A Synopsis of AFP's "Prolonged Febrile Illness and Fever of Unknown Origin in Adults"

A synopsis of:
Prolonged Febrile Illness and Fever of Unknown Origin in Adults
ELIZABETH C. HERSCH, COL, MC, USA, General Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri ROBERT C. OH, LTC, MC, USA, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
Am Fam Physician. 2014 Jul 15;90(2):91-96.

     Fever of unknown origin is diagnosed as a temperature above 101°F for three more weeks without and establish course, although the definition has changed throughout history. The differential diagnosis is broad but the most common categories are infection ,malignancy or an inflammatory disease. Some medications that can cause FUO include barbiturates, antihistamines, antimicrobials, cardiovascular drugs, and NSAIDs. If a cause cannot be found after a comprehensive history and physical exam, then the minimum diagnostic workup should include CBC, chest x-ray, urinalysis, urine culture, ESR, CRP, electrolytes, LDH, creatinine, blood cultures, rheumatoid factor, serology, ultrasound and CT. Additional workup includes ferritin, cryoglobulins, ANCA, thyroid labs, complement studies, blood smear, serum plasmapheresis, PET CT and possible tissue biopsy.
     An elevated ESR May reveal an abdominal or pelvic infection, osteomyelitis or endocarditis. Procalcitonin maybe elevated in bacterial infection. Elevated LDH may be due to malaria, lymphoma, or leukemia. Ferritin may be elevated in lupus, stills disease or temporal arteritis. Cryoglobulins may be elevated in endocarditis, lupus, leukemia and lymphoma. A venous Doppler ultrasound may be helpful if the suggested cause of the fever is thromboembolism. If the origin still cannot be found, an 18F fluorodeoxyglucose positron emission tomography plus CT may help locate an area for biopsy. Areas that are commonly biopsied are lymph nodes, liver, bone marrow and temporal artery. Therapy has not been shown to be helpful. Consultation with the specialist is preferred whenever necessary.
   

A Synopsis of AFP's "Evaluation and Treatment of Constipation in Children and Adolescents"

A synopsis of:
Evaluation and Treatment of Constipation in Children and Adolescents
SAMUEL NURKO, MD, and LORI A. ZIMMERMAN, MD, Boston Children's Hospital, Boston, Massachusetts Am Fam Physician. 2014 Jul 15;90(2):82-90.

     An infant will have 3-4 stools per day for the first week of life. In infancy and and as a toddler, it will occur about twice a day,  and will eventually progress to once every 1-2 days. Infants who are breastfed may not stool for several days. Parents will worry regardless.
    Diagnosing constipation in a child is best done using the Rome III criteria found here. For childen younger than four years old, at least two of the following should be present; two or less bowel movements per week, history of excessive retention, history of painful or hard bowel movements, one or more episodes of incontinence per week, feces present in rectum, and history of large caliber stools. Patients above 4 year old may additionally have history of retentive posturing of excessive voluntary stool retention.
     Childhood constipation is often functional, meaning that the patient will voluntarily hold in stool to avoid a painful bowel movement. Ironically, this will only cause to stool to become dryer and harder to pass. The rectum will eventually stretch out and lose the sensation of having a full vault, will will perpetuate incontinence.  The full pathophysiology of fecal incontinence is poorly understood. It is common for patients who are constipated to have fluid leak from the anus, often being mistaken for diarrhea. Organic causes include hirschsprung disease, CF, anorectal malformation, and spinal cord abnormality.
   

A synopsis of AFP's "Chronic Daily Headache: Diagnosis and Management"

A synopsis of:
Chronic Daily Headache: Diagnosis and Management
JOSEPH R. YANCEY, MAJ, MC, USA, Fort Belvoir Community Hospital, Fort Belvoir, Virginia RICHARD SHERIDAN, CPT, MC, USA, 1/25 Stryker Brigade Combat Team, Fort Wainwright, Alaska KELLY G. KOREN, LT, MC, USN, Fort Belvoir Community Hospital, Fort Belvoir, Virginia Am Fam Physician. 2014 Apr 15;89(8):642-648.

     A headache is considered chronic when it occurs for at least 15 days a month for 3 consecutive months. They are further classified by either long or short duration, depending on if each individual headache lasts for more, or less, than four hours. Risk factors include obesity, medications, stress, snoring, caffeine use, and chronic pain. Lab work is not helpful in the diagnosis. Important illnesses in the differential include intracranial hemorrhage, arnold-chiari malformation, subarachnoid hemorrhage, neoplasm, ICP, hemorrhagic stroke, meningitis, encephalitis, and GCA. MRI or CT can help when ruling out these red flags.
     Short duration chronic daily headaches include brief headache syndromes and trigeminal autonomic cephalalgias. Brief headache syndromes include hypnic (during sleep), primary cough (from coughing or valsalva), primary emotional (pulsating pain from exertion), and primary stabbing (transient and localized). Trigeminal autonomic cephalalgias include chronic cluster headaches (stabbing pain behind the eye), paroxysmal hemicrania (severe unilateral orbital/ temporal pain), and SUNA/SUNCT (unilateral stabbing/ pulsating pain). Long duration chronic daily headaches include hemicrania continua (unilateral pain with injection, lacrimation, rhinorrhea, ptosis, or miosis), migraine, and tension (occipital or bandlike).
     Treatment includes nonpharmacologic therapies including cessation of tobacco/caffeine, biofeedback, relaxation techniques, good sleep hygiene, diet, and regular mealtimes. Abortive therapies include acetaminophen, NSAIDs, tramadol, and triptans. Prophylactic therapies include amitriptyline, fluoxetine, gabapentin, onabotulinumtoxinA, propranolol, tizanidine, and valproate/ topiramate. Adverse affects from medications are common in these patients, especially due to overuse.

