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.

A Brief Review of AFP's "Parkinson Disease: An Update"

This is a synopsis of:

Parkinson Disease: An Update

JOHN D. GAZEWOOD, MD, MSPH, University of Virginia Health System, Charlottesville, Virginia

D. ROXANNE RICHARDS, MD, MedStar Physician Partners at St. Clement's, Leonardtown, Maryland

KARL CLEBAK, MD, Lake Monticello Primary Care, Palmyra, Virginia

Am Fam Physician. 2013 Feb 15;87(4):267-273.

     Parkinson disease is a progressive neurodegenerative disease with symptoms of rigidity, tremor, micrographia  shuffling gait, and postural instability. The symptoms are progressive. The disease is due to degeneration of the dopaminergic neurons in the substantia nigra. There is also lewy body development as well. Although the disease is almost exclusively clinical, a positive response to levodopa can help with the diagnosis. The disease is especially tough to diagnose in the early stages, and there is often a large differential.
     As far as imaging is concerned, it has not helped much with the diagnosis other than single-photon emission CT. This has been shown to distinguish Parkinson disease from essential tremor and non-degenerative Parkinson.
     Treatment can be broken down into early and late therapy. There is a concept of "on time" and "off time" in Parkinson disease. "On time" is when the medicine is working and "off time" is when the symptoms are reoccurring. Early therapy is when there is sufficient "on time", and late therapy is used when "off time" occurs.  In early therapy, levodopa/ carbidopa, non-ergot dopamine agonists,  and MAO-b inhibitors are useful. Levodopa/ carbidopa had been very effective for motor symptoms  but is associated with dyskinesia. Dopamine agonists are less effective for motor symptoms, but associated with a lower incidence of dyskinesia.
     Late therapy should be used when the initial therapy becomes less and less effective. At that point, we can add the dopamine agonists and MAO-b inhibitors to the levo/carbidopa. Catechol O-methyltransferase inhibitors (which slows down levodopa metabolism) should be avoided due to the side effect of hepatotoxicity. Amantadine has been shown to reduce dyskinesia, but only for about 8 months, thus is has limited usefullness
     Deep brain stimulation of the subthalamic nucleus and globus pallidus interna is another option. Patients should be free of comorbidities, depression, cognitive impairment, and have had a good response to levodopa. There are significant side effects too that should be considered, which are detailed in the article.
     Physical and occupational therapy can be very effective in maintaining the patient's quality of life, depending on how advanced the disease is.
     Besides the motor symptoms, there are other issues to address. These other symptoms can also affect the patients quality of life.  Fatigue is  a common problem which can be helped with methylphenidate. Drooling can be treated with Botox or glycopyrrolate. TCA's may help with depression, but you must watch for the anticholinergic side effects. Quetiapine or clozapine can be used for psychosis (clozapine and cause agranulocytosis). Dementia is a major side effect and can be treated with Donepezil (or rivastigmine in some small studies).