Items in AFP with MESH term: Algorithms
ABSTRACT: A large number of taxonomies are used to rate the quality of an individual study and the strength of a recommendation based on a body of evidence. We have developed a new grading scale that will be used by several family medicine and primary care journals (required or optional), with the goal of allowing readers to learn one taxonomy that will apply to many sources of evidence. Our scale is called the Strength of Recommendation Taxonomy. It addresses the quality, quantity, and consistency of evidence and allows authors to rate individual studies or bodies of evidence. The taxonomy is built around the information mastery framework, which emphasizes the use of patient-oriented outcomes that measure changes in morbidity or mortality. An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. Levels of evidence from 1 to 3 for individual studies also are defined. We hope that consistent use of this taxonomy will improve the ability of authors and readers to communicate about the translation of research into practice.
Pharyngitis - Article
ABSTRACT: Sore throat is one of the most common reasons for visits to family physicians. While most patients with sore throat have an infectious cause (pharyngitis), fewer than 20 percent have a clear indication for antibiotic therapy (i.e., group A beta-hemolytic streptococcal infection). Useful, well-validated clinical decision rules are available to help family physicians care for patients who present with pharyngitis. Because of recent improvements in rapid streptococcal antigen tests, throat culture can be reserved for patients whose symptoms do not improve over time or who do not respond to antibiotics.
ABSTRACT: Chronic hepatitis C virus infection is a common and serious disease. Although an estimated 2.7 million persons in the United States have this disease, most have not yet been diagnosed. Recent advances in treatment provide successful cure in 50 to 80 percent of cases. Current drug therapy consists of a combination of pegylated interferon and ribavirin. Although all patients with chronic hepatitis C virus infection are potential candidates for treatment, pharmacologic therapy has a number of contraindications. Evaluation of suitability for treatment includes a thorough search for comorbid medical and psychiatric conditions that can be contraindications. Initial testing involves anti-hepatitis C virus antibodies, but definitive diagnosis of active disease requires detection of viral RNA. Most patients require a liver biopsy to determine the amount of hepatic fibrosis and ongoing hepatocellular inflammation. Viral genotype also should be determined: type 1 requires 12 months of treatment and does not respond as well as types 2 and 3, which require only six months of treatment. Common side effects of drug therapy include anemia, anorexia, depression, fatigue, fever, headache, myalgia, nausea, and erythema at the injection site.
Abnormal Uterine Bleeding - Article
ABSTRACT: Abnormal uterine bleeding is a common presenting symptom in the family practice setting. In women of childbearing age, a methodical history, physical examination, and laboratory evaluation may enable the physician to rule out causes such as pregnancy and pregnancy-related disorders, medications, iatrogenic causes, systemic conditions, and obvious genital tract pathology. Dysfunctional uterine bleeding (anovulatory or ovulatory) is diagnosed by exclusion of these causes. In women of childbearing age who are at high risk for endometrial cancer, the initial evaluation includes endometrial biopsy; saline-infusion sonohysterography or diagnostic hysteroscopy is performed if initial studies are inconclusive or the bleeding continues. Women of childbearing age who are at low risk for endometrial cancer may be assessed initially by transvaginal ultrasonography. Postmenopausal women with abnormal uterine bleeding should be offered dilatation and curettage; if they are poor candidates for general anesthesia or decline dilatation and curettage, they may be offered transvaginal ultrasonography or saline-infusion sonohysterography with directed endometrial biopsy. Medical management of anovulatory dysfunctional uterine bleeding may include oral contraceptive pills or cyclic progestins. Menorrhagia is managed most effectively with nonsteroidal anti-inflammatory drugs or the levonorgestrel intrauterine contraceptive device. Surgical management may include hysterectomy or less invasive, uterus-sparing procedures.
ABSTRACT: Patients with chronic cough should avoid exposure to irritants that can trigger cough, and those who smoke should stop smoking. Patients who develop chronic cough in association with angiotensin-converting enzyme inhibitor therapy should be switched to an agent from another drug class. If cough persists, a chest radiograph should be ordered to rule out malignancy and other serious conditions. Postnasal drip syndrome, asthma, and gastroesophageal reflux disease are the most likely causes of chronic cough in adults. If postnasal drip syndrome is suspected, a trial of a decongestant and a first-generation antihistamine is warranted. Pulmonary function testing with a methacholine challenge is the preferred test for confirming the diagnosis of asthma. Gastroesophageal reflux disease usually is diagnosed based on the symptoms and after a trial of therapy. If the cause of chronic cough remains unclear, high-resolution computed tomographic scanning of the chest, bronchoscopy, and referral to a pulmonary specialist may be indicated. The approach to diagnosing chronic cough in immunocompromised patients and children is similar to the approach in immunocompetent adults. However, a CD4+ cell count can help determine the potential for opportunistic infections in immunocompromised patients. Respiratory tract infections, asthma, and gastroesophageal reflux disease are the most common causes of chronic cough in children. Foreign body aspiration should be considered in young children. Congenital conditions, cystic fibrosis, and immune disorders are possible diagnoses in children with chronic cough and recurrent infection.