A Synopsis of AFP's "Diagnostic Approach to Pleural Effusion in Adults"

A synopsis of:
Diagnostic Approach to Pleural Effusion in Adults
JOSÉ M. PORCEL, M.D., Arnau de Vilanova University Hospital, Lleida, Spain RICHARD W. LIGHT, M.D., Saint Thomas Hospital, Nashville, Tennessee Am Fam Physician. 2006 Apr 1;73(7):1211-1220.

     Pleural effusion is just fluid accumulation between the pleural and parietal membranes of the thoracic cavity. Effusion caused by pressure differences is typically transudative effusion. Inflammatory and malignancy typically cause exudative effusion. Light's criteria is used to differentiate them. Exudative effusion has a
pleural to serum protein ratio above 0.5,
a pleural to serum LDH ratio above 0.6, and
a pleural LDH level greater than 2/3 the upper limit of normal.
     Patients may present with dyspnea, cough, or pleuritic chest pain. Physical examination will show dullness to percussion and reduced tactile fremitus. A thoracentesis can be performed when effusion is found on chest x ray (or CT or US if the x ray is inconclusive). PA chest films can detect as little as 200 ml and a lateral film can pick up as little as 50 ml. The thoracocentesis is done for diagnostic and therapeutic benefit. Removal of large amounts of fluid can help alleviate dyspnea.The diagnostic fluid is sent for inspection, protein, LDH, gram stain, TB, pH, and cytology. Neutrophil predominant fluid may be due to an acute process. Lymphocytic predominant fluid may be due to chronic heart failure, TB, malignancy, or thoracic duct injury. A low Ph may reveal malignancy or a connective tissue disorder. Milky appearing fluid may be chylothorax. If food particles are found, it may be due to an esophageal perforation. If the fluid is transudative, treat the cause (if known) or check TSH for hypothyroidism, urine protein for nephrotic syndrome, transaminases for cirrhosis, or pro-BNP for heart failure.  If the fluid is exudative, a pulmonary consult may be in order. These patients will need a more intense workup if the underlying cause is not apparent. This may result in a pleural biopsy, thoracoscopy, or bronchoscopy.

   

A Synopsis of AFP's "Care of the Homeless: An Overview"

A synopsis of:
Care of the Homeless: An Overview
DAVID L. MANESS, DO, MSS, and MUNEEZA KHAN, MD, University of Tennessee Health Science Center, Memphis, Tennessee Am Fam Physician. 2014 Apr 15;89(8):634-640.

     Homeless people are more likely to become ill, become hospitalized, or die at an early age. Homeless children have higher rates of asthma, iron deficiency, lead poisoning, ear infections, respiratory problems, GI issues, and emotional/behavioral issues. These patients may often present initially with advanced forms of common illnesses. It is critical to identify these people so that they can receive care tailored to their situation. Confidence, trust, and empathy must be developed with these relationships. Setting up referrals, follow ups, and monitoring lab results may be challenging. A case manager or patient advocate may help with logistics.
     Common diseases in the homeless include hypertension, diabetes, CHF, PVD, high cholesterol and CAD. Poor diet, excessive mental stress, alcohol/ drug abuse, and poor coping mechanisms can exacerbate these conditions. Lifestyle modification is especially tough in this group of individuals. Patients are also susceptible to acts or violence, rape, sexual abuse, and physical abuse. Mental illness and traumatic brain injury are other illnesses that are found in high rates in the homeless. Stable housing, cognitive rehabilitation, support services, and access to therapy are critical for an optimal outcome.
     Prevention, immunizations and periodic evaluations are as important in this population as they are in the general public. Tdap vaccinations should be offered if its been longer than 10 years. Influenza vaccination should be offered annually. Pneumococcal vaccinations should be offered appropriately. These patients should also be tested for HIV, hepatitis B and hepatitis C.  Tuberculosis should always be considered as part of a differential in a sick homeless patient.
     Foot and skin care are also important. These patients endure long periods of standing and walking, often times in old or poor fitting shoes, with unclean or wet socks. This is a great nidus for ulcerations, cellulitis, edema, and stasis. Education, early detection, proper fitting shoes, clean socks, and sanitary living conditions are helpful measures of prevention.
     The best way to provide services to these people is through a multidisciplinary PCMH style approach with outreach services and community programs. Having multiple services at one spot is an effective approach.
   
   

A Synopsis of AFP's "Diagnosis and Management of Ectopic Pregnancy"

A Synopsis of :
"Diagnosis and Management of Ectopic Pregnancy"
JOSHUA H. BARASH, MD; EDWARD M. BUCHANAN, MD; and CHRISTINA HILLSON, MD, Thomas Jefferson University, Philadelphia, Pennsylvania
Am Fam Physician. 2014 Jul 1;90(1):34-40.

