"Polymyalgia Rheumatica and Giant Cell Arteritis" (My Synopsis)

Polymyalgia Rheumatica and Giant Cell Arteritis
BRIAN UNWIN, COL, MC, USA, CYNTHIA M. WILLIAMS, CAPT (R), MC, USN, and WILLIAM GILLILAND, COL, MC, USA, Uniformed Services University of the Health Sciences, Bethesda, Maryland 
Am Fam Physician. 2006 Nov 1;74(9):1547-1554.

     Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are two diseases that are often seen together. CGA is it most common vasculitis in adults, and PMR is the most most common inflammatory disease in adults. It is important to know the GCA is an inflammation in medium to large arteries. PMR causes muscle and joint pain in the proximal muscles (hip, neck and shoulders). Occasionally there is also pitting edema, distal joint pain, and systemic symptoms. The core criteria for PMR includes; age over 50 years old, aching proximal muscles, symptoms lasting two weeks, morning stiffness of the girdle muscles for 45 minutes, and elevated ESR or CRP. A normal ESR can be estimated by using this formula (age/2 for men; for women is age/2 plus 5). The ESR in PMR is usually above 40 mm/hr. An ESR above 100mm/hr would occur in a patient with PMR and GCA.  Other lab work to order in PMR is a CBC, CK, thyroid, BMP, RF, UA, and SPEP. A chest x ray can help rule out cancer causing paraneoplastic syndrome. Treatment consists of corticosteroids with a slow taper. The treatment will last an average of 1.8 years. Older women with higher ESR may be at more risk for relapse or GCA. Patients with recurrent relapses or who cant tolerate a slow taper should be referred to a specialist. A that point, a rheumatologist may consider using a DMARD. Patients on long term steroids may need bisphosphonates, alendronate, vitamin D and calcium, or another type of prophylaxis to maintain bone density. 
     CGA can affect any medium or large artery, including the extracranial carotids, the temporal artery, or the thoracic aorta. The disease presents as a new onset temporal headache, fatigue, anorexia, or weight loss.  There may also be scalp tenderness. Jaw claudication or vision problems (diplopia, blurry vision) are signs of ischemia. Patients over 50 years old with signs and symptoms should be treated immediately to avoid progression to blindness. An elevated ESR (>50mm/hr) or CRP is another sign to have urgent treatment.  Diagnosis is made by temporal artery biopsy. The exact spot of the vasculitis should be identified on the patient's skin because taking a biopsy of an unaffected part (skip lesions) will lead to negative results. The sample should be at least 1 cm. A negative biopsy in a patient with strong clinical indication for disease may prompt a contralateral biopsy. Ultrasound may aid in performing the biopsy. After the initial treatment is started, a referral to a rheumatologist is warranted. Methotrexate is another treatment option. Treatment last for about three months. The patient will have to be monitored for a thoracic aneurysm every two years by x ray. Patients on long term steroids will need osteoporosis prophylaxis. 

"Pityriasis Rosea" (My Synopsis)

Pityriasis Rosea, by DANIEL L. STULBERG, M.D., Utah Valley Regional Medical Center, Provo, Utah JEFF WOLFREY, M.D., Good Samaritan Regional Medical Center, Phoenix, Arizona
Am Fam Physician. 2004 Jan 1;69(1):87-91.

     Pityriasis rosea is an acute rash of uncertain origin. Community outbreaks occur in clusters. Recurrence is rare, which suggests immunity. It appears to be viral, but no connection or proof has been found. It occurs mostly in children and young adults in either gender.  The first symptom is that of a generalized viral URI. Then comes the herald patch on the trunk. It is a large, round, red, raised, scaly, collarette lesion. It can easily be mistaken for eczema. Over the next few days to weeks, similar smaller (0.5-1cm) lesions start to appear over the trunk.  These lesions typically follow a "christmas tree" pattern on the back because they follow the langer lines of the skin. It looks like a V shaped pattern if present on the chest or a horizontal pattern on the abdomen. The extremities are spared. Pruritis is variable, but it is intense in a quarter of the patients. Topical treatment for the itching is effective, but oral antihistamines or steroids are an option. One study had shown that treatment with two weeks of erythromycin will resolve the rash. UV light has also helped with the rash and itching. The disease will usually resolve on its' own within 5-8 weeks. A rash lasting greater than three months may be a misdiagnosis. The differential includes tinea corporis, pityriasis lichenoides, viral exanthem, lichen planus, medication reaction, or syphilis (rash on palms and soles). 

