A Brief Synopsis of AFP's "Hypothyroidism: An Update"

A brief synopsis of: Hypothyroidism: An Update,DAVID Y. GAITONDE, MD; KEVIN D. ROWLEY, DO; and LORI B. SWEENEY, MD, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia

Am Fam Physician. 2012 Aug 1;86(3):244-251.

http://www.aafp.org/afp/2012/0801/p244.pdf

     Hypothyroidism is caused by either thyroid gland failure (primary) or poor stimulation of the thyroid gland from the pituitary gland or hypothalamus (secondary). Primary gland failure can be congential, autoimmune, or  iatrogenic. Common symptoms of hypothyroidism are weight gain, fatigue, depression, constipation, cold intolerance, dry skin, or hair loss. In children and infants, the most common signs are lethargy and failure to thrive. Menstrual irregularities and infertility are a common feature in women.  Cognitive decline may be the only symptom present in older adults.  Common signs are peripheral edema, brittle hair, goiter, pleural effusion, megacolon, and pericardial effusion. Patients may have ECG abnormalities including bradycardia and flat T waves. Lab findings may include hyponatremia, hypercapnia,  hypoxia, hyperprolactinemia,  hyperlipidemia, and elevated CK.
    Although universal screening is not recommended, patients who are symptomatic, or have risk factors,  including a history of autoimmune disease, previous radioactive iodine therapy, or a positive family history, should have a serum TSH drawn. If the TSH is elevated, then a T4 should be checked. A low T4 is seen in primary hypothyroidism and a normal T4 is seen in subclinical hypothyroidism.  A low TSH and low T4 signifies secondary hypothyroidism. Since the TSH level fluctuates, its best to check it in the morning.
     Most patients require lifelong levothyroxine (synthetic T4). The typical patient is started on 1.6 mcg/kg/day, given in the morning 30 minutes before breakfast. Certain patients need different dosages. Older patients with coronary heart disease are given 25-50 mcg/day, and increased by 25 mcg each 3-4 weeks until the optimal dose is found (a full dose could cause tachyarrhythmia and ischemia). Pregnant patients should get an extra 2 doses during the pregnancy.
     Patients with persistent symptoms should be checked for alternative causes, such as adrenal insufficiency,  depression, liver disease,  obstructive sleep apnea or chronic kidney disease. It can also be from deficiencies in B12, iron, or vitamin D. It is important to know that switching between name brand and generic medications for hypothyroidism is a bad idea because they have different bioavailabilities. myxedema coma is an extremely rare situation and should be treated in a ICU by an endocrinologist.
  

A Brief Synopsis of AFP's "Diagnosis of Secondary Hypertension: An Age-Based Approach"

A brief synopsis of : Diagnosis of Secondary Hypertension: An Age-Based Approach, ANTHONY J. VIERA, MD, MPH, and DANA M. NEUTZE, MD, PhD, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina

Am Fam Physician. 2010 Dec 15;82(12):1471-1478. 

