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Up to 60 percent of adults report that they have had nocturnal leg cramps. The recurrent, painful tightening usually occurs in the calf muscles and can cause severe insomnia. The exact mechanism is unknown, but the cramps are probably caused by muscle fatigue and nerve dysfunction rather than electrolyte or other abnormalities. Nocturnal leg cramps are associated with vascular disease, lumbar canal stenosis, cirrhosis, hemodialysis, pregnancy, and other medical conditions. Medications that are strongly associated with leg cramps include intravenous iron sucrose, conjugated estrogens, raloxifene, naproxen, and teriparatide. A history and physical examination are usually sufficient to differentiate nocturnal leg cramps from other conditions, such as restless legs syndrome, claudication, myositis, and peripheral neuropathy. Laboratory evaluation and specialized testing usually are unnecessary to confirm the diagnosis. Limited evidence supports treating nocturnal leg cramps with exercise and stretching, or with medications such as magnesium, calcium channel blockers, carisoprodol, or vitamin B(12). Quinine is no longer recommended to treat leg cramps.

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The reservation was a littered muddy wasteland, and its population endured poor health, not unlike a third world country. Native American patients suffered from conditions of squalor, alcoholism, diabetes, and drug abuse. I was initially enthusiastic to serve this population, but my ideals and tolerance were challenged through time and experience. Rescuing a teenage girl in labor with a footling breech brought my cultural incompetence to a head. I searched for validation of my service and meaningful purpose in my efforts.

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Toddlers make a transition from dependent milk-fed infancy to independent feeding and a typical omnivorous diet. This stage is an important time for physicians to monitor growth using growth charts and body mass index and to make recommendations for healthy eating. Fat and cholesterol restriction should be avoided in children younger than two years. After two years of age, fat should account for 30 percent of total daily calories, with an emphasis on polyunsaturated fats. Toddlers should consume milk or other dairy products two or three times daily, and sweetened beverages should be limited to 4 to 6 ounces of 100 percent juice daily. Vitamin D, calcium, and iron should be supplemented in select toddlers, but the routine use of multivitamins is unnecessary. Food from two of the four food groups should be offered for snacks, and meals should be made up of three of the four groups. Parental modeling is important in developing good dietary habits. No evidence exists that early childhood obesity leads to adult obesity, but physicians should monitor body mass index and make recommendations for healthy eating. The fear of obesity must be carefully balanced with the potential for undernutrition in toddlers.

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"Can we do anything for you?" The question was embarrassing. Henry had been poked and prodded and preserved far beyond his wishes. In a medical system that scorns comfort care, a resident physician is troubled by the case of an elderly man with poor quality of life. An awkward attempt at a Boy Scout service project emphasizes how poorly we comfort the terminally ill despite modern technology and interventionalism.

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PURPOSE: The object of this study was to determine factors leading to episiotomy in low-risk vaginal deliveries, including a comparison of family physicians with obstetricians. The research was also to assess the incidence of episiotomy in a large community hospital and compare it with a national rate of 40%. METHODS: A retrospective cohort design was used with computerized records from one hospital. Demographic and clinical information was extracted from the database, including parity, age, physician type, anesthesia, induction, fetal complications, and other factors. Only low-risk vaginal deliveries (n = 3120) from the year 2003 were included. RESULTS: There was an overall episiotomy incidence of 48%; obstetricians performed episiotomy in 54% of their low-risk patients and family physicians in 33% of similar women (P < .001). Adjusted for multiple factors, the odds ratio for obstetricians performing episiotomy was 2.38 [1.98 to 2.87 (95% confidence interval (CI))]. Instrument-assisted delivery was the strongest predictor for episiotomy, with an adjusted odds ratio for forceps of 5.08 [3.75 to 6.88 CI], and vacuum 2.86 [1.78 to 4.58 CI]. CONCLUSION: Episiotomy in this hospital is being performed in almost half of all vaginal births. Obstetricians are more than twice as likely to perform episiotomy as family physicians in similar patients. Instrument-assisted delivery is a strong risk factor for episiotomy.

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When used with a spermicide, the diaphragm can be a more effective barrier contraceptive than the male condom. The diaphragm allows female-controlled contraception. It also provides moderate protection against sexually transmitted diseases and is less expensive than some contraceptive methods (e.g., oral contraceptive pills). However, diaphragm use is associated with more frequent urinary tract infections. Contraindications to use of a diaphragm include known hypersensitivity to latex (unless the wide seal rim diaphragm is used) or a history of toxic shock syndrome. A diaphragm is fitted properly if the posterior rim rests comfortably in the posterior fornix, the anterior rim rests snugly behind the pubic bone, and the cervix can be felt through the dome of the device. The diaphragm should not be left in the vagina for longer than 24 hours. When the diaphragm is the chosen method of contraception, patient education is key to compliance and effectiveness. An extended visit with the physician or a nurse may be required for a woman to learn proper insertion, removal, and care of the diaphragm.

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