Mark Corson

By P. Kor-Shach. Susquehanna University. 2018.

The measure combines the probability of becoming pregnant and the risk of death from each pregnancy9 buy naltrexone 50 mg with amex. International statistical classification of diseases and related health problems buy naltrexone 50 mg fast delivery, 10th revision purchase naltrexone 50mg, Vol. Antenatal care in developing countries: promises, achievements and missed opportunities: an analysis of trends, levels and differentials, 1990-2001. From: The state of the world´s children 2006; Table 8 «Women» [Database on the Internet. From: The state of the world´s children 2006; Table 8 «Women» [Database on the Internet. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to repro- duce and the freedom to decide if, when and how often to do so. It also includes sexual health, the purpose of which is the enhancement of life and personal relations1, 2. In fact, reproductive health affects the lives of women and men from conception to birth, through adolescence to old age, and includes the attainment and maintenance of good health. Major changes are taking place in the area of maternal and child health all over the world. The need for evaluation and information has, therefore, become increasingly apparent. Different ap- proaches can be used for reviewing a wide range of aspects of health, but the general principles in perinatology, are obviously the same as in other scientific fields3: 1. All the actions executed during the research develop- ment, should be distinguishable, justifiable, and compatible with the needs of the patient or population. When planning the investigation, a number of questions must be taken into consideration6: • What is the objective of the study? It is essential that a good quality study report the exact enrolment procedures used by the study investigators. Ideally, a study protocol should not only give the report for purposes of inclusion or exclusion, instead, the clinical workup and diagnostic criteria need to be described sufficiently well so that a reader would be able to replicate the study’s enrol- ment procedures4. Retrospective studies sometimes present more difficulties in preparing the research ap- proach, because existing records may only document incompletely or inconsistently in- formation. Prospective studies, particularly clinical trials, are more likely to employ uni- form procedures for screening and enrolment. Legal and ethical considerations are important when investigating perinatal events. The laws and customs of a particular country or culture can have a significant impact on the process of investigation, helping or hin- dering access to information, the involvement of the population and professionals, the conduct of the investigation, and the ways the findings are used6. In order to quantify the purpose of the study, outcomes must be well choose in order to be powerful enough indi- cators able to answer the research question. Indicators are markers of health status, service provision or resource availability, designed to enable the monitoring of service performance or programme goals1. An awareness of an indicator’s inherent limitations is crucial to ensuring its effective use. Most importantly, indicators should be regarded as indicative or suggestive of problems or issues needing action. In some cases, indicators are measurements that have the power to summarize, represent or reflect certain aspects of the health of persons in a defined population. In other cases, they may simply serve as indirect or proxy measurements for information that is lacking. As an example, United Nation suggests the most important reproductive health indicators (table I). A good outcome should answer to these questions2: • Are the outcome measures meaningful? Characteristics of an optimum indicator2 Scientifically An indicator must be a valid, specific, sensitive and reliable reflection of that which it purports to robust measure. Valid An indicator must actually measure the issue or factor it is supposed to measure. Reliable An indicator must give the same value if its measurement were repeated in the same way on the same population and at almost the same time. Sensitive An indicator must be able to reveal important changes in the factor of interest. Specific An indicator must reflect only changes in the issue or factor under consideration. Useful An indicator must be able to act as a «marker of progress» towards improved reproductive health status, either as a direct or proxy measure of impact or as a measure of progress towards specified process goals. Representative An indicator must adequately encompass all the issues or population groups it is expected to cover. Understandable An indicator must be simple to define and its value must be easy to interpret in terms of reproductive health status. Accessible The data required should be available or relatively easy to acquire by feasible data collection methods that have been validated in field trials. Ethical An indicator must be seen to comply with basic human rights and must require only data that are consist- ent with the morals, beliefs or values of the local population. Deciding which of the approaches to use is influenced by two considerations, which level is appropriate for the review, and what kind of cases will be studied. In terms of level, the communities, health care facility, district, regional or national are the options. In choosing which cases to study, a decision needs to be taken whether these will be outcomes or processes.

