Dear Wise Owl? How Many Licks DOES it take?: A Brief Synopsis of AFP's "Appropriate and Safe Use of Diagnostic Imaging"

A Brief Synopsis of;
Appropriate and Safe Use of Diagnostic Imaging
BRIAN K. CROWNOVER, MD, and JENNIFER L. BEPKO, MD, Nellis Air Force Base Family Medicine Residency, Nellis Air Force Base, Nevada
http://www.aafp.org/afp/2013/0401/p494.html
Am Fam Physician. 2013 Apr 1;87(7):494-501.


     In the world of defensive medicine and the absolute need for an immediate diagnosis over a thorough differential diagnosis, imaging has taken a prominent role. Recent knowledge tells us that much of the imaging is unnecessary, wasteful, and harmful to the patient. According to this article, up to 2% of future cancers will be due to radiation from CT's. A chest CT will give a patient the same amount of radiation as 769 chest x rays. A barium enema is the equivalent of 615 chest x rays. An ERCP is about the same radiation as 308 chest x rays. A TIPS procedure? -you are looking at 5,385. A poor differential and chasing zebras could really cost the patient a lot on unwanted exposure.
     So what will happen? Well, besides the obvious potential for cancer, the patient may also be at risk for nephrogenic systemic fibrosis.  This is "characterized by scleroderma-like changes in the skin, internal organs, eyes, and blood vessels. This is seen mostly in gadolinium-based MRI contrast agents. Gadolinium contrast should be avoided in patients with late stage chronic kidney disease.
     The next few chapters will discuss which imaging is best for certain suspected diseases. I will add the number of equivalent chest x rays in quotations next to the imaging for fun, when available.
     In suspected ischemic stroke, a non-contrast head CT (154) should be done to rule out bleeding within three hours of onset. Beyond that, and within 24 hours, a head and neck CT angiogram or an MRA (preferred) should be performed.
     Headaches generally do not require imaging. Symptoms such as suspected meningitis, new onset in pregnancy, immunosuppression, focal neurological signs, or thunderclap onset may trigger a CT or MRI.
     Imaging for a suspected pulmonary embolism should be entertained only after the provider has determined the Wells score. A chest helical CT should be ordered if the score suggests an intermediate or high risk probability.  If the chest CT is negative and there is a very high probability, then a V/Q scan or pulmonary angiogram (1,154) can be done.
     An MI needs to be ruled out in patients presenting with chest pain. Myocardial perfusion imaging (923-2,231, depending on the contrast media) or coronary angiography (1,231) can be done. If the pain is non-recurrent, the ECG is negative, or the troponins, etc are negative, exercise stress testing can be done.
     An abdominal (769) and pelvic (538) CT is recommended for patients with RLQ pain and suspected appendicitis. If the patient is pregnant or a child, an ultrasound is preferred.  Ultrasound is the imaging of choice for cholecystitis as well. If the patient is suspected of having diverticulitis, a CT abdomen/ pelvis with contrast is done first. Women of child bearing age should have an ultrasound in this case to rule out gynecological causes, to avoid the radiation.
     Low back pain should not routinely be imagined unless the patient has pain longer than 6 weeks, age over 70 years, a history of cancer, immunosuppression, IVDA, alcohol abuse, long term corticosteroid use, trauma, or unexplained fever, weight loss, or night pain. MRI can be used at this point, but there are a lot of unrelated abnormal findings, which may be found. Although these findings may fit the picture, often times they have no role in the symptoms.
     In whole body scanning, the average patient finds 3 abnormalities, which is why it is not recommended.
   

