The Newborn Foot
ALVIN I. GORE, M.D., D.P.M., San Diego, California JEANNE P. SPENCER, M.D., conemaugh Memorial Medical Center, Johnstown, Pennsylvania
Am Fam Physician. 2004 Feb 15;69(4):865-872.
The foot can be separated into 3 anatomic regions. The hindfoot is the heel part of the foot and includes the talus and calcaneus. The forefoot is the front "fingers" part of the foot and consists of the metatarsals and phalanges. The midfoot is the.... middle part of the foot and contains everything else (navicular, cuboid, and cuneiforms).
Metatarsus adductus is the deformity where the metatarsals pitch in medially. The lateral aspect of the feet have a convexed appearance. The first and second digits have a splayed appearance and the medial midfoot develops a deep cleft in the skin. This article discusses performing the "V" test by placing the infant's foot between the clinician's index and middle finger to better observe any deformity. Treatment is conservative. Patients can perform stretching exercises, which consists of stabilizing the hindfoot while distally distracting the forefoot and correcting the position. In severe refractory cases, serial casting and bracing may be needed, but it is rare.
Clubfoot has four components to the deformity;
1. Inversion and adduction of the forefoot
2. Inversion of the heel and hindfoot (the heels may actually face each other)
3. Tight achilles causing flexed ankle "equinus" (foot stuck in plantarflexion)
4. Internal rotation if the leg
On x ray, the talus and calcaneus will appear "stacked". Basically the foot is flexed "down and in". There are two types of clubfoot. It can be extrinsic (supple) or intrinsic (rigid). Extrinsic is a severe position or soft tissue deformity and is treated with serial casting. Intrinsic deformity will need a surgical correction.
Calcaneovalgus is a deformity of the tibiotalar joint where the foot is in extreme dorsiflexion. The dorsum of the foot may be in contact with the anterior part of the distal leg. It may be associated with an overstretched achilles tendon, tight anterior leg muscles, or an externally rotated calcaneus. The deformity has an "up and out" appearance. It will oftentimes resolve on it's own. Stretching exercises can aid in resolution. It is performed by gently putting the foot in plantar flexion and inversion. Splinting or casting may be needed in severe cases.
Congenital vertical valgus is a deformity also known as "rocker bottom foot". The hindfoot is pointed down, in an "equinus" position, and the forefoot is dorsiflexed. This causes the midtarsal bones to become dislocated. Patients with this deformity may have other congential deformities as well, so a thorough exam should be performed. Stretching can be done, but surgery is usually needed.
Polydactyly is the "sixth" toe or "sixth" finger. They are primarily genetic. Treatment is usually surgery (or ligation banding if it is purely soft tissue). Syndactyly are webbed toes/ fingers. It is a genetic deformity. Treatment is not necessary and is only done for cosmetic purposes. Overlapping toes are often familial and bilateral. It is corrected with gently stretching and paper tape splinting. Surgery may be needed if treatment is delayed.
Thursday, October 31, 2013
Wednesday, October 30, 2013
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Tuesday, October 29, 2013
"Lower Extremity Abnormalities in Children" (My Synopsis)
Lower Extremity Abnormalities in Children
P MELA SASS, M.D., and GHINWA HASSAN, M.D., State University of New York–Downstate Medical Center, Brooklyn, New York
Am Fam Physician. 2003 Aug 1;68(3):461-468.
Lower extremity abnormalities in children are usually normal variations that resolve on their own. The two types of variations are rotational and angular problems. When a parent brings their child in, it is important to figure out what their exact concerns are. It may be a gait issue, a cosmetic problem, or it may just be pressure from a concerned relative to get it "checked out". A complete medical and family history are needed because these issues can have a developmental or genetic component. The physical exam includes plotting the patient on a growth chart, a neurologic exam, ROM of extremities, and assessment of joint laxity. A trendelenburg test will assess contralateral hip abductor strength. The lateral foot should be observed for flat feet.