     An ectopic pregnancy is when a fertilized egg implants anywhere in the womans body, other than the uterus. It occurs in 1-2% of all pregnancies, and is a top cause or pregnancy-related deaths. Risk factors include sterilization, advanced maternal age, history of PID, cigarette smoking, previous tubal surgery, and previous ectopic pregnancy. Symptoms include first-trimester bleeding, peritoneal signs, and abdominal pain. A transvaginal ultrasound can be done after 5.5 weeks gestation to see if there is an intrauterine pregnancy, which will rule out an ectopic (unless there are two fetuses). If not found, it is prudent to image the areas of the pelvis where an ectopic pregnancy may likely be found. 
    An important lab value to look at is the bHCG discriminatory level. When the bHCG increases to 1500-2000 mlU/mL, an intrauterine pregnancy should be seen with ultrasound (about 5.5 weeks). Laparoscopy is another option if the location cannot be found. The bHCG level should also increase by 50% every two days in intrauterine pregnancies. The bHCG will typically not increase this fast in ectopics (although 20% of the time it does!) A sudden drop in serial bHCG may signify a nonviable or a ruptured ectopic. Falling levels need to be monitored until they are undetectable, to confirm resolution of pregnancy. 
     Women with suspected ectopic pregnancy need to have their Rh status determined to decide if RhoGam immunoglobulin should be given.
     Once it is determined that that an ectopic pregnancy is present, treatment can be decided upon. Patients with extensive bleeding or intravascular compromise will benefit from a salpingectomy. If fertility is to be preserved, a salpingostomy is preferred. Otherwise a patient can  be prescribed methotrexate, which inhibits cell replication and DNA synthesis. In order to prescribe methotrexate, the gestational sac should be smaller than 3.5cm. Factors that increase treatment failure include cardiac activity in the embryo, free blood in the abdomen, high progesterone, or high bHCG (>2000 mlU/mL).  Methotrexate is contraindicated in immune compromise, liver or kidney damage, asthma, or PUD.  Following treatment, the bHCG decreases at least 15% within 7 days. It takes 5-7 weeks for the bHCG to be undetectable. 

     

A synopsis of AFPs "Prevention and Treatment of Motion Sickness"

A synopsis of
Prevention and Treatment of Motion Sickness
ANDREW BRAINARD, MD, MPH, and CHIP GRESHAM, MD, Middlemore Hospital, Auckland, New Zealand 
Am Fam Physician. 2014 Jul 1;90(1):41-46.
http://www.aafp.org/afp/2014/0701/p41.html

     Motion sickness is caused by...um.... motion. Symptoms include nausea, drowsiness, malaise and irritability.  Signs include burping, yawning, heartburn, flushing and hyperventilation. It is more effective to treat prophylactically before the symptoms occur.  With many things, the best protection is abstinence! If you must travel, try and do so in calm weather or light terrain. It is helpful to have a view of the horizon. Patients with motion sickness in planes do better when their seat is over a wing. Patients with motion sickness in cars do better in the front seat. These spots will have the least motion. Other behavioral strategies include avoiding reading, wearing sunglasses, closing eyes, avoiding alcohol, avoiding an empty stomach, and staying hydrated.
     Medication can be quite helpful to minimize signs and symptoms. Transdermal scopalamine is the most effective route for relief. Anticholinergic side affects may occur. First generation antihistamines (promethazine) are moderately effective. Diphenhydramine and meclizine are less effective but can be used.  Other medications include benzodiazepines and rizatriptan. 
    Other treatments that are commonly used include ginger root and the P6 acupressure point (on the anterior wrist). Data is limited and may be strictly placebo. 

A synopsis of AFPs Pharmacologic Management of Pain at the End of Life"

A synopsis of:
Pharmacologic Management of Pain at the End of Life
HUNTER GRONINGER, MD, Clinical Center, National Institutes of Health, Bethesda, Maryland JAYA VIJAYAN, MD, Holy Cross Hospital, Silver Spring, Maryland
Am Fam Physician. 2014 Jul 1;90(1):26-32.

     Managing pain control at the end of life is critical towards maintaining quality of life. Pain should be assessed frequently with either a pain scale, checking functional level, or through pain related symptoms (facial grimacing, tachycardia, tachypnea, or restlessness). The WHO has developed a pain ladder here, which illustrates that non-opioid medications should be used first, with stronger medications added systematically until relief is achieved. The first medication used is typically acetaminophen. Ingesting more than 4000 mg/day can cause liver toxicity. Patients taking NSAIDs for more than a week or longer should also be prescribed a PPI.
     Opioids are usually the most effective medication for pain relief. Fear of creating addiction or dependence is not a reason to withhold this medication, especially in EOL care. Side effects include sedation and respiratory depression. Patients who need dosages around the clock should be given long-acting or controlled release preparations. Short acting doses (of 10-20% of the total daily dose) can be used PRN for breakthrough pain. If identified, the dose can be given before the etiology of the pain. When changing an opioid medication, the new drug should be reduced by at least 25% and then titrated up if needed. If a patient has a hard time swallowing medication, concentrated elixirs, creams, patches, suppositories, or pumps may be considered.
     Visceral pain can be reduced when opioids are combined with NSAIDs (for inflammation) or octreotide (for obstruction). Neuropathic pain can be controlled with TCA's, SSRI's, anticonvulsants, Na channel blocking antiarrhythmics, and gabapentinoids. Since these medications may need to be titrated, opioids or tramadol can used as a bridge. Methadone can be used for neuropathic pain, but due to its complexity, only experienced physicians should prescribe it .
   
   

A Synopsis of AFP's "Diagnosis and Management of Pancreatic Cancer"

A synopsis of 
Diagnosis and Management of Pancreatic Cancer
MARIA SYL D. DE LA CRUZ, MD, Thomas Jefferson University, Philadelphia, Pennsylvania
ALISA P. YOUNG, MD, and MACK T. RUFFIN, IV, MD, MPH, University of Michigan School of Medicine, Ann Arbor, MichiganAm Fam Physician. 2014 Apr 15;89(8):62

     Pancreatic cancer is the fourth leading cause of cancer related deaths. Risk factors include family history, peutz-Jeghers syndrome, cystic fibrosis, chronic pancreatitis, tobacco use, HNPCC, BRCA1/2 carrier, obesity, and alcohol use. Screening for pancreatic cancer is not recommended at this time, although high risk patients may benefit from it. Symptoms vary according to tumor location and include pain, jaundice, itching, weight loss, anorexia, depression, dark colored urine, and acholic stool. 90% are ductal adenocarcinomas, with two thirds occurring in the pancreatic head. Signs include Courvoisier sign, Virchow node, Trousseau sign, cachexia, and abdominal tenderness. 

