Emergency contraception is used after unprotected intercourse or a contraceptive accident to prevent unwanted pregnancy. It is thought to work by stopping or delaying ovulation or preventing implantation if fertilization has already taken place. Hormonal methods, mifepristone, and intrauterine device insertion are among the methods used worldwide. Combination estrogen-progestin birth control pills are the most commonly used form of emergency contraception in the United States. According to the Yuzpe method, combination pills are taken within 72 hours after intercourse, followed by a second identical dose 12 hours later. With this method, the number of unintended pregnancies is reduced by about 75%. Nausea and vomiting are the most troublesome adverse effects, but these can be controlled with antiemetic medication taken prior to the first dose. The Food and Drug Administration, Washington, DC, has approved an emergency contraception kit consisting of 4 combination pills, a urine pregnancy test, and a patient information book. Most recently, the Food and Drug Administration has approved a progestin-only formulation, which has fewer adverse effects and equal or improved efficacy compared with the combination formula. An intrauterine device can be inserted up to 5 days after unprotected intercourse and is a cost-effective option if it is used as ongoing contraceptive protection. The most readily available form of emergency contraception consists of 2 doses of estrogen-progestin combination birth control pills or 2 levonorgestrel pills taken 12 hours apart. Emergency contraception should not be considered as an alternative to ongoing contraceptive methods, but can prevent unwanted pregnancy.
OBJECTIVE To assess relations between self-reported arthritis-related disruptions in sleep, physical activity, and social functioning and use of medical care, complementary therapies, and self-care for arthritis in older adults. DESIGN A survey of self-reported arthritis-related disruptions in sleep and daily life as risk factors for use of 15 medical, complementary, and self-care modalities for relief of arthritis symptoms. SETTING General community from 38 urban and 12 rural areas in the contiguous United States. PARTICIPANTS Nine hundred thirty-seven older persons reporting arthritis; of the 1925 in the 1993 to 1994 follow-up of the National Survey of Self-care and Aging, a population-based, stratified, random sample of noninstitutionalized Medicare beneficiaries aged 65 years and older. MAIN OUTCOME MEASURES Use of 15 medical, self-care, and complementary modalities for relief of arthritis symptoms. RESULTS Most respondents reported use of at least 1 medical, complementary, or self-care strategy for arthritis. Arthritis was reported to disrupt sleep and leisure in 32.8% and 33.4% of respondents, respectively. Individuals with sleep disruption were more likely than those without sleep disturbance to use medical, complementary, and self-care strategies (adjusted odds ratio [95% confidence interval], 2.31 [1.59-3.37] for seeing a physician; and 2.23 [1.60-3.10] for using physical modalities). Reported disruption in sleep from arthritis was associated with use of more medical, complementary, and self-care strategies than was any other disruption. CONCLUSIONS Self-reported arthritis-related disruption in sleep is associated with use of a wide range of medical, complementary, and self-care strategies. Physicians, other health care providers, and researchers should not overlook the importance of this common and often-neglected symptom.
Most patients who experience illness symptoms develop an explanatory model. More frequently than physicians realize, these attributions involve serious and potentially life-threatening medical conditions. Only a minority of patients spontaneously disclose or "offer" their ideas, concerns, and expectations. Often patients suggest or imply their ideas through "clues." Active listening is a skill for recognizing and exploring patients' clues. Without this communication skill, patients' real concerns often go unrecognized by health care professionals. Qualitative techniques including videotape analysis, postinterviewing debriefing, and interpersonal process recall were used to identify types of clues. We propose a taxonomy of clues that includes (1) expression of feelings (especially concern or worry), (2) attempts to understand or explain symptoms, (3) speech clues that underscore particular concerns of the patient, (4) personal stories that link the patient with medical conditions or risks, and (5) behaviors suggestive of unresolved concerns or unmet expectations. This clue taxonomy will help physicians recognize patients' clues more readily and thereby improve their active listening skills. A deeper understanding of the true reasons for the visit should result in increased patient satisfaction and improved outcomes.
Splenic infarction is a clinical entity seldom encountered. The most frequent causes of splenic infarction include thromboembolic phenomena, hematologic malignant neoplasms, and vasculitides. We describe a patient who sustained splenic infarction secondary to diabetes-induced, small-vessel atherosclerotic disease.
CONTEXT:Lyme disease typically presents with a skin lesion called erythema migrans (EM), which though often distinctive in appearance may be confused with cellulitis. The first-generation cephalosporin, cephalexin monohydrate, is effective for treating bacterial cellulitis but has not been recommended or studied for treating Lyme disease because of poor in vitro activity.OBJECTIVE:To describe the outcome of patients with EM who were treated with cephalexin.PATIENTS AND METHODS:Patients presenting with EM to the Lyme Disease Diagnostic Center in Westchester, NY (May 1992-September 1997). A 2-mm punch biopsy specimen of the leading edge of the EM lesion and/or blood was cultured for Borrelia burgdorferi.RESULTS:Eleven (2.8%) of 393 study patients had been initially treated with cephalexin prior to our evaluation; 9 (82%) were originally diagnosed with cellulitis. Cephalexin was administered for 8.6 days (range, 2-21 days) prior to presentation. All 11 patients had clinical evidence of disease progression, including 8 whose rash enlarged, 2 who developed seventh-nerve palsy (1 with new EM lesions), and 1 who developed new EM lesions. Borrelia burgdorferi grew in cultures from 5 patients despite a mean of 9.8 days of treatment with cephalexin (range, 5-21 days).CONCLUSION:Cephalexin should not be used to treat early Lyme disease and should be prescribed with caution during the summer months for patients believed to have cellulitis in locations where Lyme disease is endemic.
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Objective: To investigate the unique health care issues of deaf and hard-of-hearing (D&HH) persons by studying their attitudes, beliefs, and behaviors toward preventive medicine.Design: A self-administered, cross-sectional survey, written in a format comprehensible to persons whose primary language is American Sign Language.Population: One hundred forty D&HH persons recruited from southeastern Michigan, Chicago, Ill, and Rochester, NY, and 76 hearing subjects from southeastern Michigan and Rochester.Results: No significant differences existed between D&HH or hearing persons from different states. However, numerous differences existed between D&HH and hearing persons. Deaf and hard-of-hearing persons were less likely to report receiving preventive information from physicians or the media, and more likely to report receiving it from a Deaf club. They rated the following physician-initiated procedures as less important than hearing persons: discussion of alcohol consumption, smoking, depression, and diet, plus screening for hypertension, hearing loss, and cancer. Deaf and hard-of-hearing persons often considered a preventive procedure important if it was reported performed at their last health maintenance examination. They were less likely to report being asked about alcohol consumption and smoking, or to having been examined for hypertension, cancer, height, and weight. They were more likely to report receiving a hearing examination, mammogram, and Papanicolaou smear. Deaf and hard-of-hearing persons were less likely to report believing that smoking less, exercising regularly, maintaining ideal weight, and regular physical examinations improve health. Differences existed within the D&HH cohort depending on the respondent's preferred language (oral English vs American Sign Language); our sample size was too small for a complete assessment of these differences.Conclusions: Deaf and hard-of-hearing persons appear to have unique knowledge, attitudes, and behaviors regarding preventive medicine, and their attitudes are influenced by their personal experiences with physicians. Preventive practices addressed during health visits may differ between D&HH and hearing patients. Further research is needed to clarify the reasons for these differences, including within D&HH subgroups, and to develop effective mechanisms to improve the health care of all D&HH persons.
