PAs in the Bulgarian healthcare system.

This article examines the importance of the physician associate/assistant (PA) profession in the healthcare system in Bulgaria. PAs in the country primarily work in emergency medicine and surgery, and are needed in other clinical settings, such as obstetrics and gynecology and psychiatric clinics, that are experiencing challenges because of physician shortages.

A patient with rapidly growing axillary masses.

About 85,000 melanomas are diagnosed every year in the United States, but only about 3.2% are diagnosed without a primary site. This article describes a patient who presented with two rapidly growing axillary masses and was found to have metastatic melanoma of the lymph nodes with no known primary site.

Financial analysis of PA lifetime earnings and debt.

This economic analysis of physician assistant/associate (PA) career earnings sought to assess the increasing effect of student debt, its potential effect on job selection, and whether such financial obligations may influence graduates to select higher-paying specialties. The model was a 30-year-old newly graduated PA who begins working in family medicine. A simulation included wages, student debt, national household expenditures, and real estate statistics.

Financial analysis of PA lifetime earnings and debt.

This economic analysis of physician assistant/associate (PA) career earnings sought to assess the increasing effect of student debt, its potential effect on job selection, and whether such financial obligations may influence graduates to select higher-paying specialties. The model was a 30-year-old newly graduated PA who begins working in family medicine. A simulation included wages, student debt, national household expenditures, and real estate statistics.

A patient with shortness of breath after total hip replacement.

Clinical presentation of pulmonary embolism (PE) frequently is nonspecific, making patient evaluation and diagnosis challenging. Clinicians must be alert for signs and symptoms of PE in patients with risk factors and have a low threshold for ordering appropriate imaging and laboratory tests. Initial treatment concentrates on patient oxygenation and stabilization; further management of PE depends on the patient's hemodynamic stability and right ventricular strain.

Cardiac auscultation: Using physiologic maneuvers to further identify heart murmurs.

Auscultation of heart sounds and murmurs often is taught in a simulated environment with optimal listening conditions. Clinicians' auscultation skills can wither if they do not have contact with patients with valvular heart disease during clinical practice, or if they rely on handheld ultrasound devices or echocardiography. This article reviews heart murmurs and how to use physiologic maneuvers during the cardiac examination to assist in identifying murmurs.

Surgical management for Hirschsprung disease: A review for primary care providers.

Primary care providers may encounter infants and children with Hirschsprung disease, a congenital colonic defect. Although primarily a surgical problem, the disease requires extensive supportive care and a multidisciplinary approach that often extends beyond surgical correction. This article reviews the management of Hirschsprung disease.

Botulinum toxin as a treatment for refractory overactive bladder.

Detrusor overactivity is the most common cause of overactive bladder (OAB) and refers to demonstrable involuntary detrusor contractions during urodynamic studies. The number of adults age 40 years or older suffering from idiopathic urge incontinence ranges from 13% in men to 30% in women. For patients whose symptoms are refractory to conventional therapy, intradetrusor botulinum toxin injection offers a safe and effective outpatient treatment with high rates of improvement of OAB symptoms.

Emergency management of high-energy pelvic trauma.

A fractured pelvis can be a significant cause of patient morbidity and mortality. Injuries to the pelvis that result from high-energy trauma can be devastating, and patients often have other associated injuries. This article reviews the pathophysiology of pelvic fractures and how to classify and manage them in the emergency setting in order to improve patient outcomes.

Systemic lupus erythematosus: an update on treat-to-target.

Systemic lupus erythematosus involves many organ systems, and its vague and multisystem manifestations make early diagnosis and treatment difficult. However, early diagnosis and treatment offer the best chance of reducing end-organ damage and achieving remission. This article describes a new strategy called treat-to-target that may help patients achieve remission.

Understanding Brugada syndrome.

Brugada syndrome is an established cause of sudden cardiac arrest in patients without structural cardiac abnormalities. Recognition and diagnosis of this syndrome has been slowly increasing. Syncope, ventricular dysrhythmia, or sudden cardiac arrest may be the presenting symptom, although detection of the characteristic right precordial ST-segment elevation on ECG can be a potentially lifesaving intervention.

Preventing group B streptococcal infections in newborns.

Despite advances in intrapartum antibiotic prophylaxis (IAP), group B streptococcal infection continues to be a predominant cause of early-onset disease in neonates. About 2% of neonates exposed to group B Streptococcus develop clinical manifestations including sepsis, pneumonia, and meningitis. Screening in late pregnancy reduces the incidence of early-onset sepsis by more than 80%.

Managing localized unresectable hepatocellular carcinoma.

Hepatocellular carcinoma is becoming more common, and numerous treatment algorithms are available for this complex disease. This article reviews screening, diagnosis, staging, and management of hepatocellular carcinoma, including various treatments for patients who are not candidates for surgical resection and transplantation.

Gout: a comprehensive review.

The prevalence of gout in the US population is steadily increasing. Genome-wide research has found several variants of DNA sequences that predispose patients to irregular uric acid metabolism. Comorbidities linked to gout include obesity and cardiovascular disease.

Pancreatic cancer: practical strategies for early diagnosis and management.

Pancreatic cancer often is diagnosed too late for effective treatment. Knowing the risk factors, best diagnostic tests, and management options may help clinicians recognize pancreatic adenocarcinoma earlier, improving patient outcomes.