Gestational exposure to metronidazole and the risk of birth defects One of the early studies that examined whether exposure to metronidazole during pregnancy is associated with any birth defects was a retrospective cohort conducted by Scott-Gray et al safe naltrexone 50 mg. The authors analyzed outcomes of 183 pregnancies and exposure during the first and third trimesters of gestation 50mg naltrexone amex. There was no case of birth defects in children of women exposed during the first trimester of pregnancy naltrexone 50mg on line. A noteworthy finding of this study was a case of spontaneous abortion after exposure to the drug. Similar results were found in a cohort of 190 pregnant women followed by Robinson and Mirchandani in 1965 (27), and in a cohort study of 32 subjects conducted by Rodin and Hass in 1966 (28). Again, no cases of birth defects were detected after exposure during the first trimester of gestation. The work of Rodin and Hass (28) was the only study to have no children with birth defects in the comparison group. The first studies that pointed to a possible link between exposure to metronidazole and the risk of birth defects appeared in the decade of 1970. Any major congenital malformation was the outcome of interest in a prospective cohort study with data on 50282 pregnancies conducted by Heinonen et al. Both studies lacked statistical power and the number of exposed subjects was small. The authors assessed prescriptions filled during the first trimester of pregnancy for several antimicrobial compounds. Two cohorts of pregnant women who delivered live-born or stillborn infants were identified. The exposed cohort consisted of 1387 women who filled a prescription for metronidazole between 30 days before and 120 days after the onset of their last normal menstrual period. The unexposed cohort consisted of 1387 comparable women who did not fill a prescription for metronidazole during the same time. The use and refinement of data from administrative databases in the decade of 1990s and in the early 2000’s, was reflected by the publication of several case-control and retrospective cohort studies conducted with large number of subjects. These advancements increased statistical power to addressing rare issues such as birth defects (36). In one of such study, Czeizel and Rockenbauer conducted a case-control analysis using the Hungarian Case- Control Surveillance of Congenital Abnormalities dataset (37). However, since data on exposure was obtained by questionnaire-oriented interview, results could be subject to recall bias. Data on exposure was obtained from the pharmacoepidemiological prescription database from the North-Jutland, whereas data from birth defects was obtained from the Danish medical birth registry. The authors analyzed data of 138 prescriptions for metronidazole obtained by 124 women. The association between exposure during the first 215 trimester and the risk of birth defects was assessed by a case-cohort design. Pregnancy outcome was compared with that of women who were counseled during the same period for non-teratogenic exposure. There was no difference in the rate of major malformations between the groups (3 cases of birth defects among 190 women exposed (1. The results from the studies discussed above do not indicate that metronidazole used alone poses a teratogenic threat for humans after exposure during the first trimester of pregnancy (Figure 3). However, a recent study demonstrated that rodents exposed in utero to metronidazole plus miconazole had a significant increment in the incidence of axial skeletal defects (26. In adition, a population-based case-control study conducted in 2005, warned for the possible correlation between use of topical metronidazole in combination with other anti-infectives and human birth defects (39). Benefit of metronidazole in the reduction of preterm birth was demonstrated for the use of this agent in association with other antibiotics. However, more evidence is needed to assess the risk of birth defects, when metronidazole is used in combination with other drugs. Therefore, once organogenesis is complete, associations of metronidazole with other antibiotics should be considered for treating infections that predispose to preterm birth, when other equally effective therapeutic options are not available or are contraindicated. Teratogenic effects in mouse fetuses subjected to the concurrent in utero exposure to miconazole and metronidazole. Failure of metronidazole to prevent preterm delivery among pregnant women with asymptomatic Trichomonas vaginalis infection. Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. Effect of metronidazole in patients with preterm birth in preceding pregnancy and bacterial vaginosis: a placebo- controlled, double-blind study. Impact of metronidazole therapy on preterm birth in women with bacterial vaginosis flora (Gardnerella vaginalis): a randomised, placebo controlled trial. Safety of metronidazole during pregnancy: a cohort study of risk of congenital abnormalities, preterm delivery and low birth weight in 124 women. Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Antibiotics for bacterial vaginosis or Trichomonas vaginalis in pregnancy: a systematic review. Treatment of trichomoniasis in pregnancy and preterm birth: an observational study. Ampicillin and metronidazole treatment in preterm labour: a multicentre, randomised controlled trial. Ampicillin-metronidazole treatment in idiopathic preterm labour: a randomised controlled multicentre trial. Impact of treatment for bacterial vaginosis on prematurity among Brazilian pregnant women: a retrospective cohort study.

