Enuresis in Children: Common Questions and Answers.

Nocturnal enuresis is defined as nighttime urinary incontinence occurring at least twice weekly in children five years and older. Approximately 14% of children have spontaneous resolution each year without treatment. Subtypes of nocturnal enuresis include nonmonosymptomatic enuresis and primary and secondary monosymptomatic nocturnal enuresis. Monosymptomatic enuresis is characterized by nighttime bedwetting without daytime urinary incontinence. Pathophysiology of primary monosymptomatic nocturnal enuresis may be due to sleep arousal disorder, overproduction of urine, small bladder storage capacity, or detrusor overactivity. Children with nonmonosymptomatic enuresis have daytime and nighttime symptoms resulting from a variety of underlying etiologies. An in-depth history is an integral component of the initial evaluation. For all types of enuresis, a comprehensive physical examination and urinalysis should be performed to help identify the cause. It is important to reiterate to the family that bedwetting is not the child's fault. Treatment should begin with behavioral modification, which then progresses to enuresis alarm therapy and oral desmopressin. Enuresis alarm therapy is more likely to produce long-term success; desmopressin yields earlier symptom improvement. Treatment of secondary monosymptomatic nocturnal enuresis and nonmonosymptomatic enuresis should primarily focus on the underlying etiology. Pediatric urology referral should be made for refractory cases in which underlying genitourinary anomalies or neurologic disorders are more likely. .

Peripheral Nerve Entrapment and Injury in the Upper Extremity.

Peripheral nerves in the upper extremities are at risk of injury and entrapment because of their superficial nature and length. Injury can result from trauma, anatomic abnormalities, systemic disease, and entrapment. The extent of the injury can range from mild neurapraxia, in which the nerve experiences mild ischemia caused by compression, to severe neurotmesis, in which the nerve has full-thickness damage and full recovery may not occur. Most nerve injuries seen by family physicians will involve neurapraxia, resulting from entrapment along the anatomic course of the nerve. In the upper extremity, the brachial plexus branches into five peripheral nerves, three of which are commonly entrapped at the shoulder, elbow, and wrist. Patients with nerve injury typically present with pain, weakness, and paresthesia. A detailed history and physical examination alone are often enough to identify the injury or entrapment; advanced diagnostic testing with magnetic resonance imaging, ultrasonography, or electrodiagnostic studies can help confirm the clinical diagnosis and is indicated if conservative management is ineffective. Initial treatment is conservative, with surgical options available for refractory injuries or entrapment caused by anatomic abnormality.

Intrapartum Fetal Monitoring.

Continuous electronic fetal monitoring was developed to screen for signs of hypoxic-ischemic encephalopathy, cerebral palsy, and impending fetal death during labor. Because these events have a low prevalence, continuous electronic fetal monitoring has a false-positive rate of 99%. The widespread use of continuous electronic fetal monitoring has increased operative and cesarean delivery rates without improved neonatal outcomes, but its use is appropriate in high-risk labor. Structured intermittent auscultation is an underused form of fetal monitoring; when employed during low-risk labor, it can lower rates of operative and cesarean deliveries with neonatal outcomes similar to those of continuous electronic fetal monitoring. However, structured intermittent auscultation remains difficult to implement because of barriers in nurse staffing and physician oversight. The National Institute of Child Health and Human Development terminology is used when reviewing continuous electronic fetal monitoring and delineates fetal risk by three categories. Category I tracings reflect a lack of fetal acidosis and do not require intervention. Category II tracings are indeterminate, are present in the majority of laboring patients, and can encompass monitoring predictive of clinically normal to rapidly developing acidosis. Presence of moderate fetal heart rate variability and accelerations with absence of recurrent pathologic decelerations provides reassurance that acidosis is not present. Category II tracing abnormalities can be addressed by treating reversible causes and providing intrauterine resuscitation, which includes stopping uterine-stimulating agents, fetal scalp stimulation and/or maternal repositioning, intravenous fluids, or oxygen. Recurrent deep variable decelerations can be corrected with amnioinfusion. Category III tracings are highly concerning for fetal acidosis, and delivery should be expedited if immediate interventions do not improve the tracing.

Military Family Physicians' Practices and Perceptions About Reproductive Health Services for Deploying Women.