Rotational problems of the lower extremities can be seen if certain angles are greater than two standard deviations from the average. The foot progression angle measures to what degree a person's feet deviate from a straight line while walking. Hip rotation can be measured by having the patient lie prone with the knees bent. Internal hip rotation will present with the patients' legs angled away from each other, whereas external hip rotation will present with the legs crossing eachother. The thigh-foot angle compares the axis of the thigh to the angle of the foot when the knee is bent at 90 degrees. Measuring the distance between medial malleolus or medial femoral condyles (while the legs are together), can determine the amount of genu varum (bow legs) or genu valgum (knock-knees), respectively. Most patients appear genu varum from birth to two years old and then appear genu valgum at 3-7 years old. It is part of normal development. If the deformity is unilateral, greated than two standard deviations, or getting worse, then x rays are warranted.
There are three causes of intoeing (I remember calling it "pigeon toes" during Chinese jump rope). The first cause is metatarsus adductus. The forefoot is adducted and the lateral forefoot is convexed. The most common cause is intrauterine packing. Flexibility can be assessed by abducting the forefoot. It will usually resolve by the time the child turns one year old. The parent can stretch the child's midfoot, but referral to an orthopedist for serial casting will be needed if the intoeing does not resolve by eight months. The second cause is internal tibial torsion. The most common causes are intrauterine position, sleeping prone, and "sitting on the feet". the knees are facing forward but the tibial torsion causes the feet to be angled inwards. It will resolve by the time the child turns eight years old. If the deformity is significant, then corrective surgery may be needed. The third cause is femoral anteversion. It also has "pigeon toes", but this time there is femoral torsion instead of tibial torsion. Here, the feet and patellar are angled inward. The deformity peaks at 4-6 years, and then slowly resolves. The deformity is benign but surgery can be considered if it is severe.
Out-toeing is less common than intoeing. The first cause is femoral retroversion which is the opposite of femoral anteversion. The femur is twisted outwards. It is associated with stress fractures and slipped capital femoral epiphysis. Referral to an orthopedist is recommended if it does not improve within one year. External tibial torsion is the opposite of internal tibial torsion. The tibia rotates laterally to cause the out toeing. It is seen when the child is 4-7 years old. Surgery can be considered in severe cases when the patient is over 10 years old.
Flat feet is seen when ligament laxity causes the foot to sag during weight bearing. If the arch appears when the child is standing on his or her toes, then the it is not a true flat foot, and treatment is not necessary. If the foot is stiff and painful, then an orthopedic referral is needed.
P MELA SASS, M.D., and GHINWA HASSAN, M.D., State University of New York–Downstate Medical Center, Brooklyn, New York
Am Fam Physician. 2003 Aug 1;68(3):461-468.
Lower extremity abnormalities in children are usually normal variations that resolve on their own. The two types of variations are rotational and angular problems. When a parent brings their child in, it is important to figure out what their exact concerns are. It may be a gait issue, a cosmetic problem, or it may just be pressure from a concerned relative to get it "checked out". A complete medical and family history are needed because these issues can have a developmental or genetic component. The physical exam includes plotting the patient on a growth chart, a neurologic exam, ROM of extremities, and assessment of joint laxity. A trendelenburg test will assess contralateral hip abductor strength. The lateral foot should be observed for flat feet.
Rotational problems of the lower extremities can be seen if certain angles are greater than two standard deviations from the average. The foot progression angle measures to what degree a person's feet deviate from a straight line while walking. Hip rotation can be measured by having the patient lie prone with the knees bent. Internal hip rotation will present with the patients' legs angled away from each other, whereas external hip rotation will present with the legs crossing eachother. The thigh-foot angle compares the axis of the thigh to the angle of the foot when the knee is bent at 90 degrees. Measuring the distance between medial malleolus or medial femoral condyles (while the legs are together), can determine the amount of genu varum (bow legs) or genu valgum (knock-knees), respectively. Most patients appear genu varum from birth to two years old and then appear genu valgum at 3-7 years old. It is part of normal development. If the deformity is unilateral, greated than two standard deviations, or getting worse, then x rays are warranted.
