Acute pharyngitis is a common illness in both children and adults, caused by a wide variety of microbial agents. In children, approximately 20% of pharyngitis is caused by group A beta-hemolytic streptococci (GABHS); in adults, 5% of pharyngitis is due to GABHS. The signs and symptoms of infection are variable, ranging from mild sore throat with minimal physical findings to high fever and severe pain. The differential diagnosis of GABHS pharyngitis is extensive. Most cases of acute pharyngitis in both children and adults are caused by viruses. The gold standard diagnostic test for GABHS remains the throat culture. It is important to select appropriate candidates for culture to maintain the sensitivity of the test. Penicillin is still recommended as first-line treatment for documented GABHS infections. Prompt treatment is important to prevent serious sequelae of infection.

Obstetricians and gynecologists are increasingly involved in primary care. Acute bronchitis is among the most common ambulatory complaints. Although the cause of acute bronchitis is predominantly viral, 50-70% of patients presenting with this condition are treated with antibiotics. Because of the increasing bacterial resistance to antibiotics, the cost of prescription drugs, and the potential adverse reactions to them, the present management of acute bronchitis has important shortcomings. Also, inhaled bronchodilators are underused for symptomatic management. Improved awareness among physicians about the recommended management of acute bronchitis has been targeted as an important means of decreasing unnecessary antibiotic use. Patient satisfaction motivates physicians to prescribe antibiotics in managing acute bronchitis. However, patient satisfaction does not necessarily correlate with prescribing of antibiotics but rather with patient education. We present a review of the diagnosis and differential diagnosis of acute bronchitis and its management.

Interferons are proteins produced by human blood cells in response to stimulation (viral infection). The natural roles of interferons are host defense and modulation of the immune system. Therapeutic uses are based on these roles. Interferon-alpha has been widely used for malignancies, skin conditions, viral infections, and myeloproliferative disorders. Interferon-beta is a standard treatment for relapsing multiple sclerosis. Interferon-gamma therapy is currently used for chronic granulomatous disease and skin lesions (human papilloma virus related and keloids), but further research is ongoing. Side effects of interferon therapy are common and limit utility. Flulike symptoms are reported by more than 75% and depression by 10-40% of interferon users. Severe adverse effects are less common but may be life threatening, including autoimmune diseases, thrombotic-thrombocytopenic purpura, and acute renal failure. Limited use of interferon therapy during pregnancy has been described, with successful maternal and neonatal outcomes. Use of interferon therapy during early pregnancy is not an indication for termination.

Urinary incontinence (UI) is now recognized as a growing health care problem and a personal concern for women. UI is felt to be a significant aging health issue for women. Much is known about the prevalence of UI in women. Almost one third (31%) of women between the ages of 42 and 50 and two in five (38%) women over the age of 60 suffer from UI. Urine leakage varies, with about 1 in 10 women leaking enough urine that it soaks through underclothes. About one in three (30%) women have problems with incontinence during pregnancy. Society incurs a significant economic burden as a result of UI, which cost the Medicare Part A program $26.3 billion in 1995. One of the biggest obstacles to effective management of incontinence is the perception that incontinence is inevitable and irreversible, a perception almost as common among health care providers as patients. Therefore, most women do not report their UI problem to primary care practitioners. Primary care practitioners are in a key position to influence prevention, screen for incontinence, and improve outcomes of women at risk for incontinence. Current research supports the value of noninvasive, conservative treatment strategies, education, and emotional support.

Borderline ovarian tumors (BOTs) represent a small subset of epithelial ovarian cancers that were first described more than 70 years ago. Recognized in a systematic way in only the last three decades, BOTs occur most often in women in their reproductive years but are associated with an excellent long-term prognosis. The management of these tumors is primarily surgical, with the role of medical therapy a topic of ongoing research and debate.

In 1998, 140 children younger than 1 year of age were killed in motor vehicle crashes, and nearly half of those children killed were restrained. Used correctly, child safety seats dramatically reduce a child's risk of death in a motor vehicle crash, but unfortunately, incorrect use of child seats is widespread. Obstetricians and gynecologists have a unique opportunity to counsel parents on the correct restraint for their infants and to provide recommendations for the proper restraint of older children as well. The recommendations for child occupant protection are updated with new information constantly. This article will provide an overview of the current recommendations for restraining children in motor vehicles and identify sources for up-to-date information for physicians and families.