     An abdominal ultrasound is the first type of imagining typically performed. MRI, CT, and MRCP may be done secondarily. Pancreatic cysts require fine-needle aspiration. If metastasis is considered, a conformational biopsy is needed. Otherwise, a chest CT and liver function tests may be helpful. Cancer antigen 19-9 is a tumor marker for ductal adenocarcinoma. As with most cancer, detection at an early stage has the best outcome. 

     The only curative treatment is resection. This can be done in about 15-20% of the patients, but the 5 year survival is only 20%. The surgery is called a pancreaticoduodenectomy (whipple procedure). The resection includes the head of the pancreas, the second portion of the duodenum, the common bile duct, the gallbladder, and sometimes the distal stomach. Tumors in the tail or body of the pancreas are not resectable. Adjuvant treatment includes gemcitabine or fluorouracil/leucovorin, which can prolong survival by 2-3 months.  For the 80% of the patients who have cancer that is not resectable, chemotherapy and consolidation chemoradiation is used. One option is to use gemcitabine or fluorouracil with radiation.  Other therapies include irinotecan, cisplatin, or oxaliplatin (as monotherapy or in combination). Radiotherapy can be used in combination or alone. It is directed at the cancerous tissue to spare healthy tissue. The dose is dependent on patient tolerance. 

     Palliative care is considered for patients with advanced disease causing biliary obstruction, gastric outlet obstruction, malnutrition and depression. For patients with gastric outlet obstruction, an enteral stent can be used.  Gastrojejunostomy can be used in patients with a longer life expectancy. 

     Patients with successful cancer resection can be followed up with a physical exam every 3 to 6 months for two years and then annually. CA 19–9 CT and ultrasound can also be used for surveillance.

A Synopsis of AFP's "Hip Fracture: Diagnosis, Treatment, and Secondary Prevention"

A Synopsis of:

Hip Fracture: Diagnosis, Treatment, and Secondary Prevention

KIM EDWARD LeBLANC, MD, PhD, Clinical Skills Evaluation Collaboration, Philadelphia, Pennsylvania HERBERT L. MUNCIE JR., MD, Louisiana State University School of Medicine, New Orleans, Louisiana LEANNE L. LeBLANC, MD, Temple University, Philadelphia, Pennsylvania

Am Fam Physician. 2014 Jun 15;89(12):945-951

     The average age for a patient to have a hip fracture is 80 years old. Women are twice as likely as men to have one. Hip fractures are associated with poor outcome, with many patients dying within a year, or needing long term care. About one fourth regain full function. Risk factors include age above 65, family history of hip fractures, female, low bone density, prior hip fracture, and chronic use of loop diuretics, SSRI's, PPI's or levothyroxine, 

     Patients present with inability to bear weight, groin pain, or referred pain to the thigh or knee. Physical examination will show a short leg or a leg that is externally rotated and abducted. An x-ray, MRI or a bone scan can be used for diagnosis.

     The two categories of hip fracture are extracapsular and intracapsular. Extracapsular includes the intertrochanteric and subtrochanteric region. The intertrochanteric region has a good blood supply and will heal well with open reduction internal fixation. The subtrochanteric region may need an intramedullary rod or nail because it is an area of high stress. The intracapsular area has a higher incidence of avascular necrosis due to its poor blood supply and thin periosteum.

     Surgery and analgesia is the treatment of choice. Patients who get surgery within two days have a faster recovery and lower risk of complications. There is no benefit of one type of anesthesia over another. For femoral neck fractures, arthroplasty or open reduction/ internal fixation can be used. Open reduction internal fixation has a low morbidity. Arthroplasty has a lower risk of avascular necrosis. Prophylactic antibiotics and thrombolytics should be used. Low molecular weight heparin should be used 12 hours after surgery and can be used for up to 35 days.

     Patient should also be on bisphosphonate, calcium and vitamin D. Bisphosphonates, however, may increase the risk of fracture after five years of use.

A Synopsis of AFP's "Unintentional Weight Loss in Older Adults"

A Synopsis of:
Unintentional Weight Loss in Older Adults
HEIDI L. GADDEY, MD, Ehrling Bergquist Family Medicine Residency Program, Offutt Air Force Base, Nebraska KATHRYN HOLDER, MD, David Grant Medical Center, Travis Air Force Base, California
Am Fam Physician. 2014 May 1;89(9):718-722.
http://www.aafp.org/afp/2014/0501/p718.pdf

     Unintentional weight loss is defined as a 5% weight reduction within 6-12 months. It is associated with a decline in ADLs, increased hip fractures, and elevated morbidity and mortality. Since it is nonspecific, it is difficult to determine the etiology. Causes include malignancy, GI disease, medication side effect, polypharmacy, or psychiatric issues. Social factors include alcoholism, financial problems. poverty, isolation, and problems obtaining/ preparing food.  A mnemonic is the 9 D's of weight loss in the elderly (dementia, dentition, depression, diarrhea, disease, drugs, dysfunction dysgeusia, and dysphasia).  A nutritional evaluation can be completed using the nutritional health checklist found HERE. Depression and dementia questionnaires are also helpful.  Recommended test to order include CBC, BMP, LFTs, thyroid function tests, CRP, ESR,  glucose, UA, and LDH (CRP, hemoglobin, LDH and albumin are particularly high yield). If these baseline tests are normal then further workup is  unnecessary. In this case, a close follow up is all that is required.
     Treatment consists of treating the underlying problem. Diet modification including softer food, assisted feeding, or nutritional supplementation may help. Medications that stimulate appetite include megestrol, mirtazapine, cyproheptadine and dronabinol, which may be beneficial.
   