A Brief Synopsis of AFP's "Prevention of Unintentional Childhood Injury"

A brief synopsis of:

Prevention of Unintentional Childhood Injury

WESLEY M. THEURER, MAJ, MC, USA, Madigan Army Medical Center, Tacoma, Washington

AMIT K. BHAVSAR, LTC, MC, USA, Tripler Army Medical Center, Honolulu, Hawaii

Am Fam Physician. 2013 Apr 1;87(7):502-509.

http://www.aafp.org/afp/2013/0401/p502.pdf

     The most common causes of unintentional death in children are motor vehicle accidents, drowning, poisoning, fire, and suffocation. In motor vehicle accidents, proper use of restraints is the best way to reduce this risk. There is an algorithm explaining how to transition a child from a safety seat to an adult car seat. Patients younger than 2 to 4 years old should be placed in rear facing safety seats, in the back seat. Once the child has outgrown the height and weight requirements, a front facing child seat may be more appropriate, again in the back seat. A booster seat may be used in the back seat once the patient outgrows the previous seat (between 4-8 years old). The seat belt should fit appropriately across the thighs and mid-sternum to graduate to a booster seat. Once the child outgrows the booster seat, he or she should still not sit in the front seat until 13 years or older.

    Suffocation has increased in the last 20 years, even though the amount of SIDS cases has gone down. The most common cause is infants wedging their heads in the corner playpens and cribs. It can also happen with infants getting a blanket wrapped around their neck, lying face-down on soft bedding, or if the playpen itself collapses. The best way to prevent this is to use the original mattress that the crib comes with, to ensure a proper fit. Tight fitting sheets can also reduce the risk. Cords and strings should be out of reach.

     Drowning is another unfortunate cause of unintentional death. Adult supervision of swimming children is not sufficient. Adults need to be in the water within arms reach of the child, especially those children younger than 4 years old. Often times, the child may be quietly drowning without the parent being aware. Fencing around the pool itself has been shown to be more effective than fencing around the entire yard. Supervising adults should be trained in CPR and have proper life preservers, rather than floating toys. Telephone access should be poolside as well. Children should be aware to avoid safety drains that may cause entrapment.

     As far as poisoning is concerned, education is paramount. Adults should know how to property store medications in locked cabinets with poison control stickers. If a child has ingested medication inappropriately, poison control should be contacted immediately, rather than trying to get the child to vomit.

     Having properly installed and functioning smoke detectors is the best way to prevent unintentional deaths from fires. Detectors should be check regularly, and a "home escape plan" should be developed and discussed with the children. 

     The use of bicycle helmets had greatly reduced the risk of head and brain injuries. Many states require and strictly enforce their use. Parents should set good examples and use them as well. Physicians should encourage their use, as well as reflective and bright colored clothing during bicycling.

     Physicians should make it a point to counsel patients routinely during office visits on safe practices to avoid unintentional accidents. Screening questionnaires may help to identify which practices can help each patient on an individual level.

SYNOPSIS ot the USPSTF "Menopausal Hormone Therapy for the Primary Prevention of Chronic Conditions"

U.S. Preventive Services Task Force
Menopausal Hormone Therapy for the Primary Prevention of Chronic Conditions: Recommendation Statement
http://www.aafp.org/afp/2013/0315/od1.pdf
Am Fam Physician. 2013 Mar 15;87(6):online.


     Hormone therapy has been in and out of style for many, many years. For POSTmenopausal women, the USPSTF currently recommends against its use for the prevention of chronic conditions. Although it may reduce the risk of fractures, it may also increase the risk of stroke, dementia, gallbladder disease, PE, DVT,  and urinary incontinence. This goes for both estrogen alone and estrogen combined with progestin. Basically, the risk outweigh the benefits. Women who are concerned about possible fractures are better of with weight-bearing exercises, bisphosphonates, and calcitonin. Tamoxifen or raloxifene may be a better choice for prevention of breast cancer than estrogen alone (estrogen alone has some benefit with breast cancer prevention, whereas the combined hormones do not). Lastly, this recommendation does not apply to women considering this therapy for menopausal symptoms, or those younger than 50 with surgical menopase.

