Important Advances in Clinical Medicine

Epitomes of Progress - General and Family Practice

The Scientific Board of the California Medical Association presents the following inventory of items of progress in general and family practice. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epit- ome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a par- ticular item. The purpose is to assist the busy practitioner, student, research worker or scholar to stay abreast of these items of progress in general and family practice which have recently achieved a substantial degree of authoritative acceptance, whether in his own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on General and Family Practice of the California Medical Association and the summaries were prepared under its direction. Reprint requests to: Division of Scientific and Educational Activities, California Medical Association, 731 Market St., San Francisco, CA 94103

A Little More Attention to Parasites stool studies include anemia and eosinophilia, especially in cases involving pathogenic parasites. INTESTINAL PARASITIC INFESTATION is one of the Needless to say, care and thoroughness are essen- most common human afflictions. It is often con- tial in all examinations. sidered a rarity in the United States. However, Common parasites include Ascaris lumbri- some communities in Southern California close to coides, Enterobius vermicularis, hookworms, Tri- Mexico have a high incidence of infestation, as chiuris trichiura, Giardia lamblia, Entameba his- do communities with recent influxes of Southeast tolytica, Strongyloides stercoralis and Hymenolepis Asian immigrants. nana. Taenia saginata, Schistosoma mansoni Symptoms indicative of possible parasitic infes- and Dientamoeba fragilis also are not uncom- tation include poor nutritional status, vague or mon. Not many patients have been vomit- surprisingly, acute abdominal pain, indigestion, nausea, found to be infested with more than one parasite, ing, fatigue, poor appetite, constipation, diarrhea, of two or more of the above men- chronic cough combinations gastrointestinal bleeding, headache, tioned pathogenic ones or of other nonpathogenic asthma-like conditions, and lag in growth and and ones. In multiple infestation involving Ascaris, in children. Generally, poor sanitation maturation treatment should first be directed against this para- and hygiene, increasing international personal site; mebendazole (Vermox®) is often very effec- travel, contact with domestic animals, and some tive. Mebendazole is relatively safe and is effective group activities are well known factors in its It spread. for pinworms, hookworms and whipworms. is, for childern less than In general, studies of stool specimens on three however, not recommended include separate dates are required both before and after 3 years old. Other effective regimens treatment. If results in one member of the family pyrontel pamoate (Antiminth®) or piperazine for are positive, examinations should be carried out Ascaris; Antiminth or pyrvinium pamoate (Po- in the entire family. Findings other than positive van®) for pinworms; Antiminth or thiabendazole

THE WESTERN JOURNAL OF MEDICINE 497 EPITOMES-GENERAL AND FAMILY PRACTICE (Mintezole®) for hookworms; Mintezole for whip- cervical dilatation. In order to provide a more worms and S. stercoralis; metronidazole (Fla- objective method to better monitor labor, Fried- gyl®) for E. histolytica and giardiasis; niclosa- man has developed a simple method of graphically mide (Yomesn®) for tapeworms, and stibophen displaying the progress of labor judged by time, (Fuafuadin®) or niridazole (Ambihar®) for cervical dilatation and station of the presenting schistosomiasis. Sometimes repeated therapy part. is necessary. For pinworms, simultaneous therapy This method records observations that the phy- of all the family or group members is necessary sician obtains in any event and plots these ob- as well as a repeated treatment two weeks after servations on square-ruled graph paper with hours the initial treatment. of labor as horizontal coordinates, cervical dilata- Often, the need for active treatment in parasitic tion as vertical coordinates on the left, and station infestation is relative, and withholding treatment of descent as vertical coordinates on the right. in asymptomatic cases is recommended because The method is simple to apply in everyday ob- many are self-limiting. However, it should be stetric practice and is fully described in the ref- noted also that symptoms often fluctuate, varying erences listed. from a very severe condition which leads patients Six major disorders of labor are readily char- to seek medical attention to a completely asymp- acterized by use of this method. These can be tomatic one. In children, such a fluctuating and grouped in three categories: (1) prolonged latent insidious course may disturb and delay schooling phase; (2) protraction disorders: (a) protracted and social activities. Those children often have active-phase dilatation and (b) protracted descent, multiple infestation, high eosinophile counts and and (3) arrest disorders: (a) prolonged decelera- past history of symptoms and signs. It is especially tion phase, (b) secondary arrest of dilatation and in those circumstances that the treatment of a (c) arrest of descent. Each of these disorders can seemingly self-limiting or relatively asymptomatic be further related to cause, response to treatment, infestation should be given serious consideration. and prognosis. Each disorder involves its own Also, we strongly believe that at least in certain preferred approach to management. In general, communities and locations every practicing phy- therapeutic rest is indicated for prolonged latent sician should keep abreast of the problem of phase; support and expectancy are preferred for parasitic infestation and its eradication as an in- protraction disorders; cesarean section is indicated tegral part of medical practice. in arrest disorders complicated by disproportion, MYUNG MI RYU, MD and oxytocin stimulation is reserved for arrest REFERENCES disorders occurring without disproportion. Drugs for parasitic infections. Med Lett Drugs Ther 16:5-12, Use of the graphic analytic technique adds an Jan 18, 1974 Brown HW: Basic Clinical Parasitology, 4th Ed. Englewood important new dimension to the diagnostic and Cliffs, N.J. Prentice-Hall, Inc, 1975 therapeutic capabilities of physicians caring for obstetric patients in labor. This method is recom- mended for application in everyday practice and allows for improved teaching and learning in Graphic Analysis of Obstetric Labor residency training programs. THE DIAGNOSIS of prolonged labor using only JOHN GEYMAN, MD elapsed time involves the difficulty that some REFERENCES serious labor observations may be overlooked Friedman EA: Disordered labor: Objective evaluation and man- by agement. J Fam Pract 2:167-172, Jun 1975 such a coarse criterion. Whereas some normally Friedman EA: Patterns of labor as indicators of risk. Clin progressive and uncomplicated labors may last Obstet Gynecol 16:172-183, Mar 1973 longer than defined time limits, some ominous labor patterns are potentially so hazardous that they should be recognized well before any such time limit is reached. One study has shown that Endometrial Sampling 10 percent of all labors under 20 hours considered RECENTLY THERE HAS BEEN a plethora of reports normal clinically were abnormal when progress indicating increased incidence of endometrial can- of labor was plotted graphically, and that almost cer in patients receiving estrogen therapy. The 50 percent of patients diagnosed as having ab- need for a simple and accurate method of endo- normal clinical labor had normal patterns of metrial sampling has become apparent. Since 1943

498 DECEMBER 1977 * 127 * 6