohabitating, relatively affluent, and have private health insurance. The strongest predictor for wanting a vasectomy reversal is age younger than 30 years at the time of the procedure. Evidence supports the use of the no-scalpel technique to access the vasa, because it is associated with the fewest complications. The technique with the lowest failure rate is cauterization of the vasa with or without fascial interposition. The ligation techniques should be used cautiously, if at all, and only in combination with fascial interposition or cautery. A single postvasectomy semen sample at 12 weeks that shows rare, nonmotile sperm or azoospermia is acceptable to confirm sterility. No data show that vasectomy increases the risk of prostate or testicular cancer.
ABSTRACT: Hospice is available for any patient who is terminally ill and chooses a palliative care approach. Because of the close relationship that primary care physicians often have with their patients, they are in a unique position to provide end-of-life care, which includes recognizing the need for and recommending hospice care when appropriate. The hospice benefit covers all expenses related to the terminal illness, including medication, nursing care, and equipment. Hospice should be considered when a patient has New York Heart Association class IV heart failure, severe dementia, activity-limiting lung disease, or metastatic cancer. Timely referrals are beneficial to both patient and hospice because of the cost related to initiating services and the time required to form a therapeutic relationship. Once the decision to refer to hospice is made, the family physician typically continues to be the patient's primary attending physician. The attending physician is expected to remain in charge of the patient's care, write orders, see the patient for office visits, and complete and sign the death certificate. Hospice, in turn, is a valuable physician resource when it comes to medication dosages, symptom management, and communication with patients and their families.
ABSTRACT: The exercise stress test is a useful screening tool for the detection of significant coronary artery disease. Documentation of the patient's symptoms, medications, past and current significant illnesses, and usual level of physical activity helps the physician determine if an exercise stress test is appropriate. The physical examination must include consideration of the patient's ability to walk and exercise, along with any signs of acute or serious disease that may affect the test results or the patient's ability to perform the test. The test report contains comments about the maximal heart rate and level of exercise achieved, and symptoms, arrhythmias, electrocardiographic changes and vital signs during exercise. This report allows the clinician to determine if the test was "maximal" or "submaximal." The quality of the test and its performance add to the validity of the results. The conclusion section of the test report indicates whether the test results were "positive," "negative," "equivocal" or "uninterpretable." Further testing may be indicated to obtain optional information about coronary artery disease and ischemic risk if the test results were equivocal or uninterpretable.
ABSTRACT: Inguinal and femoral hernias are the most common conditions for which primary care physicians refer patients for surgical management. Hernias usually present as swelling accompanied by pain or a dragging sensation in the groin. Most hernias can be diagnosed based on the history and clinical examination, but ultrasonography may be useful in differentiating a hernia from other causes of groin swelling. Surgical repair is usually advised because of the danger of incarceration and strangulation, particularly with femoral hernias. Three major types of open repair are currently used, and laparoscopic techniques are also employed. The choice of technique depends on several factors, including the type of hernia, anesthetic considerations, cost, period of postoperative disability and the surgeon's expertise. Following initial herniorrhaphy, complication and recurrence rates are generally low. Laparoscopic techniques make it possible for patients to return to normal activities more quickly, but they are more costly than open procedures. In addition, they require general anesthesia, and the long-term hernia recurrence rate with these procedures is unknown.
Adult Circumcision - Article
ABSTRACT: Adult circumcision can be performed under local or regional anesthesia. Medical indications for this procedure include phimosis, paraphimosis, recurrent balanitis and posthitis (inflammation of the prepuce). Nonmedical reasons may be social, cultural, personal or religious. The procedure is commonly performed using either the dorsal slit or the sleeve technique. The dorsal slit is especially useful in patients who have phimosis. The sleeve technique may provide better control of bleeding in patients with large subcutaneous veins. A dorsal penile nerve block, with or without a circumferential penile block, provides adequate anesthesia. Informed consent must be obtained. Possible complications of adult circumcision include infection, bleeding, poor cosmetic results and a change in sensation during intercourse.
External Cephalic Version - Article
ABSTRACT: External cephalic version is a procedure that externally rotates the fetus from a breech presentation to a vertex presentation. External version has made a resurgence in the past 15 years because of a strong safety record and a success rate of about 65 percent. Before the resurgence of the use of external version, the only choices for breech delivery were cesarean section or a trial of labor. It is preferable to wait until term (37 weeks of gestation) before external version is attempted because of an increased success rate and avoidance of preterm delivery if complications arise. After the fetal head is gently disengaged, the fetus is manipulated by a forward roll or back flip. If unsuccessful, the version can be reattempted at a later time. The procedure should only be performed in a facility equipped for emergency cesarean section. The use of external cephalic version can produce considerable cost savings in the management of the breech fetus at term. It is a skill easily acquired by family physicians and should be a routine part of obstetric practice.
ABSTRACT: The intrauterine device, a common form of birth control in the early 1970s, is now avoided by American physicians and women because of concern about complications. This concern is largely the result of the problems reported with use of an intrauterine device that is no longer manufactured. More recent intrauterine devices have an improved design, and reevaluation has shown them to be a safe, efficacious and cost-effective form of birth control. Careful patient selection and preinsertion counseling are crucial to success with the device. Recent studies conclude that the intrauterine device poses no increased risk of pelvic inflammatory disease or infertility when used by appropriately selected patients.
Epidural Analgesia During Labor - Article
ABSTRACT: Epidural analgesia is a commonly employed technique of providing pain relief during labor. The number of parturients given intrapartum epidural analgesia is reported to be over 50 percent at many institutions in the United States. The procedure has few contraindications, the primary ones being patient refusal, maternal hemorrhage and coagulopathy. Induction of epidural analgesia in early labor remains controversial. However, many physicians induce analgesia as soon as the diagnosis of active labor has been established and the patient has requested pain relief. The most common complications occurring with epidural analgesia are maternal hypotension and postdural puncture headache. Retrospective studies have demonstrated an association between epidural analgesia and increases in duration of labor, instrumental vaginal delivery and cesarean section for labor. However, several recent prospective studies have concluded that epidural analgesia does not adversely affect the progress of labor or increase the rate of cesarean section. These remain controversial issues among practicing physicians.
ABSTRACT: Lowering cholesterol can reduce the incidence of coronary heart disease. Treating hypertension reduces overall mortality and is most effective in reducing the risk of coronary heart disease in older patients. Smoking cessation reduces the level of risk to that of nonsmokers within about three years of cessation. Aspirin is likely to be an effective means of primary prevention, but a group in whom treatment is appropriate has yet to be defined. Evidence that supplementation with vitamin A or C reduces the risk of coronary heart disease is inadequate; the data for use of vitamin E are inconclusive. Epidemiologic evidence is sufficient to recommend that most persons increase their levels of physical activity. Lowering homocysteine levels through increased folate intake is a promising but unproven primary prevention strategy. Hormone replacement therapy was associated with reduced incidence of coronary heart disease in epidemiologic studies but was not effective in a secondary prevention trial.