Management of Hyponatremia - Article
ABSTRACT: Hyponatremia is an important electrolyte abnormality with the potential for significant morbidity and mortality. Common causes include medications and the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Hyponatremia can be classified according to the volume status of the patient as hypovolemic, hypervolemic, or euvolemic. Hypervolemic hyponatremia may be caused by congestive heart failure, liver cirrhosis, and renal disease. Differentiating between euvolemia and hypovolemia can be clinically difficult, but a useful investigative aid is measurement of plasma osmolality. Hyponatremia with a high plasma osmolality is caused by hyperglycemia, while a normal plasma osmolality indicates pseudohyponatremia or the post-transurethral prostatic resection syndrome. The urinary sodium concentration helps in diagnosing patients with low plasma osmolality. High urinary sodium concentration in the presence of low plasma osmolality can be caused by renal disorders, endocrine deficiencies, reset osmostat syndrome, SIADH, and medications. Low urinary sodium concentration is caused by severe burns, gastrointestinal losses, and acute water overload. Management includes instituting immediate treatment in patients with acute severe hyponatremia because of the risk of cerebral edema and hyponatremic encephalopathy. In patients with chronic hyponatremia, fluid restriction is the mainstay of treatment, with demeclocycline therapy reserved for use in persistent cases. Rapid correction should be avoided to reduce the risk of central pontine myelinolysis. Loop diuretics are useful in managing edematous hyponatremic states and chronic SIADH. In all instances, identifying the cause of hyponatremia remains an integral part of the treatment plan.
Hemolytic Anemia - Article
ABSTRACT: Hemolysis presents as acute or chronic anemia, reticulocytosis, or jaundice. The diagnosis is established by reticulocytosis, increased unconjugated bilirubin and lactate dehydrogenase, decreased haptoglobin, and peripheral blood smear findings. Premature destruction of erythrocytes occurs intravascularly or extravascularly. The etiologies of hemolysis often are categorized as acquired or hereditary. Common acquired causes of hemolytic anemia are autoimmunity, microangiopathy, and infection. Immune-mediated hemolysis, caused by antierythrocyte antibodies, can be secondary to malignancies, autoimmune disorders, drugs, and transfusion reactions. Microangiopathic hemolytic anemia occurs when the red cell membrane is damaged in circulation, leading to intravascular hemolysis and the appearance of schistocytes. Infectious agents such as malaria and babesiosis invade red blood cells. Disorders of red blood cell enzymes, membranes, and hemoglobin cause hereditary hemolytic anemias. Glucose-6-phosphate dehydrogenase deficiency leads to hemolysis in the presence of oxidative stress. Hereditary spherocytosis is characterized by spherocytes, a family history, and a negative direct antiglobulin test. Sickle cell anemia and thalassemia are hemoglobinopathies characterized by chronic hemolysis.
ABSTRACT: Overweight in childhood and adolescence is an important public health issue because of its rapidly increasing prevalence and associated adverse medical and social consequences. Recent studies have estimated that 15 percent of children in the United States are at risk for overweight, and an additional 15 percent are overweight. Important predictors of overweight include age, sex, race/ethnicity, and parental weight status. Generally, school-based prevention programs are not successful in reducing the prevalence of obesity. Treatment interventions include behavioral therapy, reduction in sedentary behavior, and nutrition and physical activity education. These interventions are moderately successful but may not be generalized to the primary care setting. Family physicians should focus on identifying at-risk and overweight children and adolescents at an early stage and educating families about the health consequences of being overweight. Interventions should be tailored to the patient and involve the entire family.
Geriatric Failure to Thrive - Article
ABSTRACT: In elderly patients, failure to thrive describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity. Four syndromes are prevalent and predictive of adverse outcomes in patients with failure to thrive: impaired physical function, malnutrition, depression, and cognitive impairment. Initial assessments should include information on physical and psychologic health, functional ability, socioenvironmental factors, and nutrition. Laboratory and radiologic evaluations initially are limited to a complete blood count, chemistry panel, thyroid-stimulating hormone level, urinalysis, and other studies that are appropriate for an individual patient. A medication review should ensure that side effects or drug interactions are not a contributing factor to failure to thrive. The impact of existing chronic diseases should be assessed. Interventions should be directed toward easily treatable causes of failure to thrive, with the goal of maintaining or improving overall functional status. Physicians should recognize the diagnosis of failure to thrive as a key decision point in the care of an elderly person. The diagnosis should prompt discussion of end-of-life care options to prevent needless interventions that may prolong suffering.
Diagnosis and Management of Galactorrhea - Article
ABSTRACT: After infancy, galactorrhea usually is medication-induced. The most common pathologic cause of galactorrhea is a pituitary tumor. Other causes include hypothalamic and pituitary stalk lesions, neurogenic stimulation, thyroid disorders, and chronic renal failure. Patients with the latter conditions may have irregular menses, infertility, and osteopenia or osteoporosis if they have associated hyperprolactinemia. Tests for pregnancy, serum prolactin level and serum thyroid-stimulating hormone level, and magnetic resonance imaging are important diagnostic tools that should be employed when clinically indicated. The underlying cause of galactorrhea should be treated when possible. The decision to treat patients with galactorrhea is based on the serum prolactin level, the severity of galactorrhea, and the patient's fertility desires. Dopamine agonists are the treatment of choice in most patients with hyperprolactinemic disorders. Bromocriptine is the preferred agent for treatment of hyperprolactin-induced anovulatory infertility. Although cabergoline is more effective and better tolerated than bromocriptine, it is more expensive, and treatment must be discontinued one month before conception is attempted. Surgical resection rarely is required for prolactinomas.