Biomedical subjects
Publications and source records attributed to A S Coco.
Infectious vaginitis is a common clinical problem. Unfortunately, treatment, including self-medication, is often instituted before an adequate evaluation has been performed. An accurate diagnosis can usually be made in the office setting, and effective pharmacologic treatments are readily available.
BACKGROUND AND OBJECTIVES: In the context of a dramatic increase in US cesarean delivery rates over the past 30 years and explicit national goals to decrease the cesarean rate, previous retrospective studies have shown that pregnant women cared for by family physicians may be less likely to undergo cesarean delivery, compared with patients cared for by obstetricians. METHODS: We conducted a retrospective chart review of 3,560 deliveries from the family practice service of a community-based family practice residency from 1986-1995, focusing primarily on cesarean delivery rates during two periods of time. During period 1 (n = 1,063), all attending were private practice obstetricians. After a transition period, all births were attended by family medicine faculty (period 2, n = 1,346). RESULTS: The total cesarean delivery rate declined from 16.7% in period 1 to 11.1% in period 2. Repeat cesareans declined from 8.5% to 2.9%. CONCLUSIONS: In this community-based residency, a change in the specialty of the attending physician was associated with a 34% decline in the cesarean delivery rate. The observed decline in the cesarean rate could not be accounted for by any change in patient demographics or secular trends in cesarean delivery rates.
Primary dysmenorrhea is defined as cramping pain in the lower abdomen occurring just before or during menstruation, in the absence of other diseases such as endometriosis. Prevalence rates are as high as 90 percent. Initial presentation of primary dysmenorrhea typically occurs in adolescence. It is a common cause of absenteeism and reduced quality of life in women. The problem is often underdiagnosed and undertreated. Women with primary dysmenorrhea have increased production of endometrial prostaglandin, resulting in increased uterine tone and stronger, more frequent uterine contractions. A diagnostic evaluation is unnecessary in patients with typical symptoms and no risk factors for secondary causes. Nonsteroidal anti-inflammatory medications are the mainstay of treatment, with the addition of oral contraceptive pills when necessary. About 10 percent of affected women do not respond to these measures. It is important to consider secondary causes of dysmenorrhea in women who do not respond to initial treatment. Many alternative treatments (ranging from acupuncture to laparoscopic surgery) have been studied, but the supporting studies are small, with limited long-term follow-up.
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.