The site of the live vaccinia virus inoculation continues to enlarge and fails to heal purchase naltrexone 50mg online. In patients with eczema cheap naltrexone 50 mg otc, typical vaccinia-type lesions can occur in the areas of active eczema buy naltrexone 50mg amex. This process, called eczema vaccinatum, can also be very serious, and patients with eczema should not receive the smallpox vaccine if it can be avoided. A 38-year-old patient presents to the emergency room with a minor injury and is found to have a blood pressure of 145/95. Confirm another high blood pressure reading within 2 months and provide advice on lifestyle modifications d. Recheck blood pressure within 1 year and provide advice on lifestyle modifica- tions e. Which of the following represents the currently recommended goal for blood pressure control in a diabetic? A 60-year-old white male just moved to town and needs to establish care for coronary artery disease. He had a heart attack last year, but gradu- ally eliminated several prescription medications (he does not recall the names) that he was on at the time of hospital discharge. However, he has been very conscientious about low-fat, low-cholesterol eating habits. Review his previous medications and resume an angiotensin converting enzyme inhibitor 416. In the preceding patient, for secondary prevention of further myocar- dial infarction, the patient should be placed on (in addition to aspirin) a. A 50-year-old white male who comes for general checkup is a healthy nonsmoker, free of hypertension, diabetes, or cardiac disease; however, his 53-year-old brother had coronary artery bypass surgery this year. None specifically required based on current risks General Medicine and Prevention 231 418. A 32-year-old diabetic female who takes an estrogen-containing oral contraceptive and drinks three beers per day is found to have a triglyceride level greater than 1000 mg/dL. A 45-year-old, generally healthy female on no medications comes to your office with a 10-day history of nasal congestion, sore throat, dry cough, and initial low-grade fever, all of which were nearly resolved. However, over the past 24 to 48 h she has developed a sharp chest pain, worse with deep inspiration or cough, but no dyspnea. A 25-year-old Hispanic male PhD candidate recently traveled to rural Mexico for 1 month to gain further information for his dissertation regarding socioeconomics. However, over the 2 to 3 weeks since coming home, he has continued to have occa- sional loose stools plus vague abdominal discomfort and bloating. In August you saw a debilitated 80-year-old female who required nursing home placement. She had had no immunizations for many years except for a pneumococcal vaccine 3 years ago when discharged from the hospital after a stay for pneumonia. An asymptomatic 50-year-old man who has smoked one pack of cig- arettes per day for 30 years comes to you for a general checkup and wants “the works” for cancer screening. Based on American Cancer Society guidelines for early detection of breast cancer, this patient at standard risk should be advised to a. On presentation for yearly exam, a healthy, non–sexually active post- menopausal 60-year-old female gives a history of having had normal yearly mammograms and normal yearly Pap smears over the past 10 years, but never an endometrial tissue sample or any screening test for ovarian cancer. You have been asked to perform a preoperative consultation on a 65-year-old male who will be undergoing transurethral resection of the prostate for urinary retention. Of the following findings, which you detect by history, physical, and lab, which is of most concern in predicting a car- diac complication in this patient undergoing noncardiac surgery? A 78-year-old female comes to your office with symptoms of insom- nia nearly every day, fatigue, weight loss of over 5% of body weight over the past month, loss of interest in most activities, and diminished ability to concentrate. Although further testing may be necessary, based on this his- tory the most likely diagnosis is a. A 20-year-old college basketball player is brought to the university urgent care clinic after developing chest pain and palpitations during prac- tice, but no dyspnea or tachypnea. There is no unusual family history of cardiac diseases, and social history is negative for alcohol or drug use. For each numbered item, select the one lettered option with which it is most closely associated. Items 433–435 The initial choice of an antihypertensive agent may depend on concomitant factors. For each of the conditions below, indicate the medication choice that would give the best additional benefit after blood pressure control. For each of the conditions below, indicate the medication choice that needs to be avoided above all others. A 92-year-old woman with type 2 diabetes mellitus has developed cellulitis and gangrene of her left foot. She requires a lifesaving amputation, but refuses to give consent for the surgery. She has been ambulatory in her nursing home but states that she would be so dependent after surgery that life would not be worth living for her. A 20-year-old complains of diarrhea, burning of the throat, and diffi- culty swallowing over 2 months. Bullae and erythema develop around the bite, and some skin necrosis becomes apparent.