http://www.aafp.org/afp/2010/1215/p1471.html

     Hypertension is one of the most common illnesses seen today. It is a predictor of serious illness, which is why blood pressure is considered a "vital sign". Oftentimes, a cause can not be found, so the patient is given anti-hypertensive pills and sent on their way. Up to 10% of these patients have secondary hypertension, which can be corrected without anti-hypertensive medications. Depending on the age of the patient, different etiologies are more common than others for secondary hypertension. 
     First, when a patient presents with elevated blood pressure, it needs to be check two other times during two other occasions. Correct positioning of the cuff, cuff size, diet, and a full medication review should be performed to avoid chasing any zebras.  Common medications that can cause elevated hypertension are OCP's, steroids  diet pills, amphetamines  lithium, TCA's, decongestants, and several herbs, like ma huang and ginseng.  If the patient is a child, the onset of hypertension was rapid, or the history simply does not seem typical, investigating other causes of hypertension should be considered.
     Patients under 18 years old may have secondary hypertension from renal parenchymal disease or  coarctation of the aorta. Renal parenchymal disease includes glomerulonephritis, reflux nephropathy, and congenital abnormalities.  A BUN, creatinine, UA, urine culture, and renal ultrasound should be ordered. In aortic coarctation,  a murmur may be heard, or there may be a pressure difference between bilateral brachial, or brachial and femoral pulses.  Rib notching may be seen on x ray. MRI or transthoracic echocardiology can be done to rule out coarctation. 
     In patients between the ages of 19 to 39, common causes of secondary hypertension are renal artery stenosis, and thyroid dysfunction. In this age group, the renal artery stenosis is due to decreased renal perfusion from fibromuscular dysplasia   A high pitched, holosystolic, renal bruit may be heard. MRI with gadolinium, CT angiography, or doppler ultrasound can be used to diagnose this.  HypOthyroidism can cause an elevation in diastolic pressure. HypERthyroidism can raise systolic pressures. TSH can be tested in this age group, as well as any older subgroup.
     Patients between the ages of 40 to 64 may have elevated pressure from aldosteronism, obstructive sleep apnea, pheochromocytoma, or cushing syndrome. Patients with elevated aldosterone syndromes may have hypokalemia. The best test is to check morning aldosterone/renin levels. These patients may need to be referred for confirmatory testing.  In obstructive sleep apnea, a polysomnography or a clinical assessment tool with nighttime pulse oximetry may be positive. Pheochromocytoma patients will have the 6 P's (Pounding headaches, Palpitations, Palor, Panic, Pressue/Paroxysmal burst, and Perspiration) as well as the "rule of 10's (10% familial, 10% bilateral, 10% malignant, 10% calcify, 10% extramedullary). 24-hour urinary metanephrines or plasma free metanephrines should be checked. Cushing disease patients will present with a buffalo hump, central obesity, moon facies and stria, but I would bet that your cushing patient won't have any of these classic signs (unless your patient is a medical textbook model...) Tests to rule out this disease include a 24-hour urinary free cortisol, low-dose dexamethasone suppression test or late-night salivary cortisol test.
    In patients older than 65 years old with secondary hypertension, the most common causes are renal artery stenosis or renal failure.   Patients who develop hypertension late in life, those with atherosclerosis, or rapid deterioration of renal function when started on ACEI's or ARB's may have secondary hypertension. They can be imaged by MRi with gadolidium or CT angiography. Patients with suspected renal failure should get an ultrasound, GFR, and a UA with albumin level. 

Death by Thrombus or exsanguination? A Brief Synopsis of AFP's "Perioperative Antiplatelet Therapy"

A brief synopsis of; Perioperative Antiplatelet Therapy

PIERRE GUY CHASSOT, MD; CARLO MARCUCCI, MD; and ALAIN DELABAYS, MD, University Hospital of Lausanne, Lausanne, Switzerland, DONAT R. SPAHN, MD, University Hospital of Zürich, Zürich, Switzerland

Am Fam Physician. 2010 Dec 15;82(12):1484-1489.