A Synopsis of AFP's "Nausea and Vomiting of Pregnancy"

A Synopsis of
Nausea and Vomiting of Pregnancy
HOWARD ERNEST HERRELL, MD, East Tennessee State University, Johnson City, Tennessee
Am Fam Physician. 2014 Jun 15;89(12):965-970
http://www.aafp.org/afp/2014/0615/p965.pdf

     Three quarters of pregnant women experience nausea and vomiting. It starts by week four, peaks by week nine, and resolves by the end of the first trimester. Risk factors include lower education, lower income, older patients, multiple gestations, a history of motion sickness, a history of migraines, and nausea associated with OCP use. When nausea and vomiting affect electrolyte levels, it is known as hyperemesis gravidarum. Patients may have up to three episodes of vomiting per day. The cause of nausea and vomiting is unknown but may be due to HCG levels. High levels of HCG are associated with multiple gestation, twin pregnancy, or molar pregnancy. If the nausea and vomiting is uncomplicated, it is related to a lower risk of miscarriage, a lower risk of preterm delivery, a lower risk of growth restriction, and a lower risk of fetal death. If there is weight loss associated with the nausea and vomiting (or refractory symptoms), then there is an increase risk of growth restriction or lower birth rate. Parenteral or enteral nutrition may be needed of the nausea and vomiting are sever enough to require hospitalization. 
     When a pregnant patient presents with nausea and vomiting, infection and surgical conditions are first ruled out. If the cause is dehydration, then fluid replacement is given. Thiamine is added if a dextrose containing solution is used (to protect against wernicke's encephalitis). The first therapy that is tried for nausea and vomiting is vitamin B6. If that does not help, then doxylamine is given. The combination of these two medications can reduce the symptoms by up to 70%. If the symptoms don't resolve then promethazine can be added. Dimenhydrinate may be substituted for doxylamine. If symptoms persist, then other medications are considered. Ondansetron has comparable effectiveness as promethazine, but it is expensive. Metoclopramide can be considered but there is a risk of tardive dyskinesia and should not be used earlier than 10 weeks gestation. Methylprednisolone may be helpful but is contraindicated for use before 10 weeks because of a risk of cleft lip.
     

A Synopsis of AFP's "Infiltrative Anesthesia in Office Practice"

A synopsis of;
Infiltrative Anesthesia in Office Practice
JOSHUA L. LATHAM, DO, and SEAN N. MARTIN, DO, Headquarters Air Armament Center Family Medicine Residency, Eglin Air Force Base, Florida
Am Fam Physician. 2014 Jun 15;89(12):956-962.
http://www.aafp.org/afp/2014/0615/p956.pdf

     The use of infiltrative anesthesia is part of any office procedure that requires pain relief. Lidocaine, lidocaine with epinephrine, and bupivacaine are in the amide class. Procaine and tetracaine are in the ester class. If there is an allergy to one medication, one from another class should be chosen. Both classes work by blocking sodium channels in the nerve. LIdocaine is the most common one used. Adding epinephrine prolongs the duration of action.  It IS safe for use on the nose, ears, digits, and penis. It is contraindicated in patients with peripheral artery disease. Bupivacaine has a higher risk of toxicity compared to lidocaine. It may also cause ventricular fibrillation and a wide QRS. It is contraindicated in pregnancy.
     With these agents, using the smallest needle possible (27 gauge or more) will be much less painful for the patient. Other techniques include pinching the skin or vibrating the area. The anesthesia should be injected slowly and steady, while withdrawing the needle. Buffering the lidocaine with bicarbonate and using room temperature medication can also reduce pain.
    When using infiltrative anesthetics, they can either be injected in an area locally, or they can directed specifically to block a nerve. Local infiltration is the most common technique. it is used for small lacerations or skin biopsies. A field block is used in skin abscesses, in contaminated areas, and in places where tissue distortion can affect outcome (vermillion border). Anesthetics are strategically placed around the area to block innervations circumferentially. 
     Nerve blocks are placed at specific anatomical locations to affect the nerve that lives there. I would consider reviewing the original article to see the figures provided and read the description of the proper anatomical location.  The forehead can be numbed by blocking the supraorbital and supratrochlear nerve (V1 of the trigeminal nerve). The lower eyelid and upper lip are innervated by the infraorbital nerve (V2 of the trigeminal nerve). The lower lip and chin are innervated by the mandibular nerve (V3 of the trigeminal nerve).
     Digital nerve blocks can be used if local infiltration is not possible due to the confined space. Each digit has two palmar digital nerves and two dorsal digital nerves. When the first or fifth digit is concerned, all four nerves must be blocked. When the middle three digits are concerned, only the palmar digital nerves need to be blocked. 

A Synopsis of AFP's "Evaluation of Scrotal Masses"

A synopsis of:
Evaluation of Scrotal Masses
PAUL CRAWFORD, MD, and JUSTIN A. CROP, DO, Nellis Family Medicine Residency, Las Vegas, Nevada
Am Fam Physician. 2014 May 1;89(9):723-727.
http://www.aafp.org/afp/2014/0501/p723.pdf