There are three causes of intoeing (I remember calling it "pigeon toes" during Chinese jump rope). The first cause is metatarsus adductus. The forefoot is adducted and the lateral forefoot is convexed. The most common cause is intrauterine packing. Flexibility can be assessed by abducting the forefoot. It will usually resolve by the time the child turns one year old. The parent can stretch the child's midfoot, but referral to an orthopedist for serial casting will be needed if the intoeing does not resolve by eight months. The second cause is internal tibial torsion. The most common causes are intrauterine position, sleeping prone, and "sitting on the feet". the knees are facing forward but the tibial torsion causes the feet to be angled inwards. It will resolve by the time the child turns eight years old. If the deformity is significant, then corrective surgery may be needed. The third cause is femoral anteversion. It also has "pigeon toes", but this time there is femoral torsion instead of tibial torsion. Here, the feet and patellar are angled inward. The deformity peaks at 4-6 years, and then slowly resolves. The deformity is benign but surgery can be considered if it is severe.
Out-toeing is less common than intoeing. The first cause is femoral retroversion which is the opposite of femoral anteversion. The femur is twisted outwards. It is associated with stress fractures and slipped capital femoral epiphysis. Referral to an orthopedist is recommended if it does not improve within one year. External tibial torsion is the opposite of internal tibial torsion. The tibia rotates laterally to cause the out toeing. It is seen when the child is 4-7 years old. Surgery can be considered in severe cases when the patient is over 10 years old.
Flat feet is seen when ligament laxity causes the foot to sag during weight bearing. If the arch appears when the child is standing on his or her toes, then the it is not a true flat foot, and treatment is not necessary. If the foot is stiff and painful, then an orthopedic referral is needed.
Monday, October 28, 2013
"Pertussis: A Reemerging Infection" (My Synopsis)
Pertussis: A Reemerging Infection
JONATHAN M. KLINE, PharmD, BCPS; WILLIAM D. LEWIS, MD; ELEANOR A. SMITH, MD; LLOYD R. TRACY, MD; and SARAH K. MOERSCHEL, MD, West Virginia University School of Medicine, Eastern Division, Harpers Ferry, West Virginia
Am Fam Physician. 2013 Oct 15;88(8):507-514.
Pertussis is an upper respiratory infection also known as whooping cough. It has a 7-10 day incubation period. The presentation in the incubation period varies widely. There are three stages of pertussis after the incubation period. The first stage is the catarrhal stage. It lasts for up to two weeks. The presentation includes malaise, rhinorrhea, sneezing, lacrimation, and cough. The patient may be afebrile and highly contagious. The second stage is the paroxysmal stage. It can last from 1-6 weeks. This is the stage where the patient presents with the classic paroxysmal cough, in which the patient can have a severe coughing spell in between "whoops" of inspiration. This occurs because the patient has difficulty expelling the thick secretions from the lungs. The paroxysms can lead to emesis, cyanosis, proptosis, salvation, distended neck veins, and lacrimation. The last stage is the convalescence stage. In this stage, the coughing abates and the patient becomes susceptible to other URIs. This stage lasts up to three weeks. Atypical presentation of pertussis is common and may only present as a chronic cough. Any patient with a chronic cough of greater than three weeks may have atypical pertussis.
Infants who have not received the full series of vaccinations may only have partial immunity. Patients who become infected with pertussis under the age of six months should be admitted to the hospital. Complications in this group are apnea, pneumonia, seizures, and death. Adults may present with weight loss, urinary incontinence, syncope, rib fractures (from coughing), subconjunctival hemorrhage, abdominal hernias, and vertebral artery dissection.
Laboratory testing on pertussis is done by culture or PCR. Cultures can be taken from nasopharyngeal aspirate or a posterior nasopharyngeal swab. PCR has a higher sensitivity. Serological testing is done on patients who present after symptoms for many weeks.