A Brief Sysnopsis of AFP's "Practice Guidelines : IDSA Releases Guidelines for Management of Acute Bacterial Rhinosinusitis"

 A brief synopsis of "Practice Guidelines : IDSA Releases Guidelines for Management of Acute Bacterial Rhinosinusitis"

Am Fam Physician. 2013 Mar 15;87(6):445-449.

http://www.aafp.org/afp/2013/0315/p445.html

     Every patient who has a cold, wants antibiotics. It is important to know when an infection is viral and when it is bacterial. Symptoms to look for are; no improvement for 10 days, fever of at least 102'F, purulent nasal discharge or facial pain for 3 days, or worsening signs or symptoms. The first line antibiotic is amoxicillin/clavulanate in both children and adults. Doxycycline is a good alternative. The second-line therapy of a third-generation cephalosporin plus clindamycin can be used in children with "non-type I penicillin allergy" or a "non-type I hypersensitivity" to penicillin. Levofloxacin is recommended in children with type I hypersensitivity to penicillin. If an adult has a penicillin allergy, doxycycline or a respiratory fluoroquinolone may be used. Therapy should be given to adults for 5-7 days, and 10-14 days in children.
     If the patient does not improve after 3-5 days or worsens within 2-3 days, the treatment must be reevaluated. Cultures should be taken, preferably by direct sinus aspiration, to rule out resistant bugs. Structural abnormalities should be evaluated as well. If imaging is needed, CT is recommended over MRI. You should also consider referring to a specialist.

A Quick, Explosive Bowl of AFP's "Evaluation of Chronic Diarrhea"

A brief synopsis of: Evaluation of Chronic Diarrhea

GREGORY JUCKETT, MD, MPH, and RUPAL TRIVEDI, MD, West Virginia University, Morgantown, West Virginia

Am Fam Physician. 2011 Nov 15;84(10):1119-1126.

http://www.aafp.org/afp/2011/1115/p1119.html?printable=afp

     According to the most trusted medical reference online, Wikipedia, diarrhea is defined as "3 or more loose or liquid bowel movements per day". This article defines it as a change in consistency for more than 4 weeks. There are three basic categories of diarrhea: watery, fatty, and inflammatory.
     Let's start with watery diarrhea. There are three subcategories: osmotic, secretory, and functional. Watery diarrhea can be classified by doing a fecal osmotic gap. A high osmotic gap (>125 mOsm per kg) would point to osmotic diarrhea. If fasting improved the diarrhea and there is a positive hydrogen breath test, then the most likely cause is lactose intolerance. A fecal pH test below 5.5 would point towards that as well.
     If the osmotic gap is low (<50 mOsm per kg), then it is most likely secretory. You (or an intern) may need to collect a 24 hour stool sample to "quantify stool production". Once anatomic defects are ruled out (through sigmoidoscopy, colonoscopy and radiography), stool culture, ova and parasite can be done to look for infections. A stool acid fast staining test can pick out Cryptosporidium, which can be missed. Hormone secreting endocrine tumors can be ruled out as well with metanephrine (for pheochromocytoma), TSH, serum peptides, urinary histamine and ACTH levels. If the patient is older with nocturnal diarrhea, and does not improve with fasting, the cause may be microscopic colitis. This can be confirmed with biopsy of the transverse colon. Or the problem could just be excessive use of stimulant laxatives (which may also cause osmotic diarrhea).
     If the osmotic gap is normal, then the diarrhea is functional. If the symptoms fit into the Rome III or Manning criteria, the cause may be irritable bowel syndrome. If so, a colonoscopy is not necessary. The patient should respond to fiber, exercise and dietary changes. The patient should also be screened for celiac if these changes do not improve the symptoms. Patients with type 1 diabetes, thyroid disease, chronic fatigue, iron deficiency anemia, weight loss, infertility, or elevated liver enzymes should be screened as well.
     The second class of  diarrhea is fatty diarrhea. The two main causes here are malabsorption issues and pancreatic insufficiency.  Some malabsorptive causes can be celiac (hello again!), intestinal bypass, mesenteric ischemia, Whipple disease, giardiasis and bacterial overgrowth. A celiac panel of IgA antiendomysium and anti-tissue transglutaminase antibodies are accurate predictors. A stool chymotrypsin and confirmatory secretin test can determine if it is pancreatic insufficiency.  Otherwise the other causes may be investigated.
      The last class is inflammatory diarrhea. This is usually due to IBD or and infection such as C. diff. A positive stool for blood, WBC's and calprotectin would lead towards IBD, and a biopsy would be needed to confirm. If the patient has a history of travel, camping, recent antibiotic use, drinking unpasteurized milk, excessive PPI's or a recent hospital stay,  you may want to rule out infection as described above. Stool cytotoxin assay may help if you think the patient has that new hyper-virulent strain of C.diff.

