Adolescent Idiopathic Scoliosis: Common Questions and Answers.

Adolescent idiopathic scoliosis affects 1% to 3% of U.S. adolescents. It is defined by a lateral curvature of the spine (Cobb angle) of at least 10 degrees in the absence of underlying congenital or neuromuscular abnormalities. Adolescent idiopathic scoliosis may be detected via the forward bend test and should be confirmed with scoliometer measurement. Mild scoliosis is usually asymptomatic; it may contribute to musculoskeletal back pain, but there is no evidence that it causes disability or functional impairment. Patients with severe scoliosis (Cobb angle of 40 degrees or more) may have physical pain, cosmetic deformity, psychosocial distress, or, rarely, pulmonary disorders. Several studies have shown modest benefit from bracing and scoliosis-specific physical therapy to limit progression in mild to moderate scoliosis, but there were no effects on quality of life. Because no high-quality studies have proven that surgery is superior to bracing or observation, it should be reserved for severe cases. There is little evidence that treatments improve patient-oriented outcomes. The U.S. Preventive Services Task Force and the American Academy of Family Physicians found insufficient evidence to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis in children and adolescents 10 to 18 years of age.

High Blood Pressure in Children and Adolescents.

High blood pressure in children and adolescents is a growing health problem that is often overlooked. Children should be screened for elevated blood pressure annually beginning at three years of age or at every visit if risk factors are present. In children younger than 13 years, elevated blood pressure is defined as blood pressure in the 90th percentile or higher for age, height, and sex, and hypertension is defined as blood pressure in the 95th percentile or higher. In adolescents 13 years and older, elevated blood pressure is defined as blood pressure of 120 to 129 mm Hg systolic and less than 80 mm Hg diastolic, and hypertension is defined as blood pressure of 130/80 mm Hg or higher. Ambulatory blood pressure monitoring should be performed to confirm hypertension in children and adolescents. Primary hypertension is now the most common cause of hypertension in children and adolescents. A history and physical examination and targeted screening tests should be done to evaluate for underlying medical disorders, and children and adolescents with hypertension should be screened for comorbid cardiovascular diseases, including diabetes mellitus and hyperlipidemia. Hypertension in children is initially treated with lifestyle changes such as weight loss if overweight or obese, a healthy diet, and regular exercise. Children with symptomatic hypertension (e.g., headaches, cognitive changes), stage 2 hypertension without a modifiable factor such as obesity, evidence of left ventricular hypertrophy on echocardiography, any stage of hypertension associated with chronic kidney disease or diabetes, or persistent hypertension despite a trial of lifestyle modifications require antihypertensive medications and should be evaluated for cardiovascular damage with echocardiography. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics are effective, safe, and well-tolerated in children.

How physicians cope with stillbirth or neonatal death: a national survey of obstetricians.

OBJECTIVE: To identify U.S. obstetricians' experiences and attitudes about perinatal death, their coping strategies, and their beliefs about the adequacy of their training on this topic. METHODS: A total of 1,500 randomly selected U.S. obstetricians were mailed a self-administered survey about their experiences and attitudes in dealing with perinatal death. Physicians received up to three copies of the survey, a reminder card, and a $2 cash incentive. Eight hundred four physicians (54%) completed the entire survey. RESULTS: Seventy-five percent of respondents reported that caring for a patient with a stillbirth took a large emotional toll on them personally, and nearly one in 10 obstetricians reported they had considered giving up obstetric practice because of the emotional difficulty in caring for a patient with a stillbirth. Talking informally with colleagues (87%) or friends and family (56%) were the most common strategies used by physicians to personally cope with these situations. CONCLUSION: Perinatal death has a profound effect on the delivering obstetrician, and a significant number of participants in our study have even considered giving up obstetrics altogether. Improved bereavement training may help obstetricians care for grieving families but also cope with their own emotions after this devastating event. LEVEL OF EVIDENCE: II.

Genital Cancers in Women: Ovarian Cancer.

More than 20,000 US women are diagnosed with ovarian cancer each year. The average lifetime risk is 1.3%, but risk increases with BRCA1 or BRCA2 gene mutations (40% and 18% risk, respectively, by age 70 years) or hereditary nonpolyposis colorectal cancer syndrome (12% lifetime risk). Other risk factors include smoking, possibly past clomiphene use, and more years of ovulation. Symptoms are nonspecific. Abdominal pain is most common; others include pelvic pain, bloating, and early satiety. When ovarian cancer is suspected, evaluation should begin with transvaginal ultrasonography with Doppler studies. Cancer antigen 125 testing can be obtained, but levels are not elevated in all patients. Other biomarkers (eg, OVA1) and scoring systems can be used to help determine if cancer is present. When diagnosed early (stage I), the 5-year survival rate is 90% for epithelial ovarian cancer. However, most patients with epithelial ovarian cancer are diagnosed in stage III or later, with a 5-year survival rate of 17% to 39%. Treatment involves total abdominal hysterectomy and bilateral salpingo-oophorectomy, with or without chemotherapy. Fertility-preserving options can be considered in some early-stage cancers, followed by more definitive surgical procedures. There is no evidence that routine screening is beneficial and it is associated with significant harms from unnecessary procedures. Women with genetic syndromes that increase risk should be considered for prophylactic bilateral salpingo-oophorectomy.