Treatment includes macrolides or TMP/SMX. It should be started within three weeks of onset of symptoms, or within six weeks in patients younger than 1 year. Treatment prevents the spread of the disease and does not help in remission. Antibiotic prophylaxis can be given to all close contacts for three weeks. Prophylaxis can be withheld in those who will not have contact with infants younger than 6 months. The prophylaxis of choice is azithromycin.
Vaccination is the current form of prevention. There are two versions of the vaccine: DTaP and Tdap. The difference is that the DTaP has a higher concentration of the diphtheria toxoid. Tdap is used in patients older than six years old because the DTaP has an increased risk of reaction at the injection site. The vaccination schedule for DTaP is given at 2, 4, 6, and 15-18 months. It it given one more time at age 4-6 years. Patients between 11-18 years old and 19-64 years old get a Tdap booster. A Tdap booster is also given at 7-10 years to patients who did not get the full 5 dose childhood schedule, if pregnant (at 27-36 weeks), and if 65 or older and in contact with children less than 1 year old.
JONATHAN M. KLINE, PharmD, BCPS; WILLIAM D. LEWIS, MD; ELEANOR A. SMITH, MD; LLOYD R. TRACY, MD; and SARAH K. MOERSCHEL, MD, West Virginia University School of Medicine, Eastern Division, Harpers Ferry, West Virginia
Am Fam Physician. 2013 Oct 15;88(8):507-514.
Pertussis is an upper respiratory infection also known as whooping cough. It has a 7-10 day incubation period. The presentation in the incubation period varies widely. There are three stages of pertussis after the incubation period. The first stage is the catarrhal stage. It lasts for up to two weeks. The presentation includes malaise, rhinorrhea, sneezing, lacrimation, and cough. The patient may be afebrile and highly contagious. The second stage is the paroxysmal stage. It can last from 1-6 weeks. This is the stage where the patient presents with the classic paroxysmal cough, in which the patient can have a severe coughing spell in between "whoops" of inspiration. This occurs because the patient has difficulty expelling the thick secretions from the lungs. The paroxysms can lead to emesis, cyanosis, proptosis, salvation, distended neck veins, and lacrimation. The last stage is the convalescence stage. In this stage, the coughing abates and the patient becomes susceptible to other URIs. This stage lasts up to three weeks. Atypical presentation of pertussis is common and may only present as a chronic cough. Any patient with a chronic cough of greater than three weeks may have atypical pertussis.
Infants who have not received the full series of vaccinations may only have partial immunity. Patients who become infected with pertussis under the age of six months should be admitted to the hospital. Complications in this group are apnea, pneumonia, seizures, and death. Adults may present with weight loss, urinary incontinence, syncope, rib fractures (from coughing), subconjunctival hemorrhage, abdominal hernias, and vertebral artery dissection.
Laboratory testing on pertussis is done by culture or PCR. Cultures can be taken from nasopharyngeal aspirate or a posterior nasopharyngeal swab. PCR has a higher sensitivity. Serological testing is done on patients who present after symptoms for many weeks.
Treatment includes macrolides or TMP/SMX. It should be started within three weeks of onset of symptoms, or within six weeks in patients younger than 1 year. Treatment prevents the spread of the disease and does not help in remission. Antibiotic prophylaxis can be given to all close contacts for three weeks. Prophylaxis can be withheld in those who will not have contact with infants younger than 6 months. The prophylaxis of choice is azithromycin.
Vaccination is the current form of prevention. There are two versions of the vaccine: DTaP and Tdap. The difference is that the DTaP has a higher concentration of the diphtheria toxoid. Tdap is used in patients older than six years old because the DTaP has an increased risk of reaction at the injection site. The vaccination schedule for DTaP is given at 2, 4, 6, and 15-18 months. It it given one more time at age 4-6 years. Patients between 11-18 years old and 19-64 years old get a Tdap booster. A Tdap booster is also given at 7-10 years to patients who did not get the full 5 dose childhood schedule, if pregnant (at 27-36 weeks), and if 65 or older and in contact with children less than 1 year old.