Running Can Kill! A Brief Synopsis of AFP's "Evaluation of Occult Gastrointestinal Bleeding"

This is a brief synopsis of 

Evaluation of Occult Gastrointestinal Bleeding

BULL-HENRY K, AL-KAWAS FH 

March 15 2013 Vol. 87 No. 6

http://www.aafp.org/afp/2013/0315/p430.html

     Occult GI bleeding can occur anywhere in the GI tract. Upper tract and small bowel often cause iron deficiency anemia. The other reason to suspect occult bleeding is though FOBT (the o stands for "occult"). Causes of occult upper tract bleeding include esophagitis, ulcers, vascular ectasias, cancer, and Cameron ulcers (linear ulcers from a hiatal hernia). Lower tract bleeding causes include, cancer, polyps, and ectasias.

     The most common cause of occult bleeding in patients younger than 40 are small bowel tumors, celiac, and crohn's disease. In patients older than 40, its vascular ectasias and NSAIDs. A less common cause is through transient intestinal ischemia from long distance running. 

     A thorough history is important when GI bleeding is suspected. Unintentional weight loss,  medications (aspirin, NSAIDs, anticoagulants) and family history could be strong clues. Patients with a history of gastric bypass may have iron absorption issues. On the physical exam, look for dermatitis herpetiformis in celiac disease, erythema nodosum in Crohn disease  spoon nails in Plummer-Vinson syndrome, lip and mouth freckles in Peutz-Jeghers syndrome, or hyperextensible joints in Ehlers-Danlos syndrome. 

     This article does a great job in determining which test to use to find the bleed. If its upper GI, then go with EGD. If its proximal small bowel, then push enteroscopy can be used. It may make more sense to go with the deep enteroscopy because is can also see the mid and distal small bowel. Bleeding in the small bowel can also be seen with capsule endoscopy or CT enteroscopy. Lower tract can be seen with colonoscopy. Barium studies aren't that useful these days.

     There are two algorithms in this article. The first one says that if there is a positive FOBT without iron deficiency anemia, perform a colonoscopy. An EGD should additionally be preformed if there are any upper tract symptoms. The second algorithm is for iron deficiency anemia. All patients with iron deficiency anemia should get a colonoscopy and EGD because GI blood loss should be considered the cause unless otherwise proven. If negative, capsule endoscopy should be done. If negative, the test can be repeated or CT enteroscopy may be performed. If any of these tests come back with positive findings, the patient can be treated accordingly.

This is a brief synopsis of AFP's Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations"

This is a brief synopsis of:

Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations  

MOLLY A. FEELY, MD; C. SCOTT COLLINS, MD; PAUL R. DANIELS, MD; ESAYAS B. KEBEDE, MD; AMINAH JATOI, MD; and KAREN F. MAUCK, MD, MSc, Mayo Clinic, Rochester, Minnesota

