Anatomy correlations: introducing clinical skills to improve performance in anatomy.

BACKGROUND AND OBJECTIVES: Gross anatomy is one of the preclinical cornerstones of medical education, but many practitioners feel that medical students' knowledge of anatomy is inadequate. To help students understand the clinical relevance of anatomy studies, Ohio State University faculty developed a course called "Anatomy Correlations." This course introduces students to basic physical examination techniques correlated to gross anatomy dissections and allows them to practice techniques learned. METHODS: Anatomy grades prior to the introduction of the course were compared with anatomy grades after the introduction of the course to see if the course improved knowledge of gross anatomy. Analysis controlled for initial differences in academic aptitude. RESULTS: Students taking the course in its new form scored higher in anatomy than did students taking anatomy before the course was offered. CONCLUSION: Introducing physical examination skills that correlate with anatomy studies can lead to improvement in anatomy scores.

Assessing breast cancer risk in women.

Understanding modifiable and nonmodifiable factors that increase or decrease breast cancer risk allows family physicians to counsel women appropriately. Nonmodifiable factors associated with increased breast cancer risk include advanced age, female sex, family history of breast cancer, increased breast density, genetic predisposition, menarche before age 12 years, and natural menopause after age 45 years. Hormonal factors associated with breast cancer include advanced age at first pregnancy, exposure to diethylstilbestrol, and hormone therapy. Environmental factors include therapeutic radiation. Obesity is also associated with increased rates of breast cancer. Factors associated with decreased cancer rates include pregnancy at an early age, late menarche, early menopause, high parity, and use of some medications, such as selective estrogen receptor modulators and, possibly, nonsteroidal anti-inflammatory agents and aspirin. No convincing evidence supports the use of dietary interventions for the prevention of breast cancer, with the exception of limiting alcohol intake.

Screening for breast cancer: current recommendations and future directions.

Breast cancer is one of the most significant health concerns in the United States. Recent reviews have questioned the value of traditional breast cancer screening methods. Breast self-examination has been shown not to improve cancer-specific or all-cause mortality in large studies, but it is commonly advocated as a noninvasive screen. Patients who choose to perform self-examination should be trained in appropriate technique and follow-up. The contribution of the clinical breast examination to early detection is difficult to determine, but studies show that sensitivity is highly dependent on time taken to do the examination. Up to 10 percent of cancers are mammographically silent but evident on clinical breast examination. The U.S. Preventive Services Task Force recommends mammography for women older than 40 years who are in good health, but physicians should consider that sensitivity is lower for younger women. Digital mammography is somewhat more sensitive in younger women and women with dense breasts, but outcome studies are lacking. Although magnetic resonance imaging shows promise as a screening tool in some high-risk women, it is not currently recommended for general screening because of high false-positive rates and cost. The American Cancer Society recommends annual magnetic resonance imaging as an adjunct to screening mammography in high-risk women 30 years and older.

Teaching cervical dilation measurement to family medicine residents.

BACKGROUND AND OBJECTIVES: Cervical dilation measurement is difficult to teach. This pilot study's objective was to determine if residents participating in an innovative workshop improved their cervical measurement accuracy when using soft cervical models in the classroom. METHODS: Resident physicians measured cervical models before and after the workshop. We compared pre-workshop and post-workshop coefficients of variation using a standard t test. CONCLUSION: Residents reduced their measurement error from 38.2% to 15.6%.

Viral croup.

Viral croup is the most common form of airway obstruction in children six months to six years of age. The frightening nature of croup often prompts parents and caregivers to seek physician consultation. For children with mild croup, symptomatic care and mist therapy may be all that is necessary. Epinephrine has been used for decades to treat more severe cases of croup, but recent meta-analyses have found that glucocorticoid use is associated with shorter hospital stays, improvement in croup scores, and less use of epinephrine. Studies have shown that treatment with 0.6 mg per kg of oral dexamethasone is as effective as intramuscular dexamethasone or 2 mg of nebulized budesonide. Oral dexamethasone in dosages as low as 0.15 mg per kg also may be effective. While more studies are needed to establish guidelines, oral dexamethasone can be used to treat mild to moderate croup with close follow-up and instructions for further care, if needed.

Common problems in patients recovering from chemical dependency.

Chemical dependency is a common, chronic disease that affects up to 25 percent of patients seen in primary care practices. The treatment goal for patients recovering from chemical dependency should be to avoid relapse. This requires physicians to have an open, nonjudgmental attitude and specific expertise about the implications of addiction for other health problems. First-line treatment for chemical dependency should be nonpharmacologic, but when medication is necessary, physicians should avoid drugs that have the potential for abuse or addiction. Medications that sedate or otherwise impair judgment also should be avoided in the recovering patient. Psychiatric illnesses should be aggressively treated, because untreated symptoms increase the risk of relapse into chemical dependency. Selective serotonin reuptake inhibitors may help to lower alcohol consumption in depressed patients, and desipramine may help to facilitate abstinence in persons addicted to cocaine. If insomnia extends beyond the acute or postacute withdrawal period, trazodone may be an effective treatment. If nonpharmacologic management of pain is not possible, nonaddictive medications should be used. However, if non-addictive medications fail, long-acting opiates used under strict supervision may be considered. Uncontrolled pain in itself is a relapse risk.

Management of Crohn's disease--a practical approach.

Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract that affects up to 480,000 persons in the United States. Symptoms include abdominal pain, diarrhea, fever, malaise, and arthralgias, and cause considerable morbidity. Speculation about genetic, environmental, dietary, infectious, and immunologic etiologies has led to treatment modalities directed at each theoretic cause, but therapy guidelines are determined by the severity of disease. Use of salicylates and/or antibiotics can be effective in mild to moderate disease, while steroids are the accepted therapy for more severe active disease. Azathioprine and other immunosuppresant drugs can be used as adjunctive therapy for active Crohn's disease and may help to maintain remission. Infliximab, an antibody to human tumor necrosis factor alpha, has proved successful in the treatment of severe refractory disease and generally causes only mild side effects. Therapy for Crohn's disease must involve treating comorbid conditions to improve the quality of life of patients.

Management of the acute migraine headache.

As many as 30 million Americans have migraine headaches. The impact on patients and their families can be tremendous, and treatment of migraines can present diagnostic and therapeutic challenges for family physicians. Abortive treatment options include nonspecific and migraine-specific therapy. Nonspecific therapies include analgesics (aspirin, nonsteroidal anti-inflammatory drugs, and opiates), adjunctive therapies (antiemetics and sedatives), and other nonspecific medications (intranasal lidocaine or steroids). Migraine-specific abortive therapies include ergotamine and its derivatives, and triptans. Complementary and alternative therapies can also be used to abort the headache or enhance the efficacy of another therapeutic modality. Treatment choices for acute migraine should be based on headache severity, migraine frequency, associated symptoms, and comorbidities.

Diagnosis and management of acute bronchitis.

Acute bronchitis is one of the top 10 conditions for which patients seek medical care. Physicians show considerable variability in describing the signs and symptoms necessary to its diagnosis. Because acute bronchitis most often has a viral cause, symptomatic treatment with protussives, antitussives, or bronchodilators is appropriate. However, studies indicate that many physicians treat bronchitis with antibiotics. These drugs have generally been shown to be ineffective in patients with uncomplicated acute bronchitis. Furthermore, antibiotics often have detrimental side effects, and their overuse contributes to the increasing problem of antibiotic resistance. Patient satisfaction with the treatment of acute bronchitis is related to the quality of the physician-patient interaction rather than to prescription of an antibiotic.