http://www.aafp.org/afp/2010/1215/p1484.html

     The decision whether or not to stop antiplatelet therapy is often an issue for the family physician who is managing a patient who need surgery. It is often debated between the surgeon and the primary care provider. The big question is, "is the patient more likely to throw a clot or bleed to death?"
     Antiplatelet therapy is used after a stroke, MI, ACS, and other thrombogenic situations. It is also important after coronary revascularization and stent placement.  These treatments "act as unstable plaques" until they either heal. Bare metal stents require 6 weeks to 3 months for smooth muscle and endothelium to cover it, respectively  It can take much longer  (up to 3 years) in drug-eluding stents. This is why clopidogrel treatment is given for 6 weeks with bare metal stents and a least a year with drug eluding stents.  It should be used for 2-4 weeks in angioplasty without stents, 3-6 months in an MI, and 6-12 months in an unstable ACS. Aspirin should also be used in these patients. Previous studies have shown that stopping aspirin, even two years later, can cause thrombosis. Thus, aspirin should be a lifelong medication in these patients.
    In general, there is a 20% increase in perioperative bleeding when on aspirin or clopidogrel.  The risk of hemorrhage is up by 50% (which isn't that much considering that the risk of hemorrhage in surgery is small to begin with). Whats interesting is, although it may take longer to get the bleed under control, the surgical mortality is the same. However, stopping antiplatelet therapy is associated with up to a 40% increase in MI and up to an 85% increase in mortality. Thus, the risk of thrombosis is higher than the risk of hemorrhage.
    Aspirin should be used forever in patients who use it for secondary prevention. The only time it may make sense to stop it is in diabetic patients using aspirin for primary prevention. Patients on dual antiplatelet therapy after stent placement should not have elective operations done during this time. If an emergency operation is needed and the clopidogrel must be stopped, the aspirin should be continued.

A Brief Synopsis of AFP's "Diagnosis, Initial Management, and Prevention of Meningitis"

A brief synopsis of: Diagnosis, Initial Management, and Prevention of Meningitis, DAVID M. BAMBERGER, MD, University of Missouri–Kansas City School of Medicine, Kansas City, Missouri

Am Fam Physician. 2010 Dec 15;82(12):1491-1498.

http://www.aafp.org/afp/2010/1215/p1491.html

     Considering the recent outbreak in upstate New York, I thought it would be appropriate to review meningitis (i'll save bird flu for next week). Meningitis is usually bacterial or viral (aseptic).  Bacterial is more rare and way more dangerous. The most common types of aseptic meningitis are enterovirus, HSV, HZV and Borrelia burgdoferi.  Enterovirus and arbovirus are prevalent in the summer and fall months. 
     In adults, most patients with bacterial meningitis will have either fever, neck stiffness, altered mental status or headache. Some will present with a recent history of otitis, sinusitis, pneumonia, or an immunocompromised state. A petechial rash may also be seen in meningococcal meningitis. Seizures, focal neurological findings, and altered consciousness is more commonly seen in pneumococcal meningitis. Younger adults are less likely to present with seizures and hemiparesis, but more commonly with headaches, nausea, vomiting, and nuchal rigidity. Younger children will present with lethargy, irritability and a history of a recent URI. They may also "catch" a seizure at this young age. So you get the point, right? we have a serious disease with high mortality, but subtle clinical findings. Thus, if you can't come up with an explanation for all the symptoms, you better evaluate that CSF.
     A lumbar puncture is generally a safe procedure. We all have fear that we will cause a brain herniation when we hear the "pop", but as long as the patient the patient does not have any neurological issues (shunts trauma, papilledema, etc), you will be safe. Of course, if the patient had a seizure or is impaired, a CT will be necessary. Regardless, you still need to get blood cultures and start empiric therapy before the CT. Sitting on therapy for as little as 2 hours could affect the outcome poorly. Starting therapy before the LP will decrease the amount of bacteria available to culture, and may affect the glucose level, protein level , and ability to culture the bug for antibiotic sensitivity testing. It will not affect the gram stain of PCR results. 
     For empiric therapy, give vancomycin and ceftriaxone. Add ampicillin if the patient is over 50 years old  and an alcoholic. If the patient had a penetrating trauma, a CSF shunt or is post surgery, switch out the ceftriaxone for cefepime. If the patient is less than a month old, try ampicillin and cefotaxime. If you suspect M. Tuberculosis or S.pneumoniae , you can add dexamethasone.
     Aseptic meningitis is a less serious infection. It can be diagnosed by PCR of the CSF. An RPR, VDRL, or HIV antibody test may be done if the history warrants.  Fungal and TB meningitis can be diagnosed with PCR as well. Cryptococcal is the most common fungal cause and can be treated with amphotericin b and flucytosine.