Am Fam Physician. 2013 Mar 15;87(6):414-418

http://www.aafp.org/afp/2013/0315/

     Pre Op testing is a way to determine if a patient is suitable for surgery, or to see if they can survive it. It is done on almost every patient going to the OR, but it generally has not been proven useful.  Testing is decided by "low level evidence and expert opinion". Nonetheless, it routinely done regardless of it medical necessity.
     The first thing to consider  is the risk of the procedure  An example of high risk procedures are vascular surgeries, such a peripheral or aortic. Intermediate risk procedures are intraperitoneal, intrathoracic, head, neck, prostate, and orthopedic surgeries. Low risk procedures are breast, ambulatory, endoscopic, and cataract surgeries.
     ECG is a test that is almost always performed on all pre op patients. It is not generally recommended in asymptomatic patients undergoing low risk procedures  it is however recommended in high risk procedures.  For intermediate risk procedures, the patient should have at least 1 risk factor, such as CHF, cardiovascular disease, diabetes requiring insulin, ischemic heart disease  creatinine greater than 2mg/dL,  or undergoing intrathoracic, intra-abdominal or suprainguinal vascular surgery.
     Chest x ray is another commonly ordered procedure that is not needed. It is only recommended for those with new or unstable cardiopulmonary signs/symptoms, or in those with increased risk of post op pulmonary complications. Patients with other risk factors such as COPD or CHF will not benefit from the X ray.
     The story is similar with ordering routine lab work  Urinalysis is only recommended in those getting surgical implants or invasive urological procedures  Electrolytes and creatinine need only be tested if your clinical judgement, through the history and physical, warrant it. One guideline recommends testing in patients over 40. Glucose can be checked in patients suspected of undiagnosed diabetes,m  and A1C in diabetics.  A CBC can be ordered if you expect the procedure to have significant blood loss, or you think that the patient may have anemia. Coagulation testing can be -performed if you suspect a possible disorder, impaired hemostasis  or if the patients is on anticoagulants.
     So to make a long story short, there are no standard pre op tests for the asymptomatic patient undergoing a low risk procedure  Once the procedure becomes more risky, or the patient has more issues, the physician must use his clinical decision making skills on a case by case basis to decide what to do and what test to order.

A Brief Synopsis of AFP's Article "Screening for Prostate Cancer: Recommendation Statement"

A brief review of:
Screening for Prostate Cancer: Recommendation Statement                                    
Am Fam Physician. 2013 Feb 15;87(4):
http://www.aafp.org/afp/2013/0215/od1.html


    According to the USPSTF, PSA testing is not recommended. The main goal of testing is to find patients that would benefit from treatment and decrease morbitiy and mortality. Most cases of prostate cancer have a good prognosis without treatment. Many patients will have a tumor that will progress slowly or remain asymptomatic. Most patients who do die of prostate cancer are older than 75 years old.  
     Patients are overdiagnosed due to the screening up to 50% of the time. Depending on the cutoff values, there could be a false positive rate of up to 80%! This can lead to many unnecessary biopsies. According to this article, prostate cancer may be found on biopsy of up to 25% of men regardless of PSA value. Up to 33% of patients can have adverse reactions to the biopsy, including pain, fever, bleeding, infection, and urinary problems.
     If the patient decides on treatment, there are more issues.  Up to 5 patients in 1000 will die within one month of having surgery and up to another 70 will have serious complications. If the patients gets surgery and radiotherapy, up to 300 out of 1000 will have urinary incontinence and erectile dysfunction.  It has been shown that watchful waiting had the same morbidity as aggressive treatment.
   The bottom line is that the benefits do not outweigh the risks.

A Brief Synopsis of AFP's "Identification and Treatment of Amblyopia"

A brief synopsis of :
 Identification and Treatment of Amblyopia

YASMIN S. BRADFIELD, MD, University of Wisconsin, Madison, Wisconsin

Am Fam Physician. 2013 Mar 1;87(5):348-352.

http://www.aafp.org/afp/2013/0301/p348.html

     Amblyopia is an abnormal visual development causing blurriness in the retina, disuse of the opposite visual cortex. causing problems in vision.  It is a very treatable condition if diagnosed early.
     There are 5 types of amblyopia. Strabismic amblyopia is an eye misalignment where the brain cannot fuse the two images into one. Anisometropic (refractive) amblyopia is where the eyes focus differently, causing one eye to be blurred. These two types can be combined, having both problems superimposed in one patient. Ametropic amblyopia is bilateral symmetric refractive error, causing chronic blur in both eyes.  Deprivation amblyopia is do to an obstruction in the visual axis.