     A scrotal mass is a good reason for an evaluation.  The diagnosis can first be separated by pain.  A painful high-riding or horizontal testicle may be testicular torsion. An ultrasound will show a decrease in blood flow. CRP will be less than 24 mg/L. There may be associated nausea and vomiting. Torsion will need a surgical evaluation within 6 hours to save it (time is testical). The presence of the blue dot sign (bluish skin on the superior pole) is specific for torsion of the testicular appendage. Torsion of the appendage is most common in prepubertal males. Ultrasound (and possibly exploratory surgery) is needed for diagnosis. Otherwise the differential is epididymitis, inguinal hernia, ot testicular cancer. 
     Epididymitis will present with a positive prehn sign (pain is relieved with scrotal elevation) and an elevated CRP (>24 mg/L). It is unilateral but can spread. symptoms include fever, erythema, and dysuria. Ultrasound will show increased blood flow. Chlamydia and Neisseria are common bacterial causes. 
     A non painful scrotal mass cN BE Mny things. If the mass transilluminates, it most likely is a hydrocele. A varicocele will present with a "bag of worms" on palpation (it becomes more pronounced with valsalva). Varicocele repair can have a positive impact on fertility. If it is reducible, it may be a hernia. If it is a strangulated hernia, it is a surgical emergency. Otherwise, an ultrasound and urologic evaluation is needed. Differential includes testicular cancer or ans incidental mass. 
     Testicular cancers are more likely to be malignant when discovered in children. Risk factors include Klinefelters, cryptorchidism, or a family/previous history. Testing includes AFP, beta-HCG, and lactate dehydrogenase. A mass smaller than 5mm with negative markers is more likely benign. Excision biopsy may be needed if it is considered malignant. 

A Synopsis of AFP's "Leukemia: An Overview for Primary Care"

Leukemia: An Overview for Primary Care

AMANDA S. DAVIS, MD, AnMed Health Family Medicine Residency Program, Anderson, South Carolina

ANTHONY J. VIERA, MD, MPH, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina

MONICA D. MEAD, MD, University of California–Los Angeles, Los Angeles, California
Am Fam Physician. 2014 May 1;89(9):731-738.

     Leukemia is caused by an uncontrolled stem cell proliferation in the bone marrow. The four subtypes include acute lymphoblastic leukemia (ALL), acute myelogenous leukemia (AML), chronic lymphocytic leukemia (CLL), and chronic myelogenous leukemia (CML). Risk factors include radiation exposure (as little as a couple of CT's), Down syndrome, neurofibromatosis, benzene, or household pesticides exposure in utero or in the first 3 years of life. 
    ALL is most common in children and young adults. Signs and symptoms include fever, lethargy, bleeding, muscle aches, and enlargement of the spleen, liver or lymph nodes. Blast cells are seen on peripheral smear or bone marrow aspirate. AML is mostly in adults. Symptoms include fever, fatigue, weight loss, shortness of breath, chest pain, bruising, nosebleeds, and menorrhagia. Pain is not common. 
     Chronic leukemia is often discovered incidentally and is more common in adults. CLL may present with an enlarged liver, spleen or lymph nodes. CML may present solely with splenomegaly.  Bleeding and bruising are rare in chronic leukemia. 
     Leukocytosis is the first laboratory indication of possible leukemia. The type of WBC proliferation will help guide diagnosis. Monocyte predominance is seen in chronic infections, such as connective tissue disorders or TB. Basophilia is common in viral infections or inflammatory conditions. Lymphocytosis is seen in EBV, CMV, TB, pertussis, or asplenia. Eosinophilia is seen in parasitic, allergic or connective tissue disorders. Neutrophil predominance can be due to inflammation, stress, drugs, or infection. 
     The criteria to order a peripheral smear includes leukocytosis, WBC count >20,000/uL, enlarged liver, spleen or lymph nodes, constitutional symptoms (fatigue, fever, night sweats) or anemia thrombocytopenia, or thrombocytosis.  
     Acute leukemia will have an increase in hematopoietic precursor blast cells. AML will have auer rods on peripheral smear or with immunophenotyping (which is done using flow cytometry or cytogenetic testing). Chronic leukemia will present with a clonal expansion of B lymphocytes (>5000/uL). Bone marrow aspiration is not necessary. CML will have the Philadelphia chromosome on immunophenotyping. 
    Treatment of leukemia should be left up to the heme-onc specialists. Tumor lysis syndrome can occur with treatment. The destroyed cancer cells can cause electrolyte disturbances and renal injury. Patients who receive immunosuppression  therapy may present with a neutropenic fever, prompting the use of broad spectrum antibiotic therapy. Survivors of leukemia have an increase risk of other cancer subtypes, especially ALL later in life. Children also have an increased risk of joint osteonecrosis. 

A Synopsis of AFP's "Neglected Parasitic Infections: What Every Family Physician Needs to Know"

Neglected Parasitic Infections: What Every Family Physician Needs to Know
DANA WOODHALL, MD; JEFFREY L. JONES, MD, MPH; PAUL T. CANTEY, MD, MPH; PATRICIA P. WILKINS, PhD; and SUSAN P. MONTGOMERY, DVM, MPH, Centers for Disease Control and Prevention, Atlanta, Georgia
Am Fam Physician. 2014 May 15;89(10):803-811