INTRODUCTION: Incomplete or inadequate provision of contraceptive services to servicewomen can have a profound impact on military health, readiness, and financial outcomes. This study examined the reproductive health practices and perceptions among family medicine physicians caring for servicewomen. MATERIALS AND METHODS: We conducted an anonymous survey of 568 registered attendees at the March, 2018 Uniformed Services Academy of Family Physicians annual meeting. The response rate was 52.8% and 69% of responders met inclusion criteria. RESULTS: Our sample of family medicine physicians was 58.3% male and 85.3% Caucasian. In all, 18.3% were current residents, 42.9% graduated between 2008 and 2017, and 38.7% graduated before 2008. A previous deployment was reported by 55.1%.Among physicians with a deployment history, 20.8% reported difficulty prescribing contraception during deployment because they were unable to obtain a patient's desired method, 2.6% reported servicewomen not accessing contraception because of fear and stigma associated with sexual activity in the deployed setting, and 22.1% reported problems with both factors.Among physicians performing pre-deployment and other readiness visits for active duty servicewomen, 17.4% reported not discussing contraception at these encounters because of competing priorities and 1.5% because of ethical/religious concerns. Physicians who could offer more rapid access to subdermal implants (within 2 weeks) were more likely to discuss contraception (87.0% versus 64.7%, p = 0.005).When discussing the use of contraception in the deployed environment, 15.8% of physicians would not prescribe oral contraceptives, 12.3% would not prescribe intrauterine methods, and 14.3% would not prescribe subdermal implants. Physicians who previously deployed were more likely to report they would offer oral contraceptives (91% versus 75.0%, OR 3.4 [95% CI 1.44-8.48], p = 0.002) for women in the deployed setting compared to those who have not deployed. More timely (<2 weeks) access to subdermal implant insertion was associated with a greater rate of offering subdermal implants (91.9% versus 79.6%, p = 0.02).When discussing contraceptive options with all women, 27.3% of physicians do not prescribe emergency contraception because of training, ethical, and/or religious reasons. Some reported they would neither prescribe nor refer women for the following methods: emergency contraception (4.5%), intrauterine contraception (9.3%), and subdermal implants (7.3%). CONCLUSIONS: The results of this study support the need to develop a consistent, standardized, and evidence-based pre-deployment process and expanded resources in deployed environments for services related to the provision of reproductive health. Optimal strategies may aim to reduce barriers to care and enable the highest quality of health care through provider education, resource allocation, revised appointment times and content, and diversity among provider experience. Further research is needed to determine the influence of physician practice patterns on patient reproductive health outcomes and interventions to modify these practices to improve patient outcomes and military readiness.

Equivalent comfort contours for fore-and-aft, lateral, and vertical whole-body vibration in the frequency range 1.0 to 10 Hz.

Standards assume vibration discomfort depends on the frequency and direction of whole-body vibration, with the same weightings for frequency and direction at all magnitudes. This study determined equivalent comfort contours from 1.0 to 10 Hz in each of three directions (fore-and-aft, lateral, vertical) at magnitudes in the range 0.1 to 3.5 ms-2 r.m.s. Twenty-four subjects sat on a rigid flat seat with and without a beanbag, altering the pressure distribution on the seat but not the transmission of vibration. The rate of growth of vibration discomfort with increasing magnitude of vibration differed between the directions of vibration and varied with the frequency of vibration. The frequency-dependence and direction-dependence of discomfort, therefore, depended on the magnitude of vibration. The beanbag did not affect the frequency-dependence or direction-dependence of vibration discomfort. It is concluded that different weightings for the frequency and direction of vibration are required for low and high magnitude vibration. Practitioner summary: When evaluating whole-body vibration to predict vibration discomfort, the weightings appropriate to different frequencies and different directions of vibration should depend on the magnitude of vibration. This is overlooked in all current methods of evaluating the severity of whole-body vibration.

Exercise Stress Testing: Indications and Common Questions.

Exercise stress testing is a validated diagnostic test for coronary artery disease in symptomatic patients, and is used in the evaluation of patients with known cardiac disease. Testing of asymptomatic patients is generally not indicated. It may be performed in select deconditioned adults before starting a vigorous exercise program, but no studies have compared outcomes from preexercise testing vs. encouraging light exercise with gradual increases in exertion. Preoperative exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery or who have active cardiac symptoms before undergoing nonemergent noncardiac surgery. Exercise stress testing without imaging is the preferred initial choice for risk stratification in most women. Sensitivity and specificity increase with the use of adjunctive imaging such as echocardiography or myocardial perfusion imaging with single-photon emission computed tomography. Exercise stress testing is rarely an appropriate option to evaluate persons with known coronary artery disease who have no new symptoms less than two years after percutaneous intervention or less than five years after coronary artery bypass grafting. The Duke treadmill score has excellent prognostic value for exercise stress testing. Imaging is not necessary if patients are able to achieve more than 10 metabolic equivalents on exercise stress testing. Exercise stress testing is not indicated before noncardiac surgeries in patients who can achieve 4 metabolic equivalents without symptoms.

Common Questions About Recurrent Urinary Tract Infections in Women.