     Red reflex testing, started at birht, can detect risk factors for amblyopia. Determining fixation preference by covering each eye while the child is focusing on a target can be a clue as well. This is usually done before the patient is 2 1/2 years old. Vision screening with the classic "eye chart" is done when the child is 3 years old or older. Be careful how your cover each eye because children will often cheat and peak around the sides of the patch. As for myself, I memorized the chart, so watch out for kids like me as well. If the patient is under 5 with a vision less than 20/40 in either eye, older than 5 with a vision of 20/32 in either eye, or has a difference of two lines between each eye, then they should be referred out.
     Treatment for amblyopia is done 1 of 2 ways. Atropine drops can be given IN THE BAD EYE to stop accommodation of that eye. This is primarily for patients 7 years and older. The other option is to have the patient wear a patch (AYE, MATEE!)  for 2 hours a day. This is a fine treatment at any age, although there is a 25% recurrence rate, and the constant teasing from classmates (and bloggers) wont help either. 

A Brief Synopsis of AFP's "Reducing the Risk of Adverse Drug Events in Older Adults"

This is a brief synopsis of

Reducing the Risk of Adverse Drug Events in Older Adults

RICHARD W. PRETORIUS, MD, MPH; GORDANA GATARIC, MD; STEVEN K. SWEDLUND, MD; and JOHN R. MILLER, RPh, Wright State University Boonshoft School of Medicine, Dayton, Ohio

Am Fam Physician. 2013 Mar 1;87(5):331-336.

http://www.aafp.org/afp/2013/0301/p331.html

     If you are like me, then you have a lot of friends on Facebook who like to remind you about  how many deaths are caused by medicine. This article focuses on a common problem in medicine, which can and should be prevented. Patients are often on medication that is either redundant, unnecessary  or inappropriate.  Over 16% of older adults hospital admissions is due to an adverse drug event (33% of patients older than 75 years). The 5 categories of adverse drug events are:
1) adverse drug reactions
2) medication error
3) therapeutic failure
4) adverse drug withdrawal event
5) overdose
     The most common medications with adverse events are antithrombotics, diuretics, and NSAIDs. The most common manifestations are falls, orthostatic hypotension, heart failure, and delirium  There are specific medications that should be avoided. Antipsychotics should not be prescribed for more than a month at a time. NSAIDs should be limited to 3 weeks at a time. PPIs should be reevaluated after 8 weeks. Aspirin should only be used if patients have a history of vascular issues or arterial occlusion. Benzodiazepines and SSRIs should be avoided in patients with a fall history.
     It is important that prescribers know the side effects of the medications that they are handing out. The patient should know them as well.  Medications that people have been on long term may need to be age adjusted. Often times, patients are given medications or dosages for short term use, and they never get stopped or reduced. Self medication or OTC medications can add to the problems as well. Starting more than 1 medication at a time can lead to confusion as to which medication is the culprit. Medications should be given at the lowest acceptable dose and then increased as needed.  If side effects do occur, its better to try and lower the dose rather than adding another medication to treat the side effects.
     It is paramount to review medication lists regularly with the patient.  Several clinical tools have been developed (Beers, Stopp, and Start) to avoid these situations. Patient should be questioned about possible ad verve conditions or side affects at every visit. Visits should be frequent and at regular intervals.  Clinical judgement is important as well.
   