     This article will focus on four parasitic infections; Chagas disease, toxocariasis, cysticercosis, and toxoplasmosis. Chagas disease is caused from the parasite Trypanosoma cruzi. The CDC lifecycle can be found HERE. In a nutshell, a "kissing" bug (triatomine) bites a human and infects him or her with the parasite that it contracted from biting another human. It can also be spread through blood transfusion, organ transplantation, contaminated food, or congenitally. It is endemic to Mexico, Central and South America. It is usually asymptomatic, but it can cause conduction problems, heart failure, megacolon, megaesophagus, stroke, or cardiac disease. Treatment consists of Benznidazole and nifurtimox. Pregnant patients should not be treated because of adverse side effects. Congenital infections include anemia, low birth weight, low Apgar scores, thrombocytopenia, myocarditis, encephalitis, or hepatosplenomegaly. 
     Toxocariasis is caused by roundworms Toxocara canis and T. Cati. The CDC lifecycle can be found HERE. Humans become infected by either eating contaminated, undercooked meat, or by ingesting soil that has been contaminated with parasitic eggs from infected dogs or cats. Most patients are asymptomatic (covert toxocariasis). Young children (2-4 years old) present with visceral toxocariasis, an inflammatory response characterized by fever, wheezing, coughing, abdominal pain, anorexia, and fatigue. Older children (5-8 years old) may present with ocular manifestations including strabismus, granulomas, granulomatous masses, vision loss, or granulomas with traction bands. Serological testing is available. Treatment includes albendazole and mebendazole, with steroids it there is inflammation. 
     Cysticercosis is caused by an infection from the parasite Taenia Solium. The lifecycle can be found on the CDC website HERE. There are two cycles to this parasite. Humans can be infected by eating infected, undercooked pork, which manifest as intestinal tapeworms. Humans can also be infected through fecal-oral contact with the feces of other infected humans (which will contain eggs). The eggs with hatch and develop cysterci in various organs, including muscle, brain, and eyes. Symptoms include cysterci lumps under the skin, seizures, meningitis, headaches, intracranial hypertension, or hydrocephalus. Diagnosis is done with serology and imaging. Treatment consists of symptomatic control, steroids, and albendazole.
     Toxoplasmosis is due to an infection with Toxoplasma gondii. The CDC chart can be found HERE. Humans are infected through ingestion of raw, contaminated meat, contaminated water, or fruits and vegetables contaminated with cat feces (in the soil). Cats can shed parasites in their feces (we have all heard about pregnant women and litter boxes). Most patients are asymptomatic, but some may present with flu-like symptoms or encephalitis. Congenital toxoplasmosis can result in a miscarriage. Testing includes immunoglobulin serology and a toxoplasma avidity test. Amniotic fluid can be tested as early as 18 weeks gestation. Treatment is usually not necessary, but when it is, Pyrimethamine, sulfadiazine or leucovorin are used. 

A Synopsis of AFP's "Surgical and Nonsurgical Management of Gallstones"

A Synopsis of:
Surgical and Nonsurgical Management of Gallstones
SHERLY ABRAHAM, MD; HAIDY G. RIVERO, MD; IRINA V. ERLIKH, MD; LARRY F. GRIFFITH, MD; and VASANTHA K. KONDAMUDI, MD, The Brooklyn Hospital Center, Brooklyn, New York
Am Fam Physician. 2014 May 15;89(10):795-802
http://www.aafp.org/afp/2014/0515/p795.pdf

     Gallstones are made of cholesterol or calcium. Risk factors for gallstone formation include diabetes, obesity, metabolic syndrome, dyslipidemia, hyperinsulinemia, and high-calorie diets. Typical presentation includes abrupt, steady, right upper quadrant pain. Pain peaks within one hour and resolves after the stone passes (1-5 hours). Complications include acute cholecystitis (fever, leukocytosis, RUQ pain), cholangitis (charcot's triad is fever, jaundice and abdominal pain), and gallstone pancreatitis (sphincter of Oddi obstruction).  Choledocholithiasis is an obstruction of the common bile duct. Risk factors include symptoms of cholangitis, a bilirubin level above 4 mg/dl, or a common bile duct wider than 6mm. 
    Ultrasound is the first line choice of imaging because of cost and low invasiveness. CT is superior to ultrasound, but it is more expensive and has radiation exposure. MRCP is a second line choice as well.
     HIDA scan is used to visualize the biliary tree and assess liver and gallbladder function.  The patient is given iminodiacetic acid which can be detected with a gamma camera as it travel through the liver and gallbladder in the bile. ERCP is diagnostic and therapeutic because is can be used to retrieve the stone, add a stent, or collect a biopsy.  
     Treatment depends on several factors. If the gallstone is asymptomatic, the patient can be followed clinically or sent for laparoscopic cholecystectomy. Symptomatic patients should be treated with NSAIDs or narcotics (meperidine or ketorolac). Scopolamine is not as effective. Complications (choledocholithiasis, cholecystitis, pancreatitis) may be referred to surgery as well.  If the patient is not a candidate for surgery, treatments such as oral dissolution therapy or extracorporeal shock wave therapy can be considered. Oral dissolution therapy is best with gallstones 5 mm or smaller, although the therapy can take up to two years. Patients with calcified gallbladders, hemolytic anemia, stones larger than 3 cm, morbid obesity undergoing bariatric surgery, native american heritage, or bladder dysmotility are exceptions to expectant management.
     Antibiotic prophylaxis is generally not required for laparoscopic cholecystectomy. High risk patients may benefit from a single dose of cefazolin. 
     Pregnant patients should not be given NSAIDs. Meperidine is appropriate. Ursodeoxycholic acid is another option. Surgery can be considered for patients in recurrent or intractable pain. 

A Synopsis of AAFP's "Update on Latent Tuberculosis Infection"

Update on Latent Tuberculosis Infection
Hartman-Adams H, Clark K, Juckett G
June 1 2014 Vol. 89 Number 11