"An Approach to Interpreting Spirometry" (My Synopsis)

An Approach to Interpreting Spirometry
TIMOTHY J. BARREIRO, D.O., and IRENE PERILLO, M.D., University of Rochester School of Medicine and Dentistry, Rochester, New York
Am Fam Physician. 2004 Mar 1;69(5):1107-1115.

     Spirometry is an important test to do in the office setting because a history and physical exam are poor tools to diagnosis obstructive ventilatory patterns. Spirometry measures how fast the lungs can change volume during forced exhalation. A flow volume loop is created which will show characteristic patterns depending on the disease process.  The FVC is the amount of air that the patient can forcefully exhale. The FEV1 is the portion of the air that is exhaled in one second. The ratio that is measured is the FEV1/FVC. The ratio in a normal patient is over 80%, and the results are normalized based on the height, weight, race, and gender of the patient. Spirometry can be done on patients who are current or former smokers over the age of 44 years. A baseline test may be considered in patients who are taking medications with pulmonary toxicity.  The test is also used to track treatment response. Contraindications include recent surgery of the abdomen, thoracic, or eye, recent myocardial infarction, unstable angina, pneumothorax, hemoptysis, or an acute disorder than would hinder performing the test. The spirometry should be performed three times to determine the validity of the results. The difference between the three results should not exceed 0.2L.
    In patients with obstruction, the FVC may be normal or low, the FEV1 will be low, and the FEV1/FVC ratio will be less than 0.7. In this case, a bronchodilator challenge test can be ordered.  A bronchodilator is given and the spirometry is repeated. A positive test will show a rise in 12% in FEV1, and 200 ml increase in FVC or FEV1, or a 15-25% increase in FEV25-75%. This test is positive in reversible airway disease. If the test is negative and the bronchodilation does not change the spirometry results, then the patient has an obstructive ventilatory impairment. 
     In patients with a restrictive impairment, the FVC and FEV1 will be low, but the ratio of FEV1/FVC will be normal (above 0.7).  These patients need to be referred for static lung volumes (DLCO, DLCO/VA, ERV) to determine severity (DLCO can also be done in obstruction to determine asthma vs COPD; it goes up in asthma). A maximum voluntary ventilation maneuver (MMVM) can be done to determine if the restriction is due to poor patient effort, neuromuscular disease, or airway lesion. 
     In either case, severity must be determined after the spirometry is interpreted. 

"Pediculosis and Scabies: A Treatment Update" (My Synopsis)

Pediculosis and Scabies: A Treatment Update
KAREN GUNNING, PharmD, University of Utah College of Pharmacy, Salt Lake City, Utah KARLY PIPPITT, MD, University of Utah School of Medicine, Salt Lake City, Utah BERNADETTE KIRALY, MD, University of Utah School of Medicine, Salt Lake City, Utah MORGAN SAYLER, PharmD, University of Iowa College of Pharmacy, Iowa City, Iowa
Am Fam Physician. 2012 Sep 15;86(6):535-541.

     Pediculosis is an infestation of lice on the head, body, or pubic region. The typical presentation is pruritus after 2-6 weeks of infestation. Since it is a delayed hypersensitivity reaction, subsequent infections will cause itching in 1-2 days. Constant scratching will lead to excoriations, lichenification, hyperpigmentation, and cellulitis. Diagnosis is made when a live louse is found. Finding a nit (a louse egg) is not diagnostic.  A good place to check for head lice is behind the ears and on the back of the neck. When a diagnosis is made, all members of the household should be examined and treated. Washing clothing, bedsheets, and towels (fomites) in hot water (122° F) will eradicate the parasites. Pubic lice can will be found in pubic hair and the seams of clothing. Patients who present with pubic lice should be checked for other STI's as well. 
     First line treatment is with permethrin. It is left in  the patients' damp hair for 10 minutes once a week. Two treatments should be effective. Resistant communities (such as England) can be treated with malathion. Oral ivermectin is a second line medication when there is resistance to either topical treatment. Nonpharmacologic treatments include wet combing with a lice comb and a leave-in conditioner. Another option to consider is to apply Cetaphil Gentle Skin Cleanser to the scalp, comb out after two minutes, dry with a hair dryer, and shampoo the hair after 8 hours. 
     Scabies presents with a generalized itchy rash, which is worse at night.  It may present as excoriations, eczemations, pyoderma, papules, nodules, or vesicles. The face and neck are spared (except in infants).  A burrow type lesion (short, gray, wavy lines) may be found on the hands, feet and in the finger webs.  Diagnosis can be made by finding a mite, egg or fecal matter on a skin scraping of the lesion. Treatment consists of permethrin cream on the entire body (neck down) for 8-14 hours. A second treatment can be done a week later. The pruritus may continue for up to two more weeks.  Oral ivermectin is second line therapy (due to cost).  Cloth washing should be at 140°F and with a hot clothes dryer.
     Norwegian scabies (or crusted scabies) presents as a generalized scaling, nail abnormalities, and thick, crusted lesions on the feet and hands. Pruritis is not present or minimal. An outbreak may have thousands of mites on the body, whereas in traditional scabies, there may only be a dozen. It is tougher to treat as well. Treatment includes daily permethrin cream and frequent oral ivermectin.

