This case report summarizes the sequence of events that led to the detection of a molar pregnancy missed by ultrasound and initial pathology examinations. This patient illustrates that following serial quantitative beta-human chorionic gonadotropin (B-hCG) levels after spontaneous, therapeutic, and elective abortions will help detect potentially life-threatening molar and ectopic pregnancies. Further research is needed to determine the optimal frequency of B-hCG testing. For now, maternity care providers can follow the American College of Obstetrics and Gynecology recommendation that abnormal bleeding for more than 6 weeks after any pregnancy should be evaluated with B-hCG testing. Earlier testing may be considered.

A 38-year-old woman presented with painful lesions on both shins that first appeared a few days earlier. Physical examination revealed multiple red tender nodules on both legs. The patient had been treated with nonsteroidal anti-inflammatory drugs for having a few months without any improvement. The patient was referred to a dermatologist and a rheumatologist, who confirmed our diagnosis of chronic erythema nodosum (EN). She returned to the clinic 3 months later complaining of having numbness in the soles of her feet for a few weeks. Her serum vitamin B12 level was 118 pg/mL (normal range 135 to 911). After 4 weeks of twice weekly injections of vitamin B12 at a dose of 1000 mcg, there was a clear alleviation of the numbness, and the EN completely resolved without evidence of recurrence on follow-up. Because it seems that vitamin B12 caused resolution of EN in this case, we recommend that physicians consider testing for vitamin B12 deficiency in patients with EN.

Over 70% of the estimated 5 million office visits per year for migraine headache are to family physicians. Both the number of visits and proportion of migraine patients seeking medical care are increasing rapidly. Patient satisfaction with migraine care by primary care physicians is reported to be low but most data are obtained from patients referred to subspecialists or entered in clinical trials. We surveyed patients who consulted family physicians in 10 Kansas practices during 2002 to assess patient satisfaction and investigate any differences between satisfied and unsatisfied migraine patients. Of our 447 respondents, 74% were "satisfied" or "very satisfied" with migraine care by family physicians. Dissatisfied patients were significantly more likely to report moderate or severe migraine-related disability and less likely to use triptans or to have most medications paid by insurance. Dissatisfied patients were twice as likely to have discontinued taking triptans than satisfied patients. Patient satisfaction with migraine treatment in family practice is substantially higher than generally reported. Statistically significant differences exist between satisfied and dissatisfied patients.

The American Board of Family Medicine (ABFM) is committed to offering cognitive examinations that are both pertinent to the specialty of family medicine and psychometrically sound. This article reviews the history of the development of the blueprint of the ABFM certification and recertification cognitive examinations and describes the creation of a new one. The design of the new blueprint represents a significant change. The intention of the new plan is to create a continuously evolving approach that will assure family physicians that the content of their specialty board certification/recertification examination is relevant to their practices and to the discipline. The ABFM anticipates that assessments based on the new blueprint will assist family physicians in attaining and maintaining the knowledge required to practice high quality family medicine by focusing their certification and recertification examinations and, therefore, studies for those examinations on material that is relevant to their practices.

Translation of new knowledge into practice proceeds through 3 stages, from awareness through acceptance to adoption. Translational research focuses almost exclusively on the first 2 stages. We argue that improving the disappointing results of translation efforts will require a detailed understanding of how adoption takes place. We summarize research in cognitive science that illustrates how accepted "declarative" knowledge (acquired through lectures, reading, and discussion) differs (even down to its locus in the brain) from adopted "procedural" knowledge that is acted on in clinical practice. We suggest strategies that can capitalize on the cognitive processes by which declarative knowledge is proceduralized, as a means of making translation more effective, including (1) structured case-level feedback, automated or from human consultants, during the declarative stage; (2) practice in context early in the procedural stage; and (3) deliberative practice when procedural knowledge has been formed but is still being refined.

Cerebrovascular disease is the third leading cause of mortality and the leading cause of long-term neurological disability in the United States. Most strokes are of ischemic origin and, other than cardioembolic or small vessel strokes, are caused by the development of platelet-fibrin thrombi on an atherosclerotic plaque. This underlying disease mechanism shares important features with coronary artery disease and peripheral artery disease, highlighting the systemic nature of atherothrombosis and the elevated cross risk in stroke patients for ischemic events in other vascular beds. It has been estimated that up to 80% of ischemic strokes could be prevented with application of currently available treatments for blood pressure, cholesterol, and antithrombotic therapies. Stroke is not, like cancer, waiting for a scientific breakthrough; stroke preventive treatments are well understood and widely available. It is only the application of these treatments to patients, many of whom do not visit physicians, that is lacking. Clearly, better education of the public and active participation of primary care physicians is essential to get the message out to all those at risk.

Certainly we could improve our identification, diagnosis, and initial treatment approaches to the large numbers of depressed patients we see in primary care. However, until we have established the kind of systematic follow-up and follow-through that the US Preventive Services Task Force said is a prerequisite for its recommendation to routinely screen for depression, none of these earlier actions will make much difference. Recently, a number of controlled trials of innovative approaches to care management have demonstrated clearly how much patient outcomes are improved when systematic follow-up is in place. The problem is that there are few examples of such systems in real clinical practices. This article describes the main components of such a systematic approach.

Magnetic resonance imaging (MRI) is a widely used imaging tool. Interest in the applicability of this modality in the realm of breast imaging has been steadily increasing over the past 25 years. The purpose of this article is to explore the use of contrast-enhanced MRI in breast imaging as it relates to the primary care physician. The mechanism, factors affecting image quality, basics of interpretation guidelines, and the uses and contraindications for this technique are explored. In addition, studies exploring the use of MRI in various areas of breast imaging are presented. It is hoped that the reader will become knowledgeable in the current utility of the tool as it relates to breast imaging.