Volume 99, Issue 5

A predominantly white, suburban, indigent population of pregnancy women were followed up to determine the incidence of domestic violence and its effect on preterm delivery, low birth weight, and outcome of pregnancy (infant admission to the neonatal intensive care unit. A total of 489 gravidas were screened for domestic violence and drug and alcohol abuse. Patients were assigned to the control group if they had no substance abuse and no domestic violence and to the study group if they had no substance abuse but were victims of domestic violence. Of the total study population, 20% were victims of domestic violence. Among patients suffering domestic violence, 22 % had preterm deliveries as compared with 9% of patients without domestic violence (P= .002). Sixteen percent of patientsin the study group had low-birth-weight babies compared with 6% of women in the control group (P= .002). No significant relationship was found between domestic violence and admission to the neonatal intensive care unit. Therefore, domestic violence is a risk factor for preterm delivery and low-birth-weight infants.

Asthma has become a serious challenge to clinical medicine today, with an increase in incidence, morbidity, and mortality over the past two decades. Asthma continues to be a problem despite increased knowledge of the pathophysiology of asthma coupled with the development of a variety of new and innovative medications that can be used to treat asthma. Five areas involving asthma management are reviewed and involve a failure to do the following: (1) identify disease instability and progression; (2) adopt an optimal pharmacologic treatment plan; (3) identify and help the patient avoid environmental triggers; (4) evaluate and treat certain disruptive psychodynamic issues; and (5) use essential nonpharmacologic modes of therapy such as osteopathic manipulation, nutritional considerations, physical training, and controlled breathing techniques that may help to favorably modify the asthma disease process.

One challenge confronting physicians in the 1990s is' the delivery of cost-effective quality healthcare to the elderly. Given current utilization, federal expenditures on Medicare and other federal healthcare programs are projected to increase to more than 6% of the gross national product by the year 2030. Physicians' practice habits will have an impact on the cost of caring for the nation's elderly. It is therefore essential for physicians to recognize their role in delivering quality geriatric care. First, they must be active and diligent in the pursuit of practice guidelines that support changes in the current standards of care. Second, physiciansshould consider alternative approaches to present practice patterns such as physician-managed home health services. Finally, physicians need to take a proactive approach to quality by supporting continuous quality improvement. The purpose of this review is to present some of the existing established practice guidelines, data to support the use of physician-managed home care as an alternative practice approach, and suggestions to incorporate the principles of continuous quality improvement to serve as one practice model that can be used by physicians to improve the quality of medical care given to America's elderly.

Cystic neoplasms of the pancreas are relatively rare. This makes the evaluation and treatment of these tumors widely varied. The authors describe a patient who came to our hospital with complaints of abdominal pain, but no other related symptoms. Diagnostic evaluation of the patient yielded normal results, except for inspection and palpation of the abdominal areas, which revealed a large epigastric mass; this finding was confirmed subsequently by ultrasonographic examination and computed tomographic scanning. This article presents the case and reviews the literature, specifically related to diagnosis and current treatments.

Many inexperienced physicians are uncertain as to how to go about gathering a sexual history. They have had courses in basic history taking, but they do not know how to go about obtaining the information in a nonthreatening way. Their opportunities for interaction with real patients have typically been limited. Scripted role play is a very effective method for providing residents with an opportunity to enhance their sexual-history-taking skills. This article describes scripted role play as a teaching method; explains why it is effective for teaching sexual history taking; presents general guidelines for script writing for this purpose; details how to organize a teaching session; and provides some tips for thesession facilitator.