ITEMS IN AFP WITH MESH TERM:
Anti-Inflammatory Agents, Non-Steroidal
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.
Update on Helicobacter pylori Treatment - Article
ABSTRACT: One half of the world's population has Helicobacter pylori infection, with an estimated prevalence of 30 percent in North America. Although it is unclear whether eradication of H. pylori improves symptoms in patients with nonulcer dyspepsia, there is strong evidence that eradication of this bacteria improves healing and reduces the risk of recurrence or rebleeding in patients with duodenal or gastric ulcer. A "test-and-treat" strategy is recommended for most patients with undifferentiated dyspepsia. With this approach, patients undergo a noninvasive test for H. pylori infection and, if positive, are treated with eradication therapy. This strategy reduces the need for antisecretory medications as well as the number of endoscopies. The urea breath test or stool antigen test is recommended. Until recently, the recommended duration of therapy for H. pylori eradication was 10 to 14 days. Shorter courses of treatment (i.e., one to five days) have demonstrated eradication rates of 89 to 95 percent with the potential for greater patient compliance. A one-day treatment course consists of bismuth subsalicylate, amoxicillin, and metronidazole, all given four times with a one-time dose of lansoprazole. In children with documented H. pylori infection, however, all regimens should continue to be prescribed for seven to 14 days until short-course treatment is studied and its effectiveness has been established in this population.
Acute Ankle Sprain: An Update - Article
ABSTRACT: Acute ankle injury, a common musculoskeletal injury, can cause ankle sprains. Some evidence suggests that previous injuries or limited joint flexibility may contribute to ankle sprains. The initial assessment of an acute ankle injury should include questions about the timing and mechanism of the injury. The Ottawa Ankle and Foot Rules provide clinical guidelines for excluding a fracture in adults and children and determining if radiography is indicated at the time of injury. Reexamination three to five days after injury, when pain and swelling have improved, may help with the diagnosis. Therapy for ankle sprains focuses on controlling pain and swelling. PRICE (Protection, Rest, Ice, Compression, and Elevation) is a well-established protocol for the treatment of ankle injury. There is some evidence that applying ice and using nonsteroidal antiinflammatory drugs improves healing and speeds recovery. Functional rehabilitation (e.g., motion restoration and strengthening exercises) is preferred over immobilization. Superiority of surgical repair versus functional rehabilitation for severe lateral ligament rupture is controversial. Treatment using semirigid supports is superior to using elastic bandages. Support devices provide some protection against future ankle sprains, particularly in persons with a history of recurrent sprains. Ankle disk or proprioceptive neuromuscular facilitation exercise regimens also may be helpful, although the literature supporting this is limited.
ABSTRACT: Patellofemoral pain syndrome (PFPS) is the most common cause of knee pain in the outpatient setting. It is caused by imbalances in the forces controlling patellar tracking during knee flexion and extension, particularly with overloading of the joint. Risk factors include overuse, trauma, muscle dysfunction, tight lateral restraints, patellar hypermobility, and poor quadriceps flexibility. Typical symptoms include pain behind or around the patella that is increased with running and activities that involve knee flexion. Findings in patients with PFPS range from limited patellar mobility to a hypermobile patella. To confirm the diagnosis, an examination of the knee focusing on the patella and surrounding structures is essential. For many patients with the clinical diagnosis of PFPS, imaging studies are not necessary before beginning treatment. Radiography is recommended in patients with a history of trauma or surgery, those with an effusion, those older than 50 years (to rule out osteoarthritis), and those whose pain does not improve with treatment. Recent research has shown that physical therapy is effective in treating PFPS. There is little evidence to support the routine use of knee braces or nonsteroidal anti-inflammatory drugs. Surgery should be considered only after failure of a comprehensive rehabilitation program. Educating patients about modification of risk factors is important in preventing recurrence.
Treatment Options for Actinic Keratosis - Article
ABSTRACT: Actinic keratoses are rough, scaly lesions that commonly occur on sun-exposed areas of the skin. The prevalence of the condition increases with age. Actinic keratoses are thought to be carcinomas in situ, which can progress to squamous cell carcinomas. The decision to treat can be based on cosmetic reasons; symptom relief; or, most importantly, the prevention of malignancy and metastasis. Treatment options include ablative (destructive) therapies such as cryosurgery, curettage with electrosurgery, and photodynamic therapy. Topical therapies are used in patients with multiple lesions. Fluorouracil has been the traditional topical treatment for actinic keratoses, although imiquimod 5% cream and diclofenac 3% gel are effective alternative therapies. There are too few controlled trials comparing treatment modalities for physicians to make sound, evidence-based treatment decisions.