"Common Eye Emergencies" (My Synopsis)

Common Eye Emergencies
CHRISTOPHER D. GELSTON, MD, University of Colorado School of Medicine, Aurora, Colorado
Am Fam Physician. 2013 Oct 15;88(8):515-519.

     The eye injuries discussed in this article are retinal detachment, globe injuries, and chemical injuries. Retinal detachment is when the retina separates from the epithelium of the back of the eye. Usually the posterior vitreous detaches, which causes the retina to stretch and tear. The vitreous humor gets into the tear and under the retina, causing the separation. Symptoms include unilateral scotomas and increased floaters. If the retina is only torn, the vision may appear a bit cloudy or even normal. If the retina is detached, it may present as a rapidly expanding area of vision loss. When the macula is involved, the vision deficit becomes more prominent. Diagnosis comes from a proper fundic exam and an ocular ultrasound. Treatment consists of a ophthalmologist referral. Surgery will ultimately be needed. These patients have a higher risk of detachment in the opposite eye so they should be evaluated regularly.
     A mechanical globe injury occurs when a laceration or rupture occurs in the cornea, usually from a foreign body. It presents as eye pain, tearing, redness, or decreased vision after trauma. Diagnosis comes from a complete eye exam with a penlight or slit lamp. Fluorescein dye may help visualization of the laceration. If the foreign body is visible, it should not be removed. Lacerations smaller than 1 cm can be treated with topical antibiotics. If a globe injury has occurred, it is important not to increase pressure on the eye. Antiemetics can be given to reduced the risk of valsalva pressure. Systemic prophylactic antibiotics (levofloxacin or moxifloxacin) can be given to protect against posttraumatic endophthalmitis. A tetanus shot and immediate ophthalmologic referral is needed. 
     Chemical burns occur when an noxious fluid gets in the eye. It can damage the epithelium and cause conjunctival and scleral ischemia. Alkaline fluids are worse than acidic solutions. Symptoms include pain, redness, decreased vision and increased sensitivity to light.  Examination will show swelling, cloudiness, conjunctival injection or conjunctival ischemia (a white eye). The extent of the burn can be quantified by the amount of limbal ischemia. No ischemia is a grade I burn. A grade II burn will have ischemia in less than a third of the limbus. Grade III will have stromal haze than obscures the iris detail and up to half of the limbus will be ischemic. A grade IV burn will have ischemia in more than half of the limbus. Treatment includes copious flushing of the eye with at least 2L of fluid. The pH can be checked after 5 minutes to determine when it is in a safe range 7-7.5. 

"Pituitary Adenomas: An Overview" (My Synopsis)

Pituitary Adenomas: An Overview
MARCY G. LAKE, DO, U.S. Naval Hospital, Sigonella, Italy LINDA S. KROOK, MD, Naval Hospital, Bremerton, Washington SAMYA V. CRUZ, MD, U.S. Naval Hospital, Rota, Spain
Am Fam Physician. 2013 Sep 1;88(5):319-327.