A Brief Synopsis of AFP's "Management of Chronic Tendon Injuries"

A brief synopsis of:

Management of Chronic Tendon Injuries

MARC A. CHILDRESS, MD, Fort Belvoir Community Hospital, Fort Belvoir, Virginia

ANTHONY BEUTLER, MD, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Am Fam Physician. 2013 Apr 1;87(7):486-49

http://www.aafp.org/afp/2013/0401/p486.html

     Most chronic tendon injuries tend to be from overuse (and I have a left elbow to prove it). These areas typically have a poor blood supply with collagen separation and degeneration.  Rather than bleeding and inflammation, the pain is mediated by glutamate and non-prostaglandin pathways. NSAIDs are considered first line medication but there is little evidence to support this, and the side effects (GI, renal, and cardiovascular issues) outweigh the benefits. In general, steroid injections may provide short term pain relief, but long term benefit has not been proven.
     There are two types of Achilles tendinopathy; midsubstance and insertional.  Midsubstance tendinopathy is located approximately in the middle of the Achilles tendon. First line treatment is eccentric strengthening of the gastrocnemius and soleus. This article has a nice table and picture of the exercise, which appears to be a modified calf raise. The classic therapies (ultrasound, electric stimulation, massage, surgery and stretching) have not been shown consistently to improve long term function. Insertional tendinopathy is located distal to the midsubstance injury, near the insertion of the Achilles. Eccentric stretching is not as helpful, but has shown benefit in about 30% of these injuries. The patient should also be in a walking boot for 4-6 weeks.
     Eccentric exercise is a first line treatment for patella tendinopathy, which consists of a type of slow knee bend (please see figure 3 of this article). This has been shown to be of greater benefit than surgery or injections of sclerosing agents.
     Lateral epicondylitis is pain that can be reproduced by forearm extension and pronation against resistance. The best therapy here is wrist extensor strengthening and stretching. Steroid injection provide short term pain relief, but may affect long term cure rates. Studies have shown benefit with autologous blood and platelet-rich plasma injections, as well as nitroglycerin patch.
     Rotator cuff tendinopathy can be caused by repetitive actions of throwing, lifting, and overhead motions. Imagining is helpful to determine the extent of the injury and to rule out a possible tear. The main therapy is strengthening the rotator cuff, stabilizing the scapula, and increasing range of motion  Steroid injections can be used to help relieve pain during therapy, but the location of injection may not be important.
     Prolotherapy is the injection of irritants to induce healing. Examples are dextrose, autologous blood and platelet-rich plasma. Other therapies  such as lasers, phonophoresis, ultrasound and iontophoresis have had mixed results and are not a substitute for first line therapy.
   

A Quick Blurb of AFP's "AASM Updates Treatment Guidelines for Restless Legs Syndrome and Periodic Limb Movement Disorder"

A brief synopsis of :

AASM Updates Treatment Guidelines for Restless Legs Syndrome and Periodic Limb Movement Disorder BY CARRIE ARMSTRONG

Am Fam Physician. 2013 Feb 15;87(4):290-292.

http://www.aafp.org/afp/2013/0215/p290.html?printable=afp

     Restless leg syndrome is this uncontrollable urge to move your legs at night. You may have seen something similar on YouTube, but this has nothing to do with the Harlem hake. The most effective medication for moderate to severe RLS is pramipexole and ropinirole. The side effects (nausea and others) will resolve with stopping the medication. Levodopa can be used with intermittent RLS if daily medication is not recommended. Cabergoline can be used if the other medication are not effective, although cabergoline is not well tolerated. Medications such as gabapentin, pregabalin, carbamazepine, ans clonidine should no longer be used as first or second line medications due to the creation of the better alternatives described above. 
     Benzos, VPA, Valerian and Amantadine  have not been proven to be beneficial and really should not be considered at this time.
     This article does not recommend medications for periodic limb movement disorder. 

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.