Friday, October 25, 2013
"Treatment of Obstructive Sleep Apnea in Primary Care" (My Synopsis)
Treatment of Obstructive Sleep Apnea in Primary Care
LYLE D. VICTOR, M.D., M.B.A., Oakwood Hospital and Medical Center, Dearborn, Michigan
Am Fam Physician. 2004 Feb 1;69(3):561-569.
A good friend of mine called me and said that his wife thinks that he has sleep apnea. "Is that bad?", he said. I gave him a brief overview, and then decided that it would be a good topic to review today. SO AWAY WE GO!
OSA is a partial or complete airway obstruction which causes breathing to stop during sleep. It is seen in overweight patients who snore. They will often be sleepy during the day. Disease severity can be measured with an "apnea-hypopnea index". If the number of apneic or hypopneic episodes equal 20 or more per hour, then treatment is recommended.
First line therapy is sleep hygiene. Patients should allot enough time to dedicate to sleep. Deprivation of sleep can cause snoring. Things that affect nasal outflow (rhinitis, polyps, septal deviation) and mouth breathing are risk factors for OSA. Patients with OSA should avoid alcohol and sedatives because they can increase snoring by relaxing the tongue and parapharyngeal muscles. Most patients with OSA are overweight or obese. Weight loss of 20-30 lbs. will lead to significant improvement. Patients may also get relief if they sleep at an elevated position.
If sleep hygiene is not fully effective, then the patient will need CPAP. This is a mask that the patient wears when they go to bed. It pushes air into the nostrils to keep the pharyngeal airway open. Patients usually require 6-12 cm of pressure to reduce the number of episodes each night. The pressure may be reduced slightly after a month of use or if the patient has some weight loss. Many patients have a hard time tolerating the mask while sleeping. One way to address this is to uses bilevel pressure ventilation, which lowers the pressure upon exhalation. This will reduce the work of breathing. Other strategies to help with patient compliance is to make sure the mask fits right, using nasal pillows, using a full face mask, adding a humidifier, or giving the patient a nasal steriod spray. Complications of CPAP include air leakage, claustrophobia, skin irritation, and conjunctivitis.
Surgery is another option if the patient cannot tolerate CPAP. Uvulopalatoplasty removes part of the soft palate and uvula. Jaw surgery attempts to advance the maxillomandibular bone. Another technique moves "the anterior tip of the mandible forward along with its lingual attachments". Another approach, which uses maxillary and mandibular osteotomies, is more invasive. Tracheostomy is a last resort treatment, used in respiratory failure or in severe apnea.
Oxygen is partially effective by treating desaturation, but it does not reverse the obstruction.
LYLE D. VICTOR, M.D., M.B.A., Oakwood Hospital and Medical Center, Dearborn, Michigan
Am Fam Physician. 2004 Feb 1;69(3):561-569.
A good friend of mine called me and said that his wife thinks that he has sleep apnea. "Is that bad?", he said. I gave him a brief overview, and then decided that it would be a good topic to review today. SO AWAY WE GO!
OSA is a partial or complete airway obstruction which causes breathing to stop during sleep. It is seen in overweight patients who snore. They will often be sleepy during the day. Disease severity can be measured with an "apnea-hypopnea index". If the number of apneic or hypopneic episodes equal 20 or more per hour, then treatment is recommended.
First line therapy is sleep hygiene. Patients should allot enough time to dedicate to sleep. Deprivation of sleep can cause snoring. Things that affect nasal outflow (rhinitis, polyps, septal deviation) and mouth breathing are risk factors for OSA. Patients with OSA should avoid alcohol and sedatives because they can increase snoring by relaxing the tongue and parapharyngeal muscles. Most patients with OSA are overweight or obese. Weight loss of 20-30 lbs. will lead to significant improvement. Patients may also get relief if they sleep at an elevated position.