     Tuberculosis affects about one third of the world's population. The classic symptoms include cough, hemoptysis, weight loss, fever, and night sweats. Approximately 10-15% of these people have latent infection. 5-10% of latent infections progress to active disease, which will occur within 2 years for half of these patients. Risk factors for progression include age less than 5 years, low body weight, diabetes, drug/alcohol abuse, GI bypass, immunosuppression, and others. Latent infection is noninfectious. Sputum AFB is negative.
     Screening is based on risk stratification.  Factors include recent immigration from a high risk area (especially Asia), being a health care professional, working in an "institution", and being homeless. Low-risk patients should not be tested due to possible false positive tests. The two testing options are the Tuberculin skin test (TST) and the interferon-gamma release assay (IGRA). They cannot distinguish between active and latent infection. TST is more sensitive and IGRA is more specific. High risk patients with negative TST can have a confirmatory IGRA. Low risk patients with a positive TST should have a confirmatory IGRA to avoid unnecessary treatment.  ***PEARL OF THE ARTICLE** Apparently, having the BCG vaccine within 10 years can in fact create a false positive TST test 20% of the time. Board question writers.. start your engines! In this case, IGRA is preferred over TST. It is also preferred in patients who may not return to have the test read. TST is the test of choice in patients younger than 5 years old. For patients with recent exposure, a patient may not show positive conversion with either test for 3 months. High risk patients with recent exposure should get "window prophylaxis" until a screening test can be reliably performed. Sometimes a patient may need a second TST to get a positive reaction (booster effect- ***another BOARD REVIEW PEARL**).
     There are four treatment regimens. Isoniazid can be given for 9, 6, or 4 months. The longer the treatment, the more effective, more expensive, more patient compliance, and more liver toxicity. A new regimen of 12 weekly doses of isoniazid and rifapentine are as effective as the 9 month long dose of isoniazid. It has better compliance but is more expensive. 
     

A Synopsis of AAFPs "Salivary Gland Disorders"

A Synopsis of:
Salivary Gland Disorders
KEVIN F. WILSON, MD; JEREMY D. MEIER, MD; and P. DANIEL WARD, MD, MS, University of Utah School of Medicine, Salt Lake City, Utah
Am Fam Physician. 2014 Jun 1;89(11):882-888.
http://www.aafp.org/afp/2014/0601/p882.pdf

     The salivary glands include the parotid, submandibular, sublingual, and some minor ones that line the mouth. The three types of disorders include obstruction, neoplasm, and infection. The initial typical symptom is inflammation. If there are systemic findings (fever, joint pain) then the inflammation may be due to sjogren's syndrome, lymphoma, fungal, or mycobacterial. Acute localized inflammation may be either viral or bacterial. Recurrent localized inflammation will need to be evaluated for duct obstruction.
     Acute suppurative sialadenitis is bacterial inflammation of the parotid gland. Risk factors include diabetes, hypothyroidism, use of anticholinergic medications, renal failure, and sjogren's. Treatment includes empiric antibiotics (amoxicillin-clavulanate), warm compresses, sialagogues, hydration, oral hygiene, and salivary gland massage.
     Recurrent parotitis of childhood appears as fever malaise, pain, and swelling of the parotid gland. Treatment is the same as above.
     Chronic sialadenitis is thought to be due to obstruction of the parotid gland. Treatment consists of sialagogues, hydration, massage and anti-inflammatory medication.
     Sialolithiasis are stones in the submandibular gland. Symptoms include postprandial pain and swelling. A stone may be found through palpation (under anesthesia) or imaging. Stones in the parotid duct may require surgery.
     Viral infections include mumps and HIV. Mumps occur mostly in children less than 15 years old. It is highly contagious and spreads through respiratory droplets. It is nonsuppurative and diagnosed through viral serology. Treatment is supportive. HIV is associated with cysts in the salivary glands and xerostomia.
     Neoplasms present as painless, asymptomatic, and slow-growing. Diagnosis is made with biopsy and imaging. Pleomorphic adenomas are the most common tumor. They are found in the parotid gland and can become malignant with time. Warthin tumors are benign tumors found in older male smokers. Mucoepidermoid carcinoma is a low grade tumor with excellent prognosis if treated. Adenoid cystic carcinoma invades the nerves and can cause facial weakness. Treatment is resection.

A Synopsis of "Evaluation and Treatment of Neonatal Hyperbilirubinemia"

Evaluation and Treatment of Neonatal Hyperbilirubinemia KAREN E. MUCHOWSKI, MD, Naval Hospital Camp Pendleton Family Medicine Residency Program, Camp Pendleton, California Am Fam Physician. 2014 Jun 1;89(11):873-878. 

http://www.aafp.org/afp/2014/0601/p873.pdf 

     Severe neonatal hyperbilirubinemia can cause kernicterus in about 2% of infants, however it is usually benign. Symptoms include hypertonia, arching, retrocollis, opisthotonus, fever, and high pitched crying. Risk factors include cephalohematoma, bruising, exclusive breast feeding, and weight loss greater than 8%. Total serum bilirubin (TSB), transcutaneous bilirubin, or risk scores can be used to screen patients. Some institutions prefer to do universal screening. AAFP says that screening has no effect on clinical outcomes.  

     It is important for the old-timer docs to know that you can not visually predict bilirubin level though visual inspection. It is more accurate to plot the level on a nomogram HERE (BTW that was my first ever link on my blog- go me!" The treatment is typically phototherapy (at a frequency of 460-490 nm). There is no standard protocol for exact type or amount of light.  Fiber optic lights are only about half as good as conventional. Adverse effects of phototherapy include separation from mom, increased blood draws, longer hospital stays, and more visits to health care professionals during infancy. Exchange transfusion is considered if the patient has a TSB above 25 ng/dL and signs of encephalopathy. Complications occur 5% of the time. 

     Hyperbilirubinemia is more a function of calorie deprivation rather than breastfeeding exclusivity. frequency needs to be increased in these children. Intake can be approximated by monitoring daily wet diapers (4-6 is adequate) and stools (3-4). Encouragement and continued maternal interaction by doctors and nurses is helpful in promoting breastfeeding throughout infancy. 

     Studies on long term effects have shown no difference in cognition or neurologic function between patients with RSB levels  above or below 13.  Those with a positive coombs test had lower cognitive scores. Infants with TSB above 19 have had an increased incidence of ADD.  

  

ARE YOU MISSING ME???

Sorry I haven't called. Yes I miss you too....

I have been doing some intense studying for licencing and will be back JUNE 2nd !! I hope you are as excited as I am to get caught up on all the AFP journals!!