Volume 96, Issue 8

In a prospective study using a cutoff value of 140 pg/mL, serum estradiol 17-B assay had a sensitivity of 83% and a specificity of 100% in differentiating ectopic pregnancy (6 patients) from normal pregnancy with threatened abortion proceeding to viability (7 patients). In differentiating threatened abortion from spontaneous abortion (9 patients), the estradiol assay had a sensitivity of 88.9% and a specificity of 100%. All but one of the patients with ectopic pregnancy had estradiol levels below the cutoff value of 140 pg/mL, as did all but one of the patients who had spontaneous abortion. All the patients who had threatened abortion that progressed to viability had values well above the cutoff level. The mean estradiol values for the viable pregnancy group were significantly different from those of the other two groups. These data suggest that, at the institution where this study was done, serum estradiol determinations may be of value in the differentiation of both ectopic pregnancy and spontaneous abortion from threatened abortion but appears to be of very limited usefulness in distinguishing ectopic pregnancy from spontaneous abortion. The validity of these conclusions is limited by the small number of subjects. Further studies comprising greater numbers of subjects are needed.

Management of patients whose Papanicolaou smears show atypical squamous cells of undetermined significance (ASCUS) is a complex challenge for the family physician. It is critical that patients with the ASCUS smear be properly evaluated and triaged, as the ASCUS smear may be a manifestation of high-grade disease in 20% or more of cases. Several options for triage exist. Colposcopy is considered by many the option of choice. However, alternative options include cervicography, speculoscopy, and human papillomavirus subtyping. For proper management of the patient with the ASCUS smear, the clinician must consider the patient's Pap test history, risk factors for cervical cancer, and the cytopathologist's interpretation/recommendation.

Factitious disorders are fabricated illnesses. Conceptually, these disorders lie in the gray zone between malingering and real diseases. Clinical awareness will prevent unnecessary diagnostic and therapeutic interventions. The author profiles those patients and symptoms that accompany factitious disorders as well as factitious disorders by proxy. In the case of the latter, child abuse may be uncovered as well. Although rare, factitious disorders will be present in a busy primary care practice. Clinical detection based on patient profiles can aide discovery. Early recognition and management may prevent a chronic and debilitating course from culminating into one in which the person becomes a "professional patient."

The evolution of the healthcare marketplace to a managed care-based system requires dramatic changes in the fragmented medical education infrastructure and curricula to more adequately train the physician workforce needed to staff and support the new system_ Graduating physicians, in large numbers, feel poorly prepared to function effectively in the very areas adjudged to be essential to a successful transition, such as cost effective care and caring for patients in outpatient settings. Managers of the new systems, such as health maintenance organizations, have expressed dissatisfaction with the skill levels of many of the practitioners whom they are hiring; Many physicians who have made the transition to a new practice paradigm by restructuring their practices are dissatisfied with several aspects of the new practice environment and equally concerned about the quality of care they can deliver. The conflict between rhetoric and incentives, and the difficulty of reforming a fragmented academic system pose barriers to effective change as the nation's academic health centers prepare to respond. Osteopathic medicine is better positioned to change because of its community-based education, its track record in primary care, and its national move to create a vertically integrated continuum of education from undergraduate through graduate study. Medical education and workforce issues are essential components of the cost, quality, and access triad. Without reform in medical education, the ability of the new paradigm to adequately address these other issues is critically compromised.

A 67-year-old woman was seen in the emergency department because of severe pain and inability to move her left shoulder after falling on an abducted left arm. The fall was the result of a near-syncopal episode. On examination, the left arm was hyperabducted and elevated approximately 80 degrees from the horizontal plane. Furthermore, the patient was unable to move her left arm. Radiographs of the shoulder revealed an inferior dislocation of the glenohumeral joint. Closed reduction in the emergency department was successful. This rare but classic case of inferior glenohumeral dislocation (Iuxatio erecta humeri) serves to emphasize that a heightened awareness for this injury is necessary if it is to be recognized and treated appropriately. It is important to obtain orthopedic consultation or follow-up (or both) for this injury, because of the high incidence of accompanying tears of the rotator cuff. Neurovascular compromise is also commonly associated with this dislocation. The neurologic injuries are more common than the vascular injuries but tend to resolve after reduction.