If sleep hygiene is not fully effective, then the patient will need CPAP. This is a mask that the patient wears when they go to bed. It pushes air into the nostrils to keep the pharyngeal airway open. Patients usually require 6-12 cm of pressure to reduce the number of episodes each night. The pressure may be reduced slightly after a month of use or if the patient has some weight loss. Many patients have a hard time tolerating the mask while sleeping. One way to address this is to uses bilevel pressure ventilation, which lowers the pressure upon exhalation. This will reduce the work of breathing. Other strategies to help with patient compliance is to make sure the mask fits right, using nasal pillows, using a full face mask, adding a humidifier, or giving the patient a nasal steriod spray. Complications of CPAP include air leakage, claustrophobia, skin irritation, and conjunctivitis.
Surgery is another option if the patient cannot tolerate CPAP. Uvulopalatoplasty removes part of the soft palate and uvula. Jaw surgery attempts to advance the maxillomandibular bone. Another technique moves "the anterior tip of the mandible forward along with its lingual attachments". Another approach, which uses maxillary and mandibular osteotomies, is more invasive. Tracheostomy is a last resort treatment, used in respiratory failure or in severe apnea.
Oxygen is partially effective by treating desaturation, but it does not reverse the obstruction.
Thursday, October 24, 2013
"Dermatologic Conditions in Skin of Color: Part II. Disorders Occurring Predominantly in Skin of Color" (My Synopsis)
Dermatologic Conditions in Skin of Color: Part II. Disorders Occurring Predominantly in Skin of Color
ROOPAL V. KUNDU, MD, and STAVONNIE PATTERSON, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Am Fam Physician. 2013 Jun 15;87(12):859-865.
This article focuses on 5 issues; dermatosis papulosa nigra, pseudofolliculitis barbae, acne keloidalis nuchae, keloids, and general hair disorders.
Dermatosis papulosa nigra looks like multiple, small (1-5mm) dark-brown papules on the head and neck (think Morgan Freeman). It is benign. Treatment is not needed unless the patient wants them removed for cosmetic reasons.
Pseudofolliculitis barbae are the razor bumps that occurs when the hair curls back on itself and penetrates the skin. The best way to treat this is to either stop shaving, destroy the follicles, or permanently remove the hair. Proper shaving techniques includes shaving in the direction of the hair growth, using clippers or single blade razors, not making the skin taut during shaving, and avoiding plucking. Leaving it "scruffy" will also work. Properly preparing the skin (brushing the hair, applying warm compresses, gently massaging the area) can also reduce the inflammation. Applying topical steroids, benzoyl peroxide, retinoids, and topical antibiotics may also help.
Acne keloidalis nuchae is a chronic inflammation of the follicles on the back of the head. It looks similar to a keloid and is associated with hair loss. The etiology is not known. Treatment consists of topical and intralesional steroids, antibiotics, retinoids, as well as imiquimod, laser therapy, and surgery.
Keloids are benign growths of hypertrophic scar tissue over areas of previous trauma, such as acnes, piercings, tattoos, surgery, or infections (think of that big branded Omega sign on the shoulders of many professional athletes). Prevention is the best intervention (like not getting tattooed, pierced, or "branded") Avoiding excessive movement of a lesion or incision and keeping it clean may also help. Medications include intralesional steroids, fluorouracil, bleomycin, excision, radiation and cryotherapy. Steroid injections are the first line treatment and can be used every 1-2 months.
Hair of dark skinned ethnicities is more curly and brittle. These people wash their hair less to avoid breakage. It should be washed at least every 1-2 weeks to get rid of the buildup of hair products. Conditioning can soften the hair and reduce fragility. Hair grease and emollients can help, but it can increase the incidence of acne, irritation, and seborrheic dermatitis. Chemically straightening this hair more than once every two months can cause it to break. Using heat to straighten it can cause damage. Heat should not be used more than once every 1-2 weeks. Traction alopecia occurs when tight braids and weaves pull out the hair that it is anchored to. It is more prominent in the frontal and temporal area. Centrifugal cicatricial alopecia is hair loss at the crown of the head. Etiology is unknown. It is a scarring alopecia thought to be from excessive relaxers, traction and heat.
