A Brief Synopsis of AFP's "Practice Guidelines ACR Issues Recommendations on Therapies for Osteoarthritis of the Hand, Hip, and Knee"

A brief synopsis of:
Practice Guidlines; ACR Issues Recommendations on Therapies for Osteoarthritis of the Hand, Hip, and Knee   
 http://www.aafp.org/afp/2013/0401/p515.html
Am Fam Physician. 2013 Apr 1;87(7):515-516.

     This is a pretty short article on therapy recommendations for osteoarthritis. Let's start off with the hand. After the patients ability is assessed, the patient can be given assistive devices or a splint. Initial medication can be NSAIDs (oral or topical), topical capsaicin, and Tramadol  Patients older than 75 should be given topical over oral meds when available. In knee osteoarthritis, patients should participate in aquatic, aerobic or resistance exercise. Tai chi is also recommended. If the pain is chronic, moderate, or severe, acupuncture or TENS can be used, especially if they refuse arthroplasty. Medial wedged insoles can be used for patients with lateral compartment osteoarthritis. Patients can also have intraarticular corticosteroid injections, NSAIDs and Tramadol. Recommendations for the hip are similar to the knee recommendations for exercise and medication. They may also benefit from a walking aid. Chondroitin ans glucosamine are not recommended for hip osteoarthritis  There is no recommendation for tai chi either.

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.