Items in AFP with MESH term: Algorithms
ABSTRACT: Patients with community-acquired pneumonia often present with cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with suspected community-acquired pneumonia, the physician should first assess the need for hospitalization using a mortality prediction tool, such as the Pneumonia Severity Index, combined with clinical judgment. Consensus guidelines from several organizations recommend empiric therapy with macrolides, fluoroquinolones, or doxycycline. Patients who are hospitalized should be switched from parenteral antibiotics to oral antibiotics after their symptoms improve, they are afebrile, and they are able to tolerate oral medications. Clinical pathways are important tools to improve care and maximize cost-effectiveness in hospitalized patients.
Management of Spontaneous Abortion - Article
ABSTRACT: Spontaneous abortion, which is the loss of a pregnancy without outside intervention before 20 weeks' gestation, affects up to 20 percent of recognized pregnancies. Spontaneous abortion can be subdivided into threatened abortion, inevitable abortion, incomplete abortion, missed abortion, septic abortion, complete abortion, and recurrent spontaneous abortion. Ultrasonography is helpful in the diagnosis of spontaneous abortion, but other testing may be needed if an ectopic pregnancy cannot be ruled out. Chromosomal abnormalities are causative in approximately 50 percent of spontaneous abortions; multiple other factors also may play a role. Traditional treatment consisting of surgical evacuation of the uterus remains the treatment of choice in unstable patients. Recent studies suggest that expectant or medical management is appropriate in selected patients. Patients with a completed spontaneous abortion rarely require medical or surgical intervention. For women with incomplete spontaneous abortion, expectant management for up to two weeks usually is successful, and medical therapy provides little additional benefit. When patients are allowed to choose between treatment options, a large percentage will choose expectant management. Expectant management of missed spontaneous abortion has variable success rates, but medical therapy with intravaginal misoprostol has an 80 percent success rate. Physicians should be aware of psychologic issues that patients and their partners face after completing a spontaneous abortion. Women are at increased risk for significant depression and anxiety for up to one year after spontaneous abortion. Counseling to address feelings of guilt, the grief process, and how to cope with friends and family should be provided.
ABSTRACT: Microscopic hematuria, a common finding on routine urinalysis of adults, is clinically significant when three to five red blood cells per high-power field are visible. Etiologies of microscopic hematuria range from incidental causes to life-threatening urinary tract neoplasm. The lack of evidence-based imaging guidelines can complicate the family physician's decision about the best way to proceed. Patients with proteinuria, red cell casts, and elevated serum creatinine levels should be referred promptly to a nephrology subspecialist. Microscopic hematuria with signs of urinary tract infection should resolve with appropriate treatment of the underlying infection. Patients with asymptomatic microscopic hematuria or with hematuria persisting after treatment of urinary tract infection also need to be evaluated. Because upper and lower urinary tract pathologies often coexist, patients should be evaluated using cytology plus intravenous urography, computed tomography, or ultrasonography. When urine cytology results are abnormal, cystoscopy should be performed to complete the investigation.
ABSTRACT: Arrhythmogenic right ventricular dysplasia (ARVD) is a disorder in which normal myocardium is replaced by fibrofatty tissue. This disorder usually involves the right ventricle, but the left ventricle and septum also may be affected. Although the exact prevalence of ARVD is unknown, it is thought to occur in six per 10,000 persons in certain populations. After hypertrophic heart disease, it is the number one cause of sudden cardiac death in young persons, especially athletes. Patients with ARVD are usually men younger than 35 years who complain of chest pain or rapid heart rate. In some cases, sudden cardiac death is the first presentation. The initial diagnosis of ARVD is based on the presence of major and minor criteria established in 1994. Further confirmation of the diagnosis includes noninvasive studies, such as echocardiography and magnetic resonance imaging of the heart, and invasive studies such as ventricular angiography and endomyocardial biopsy. Patients with ARVD are treated initially with antiarrhythmic agents with serious consideration for automatic implantable cardioverter-defibrillator placement. In patients with persistent symptomatic arrhythmias, radiofrequency ablation, ventriculotomy, or even cardiac transplant may be necessary.
ABSTRACT: The Kidney Disease Outcome Quality Initiative of the National Kidney Foundation published clinical practice guidelines on chronic kidney disease in February 2002. Of the 15 guidelines, the first six are of greatest relevance to family physicians. Part II of this two-part review covers guidelines 4, 5, and 6. Glomerular filtration rate is the best overall indicator of kidney function. It is superior to the serum creatinine level, which varies with age, sex, and race and often does not reflect kidney function accurately. The glomerular filtration rate can be estimated using prediction equations that take into account the serum creatinine level and some or all of specific variables (age, sex, race, body size). In many patients, estimates of the glomerular filtration rate can replace 24-hour urine collections for creatinine clearance measurements. Urine dipsticks generally are acceptable for detecting proteinuria. To quantify proteinuria, the ratio of protein or albumin to creatinine in an untimed (spot) urine sample is an accurate alternative to measurement of protein excretion in a 24-hour urine collection. Patients with persistent proteinuria have chronic kidney disease. Other techniques for evaluating patients with chronic kidney disease include examination of urinary sediment, urine dipstick testing for red and white blood cells, and imaging studies of the kidneys (especially ultrasonography). These techniques also can help determine the underlying cause of chronic kidney disease. Family physicians should weigh the value of the National Kidney Foundation guidelines for their clinical practice based on the strength of evidence and perceived cost-effectiveness until additional evidence becomes available on the usefulness of the recommended quality indicators.