ROOPAL V. KUNDU, MD, and STAVONNIE PATTERSON, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Am Fam Physician. 2013 Jun 15;87(12):859-865.
This article focuses on 5 issues; dermatosis papulosa nigra, pseudofolliculitis barbae, acne keloidalis nuchae, keloids, and general hair disorders.
Dermatosis papulosa nigra looks like multiple, small (1-5mm) dark-brown papules on the head and neck (think Morgan Freeman). It is benign. Treatment is not needed unless the patient wants them removed for cosmetic reasons.
Pseudofolliculitis barbae are the razor bumps that occurs when the hair curls back on itself and penetrates the skin. The best way to treat this is to either stop shaving, destroy the follicles, or permanently remove the hair. Proper shaving techniques includes shaving in the direction of the hair growth, using clippers or single blade razors, not making the skin taut during shaving, and avoiding plucking. Leaving it "scruffy" will also work. Properly preparing the skin (brushing the hair, applying warm compresses, gently massaging the area) can also reduce the inflammation. Applying topical steroids, benzoyl peroxide, retinoids, and topical antibiotics may also help.
Acne keloidalis nuchae is a chronic inflammation of the follicles on the back of the head. It looks similar to a keloid and is associated with hair loss. The etiology is not known. Treatment consists of topical and intralesional steroids, antibiotics, retinoids, as well as imiquimod, laser therapy, and surgery.
Keloids are benign growths of hypertrophic scar tissue over areas of previous trauma, such as acnes, piercings, tattoos, surgery, or infections (think of that big branded Omega sign on the shoulders of many professional athletes). Prevention is the best intervention (like not getting tattooed, pierced, or "branded") Avoiding excessive movement of a lesion or incision and keeping it clean may also help. Medications include intralesional steroids, fluorouracil, bleomycin, excision, radiation and cryotherapy. Steroid injections are the first line treatment and can be used every 1-2 months.
Hair of dark skinned ethnicities is more curly and brittle. These people wash their hair less to avoid breakage. It should be washed at least every 1-2 weeks to get rid of the buildup of hair products. Conditioning can soften the hair and reduce fragility. Hair grease and emollients can help, but it can increase the incidence of acne, irritation, and seborrheic dermatitis. Chemically straightening this hair more than once every two months can cause it to break. Using heat to straighten it can cause damage. Heat should not be used more than once every 1-2 weeks. Traction alopecia occurs when tight braids and weaves pull out the hair that it is anchored to. It is more prominent in the frontal and temporal area. Centrifugal cicatricial alopecia is hair loss at the crown of the head. Etiology is unknown. It is a scarring alopecia thought to be from excessive relaxers, traction and heat.
Wednesday, October 23, 2013
"Recommendations for Preconception Counseling and Care" (My Synopsis)
Recommendations for Preconception Counseling and Care
NARGES FARAHI, MD, and ADAM ZOLOTOR, MD, DrPH, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Am Fam Physician. 2013 Oct 15;88(8):499-506.
Although half of all pregnancies are unintentional, preconception care can greatly benefit the fetus. All patients of reproductive age should be counseled on contraception, as well as health risks that may affect pregnancy. Patients considering becoming pregnant should consider environmental exposures, genetic history, medications, psychiatric illness, psychosocial factors, and substance abuse. Workplaces which may exposure expecting mothers to toxins include clinical and laboratory health care, dry cleaning, manufacturing, printing, and agriculture. Mercury exposure from certain fish should also be considered. Patients with a personal or family history of genetic or congential disorders should be referred for genetic counseling and carrier testing. Teratogenic medications should be stopped. Patients should be screened for depression, anxiety, substance abuse and intimate partner violence. All women should be screened for HIV, measles immunity, and rubella immunity. All high risk women should be screened for chlamydia, gonorrhea, syphilis and TB.
All women considering having children should start taking 400 mcg of folic acid and continue until 12 weeks gestation. Patients with epilepsy, diabetes, obesity, or at high risk of neural tube defects, can take 4-5 mg daily.
