ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Primary care physicians should have a working knowledge of rheumatic diseases of childhood that manifest primarily as musculoskeletal pain. Children with juvenile rheumatoid arthritis can present with painless joint inflammation and may have normal results on rheumatologic tests. Significant morbidity may result from associated painless uveitis, and children with juvenile rheumatoid arthritis should be screened by an ophthalmologist. The spondyloarthropathies (including juvenile ankylosing spondylitis and reactive arthritis) often cause enthesitis, and patients typically have positive results on a human leukocyte antigen B27 test and negative results on an antinuclear antibody test. Patients with acute rheumatic fever present with migratory arthritis two to three weeks after having untreated group A beta-hemolytic streptococcal pharyngitis. Henoch-Schbnlein purpura may manifest as arthritis before the classic purpuric rash appears. Systemic lupus erythematosus is rare in childhood but may cause significant morbidity and mortality if not treated early. Nonsteroidal anti-inflammatory drugs and physical therapy may be useful early interventions if a rheumatic illness is suspected. Family physicians should refer children when the diagnosis is in question or subspecialty treatment is required. Part I of this series discusses an approach to diagnosis with judicious use of laboratory and radiologic testing.
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.
ABSTRACT: Chronic foot pain is a common and often disabling clinical complaint that can interfere with a patient's routine activities. Despite careful and detailed clinical history and physical examination, providing an accurate diagnosis is often difficult because chronic foot pain has a broad spectrum of potential causes. Therefore, imaging studies play a key role in diagnosis and management. Initial assessment is typically done by plain radiography; however, magnetic resonance imaging has superior soft-tissue contrast resolution and multiplanar capability, which makes it important in the early diagnosis of ambiguous or clinically equivocal cases when initial radiographic findings are inconclusive. Computed tomography displays bony detail in stress fractures, as well as in arthritides and tarsal coalition. Bone scanning and ultrasonography also are useful tools for diagnosing specific conditions that produce chronic foot pain.
ABSTRACT: Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.
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.
ABSTRACT: Herbs, vitamins, and other dietary supplements may augment or antagonize the actions of prescription and nonprescription drugs. St. John's wort is the supplement that has the most documented interactions with drugs. As with many drug-drug interactions, the information for many dietary supplements is deficient and sometimes supported only by case reports. Deleterious effects are most pronounced with anticoagulants, cardiovascular medications, oral hypoglycemics, and antiretrovirals. Case reports have shown a reduction in International Normalized Ratio in patients taking St. John's wort and warfarin. Other studies have shown reduced levels of verapamil, statins, digoxin, and antiretrovirals in patients taking St. John's wort. Physicians should routinely ask patients about their use of dietary supplements when starting or stopping a prescription drug, or if unexpected reactions occur.
Hypertensive Disorders of Pregnancy - Article
ABSTRACT: The National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy has defined four categories of hypertension in pregnancy: chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. A maternal blood pressure measurement of 140/90 mm Hg or greater on two occasions before 20 weeks of gestation indicates chronic hypertension. Pharmacologic treatment is needed to prevent maternal end-organ damage from severely elevated blood pressure (150 to 180/100 to 110 mm Hg); treatment of mild to moderate chronic hypertension does not improve neonatal outcomes or prevent superimposed preeclampsia. Gestational hypertension is a provisional diagnosis for women with new-onset, nonproteinuric hypertension after 20 weeks of gestation; many of these women are eventually diagnosed with preeclampsia or chronic hypertension. Preeclampsia is the development of new-onset hypertension with proteinuria after 20 weeks of gestation. Adverse pregnancy outcomes related to severe preeclampsia are caused primarily by the need for preterm delivery. HELLP (i.e., hemolysis, elevated liver enzymes, and low platelet count) syndrome is a form of severe preeclampsia with high rates of neonatal and maternal morbidity. Magnesium sulfate is the drug of choice to prevent and treat eclampsia. The use of magnesium sulfate for seizure prophylaxis in women with mild preeclampsia is controversial because of the low incidence of seizures in this population.
Acute and Chronic Paronychia - Article
ABSTRACT: Paronychia is an inflammation of the folds of tissue surrounding the nail of a toe or finger. Paronychia may be classified as either acute or chronic. The main factor associated with the development of acute paronychia is direct or indirect trauma to the cuticle or nail fold. This enables pathogens to inoculate the nail, resulting in infection. Treatment options for acute paronychia include warm compresses; topical antibiotics, with or without corticosteroids; oral antibiotics; or surgical incision and drainage for more severe cases. Chronic paronychia is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. The patient should avoid exposure to contact irritants; treatment of underlying inflammation and infection is recommended, using a combination of a broad-spectrum topical antifungal agent and a corticosteroid. Application of emollient lotions may be beneficial. Topical steroid creams are more effective than systemic antifungals in the treatment of chronic paronychia. In recalcitrant chronic paronychia, en bloc excision of the proximal nail fold is an option. Alternatively, an eponychial marsupialization, with or without nail removal, may be performed.
The Injured Ankle - Article
ABSTRACT: Ankle injuries are common presenting complaints in both emergency departments and family physicians' offices. Approximately 1 million ankle injuries occur annually in the United States; most of them are sprains resulting from inversion injuries. Treatment options differ according to the grade of injury--grade I and grade II sprains usually respond to rest and immobilization, while grade III sprains require casting or, possibly, surgery. A chronic "ankle" injury should prompt evaluation for other conditions, such as talar dome lesion. Most ankle injuries can be treated adequately in the family physician's office, although some of the more serious injuries should be referred to an orthopedic specialist for further evaluation.
Conjunctivitis - Article
ABSTRACT: Conjunctivitis refers to any inflammatory condition of the membrane that lines the eyelids and covers the exposed surface of the sclera. It is the most common cause of "red eye". The etiology can usually be determined by a careful history and an ocular examination, but culture is occasionally necessary to establish the diagnosis or to guide therapy. Conjunctivitis is commonly caused by bacteria and viruses. Neisseria infection should be suspected when severe, bilateral, purulent conjunctivitis is present in a sexually active adult or in a neonate three to five days postpartum. Conjunctivitis caused by Chlamydia trachomatis or Neisseria gonorrhoeae requires aggressive antibiotic therapy, but conjunctivitis due to other bacteria is usually self-limited. Chronic conjunctivitis is usually associated with blepharitis, recurrent styes or meibomianitis. Treatment requires good eyelid hygiene and the application of topical antibiotics as determined by culture. Allergic conjunctivitis is distinguished by severe itching and allergen exposure. This condition is generally treated with topical antihistamines, mast-cell stabilizers or anti-inflammatory agents.