A Brief Synopsis of AFP's "Diabetic Ketoacidosis: Evaluation and Treatment"

A brief synopsis of

Diabetic Ketoacidosis: Evaluation and Treatment

DYANNE P. WESTERBERG, DO, Cooper Medical School of Rowan University, Camden, New Jersey

Am Fam Physician. 2013 Mar 1;87(5):337-346.

http://www.aafp.org/afp/2013/0301/p337.html

     DKA is a dangerous consequence of uncontrolled type 1 diabetes, but it can occur in type 2 as well. It occurs more often in females and in younger patients. The most common cause of death from DKA is cerebral edema.
    Patients with DKA will complain of polyuria with polydipsia, weight loss, fatigue, vomiting, dyspnea, abdominal pain, polyphagia, a recent illness, tachycardia, dry mouth, and orthostatic hypotension. They may have fruity breath, Kussmaul breathing, tiredness, lethargy or even in a stupor.
     The main differentials are all the other causes of anion gap metabolic acidosis (see "MUDPILES"), pancreatitis  gastroenteritis, MI, starvation ketosis, or hyperosmolar state. In hyperosmolar state, the ketone level is low.
     The lab values that should lead you to the diagnosis are a glucose greater than 250 mg/dL, elevated ketones, a pH less than 7.3, and a bicarbonate level less than 18 mEq/L. Changes in pH, bicarbonate, anion gap, and mental status can be used to gauge the severity. Serum ketone measurements are preferred because B-hydroxybutyrate (the primary ketone in DKA) is not picked up by urinalysis  Electrolytes, creatinine  phosphate  A1C, osmolality and BUN should also be measured.
     Fluid replacement is the treatment for DKA.  NS is given at 1 L/hr. This can be lowered to 250-500 mL/hr later on. The solution can also be changed to 1/2NS  once the sodium reaches 135 mEq/L. Dextrose can be added once the glucose drops below 200.
     Insulin can be added 1-2 hours after you start fliuds at 0.1 u/kg bolus and 0.1 u/kg/hr.  Glucose should drop 50-70 mg/dL per hour. Once the glucose gets to 200, you can drop the insulin down to 0.05-0.1 u/kg/hr. Glucose should be maintained at 150-200, so you may need to add dextrose to get there. Once the glucose is below 200, the bicarb is at 18 or higher, and the pH is above 7.3, then the DKA has resolved.
     K should also be monitored in patients with DKA.  It should be at 4-5 mEq/L. K should be given at 10-15 mEq/hr. If the K goes to 5.2 or above, hold it. If it goes below 4, you can bump it up to 20-30 mEq/hr. If it goes below 3.2, hold the insulin.
     Replacing bicarbonate, phospate, or magnesium has not been shown to change outcomes, but it is still recommended. It should be replaced when the pH is below 6.9. If the phosphate goes below 1 mg/dL, add 20-30 mEq's to the IV. Mg can be replaced if it falls below 1.2 mg/dL.

SAVE THE TATA'S; A Brief synopsis of AFP's "Breast Cancer Screening Update"

This a brief synopsis of:
Breast Cancer Screening Update

MARIA TRIA TIRONA, MD, Edwards Comprehensive Cancer Center, Huntington, West Virginia

Am Fam Physician. 2013 Feb 15;87(4):274-278.

     Breast cancer screening has been a hot topic recently. According to this article, each society that puts out recommendations has there own opinion, but they are all generally similar  It really comes down to risk vs. reward, and chasing incidental findings.
     Breast self exams are no longer recommended, although now, women should take notice of any changes in breast shape and feel, without using a specific exam technique.  So instead of self breast exams, they should practice "breast self awareness".
     Most societies still recommend clinical exams, although it does not change mortality when combined with mammography. I think the exam should be discussed with the patient on a case by case basis, but should not replace imagining. As far as when to start doing mammograms, 50 years old is the baseline.  Depending on risk factors (BRCA, family history, etc) you may want to screen more aggressively. If clinical decision warrants,  patients can be screened starting at age 40. They can be done every 1-2 years, depending on who you ask. Most believe you can stop them after 74, or whenever you think treatment would not longer be necessary.