Recurrent urinary tract infections (UTIs) are common in women, including healthy women with normal genitourinary anatomy. Recurrent UTI is typically defined as three or more UTIs within 12 months, or two or more occurrences within six months. The same species that caused previous infections is typically responsible for recurrences. In premenopausal women, sexual intercourse three or more times per week, spermicide use, new or multiple sex partners, and having a UTI before 15 years of age are established risk factors. In postmenopausal women, risk is primarily increased by sequelae of lower estrogen levels. Episodes of recurrent UTI are typically characterized by dysuria and urinary frequency or hesitancy. Findings from the history or physical examination that suggest complicated infection or another disease process warrant additional evaluation. At least one symptomatic episode should be verified by urine culture to confirm the diagnosis and guide treatment. Imaging is rarely warranted. Short courses of antibiotics are as effective as longer courses. Patient-initiated treatment lowers the cost of diagnosis, number of physician visits, and number of symptomatic days compared with physician-initiated treatment. It also reduces antibiotic exposure compared with antibiotic prophylaxis. Antibiotic prophylaxis effectively limits UTI recurrence but increases the risk of antibiotic resistance and adverse effects. Cranberry products may reduce recurrent UTIs in premenopausal women, but are less effective than antibiotic prophylaxis, and data are conflicting. Optimal dosing is unknown. Postmenopausal women with atrophic vaginitis may benefit from topical estrogen therapy.

Provision of Contraception: Key Recommendations from the CDC.

The Centers for Disease Control and Prevention has released comprehensive recommendations for provision of family planning services. Contraceptive services may be addressed in five steps, and counseling may be provided in a tiered approach, whereby the most effective options are presented before less effective options. Clinicians should discuss all contraceptive methods that can be used safely by the patient, regardless of whether a method is available on site and even if the patient is an adolescent or a nulliparous woman. Physical assessment is usually limited to blood pressure evaluation before starting hormonal contraceptives or pelvic examination before placing an intrauterine device. Monitoring the patient's weight also may be helpful. If it is reasonably certain that the patient is not pregnant, any contraceptive may be started immediately. When hormonal contraceptives are selected, one year's supply should be prescribed to reduce barriers to use. Condoms should be made readily available. Documentation of visits for contraception should include patient understanding of use, benefits, and risks, plus an individualized follow-up plan. Bleeding irregularities generally are not harmful and may resolve with continued use of the contraceptive method. All patients-including adolescents; those who identify as lesbian, gay, bisexual, or transgender; and patients with disabilities or limited English proficiency-should receive high-quality care in an accommodating, nonjudgmental environment. The Centers for Disease Control and Prevention supports advance provision of emergency contraceptives. Because no test reliably verifies cessation of fertility, it is prudent to consider contraceptive use until menopause, or at least until 50 to 55 years of age.

Agranulocytosis from levamisole-adulterated cocaine.

INTRODUCTION: Afebrile neutropenia with an absolute neutrophil count (ANC) of zero in a nonimmunocompromised individual is unusual. Outlined is a case of agranulocytosis likely due to levamisole laced cocaine. Given recent publications in the news media and medical journals, this is a pertinent issue for primary care providers. CASE: A 57-year-old female presented with painful bowel movements and difficulty eating. Physical examination revealed two exquisitely tender ulcerated lesions on her lower lip and anus. Laboratory data revealed an ANC of 0 and urine drug screen positive for cocaine. She was prophylaxed with acyclovir, diflucan, and ciprofloxacin, and was started on granulocyte colony stimulating factor for four days. Her ANC normalized, but the cause of her severe neutropenia remained unclear. DISCUSSION: Levamisole is a veterinary antihelminthic used for treatment of rheumatoid arthritis and colorectal cancer in humans. 88% of regional cocaine samples are testing positive for levamisole, which is thought to potentiate cocaine's effects but can also cause agranulocytosis. CONCLUSIONS: Our patient did not fit the clinical picture for malignancy, viral infection, or bone marrow pathology. Given the high rate of levamisole adulterated cocaine and an otherwise negative work-up, this is the most likely explanation for her agranulocytosis.

Anaphylaxis: recognition and management.

Anaphylaxis is a severe, life-threatening, systemic allergic reaction that is almost always unanticipated and may lead to death by airway obstruction or vascular collapse. Anaphylaxis occurs as the result of an allergen response, usually immunoglobulin E-mediated, which leads to mast cell and basophil activation and a combination of dermatologic, respiratory, cardiovascular, gastrointestinal, and neurologic symptoms. Dermatologic and respiratory symptoms are most common, occurring in 90 and 70 percent of episodes, respectively. The three most common triggers are food, insect stings, and medications. The diagnosis of anaphylaxis is typically made when symptoms occur within one hour of exposure to a specific antigen. Confirmatory testing using serum histamine and tryptase levels is difficult, because blood samples must be drawn with strict time considerations. Allergen skin testing and in vitro assay for serum immunoglobulin E of specific allergens do not reliably predict who will develop anaphylaxis. Administration of intramuscular epinephrine at the onset of anaphylaxis, before respiratory failure or cardiovascular compromise, is essential. Histamine H(1) receptor antagonists and corticosteroids may be useful adjuncts. All patients at risk of recurrent anaphylaxis should be educated about the appropriate use of prescription epinephrine autoinjectors.