Caregivers and elderly relatives. The prevalence of caregiving in a family practice.

Persons 65 years and older are the most rapidly growing age group in the United States. As age increases, functional ability deteriorates and the need for help from another person escalates. Caring for elderly persons experiencing functional deterioration is stressful, creating hidden patients among caregivers. This study surveyed randomly selected active family practice patients 40 years and older to determine the prevalence and extent of the caregiving role and functional disability among elderly relatives. One in five patients (126/602) surveyed had caregiving responsibilities for noninstitutionalized relatives (total, 153 patients). One third of caregivers lived with the relative; most of the remaining two thirds visited their relative at least twice weekly. Caregivers reported some functional impairment in 60% of their relatives, and substantial impairment in 40%. The caregiving experience is common, and the potential for stress from managing an elderly relative's disability is substantial. Further research is needed to elaborate on the burden of the caregiver.

Teaching occupational and environmental medicine in primary care residency training programs: experience using three approaches during 1984-1991.

There is a critical shortage of physicians trained to recognize and treat occupational and environmental health problems. We implemented several required teaching programs for internal medicine and family medicine residents that focus on providing primary care for these problems. Clinical experiences were developed using the university and medical center as an example of a workplace with chemical and physical hazards. On-site experiences were also provided at local industries, but when resident stipend support for this aspect was discontinued, that part of the program was suspended. Didactic programs were associated with a statistically significant improvement in house staff knowledge scores. These occupational and environmental health issues can be introduced during residency, resulting in increased expertise in this discipline.

Obstetric risk assessment.

Obstetric risk assessment is an important component of comprehensive obstetric care. It is a tool used to evaluate the medical, psychosocial, familial, and environmental factors that increase the chance of an adverse outcome. Such outcomes may involve the mother, the infant, or both. Risk assessment collects and organizes data obtained from a pertinent history, physical examination, and laboratory assessment into an accurate and easily retrievable medical record. It can be used to adapt diagnostic or therapeutic management plans, arrange consultation or shared care with another specialist, or tailor anticipatory guidance and patient and family education.

Risk assessment.

Risk assessment is the process by which clinicians screen for conditions that, if unmanaged, result in complications of pregnancy or adverse birth outcomes and for which an intervention would improve the well-being of the mother, child, and family. One of the major US health care goals is that by the year 2000, at least 90% of pregnant women will receive risk appropriate care. This article discusses the major risks to the mother and child during pregnancy, and presents tools to assess pregnancy well-being.

Ectopic pregnancy: 'classic' vs common presentation.

Ectopic pregnancies are common, are increasing in incidence, and are preventable causes of reproductive morbidity and death. They are also frequently misdiagnosed, and are one of the most common causes for malpractice claims made against primary care physicians. The classic description of the presenting signs and symptoms of ectopic pregnancy was derived from a series of ruptured ectopic pregnancies. To decrease the complications and preserve fertility, ectopic pregnancies must be detected before they cause tubal rupture. A family medicine center experience with the diagnosis of ectopic pregnancy over a six-month period is presented. The study confirmed the expected frequency of this condition in this population but findings disclosed that the classic presentation was, in fact, uncommon. Implications for decision making derived from these case reports are discussed. A high level of clinical suspicion for this problem must be maintained.

PIP: To illustrate the way in which cases of ectopic pregnancy present in a family practice setting in contrast to the hospital setting, 7 case reports of ectopic pregnancy are reviewed. A 6-month study of ectopic pregnancies conducted at the Duke-Watts Family Medical Center showed that the classic symptoms of ectopic pregnancy occur uncommonly and to wait for some or all of the triad of symptoms delays diagnosis and treatment. The cases reported highlight the way women present with a tubal pregnancy that has not yet ruptured the fallopian tubes. None of these women presented with the classic triad of symptoms -- aberrant menses, abdominal pain, and an adnexal mass. 4 of 7 patients had risk factors for ectopic pregnancy, and 5 women had an aberrant menstrual pattern. The only woman who did not have vaginal bleeding was the woman whose tube had ruptured. None of these women has an adnexal mass when seen initially. The woman who experienced classic pain also had the ruptured fallopian tube. In 4 cases there was reluctance to consider the diagnosis. In 2 cases in which the diagnosis was considered, a less sensitive pregnancy test -- the urine test -- was ordered. Surgically, 1 tube was preserved intact. 2 other women had conservative operative procedures performed in the hope of optimizing their future fertility. A more comprehensive evaluation of pelvic complaints should be performed when risk factors such as prior ectopic pregnancies or pelvic inflammatory disease are reported. If pregnancy is diagnosed, its location needs to be ascertained by ultrasound examination. Contraceptive use does not rule out the possibility of an ectopic pregnancy, and a pregnancy, under these conditions, is more likely to be ectopic. A physician needs to insist on pathologic examination of all abortions. Exclusion of an ectopic pregnancy is indicated if no products of conception are found. There needs to be prompt referral to allow for conservative tubal surgery in cases of ectopic pregnancies diagnosed prior to rupture.

Cycle control with triphasic norgestimate and ethinyl estradiol, a new oral contraceptive agent.

Effective cycle control was demonstrated based on two multicenter, 2-year studies of the triphasic oral contraceptive (OC) agent containing the new progestin norgestimate. The estrogen in this OC is ethinyl estradiol. These open-label Phase III studies were conducted in the United States by 33 investigators at 33 sites who treated a total of 1,783 subjects, healthy women 17 to 38 years of age with menstrual cycle characteristics considered to be within the normal range. The norgestimate/ethinyl estradiol preparation was taken for up to 24 cycles. Follow-up information was collected 3 to 4 months post-treatment. Bleeding pattern analyses were based on 27,970 valid cycles. Normal cyclic bleeding patterns were experienced by most of the women during the study; only minimal and statistically and clinically insignificant variations in menstrual flow, dysmenorrhea, and premenstrual tension occurred. There was a low incidence of failed withdrawal bleeding in single cycles (less than 1.0% after cycle 6). There were no cases of amenorrhea, defined as two consecutive cycles of missed withdrawal flow. The incidence of breakthrough bleeding or spotting was highest during the initial treatment cycles and diminished with continued use of the formulation. The mean incidence of breakthrough bleeding was 2.36% in cycles 13 to 24. Apart from somewhat higher initial percentages among women new to oral contraception, the pattern of midcycle bleeding or spotting was similar to that of all women studied. Effective long-term cycle control was demonstrated in women who used this OC agent.