Items in AFP with MESH term: Patient Selection
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: Vaginal birth after cesarean section is common in this country. Physicians providing obstetric care should be aware of the potential complications. Uterine rupture occurs in approximately one of every 67 to 500 women (with one prior low-transverse incision) undergoing a trial of labor for vaginal birth after cesarean section. Rupture poses serious risks to mother and infant. There are no reliable predictors or unequivocal clinical manifestations of rupture, so physicians must maintain a high index of suspicion for possible rupture, especially in the presence of fetal bradycardia or other evidence of fetal distress. Management is surgery for prompt delivery of the infant and control of maternal hemorrhage. Newborns often require admission to an intensive care nursery. Prevention of poor outcomes depends on thorough anticipation and preparation. The physicians and the delivery institution should be prepared to provide emergency surgical and neonatal care in the event of uterine rupture.
ABSTRACT: Antibiotic resistance was once confined primarily to hospitals but is becoming increasingly prevalent in family practice settings, making daily therapeutic decisions more challenging. Recent reports of pediatric deaths and illnesses in communities in the United States have raised concerns about the implications and future of antibiotic resistance. Because 20 percent to 50 percent of antibiotic prescriptions in community settings are believed to be unnecessary, primary care physicians must adjust their prescribing behaviors to ensure that the crisis does not worsen. Clinicians should not accommodate patient demands for unnecessary antibiotics and should take steps to educate patients about the prudent use of these drugs. Prescriptions for targeted-spectrum antibiotics, when appropriate, can help preserve the normal susceptible flora. Antimicrobials intended for the treatment of bacterial infections should not be used to manage viral illnesses. Local resistance trends may be used to guide prescribing decisions.
Diagnosis and Management of Preeclampsia - Article
ABSTRACT: Preeclampsia is a pregnancy-specific multisystem disorder of unknown etiology. The disorder affects approximately 5 to 7 percent of pregnancies and is a significant cause of maternal and fetal morbidity and mortality. Preeclampsia is defined by the new onset of elevated blood pressure and proteinuria after 20 weeks of gestation. It is considered severe if blood pressure and proteinuria are increased substantially or symptoms of end-organ damage (including fetal growth restriction) occur. There is no single reliable, cost-effective screening test for preeclampsia, and there are no well-established measures for primary prevention. Management before the onset of labor includes close monitoring of maternal and fetal status. Management during delivery includes seizure prophylaxis with magnesium sulfate and, if necessary, medical management of hypertension. Delivery remains the ultimate treatment. Access to prenatal care, early detection of the disorder, careful monitoring, and appropriate management are crucial elements in the prevention of preeclampsia-related deaths.
Endometrial Biopsy - Article
ABSTRACT: Endometrial biopsy is an office procedure that serves as a helpful tool in diagnosing various uterine abnormalities. The technique is fairly easy to learn and may be performed without assistance. The biopsy is obtained through the use of an endometrial suction catheter that is inserted through the cervix into the uterine cavity. Twirling the catheter while moving it in and out of the uterine cavity enhances uptake of uterine tissue, which is aspirated into the catheter and removed. Endometrial biopsy is useful in the work-up of abnormal uterine bleeding, cancer screening, endometrial dating and infertility evaluation. Contraindications to the procedure include pregnancy, acute pelvic inflammatory disease, and acute cervical or vaginal infections. Postoperative infection is rare but may be further prevented through the use of prophylactic antibiotic therapy. Intraoperative and postoperative cramping are frequent side effects.
ACIP Releases Guidelines on the Prevention and Control of Influenza - Practice Guidelines
VBAC: Protecting Patients, Defending Doctors - Editorials
Clinical Briefs - Clinical Briefs