Items in AFP with MESH term: Algorithms

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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.


Management of Histologic Abnormalities of the Cervix - Article

ABSTRACT: The American Society for Colposcopy and Cervical Pathology sponsored a consensus conference in 2001 to develop evidence-based guidelines for women with histologic abnormalities of the cervix. The options for management of cervical intraepithelial neoplasia 1, 2, and 3 are ranked according to the strength of the recommendation and the quality of the evidence. Follow-up with repeat cytology at six and 12 months or DNA testing for high-risk types of human papillomavirus at 12 months is the preferred management approach for women with cervical intraepithelial neoplasia 1 and satisfactory initial colposcopy. If results from repeat cytology are reported as atypical squamous cells of undetermined significance or greater, or if DNA human papillomavirus testing is positive for oncogenic types of the virus, repeat colposcopy is preferred. When the initial colposcopy is unsatisfactory, a diagnostic excisional procedure is preferred. Follow-up without treatment is acceptable only in women who are pregnant and adolescents with cervical intraepithelial neoplasia 1 who had unsatisfactory colposcopy. Biopsy-confirmed cervical intraepithelial neoplasia 2 and 3 requires treatment except during pregnancy and in compliant adolescents with cervical intraepithelial neoplasia 2 and negative endocervical curettage. When colposcopy is satisfactory, treatment includes ablative or excisional procedures. A diagnostic excisional procedure is recommended in women with biopsy-confirmed cervical intraepithelial neoplasia 2 or 3 and unsatisfactory colposcopy.


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.


Medications for Migraine Prophylaxis - Article

ABSTRACT: Sufficient evidence and consensus exist to recommend propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate as first-line agents for migraine prevention. There is fair evidence of effectiveness with gabapentin and naproxen sodium. Botulinum toxin also has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention. Limited evidence is available to support the use of candesartan, lisinopril, atenolol, metoprolol, nadolol, fluoxetine, magnesium, vitamin B2 (riboflavin), coenzyme Q10, and hormone therapy in migraine prevention. Data and expert opinion are mixed regarding some agents, such as verapamil and feverfew; these can be considered in migraine prevention when other medications cannot be used. Evidence supports the use of timed-release dihydroergotamine mesylate, but patients should be monitored closely for adverse effects.


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.


Initial Evaluation of Vertigo - Article

ABSTRACT: Benign paroxysmal positional vertigo, acute vestibular neuronitis, and Meniere's disease cause most cases of vertigo; however, family physicians must consider other causes including cerebrovascular disease, migraine, psychological disease, perilymphatic fistulas, multiple sclerosis, and intracranial neoplasms. Once it is determined that a patient has vertigo, the next task is to determine whether the patient has a peripheral or central cause of vertigo. Knowing the typical clinical presentations of the various causes of vertigo aids in making this distinction. The history (i.e., timing and duration of symptoms, provoking factors, associated signs and symptoms) and physical examination (especially of the head and neck and neurologic systems, as well as special tests such as the Dix-Hallpike maneuver) provide important clues to the diagnosis. Associated neurologic signs and symptoms, such as nystagmus that does not lessen when the patient focuses, point to central (and often more serious) causes of vertigo, which require further work-up with selected laboratory and radiologic studies such as magnetic resonance imaging.


Diagnosis and Treatment of Community-Acquired Pneumonia - Article

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.


Preterm Premature Rupture of Membranes: Diagnosis and Management - Article

ABSTRACT: Preterm premature rupture of membranes is the rupture of membranes during pregnancy before 37 weeks' gestation. It occurs in 3 percent of pregnancies and is the cause of approximately one third of preterm deliveries. It can lead to significant perinatal morbidity, including respiratory distress syndrome, neonatal sepsis, umbilical cord prolapse, placental abruption, and fetal death. Appropriate evaluation and management are important for improving neonatal outcomes. Speculum examination to determine cervical dilation is preferred because digital examination is associated with a decreased latent period and with the potential for adverse sequelae. Treatment varies depending on gestational age and includes consideration of delivery when rupture of membranes occurs at or after 34 weeks' gestation. Corticosteroids can reduce many neonatal complications, particularly intraventricular hemorrhage and respiratory distress syndrome, and antibiotics are effective for increasing the latency period.


Chronic Plaque Psoriasis - Article

ABSTRACT: Chronic plaque psoriasis, the most common form of psoriasis, is a papulosquamous disease defined by erythematous plaques with a silvery scale. The diagnosis usually is clinical, but occasionally a biopsy is necessary. Psoriasis affects 0.6 to 4.8 percent of the U.S. population, and about 30 percent of affected patients have a first-degree relative with the disease. Psoriasis is a T-cell-mediated autoimmune disease, but certain medications and infections are well-known risk factors. Management of psoriasis includes education about chronicity, realistic expectations, and use of medication. Steroids and vitamin D derivatives (e.g., calcipotriene) are the mainstays of topical therapy. Topical steroids and calcipotriene together may work better than either agent alone. Patients with psoriasis involving more than 20 percent of their skin or those not responding to topical therapy are candidates for light therapy; traditional systemic therapy; or systemic treatment with immunomodulatory drugs such as alefacept, efalizumab, and etanercept.


Amenorrhea: Evaluation and Treatment - Article

ABSTRACT: A thorough history and physical examination as well as laboratory testing can help narrow the differential diagnosis of amenorrhea. In patients with primary amenorrhea, the presence or absence of sexual development should direct the evaluation. Constitutional delay of growth and puberty commonly causes primary amenorrhea in patients with no sexual development. If the patient has normal pubertal development and a uterus, the most common etiology is congenital outflow tract obstruction with a transverse vaginal septum or imperforate hymen. If the patient has abnormal uterine development, müllerian agenesis is the likely cause and a karyotype analysis should confirm that the patient is 46,XX. If a patient has secondary amenorrhea, pregnancy should be ruled out. The treatment of primary and secondary amenorrhea is based on the causative factor. Treatment goals include prevention of complications such as osteoporosis, endometrial hyperplasia, and heart disease; preservation of fertility; and, in primary amenorrhea, progression of normal pubertal development.


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