Rubeola, more commonly known as the "red measles" or "10-day measles," is a highly contagious exanthematous viral illness. Although most cases end with full recovery, rare but serious, even fatal sequelae such as encephalitis and pneumonia can occur. The incidence of measles worldwide has decreased dramatically since the introduction of effective vaccines. Nevertheless, outbreaks still occur among clusters of individuals, especially young adults, that vaccination programs have failed to reach. Susceptible young women are at unique risk because measles in pregnancy follows a more complicated course than in nonpregnant adults. Furthermore, pregnancies complicated by rubeola are more likely to end with spontaneous abortion or preterm delivery. In the United States, the currently used rubeola vaccine employs live-attenuated virus and is contraindicated in pregnancy. Nonpregnant women receiving rubeola vaccination should be advised to use effective contraception for 3 months after inoculation. These warnings persist despite the fact that an adverse pregnancy outcome after maternal measles vaccination has not been reported. Obstetrician/gynecologists must be familiar with rubeola and the management of pregnancies complicated by exposure to the disease. Furthermore, practitioners must actively seek and vaccinate susceptible individuals to minimize this ongoing threat to public health.

Rubella, also known as German measles or three-day measles, is a self-limited, mild viral illness that poses little danger to children or adults. For the developing fetus, however, infection with rubella virus is a grave threat, capable of inducing severe anomalies and permanent disability. Despite widespread vaccination programs, populations of susceptible individuals persist, among them women of childbearing age whose pregnancies remain vulnerable to congenital rubella syndrome. In the United States, the currently used rubella vaccine employs live-attenuated virus and is contraindicated in pregnancy. Nonpregnant women receiving rubella vaccination should be advised to use effective contraception for 3 months after inoculation. These warnings persist despite the fact that no clinically significant case of congenital rubella syndrome after maternal vaccination has been reported. Obstetrician/gynecologists must be familiar with rubella and the management of pregnancies complicated by exposure to the disease. Furthermore, practitioners must actively seek and vaccinate susceptible individuals to minimize this significant threat to public health.

Dr. Z., an obstetrician-gynecologist, refused to refill a narcotic prescription for a drug-seeking patient while on emergency room back-up call. For the next 6 months, he and his family were threatened and harassed by this patient. The constant fear of danger to his family dramatically affected Dr. Z., who questioned, "Is this the price of practicing medicine?"After months of being stalked and threatened by an angry former patient, Dr. A., an obstetrician/gynecologist, sought and was granted a court restraining order, which further infuriated the patient. When the threats became more pernicious, Dr. A. consulted a security expert, who evaluated her daily routine and advised her to dramatically revamp her life by changing where she shopped, continually altering her driving routes, learning self-defense skills, and constantly scanning her environment for the former patient. Despite making these striking changes, her life became unbearable as she loathed the practice of medicine that she once loved. Dr. A. stated, "Life will never be the same!"

Toxoplasma gondii is a unicellular protozoan. The definitive hosts, cats, produce hardy oocysts and sporozoites. Ingestion by a nonfeline leads to the formation of tachyzoites acutely, which cause parasitemia and further dissemination, and bradyzoites, which lead to latent infection with the formation of tissue cysts in skeletal muscle, heart muscle, and central nervous system (CNS) tissue. Toxoplasmosis can be transmitted to humans by ingestion of tissue cysts in raw or inadequately cooked infected meat or in uncooked foods that have come in contact with contaminated meat, by inadvertent ingestion of oocysts and sporozoites in cat feces, or transplacentally. Immunocompetent adults and adolescents with primary infection are generally asymptomatic, but symptoms may include mild malaise, lethargy, and lymphadenopathy. Specific treatment for nonpregnant adults and adolescents is not required. Immunosuppressed patients may experience more severe manifestations, including splenomegaly, chorioretinitis, pneumonitis, encephalitis, and multisystem organ failure. These patients are also prone to reactivation of latent infection involving the CNS. All patients with human immunodeficiency virus infection and CD4 counts <100 cells per cubic millimeter should be treated prophylactically with pyrimethamine-sulfonamide. Congenital toxoplasmosis is marked by the classic triad of chorioretinits, intracranial calcifications, and hydrocephalus. Current studies have determined that prolonged treatment (1-2 years) of neonates with fansidar is important to prevent serious sequelae. Diagnosis of acute toxoplasmosis is mainly by antibody detection and generally only undertaken in pregnant patients with risk factors for transplacental transmission. All positive screening tests in pregnant women must be confirmed at a toxoplasma reference laboratory. Recent studies have shown that polymerase chain reaction testing of amniotic fluid is useful for identification or exclusion of fetal T. gondii infection. Ultrasound can be used as an adjunct to serological screening but cannot itself definitively diagnose disease. Early-first-trimester maternal infections are less likely to result in congenital infection, but the sequelae are more severe. Transplacental passage is more common when maternal infection occurs in the latter half of pregnancy, but fetal injury is usually much less severe. Typically, infected pregnant patients are treated with pyrimethamine-sulfonamide for positive PCR-amniotic-fluid testing and with spiramycin for negative PCR-AF testing.

