Managing pain in the dying patient.

End-of-life care can be a challenge requiring the full range of a family physician's skills. Significant pain is common but is often undertreated despite available medications and technology. Starting with an appropriate assessment and following recommended guidelines on the use of analgesics, family physicians can achieve successful pain relief in nearly 90 percent of dying patients. Physicians must overcome their own fears about using narcotics and allay similar fears in patients, families and communities. Drugs such as corticosteroids, antidepressants and anticonvulsants can also help to alleviate pain. Anticonvulsants can be especially useful in relieving neuropathic pain. Side effects of pain medications should be anticipated and treated promptly, but good pain control should be maintained. The physical, psychologic, social and spiritual needs of dying patients are best managed with a team approach. Home visits can provide comfort and facilitate the doctor-patient relationship at the end of life.

The role of the family physician in the day care setting.

Injuries and infectious respiratory, gastrointestinal and dermatologic diseases are common in day care settings. Most day care injuries are contusions, abrasions and cuts involving the head and extremities. Impact-absorbing surfaces under playground equipment, safely-proofing of all play areas, increased staff supervision, and staff and parental education might reduce injuries by as much as 75 percent. Respiratory illnesses are the most common day care infections. Chemoprophylaxis with rifampin is required for all close contacts of children infected with Haemophilus influenzae type B and Neisseria meningitidis. Diarrheal illness may be caused by viral pathogens, bacterial agents such as Shigella, Campylobacter or Salmonella, or parasitic infections caused by Giardia lamblia and Cryptosporidium. Strict hand-washing procedures, especially before food preparation and after toileting, may reduce diarrheal illness by 50 percent. Head lice (Pediculosis capitis) and scabies are common dermatologic infections spread by direct contact and through clothing, bedding and hair brushes. Screening and treating affected children with permethrin preparations and thoroughly washing bedding and clothing are necessary to stop outbreaks. Use of universal precautions for the handling of stool is essential to prevent the spread of both ordinary diarrheal illnesses and serious infections such as hepatitis A and B, human immunodeficiency virus and cytomegalovirus.

A point-source epidemic of leptospirosis. Description of cases, cause, and prevention.

Leptospirosis is a zoonotic disease that consists of fever, headache, myalgias, and multiple organ involvement, has varying clinical severity and morbidity, and can occur in epidemic form. Diagnosis is based on culture or serologic demonstration of recent infection. There is evidence that doxycycline therapy started early in the course of the disease favorably affects duration and severity. Antibiotic therapy is often initiated because of a strong suspicion of the disease, before bacteriologic or serologic confirmation of the diagnosis is completed. Public health measures play an important role in minimizing the incidence of leptospirosis.