ABSTRACT: Digoxin therapy has long been used to treat heart failure; however, its effectiveness was not completely known until recently. Results of the Digitalis Investigation Group trial showed that adding digoxin to standard heart failure therapy had no effect on mortality. However, adding digoxin decreased hospitalizations related to heart failure and improved symptoms in patients treated for heart failure. Reanalyses of the trial's findings have raised new questions about the role of digoxin in heart failure treatment. These new analyses showed that low serum digoxin concentrations used in patients with more severe disease offered the most benefit. Digoxin use in women was associated with increased mortality risk. This finding should be interpreted with caution, however, because it was based on retrospective data, and the cause of this phenomenon has not been fully elucidated. Prospective clinical trials are needed to determine the serum digoxin concentration that is associated with the most clinical benefit and to determine the role of digoxin therapy for women. Digoxin generally does not have a role in the treatment of diastolic heart failure and is not a first-line therapy for managing atrial fibrillation in patients with heart failure.
Prevention of Falls in Older Patients - Article
ABSTRACT: Falls are one of the most common geriatric syndromes threatening the independence of older persons. Between 30 and 40 percent of community-dwelling adults older than 65 years fall each year, and the rates are higher for nursing home residents. Falls are associated with increased morbidity, mortality, and nursing home placement. Most falls have multiple causes. Risk factors for falls include muscle weakness, a history of falls, use of four or more prescription medications, use of an assistive device, arthritis, depression, age older than 80 years, and impairments in gait, balance, cognition, vision, and activities of daily living. Physicians caring for older patients should ask about any falls that have occurred in the past year. Assessment should include evaluating the circumstances of the fall and a complete history and physical examination, looking for potential risk factors. The most effective fall prevention strategies are multifactorial interventions targeting identified risk factors, exercises for muscle strengthening combined with balance training, and withdrawal of psychotropic medication. Home hazard assessment and modification by a health professional also is helpful.
Hyperkalemia - Article
ABSTRACT: Hyperkalemia is a potentially life-threatening metabolic problem caused by inability of the kidneys to excrete potassium, impairment of the mechanisms that move potassium from the circulation into the cells, or a combination of these factors. Acute episodes of hyperkalemia commonly are triggered by the introduction of a medication affecting potassium homeostasis; illness or dehydration also can be triggers. In patients with diabetic nephropathy, hyperkalemia may be caused by the syndrome of hyporeninemic hypoaldosteronism. The presence of typical electrocardiographic changes or a rapid rise in serum potassium indicates that hyperkalemia is potentially life threatening. Urine potassium, creatinine, and osmolarity should be obtained as a first step in determining the cause of hyperkalemia, which directs long-term treatment. Intravenous calcium is effective in reversing electrocardiographic changes and reducing the risk of arrhythmias but does not lower serum potassium. Serum potassium levels can be lowered acutely by using intravenous insulin and glucose, nebulized beta2 agonists, or both. Sodium polystyrene therapy, sometimes with intravenous furosemide and saline, is then initiated to lower total body potassium levels.
Cognitive Therapy for Depression - Article
ABSTRACT: Cognitive therapy is a treatment process that enables patients to correct false self-beliefs that can lead to negative moods and behaviors. The fundamental assumption is that a thought precedes a mood; therefore, learning to substitute healthy thoughts for negative thoughts will improve a person's mood, self-concept, behavior, and physical state. Studies have shown that cognitive therapy is an effective treatment for depression and is comparable in effectiveness to antidepressants and interpersonal or psychodynamic therapy. The combination of cognitive therapy and antidepressants has been shown to effectively manage severe or chronic depression. Cognitive therapy also has proved beneficial in treating patients who have only a partial response to adequate antidepressant therapy. Good evidence has shown that cognitive therapy reduces relapse rates in patients with depression, and some evidence has shown that cognitive therapy is effective for adolescents with depression.
Management of Active Tuberculosis - Article
ABSTRACT: Although the overall incidence of tuberculosis has been declining in the United States, it remains an important public health concern, particularly among immigrants, homeless persons, and persons infected with human immunodeficiency virus. Patients who present with symptoms of active tuberculosis (e.g., cough, weight loss, or malaise with known exposure to the disease) should be evaluated. Three induced sputum samples for acid-fast bacillus smear and culture should be obtained from patients with findings of tuberculosis or suspicion for active disease. If the patient has manifestations of extrapulmonary tuberculosis, smears and cultures should be obtained from these sites. Most patients with active tuberculosis should be treated initially with isoniazid, rifampin, pyrazinamide, and ethambutol for eight weeks, followed by 18 weeks of treatment with isoniazid and rifampin if needed. Repeat cultures should be performed after the initial eight-week treatment.