The follow-up visit soon after a negative stress test will often present itself as an opportunity for the physician to facilitate change buy 50mg naltrexone with mastercard. Suggested for further reading: Chapter 23 Chest Pain in Current Diagnosis & Treatment in Family Medicine buy naltrexone 50 mg with mastercard. University of South Alabama discount 50 mg naltrexone with mastercard, Department of Family Medicine June 30, 2008 44 Resources for patients: Chest pain, acute accessed on Familydoctor. Management of herpes zoster (shingles) and postherpetic neuralgia Am Fam Physician 2000;61:2437-44,2447-8. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. University of South Alabama, Department of Family Medicine June 30, 2008 45 Appendix University of South Alabama, Department of Family Medicine June 30, 2008 46 University of South Alabama, Department of Family Medicine June 30, 2008 47 University of South Alabama, Department of Family Medicine June 30, 2008 48 Cough 786. Arrange for definitive care of identified specific causes of cough at time of presentation or with appropriate follow-up. Cough is a normal mechanism of the body that clears secretions from the bronchial tree and trachea. Voluntary control is manifested as cough inhibition (holding back a cough) or voluntary cough. Involuntary cough is triggered by vagus nerve stimulation in the back of the throat and bronchial tree. In addition, there are life-threatening ailments like pneumonia and lung cancer that may present with cough as a chief complaint. A thorough history and physical exam is important in determining the cause of cough. Chief Complaint: Typically the complaint is ―Cough‖ Vitals: Age, respiratory rate, pulse, temperature and weight should be noted prior to going into the room through chart review and review of vital signs. General approach to history: The history for cough is primarily to identify underlying causes of cough. Green or yellow sputum was once thought to be suggestive of bacterial infection, although this remains controversial. University of South Alabama, Department of Family Medicine June 30, 2008 50 Physical: The physical exam is targeted primarily at identifying underlying causes of cough and ruling out serious pathology (i. Extremities – n/c Neuro –n/c Musculoskeletal – n/c Disease Specific Indicators: Infants ages 0 – 2 years: Disease Suggestive findings on history and physical Daycare attendance. Productive cough, tachypnea, fever, ill appearance, Pneumonia crackles on physical exam. SpO2 <95% Children Ages 2-14 years: Disease Suggestive findings on history and physical Daycare attendance. Productive cough, fever, shortness of breath, crackles Pneumonia on physical exam. Productive cough, fever, shortness of breath, Pneumonia crackles on physical exam. Weight loss, fatigue, hemoptysis, current or Lung Cancer former smoker University of South Alabama, Department of Family Medicine June 30, 2008 52 Diagnostic studies: General guidelines Types of diagnostic studies will depend upon clinical suspicion of underlying cause. University of South Alabama, Department of Family Medicine June 30, 2008 53 Suspected cause Study to order When to order In patients >6 years old to Asthma Spirometry make diagnosis and follow disease. Hot showers (breathing warm, moist air) and humidifiers may help clear the nasal passages. Hot soups and liquids such as tea may also help clear nasal passages by a vapor action. Combination products are available to target specific constellations of symptoms and can be chosen on the basis of patient complaints. Cough suppressants and decongestants are not recommended for patients less than 2 years of age. Most systemic cough suppressants suppress cough by action on the central nervous system. Patients should return for respiratory difficulty, persistent high fever, or in 2 weeks if not better. Pharmacologic - A trial of H2 blockers or Proton Pump Inhibitors is often diagnostic and therapeutic. Patients should follow up in 1 month if cough has not resolved or sooner for problems. Pets (especially house cats and dogs) are common offenders as is thick carpeting that tends to retain dust and other allergens. They are not effective acutely, but if used regularly will prevent most allergic mediated postnasal drip. Anticholinergics may be tried if patients do not tolerate antihistamines and inhaled nasal steroids. Leukotriene modifiers are approved for allergic rhinitis and may be considered although their role remains unclear. Croup: Non-pharmacologic – Cool humidified air may help with symptoms but no studies prove this. Pharmacologic – Nebulized racemic epinephrine may help relieve symptoms temporarily. University of South Alabama, Department of Family Medicine June 30, 2008 55 Follow-up - Patients should follow up in 1 week if not better and sooner for increasing work of breathing. Croup is generally a self-limited illness, but occasionally children do require intubation due to subglottic stenosis from croup. Parents should also be informed that symptoms are likely to be worse at night than during the day.