     Pituitary adenomas are very common and as many of 20% of the population may have one. The vast majority of these are incidentalomas with no clinical significance. Those larger than 10mm are called macroadenomas and those smaller are called microadenomas. The most common type of pituitary adenoma is a prolactinoma, followed by nonfunctioning, growth hormone secreting tumor, ACTH, FSH, LH and TSH. They arise from monoclonal tissue in the anterior pituitary (lactotroph, gonadotroph, corticotroph, thyrotroph, or somatotroph).
     PItuitary adenomas present either with hormone hypersecretion, hormone deficiency, mass effect complications (neurologic dysfunction), or incidentally. The most common hormone presentations are hyperprolactinemia, acromegaly, and cushing disease. If a hormonal origin is considered to be the cause, an endocrine panel (serum prolactin, IGF-1, LH/FSH, TSH, T4, and an appropriate cortisol test) should be ordered. An elevated serum prolactin above 250 mcg/L is most likely a prolactinoma. If it is above 500 mcg/L it would be a macroprolactinoma. Sometimes a non-prolactinoma will cause elevated prolactin when the tumor compresses the pituitary stalk, known as the "stalk effect".
     Neurologic symptoms from mass effect include headaches (stretching the neural sheath), visual changes (optic chiasm superiorly, cranial nerves III, IV, VI laterally), CSF rhinorrhea, seizures, and pituitary apoplexy. An MRI can be done with and without gadolinium, or a thinly cut, coronal plane CT can be used instead.
     Incidentally found adenomas occur by using imaging for unrelated reasons. A complete endocrine panel should be done in this case even if the patient is asymptomatic. If the tumor is functioning, it should be treated accordingly (prolactinomas are treated with a dopamine agonist and a GH or ACTH secreting tumor should be referred to neurosurgery and endocrinology). If it is a nonfunctioning macroadenoma, visual field testing should be done. Patients with visual symptoms (or with asymptomatic impingement on imaging) will need referral to an ophthalmologist. Patients with microadenomas or macroadenomas and normal vision will get a repeat MRI and endocrine panel in one year. If there is no change after one year, then testing can be repeated in 2-3 years. If the tumor becomes larger than 1 cm, then visual field testing should be repeated. Any changes in the endocrine panel need to be investigated.
     The three treatment goals for pituitary adenoma are lowering hormone secretion, shrinking the tumor, and fixing any hormone deficiencies. The dopamine agonists used in prolactinomas are bromocriptine and cabergoline. Side effect include nausea, vomiting and fatigue. When these medications are used in high doses to treat parkinsonism, there is an increased risk of heart valve problems (this has not been seen in levels used to treat prolactinomas). ACTH and GH secreting tumors are usually treated with transsphenoidal resection. Other options include octreotide and lanreotide, which inhibit GH secretion. Pegvisomant is a IGF-1 antagonist which is another option.  Treatments to shrink the tumor include radiation, radiosurgery, and resection.

"Outpatient Management of Alcohol Withdrawal Syndrome" (My Synopsis)

Outpatient Management of Alcohol Withdrawal Syndrome
HERBERT L. MUNCIE JR., MD, Louisiana State University School of Medicine, New Orleans, Louisiana YASMIN YASINIAN, MD, New Orleans, Louisiana LINDA OGE', MD, Louisiana State University School of Medicine, New Orleans, Louisiana
Am Fam Physician. 2013 Nov 1;88(9):589-595.