Patients who are overweight or obese are at increased risk of macrosomia, shoulder dystocia, IUGR, spontaneous abortion, stillbirth, and preeclampsia. Overweight patients who have oligomenorrhea or amenorrhea may regain fertility with weight loss. Patients who opt for bariatric surgery should wait 12-18 months after the procedure before getting pregnant. Post bariatric patients will also need a pre-pregnancy CBC and multivitamins to combat nutritional deficiencies. Patients who are underweight should be counseled about the risks of preterm or low birth weight births. Low birth weight is associated with osteoporosis, amenorrhea, infertility, arrhythmias and nutritional deficiencies.
Medications for common medical conditions may need to be altered. Patients with acne cannot take isotretinoin because it is severely teratogenic. Patients with asthma should not use oral corticosteroids because it lowers birth weight and increases the risk of preeclampsia. ACEIs and ARBs are associated with fetal anomalies and death. Diabetic patients should discontinue oral antidiabetic medications and switch to insulin. Elevated glucose can lead to congenital malformations. Patients with hyperthyroidism should use propylthiouracil instead of methimazole in the first trimester. For patients with seizure disorder, monotherapy at the lowest possible dose should be used do to the teratogenic effects of most of the antiepileptic medications. Patients who need blood thinners should not use warfarin because of its harmful side effects. Statins and atenolol should be avoided.
NARGES FARAHI, MD, and ADAM ZOLOTOR, MD, DrPH, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Am Fam Physician. 2013 Oct 15;88(8):499-506.
Although half of all pregnancies are unintentional, preconception care can greatly benefit the fetus. All patients of reproductive age should be counseled on contraception, as well as health risks that may affect pregnancy. Patients considering becoming pregnant should consider environmental exposures, genetic history, medications, psychiatric illness, psychosocial factors, and substance abuse. Workplaces which may exposure expecting mothers to toxins include clinical and laboratory health care, dry cleaning, manufacturing, printing, and agriculture. Mercury exposure from certain fish should also be considered. Patients with a personal or family history of genetic or congential disorders should be referred for genetic counseling and carrier testing. Teratogenic medications should be stopped. Patients should be screened for depression, anxiety, substance abuse and intimate partner violence. All women should be screened for HIV, measles immunity, and rubella immunity. All high risk women should be screened for chlamydia, gonorrhea, syphilis and TB.
All women considering having children should start taking 400 mcg of folic acid and continue until 12 weeks gestation. Patients with epilepsy, diabetes, obesity, or at high risk of neural tube defects, can take 4-5 mg daily.
Patients who are overweight or obese are at increased risk of macrosomia, shoulder dystocia, IUGR, spontaneous abortion, stillbirth, and preeclampsia. Overweight patients who have oligomenorrhea or amenorrhea may regain fertility with weight loss. Patients who opt for bariatric surgery should wait 12-18 months after the procedure before getting pregnant. Post bariatric patients will also need a pre-pregnancy CBC and multivitamins to combat nutritional deficiencies. Patients who are underweight should be counseled about the risks of preterm or low birth weight births. Low birth weight is associated with osteoporosis, amenorrhea, infertility, arrhythmias and nutritional deficiencies.
Medications for common medical conditions may need to be altered. Patients with acne cannot take isotretinoin because it is severely teratogenic. Patients with asthma should not use oral corticosteroids because it lowers birth weight and increases the risk of preeclampsia. ACEIs and ARBs are associated with fetal anomalies and death. Diabetic patients should discontinue oral antidiabetic medications and switch to insulin. Elevated glucose can lead to congenital malformations. Patients with hyperthyroidism should use propylthiouracil instead of methimazole in the first trimester. For patients with seizure disorder, monotherapy at the lowest possible dose should be used do to the teratogenic effects of most of the antiepileptic medications. Patients who need blood thinners should not use warfarin because of its harmful side effects. Statins and atenolol should be avoided.
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