Gout: An Update - Article
ABSTRACT: Arthritis caused by gout (i.e., gouty arthritis) accounts for millions of outpatient visits annually, and the prevalence is increasing. Gout is caused by monosodium urate crystal deposition in tissues leading to arthritis, soft tissue masses (i.e., tophi), nephrolithiasis, and urate nephropathy. The biologic precursor to gout is elevated serum uric acid levels (i.e., hyperuricemia). Asymptomatic hyperuricemia is common and usually does not progress to clinical gout. Acute gout most often presents as attacks of pain, erythema, and swelling of one or a few joints in the lower extremities. The diagnosis is confirmed if monosodium urate crystals are present in synovial fluid. First-line therapy for acute gout is nonsteroidal anti-inflammatory drugs or corticosteroids, depending on comorbidities; colchicine is second-line therapy. After the first gout attack, modifiable risk factors (e.g., high-purine diet, alcohol use, obesity, diuretic therapy) should be addressed. Urate-lowering therapy for gout is initiated after multiple attacks or after the development of tophi or urate nephrolithiasis. Allopurinol is the most common therapy for chronic gout. Uricosuric agents are alternative therapies in patients with preserved renal function and no history of nephrolithiasis. During urate-lowering therapy, the dose should be titrated upward until the serum uric acid level is less than 6 mg per dL (355 micromol per L). When initiating urate-lowering therapy, concurrent prophylactic therapy with low-dose colchicine for three to six months may reduce flare-ups.
Peptic Ulcer Disease - Article
ABSTRACT: Peptic ulcer disease usually occurs in the stomach and proximal duodenum. The predominant causes in the United States are infection with Helicobacter pylori and use of nonsteroidal anti-inflammatory drugs. Symptoms of peptic ulcer disease include epigastric discomfort (specifically, pain relieved by food intake or antacids and pain that causes awakening at night or that occurs between meals), loss of appetite, and weight loss. Older patients and patients with alarm symptoms indicating a complication or malignancy should have prompt endoscopy. Patients taking nonsteroidal anti-inflammatory drugs should discontinue their use. For younger patients with no alarm symptoms, a test-and-treat strategy based on the results of H. pylori testing is recommended. If H. pylori infection is diagnosed, the infection should be eradicated and antisecretory therapy (preferably with a proton pump inhibitor) given for four weeks. Patients with persistent symptoms should be referred for endoscopy. Surgery is indicated if complications develop or if the ulcer is unresponsive to medications. Bleeding is the most common indication for surgery. Administration of proton pump inhibitors and endoscopic therapy control most bleeds. Perforation and gastric outlet obstruction are rare but serious complications. Peritonitis is a surgical emergency requiring patient resuscitation; laparotomy and peritoneal toilet; omental patch placement; and, in selected patients, surgery for ulcer control.
ABSTRACT: Back pain is fairly prevalent in healthy children and adolescents. When children or adolescents seek medical care for back pain, it is highly likely that underlying pathology will be identified. Common causes of back pain include nonspecific pain or muscle strain, herniated disk, spondylolysis, scoliosis, and Scheuermann's kyphosis. Less common causes include tumor, infection, and sickle cell crisis. If nonspecific back pain is suspected, treatment may include home-based exercise, physical therapy, or nonsteroidal anti-inflammatory drugs. If the history and physical examination suggest underlying pathology, radiography, complete blood count, erythrocyte sedimentation rate, and a C-reactive protein measurement should be performed. Follow-up magnetic resonance imaging, computed tomography, or bone scanning may be needed depending on the suspected cause. It is generally accepted that the following factors warrant immediate evaluation: patient age younger than four years, persistent symptoms, self-imposed activity limitations, systemic symptoms, increasing discomfort, persistent night-time pain, and neurologic symptoms.
New Drugs for Alzheimer's Disease - Article
ABSTRACT: Alzheimer's disease is characterized by degeneration of various structures in the brain, with development of amyloid plaques and neurofibrillary tangles. Deficiencies of acetylcholine and other neurotransmitters also occur. Pharmacologic treatment of the disease generally seeks to correct the histopathology, the biochemical derangements or their effects. The only drugs labeled to date for the treatment of cognitive symptoms in patients with Alzheimer's disease are two cholinesterase inhibitors that prevent the breakdown of acetylcholine in the synapse. Both medications are associated with modest improvements in cognitive function. However, all benefit is lost when these drugs are discontinued; the disease then progresses to the level seen in placebo-treated patients. Tacrine, the first cholinesterase inhibitor to be so labeled, must be taken four times daily and is associated with hepatic toxicity. Donepezil is taken once daily. Side effects of the cholinesterase inhibitors include nausea, vomiting and diarrhea, which tend to subside after the titration period. Other drugs that have shown some promise in the treatment of Alzheimer's disease are vitamin E, estrogen, selegiline and a mixture of ergoloid mesylates. Anti-inflammatory drugs and nicotine are also being studied for their effects as neuroprotectors or neurotransmitter enhancers. The caregivers of patients with Alzheimer's disease may see little effect from these or other investigational agents, but nursing home placement may be delayed.
Diagnosis and Management of Gout - Article
ABSTRACT: Gout is a disease resulting from the deposition of urate crystals caused by the overproduction or underexcretion of uric acid. The disease is often, but not always, associated with elevated serum uric acid levels. Clinical manifestations include acute and chronic arthritis, tophi, interstitial renal disease and uric acid nephrolithiasis. The diagnosis is based on the identification of uric acid crystals in joints, tissues or body fluids. Treatment goals include termination of the acute attack, prevention of recurrent attacks and prevention of complications associated with the deposition of urate crystals in tissues. Pharmacologic management remains the mainstay of treatment. Acute attacks may be terminated with the use of nonsteroidal anti-inflammatory agents, colchicine or intra-articular injections of corticosteroids. Probenecid, sulfinpyrazone and allopurinol can be used to prevent recurrent attacks. Obesity, alcohol intake and certain foods and medications can contribute to hyperuricemia. These potentially exacerbating factors should be identified and modified.