     Alcohol dependence is present in up to 9% of all family medicine patients. In women, alcohol dependence is defined as those who average more than one drink a day, seven drinks a week, or more than four drinks on one occasion. In men, dependence is defined as more than two drinks a day, 14 drinks a week, or five drinks on a single occasion. Alcohol withdrawal syndrome occurs from a sudden abstinence after a long period of drinking (two weeks or more). Treatment of AWS requires identification of the condition, assessing the complication risk, and symptom recognition. Screening for alcohol abuse can be done using the CAGE questionnaire (or the AUDIT or MAST test). The four CAGE questions are:
1. Have you ever felt the need to CUT DOWN on your drinking?
2. Do you feel that people ANNOY you about how much you drink?
3. Have you ever felt GUILTY about your drinking?
4. Do you ever need an EYE opener (a drink in the morning to feel better)?
     Alcohol use disorder can be diagnosed if the patient is positive for at least two of the following:
-drinking more than expected
-persistent desire or inability to quit
-spending a lot of time getting alcohol or drinking alcohol
-having a craving, desire or urge to drink
-having problems fulfilling work, home or school obligations
-continued use despite persistent problems due to drinking
-drinking during times that are hazardous
-altering activities because of drinking
-continuing to drink even though you know it is having a harmful effect
-gaining tolerance (drinking more to attain effect)
-having withdrawal symptoms
     Withdrawal symptoms will start with 6-24 hours after last drink. AWS is diagnosed if at least two of the following symptoms occur; sweating, tachycardia, hand tremor, insomnia, nausea/vomiting, hallucinations (visual, auditory, or tactile), anxiety, psychomotor agitation, or tonic-clonic seizures. If AWS is not treated, it could lead to delirium tremens (disorientation, impaired attention, hallucinations, hyperthermia, tachycardia, tachypnea, diaphoresis, and altered consciousness). There are three stages to AWS. Stage one is mild and will present with anxiety, tremors, headaches, palpitations and GI issues. Stage two moderate and presents with sweating, systolic hypertension, tachypnea, confusion, and hyperthermia. Stage three is severe and is includes delirium tremens. AWS severity is assessed with the CIWA-Ar scale seen here (http://www.aafp.org/afp/2013/1101/afp20131101p589-f1.gif). A score of 8 or less is considered mild withdrawal. Moderate withdrawal has a score of 9-14. A score of 15-20 is moderate. Above 20 is severe. Medication is not needed in patients with a score of less than 10.
     A patient with mild or moderate AWS can be treated as an outpatient if the patient can take oral medications, is committed to the treatment, is willing to follow up frequently, and has proper support at home to assist in medication compliance. Family support is critical in the outpatient setting. Patients with severe withdrawal, serious psychiatric problems, laboratory abnormalities, or poor support at home should be treated as an inpatient.
     Patients are given thiamine and folic acid to combat and deficiencies from heavy drinking. Thiamine can lower the risk of Wernicke encephalopathy. The medications used for reducing psychomotor agitation, seizures and convulsions in AWS are benzodiazepines and anticonvulsants. Long acting benzodiazepines are more effective than intermediate or short acting benzodiazepines. Shorter acting benzodiazepines are more addictive and have a higher potential for abuse. A "loading dose" is not needed. The benzodiazepine can be given as a fixed dose or a symptom-triggered dose (triggered with a CIWAS-Ar score above 9). Symptom-triggered doses end up giving the patient less medication over a shorter period of time. There is no difference in results between either schedule. Anticonvulsants, such as carbamazepine and valproic acid, is also effective in AWS treatment. Gabapentin has shown to be equally effective.
Most patients are evaluated on a daily basis until symptoms decrease and the medication dosage is decreased. Medication can be lowered when a CIWAS-Ar is less than 10. Symptoms should be gone within a week. Patients can then be referred to an long term outpatient treatment center. If they miss an appointment or resume drinking, then they should be referred to a specialist
   

My Synopsis of "Myocardial Infarction: Management of the Subacute Period"

Myocardial Infarction: Management of the Subacute Period
MICHAEL G. MERCADO, MD, Naval Hospital Camp Pendleton Family Medicine Residency Program, Camp Pendleton, California DUSTIN K. SMITH, DO, U.S, Naval Hospital Guam, Agana Heights, Guam MICHAEL L. MCCONNON, MD, Naval Hospital Pensacola Family Medicine Residency Program, Pensacola, Florida
Am Fam Physician. 2013 Nov 1;88(9):581-588.

     Acute management of an MI usually starts with aspirin/clopidogrel, anticoagulation, fibrinolysis, echo and angiography. Depending on the LVEF and the results of the angiogram, a bypass, PCI stenting, or medical management will be recommended. Discharge medication will be prescribed depending on the situation. 
     All patients will be given aspirin indefinitely. The dose should be lowered at discharge. Patients who have an allergy to aspirin can take clopidogrel. Dual antiplatelet therapy (aspirin and clopidogrel or other P2Y12 inhibitor) is recommended for up to a year in patients with bear metal stents and at least a year in patients with drug-eluting stents. Post MI patients can be given dual therapy of 2 different P2Y12 inhibitors (clopidogrel and ticagrelor) for up to a year. A PPI can be added in patients with GI bleeding. 
     Beta blockers may be started gradually and indefinitely on patients with a LVEF less than 40%. Mortality benefit had not been documented for the first month post MI. It can be started within 24 hours after an event. It may not benefit patients who had a remote history of MI. Patients with preserved systolic function can take it for at least three years. 
     All post MI patients with a history of hypertension, diabetes, heart failure, chronic kidney injury or LVEF less than 40% should be on an ACEI. It should be continued indefinitely. ARBs can be used on those patients who cannot tolerate ACEIs. The two medications should not be used together. Aldosterone blockers (eplerenone) can reduce mortality in post MI patients with a low LVEF, diabetes or signs of heart failure. The creatinine clearance should be above 30 and the potassium should be less than 5. 
     Statins should be started and continued indefinitely on these patients before they are discharged. Patients already on a statin may benefit from a higher dose (up to 80 mg/day). The dose can be titrated to get an LDL less than 70-100. 
    Discharge planning is an important tool which is not always done properly. It includes medication review, patient education, referral to cardiac rehab, activity and lifestyle recommendations, and a follow up plan. Sexual activity can resume in a week. Driving can start in three weeks. Air travel should be halted for two weeks. Physical activity can be resumes as tolerated