The role of the obstetrician/gynecologist as the primary health care provider for women has evolved rapidly in the past decade. There has not always been agreement in the specialty about the directions in which it should proceed. In particular, a cognitive dissonance has arisen regarding the primary care role for any one physician. Just as there are strong advocates,1,2 so are there dissentients.3,4 Access to care for women and patient choice of physician are universally acknowledged as desirable and central to the issue. The often acrimonious debate derives from more theoretical constructs of subspecialty identity and integrity, economics, dilution of specialty training, and educational barriers to successful implementation. The practical, salutary implications of primary care obstetrician/gynecologists have infrequently been evaluated in any formalized fashion. Five years ago, the State of California designated obstetrician/gynecologists as primary care physicians. This paper is a retrospective analysis of how the designation was achieved and the subsequent experience of the specialty over this period of time.

A 49 year old woman presented with weight loss, diffuse abdominal pain and distension, low grade fever, massive ascites, and an increased serum CA 125 value. Computed tomography of the abdomen and pelvis and ultrasonography of the pelvis were suggestive of ovarian carcinoma. Exploratory laparotomy revealed massive ascites; diffuse peritoneal studding of numerous 1- to 2-mm implants in the bowel, omentum and abdominal wall; a cystic adnexal mass; and indurated head of the pancreas. Histopathological examination of several implants showed multiple epitheloid granulomata with rare central necrosis. The patient responded well to antituberculous therapy.

Cholera, an infectious disease caused by Vibrio cholerae, is primarily transmitted by ingestion of contaminated food or water. In severe cases, cholera may lead to severe dehydration, metabolic acidosis, and ultimately, hypovolemic shock and death. The diagnosis is confirmed by identification of V. cholerae in a stool specimen. Treatment should be started immediately by rapid replacement of fluid and electrolytes. Antibiotics such as tetracycline and doxycycline shorten the duration of illness but do not significantly affect overall mortality. Cholera can be prevented by limiting spread, survival, and growth of the organism. The current parenteral cholera vaccine is not recommended by the Public Health Service or the World Health Organization because of its limited protection. A number of oral vaccines are currently being tested in clinical trials.

This article reviews the health burden of obesity, its treatment and prevention, and potential barriers to care with special emphasis on adult women of childbearing age. From 1988 to 1994, 22% of nonpregnant women 18-49 years old in the United States were overweight (body mass index [BMI] >/= 25-29.9), and 22% were obese (BMI >/= 30). Both conditions increase the risk of chronic disease and mortality, and among women of childbearing age, overweight and obesity also increase the risk of infertility and adverse pregnancy outcomes.The three main strategies for preventing obesity are weight maintenance, weight loss for overweight and obese persons, and physical activity for all. More than 44% of nonpregnant women of childbearing age are trying to lose weight, and more than 33% are trying to maintain weight, but less than 21% of women of childbearing age use the recommended combination of physical activity and caloric restriction to try to lose or maintain weight. Pregnant women should try to gain no more than the recommended weight gain range for their prepregnancy BMI, yet about one third gain more weight.Although research has shown that advice from physicians can have an impact on their patients' eating habits and physical activity, many health professionals either provide no such advice or give inappropriate advice to women of childbearing age. Barriers may include inadequate reimbursement, time constraints, and lack of professional training. Frequent contact with women of childbearing age provides obstetricians and gynecologists and nurse specialists an opportunity to prevent and treat obesity successfully.

Each year, insomnia affects more than 60 million adults in the United States-a startling 30% to 50% of the general population. It is one of the most common presenting complaints in primary care and, like so many mental health problems, disproportionally affects women. Sleep research demonstrates that women need as much as an hour and a half more sleep than men-a (suggested) total of 8-9 hours of sleep per day. For both men and women, a good night's sleep is essential to overall physical and mental health. Sleep needs among individuals vary a great deal, but a basic step that anyone can take to feel healthy, increase energy, and even fight physical disease is to get as much sleep as needed.1