ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Polymyalgia rheumatica and giant cell arteritis are common, closely related vasculitic conditions that almost exclusively occur in patients older than 50 years. They may be manifestations of the same underlying disease and often coexist. Patients with polymyalgia rheumatica usually present with acute onset of stiffness and pain in the shoulder and pelvic musculature, which may be accompanied by fever, malaise, and weight loss. If untreated, polymyalgia rheumatica may result in significant disability. Giant cell arteritis may manifest as visual loss or diplopia, abnormalities of the temporal artery such as tenderness or decreased pulsation, jaw claudication, and new-onset headaches. Erythrocyte sedimentation rate and temporal artery biopsy help make the diagnosis. Giant cell arteritis requires urgent diagnosis because without treatment it may lead to irreversible blindness. Patients with either condition also may have nonspecific symptoms. Corticosteroids are the mainstay of therapy for both conditions, with higher doses required for treatment of giant cell arteritis. Duration of corticosteroid therapy can be five years or longer before complete clinical remission is achieved. Monitoring for corticosteroid-associated side effects such as osteoporosis and diabetes, as well as for relapses and flare-ups, is key to chronic management. The prognosis for either condition, if treated, is good.
ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a common problem among patients presenting to primary care. This condition has multiple individual and combined treatment regimens. The goals of treatment are to improve quality of life, exercise tolerance, sleep quality, and survival; and to reduce dyspnea, nocturnal symptoms, exacerbations, use of rescue medications, and hospitalizations. All patients benefit from bronchodilator medications as needed. Long-acting inhaled anticholinergics are probably more beneficial than short-acting formulations. Use of inhaled corticosteroids might benefit patients with mild COPD who have an inflammatory component or significant reversibility on spirometry. Patients with moderate to severe disease benefit from the use of long-acting inhaled anticholinergics, inhaled corticosteroids, and possibly a long-acting beta2 agonist or mucolytics. For rescue therapy, short-acting beta2 agonists or combination anticholinergics with a short-acting beta2 agonist should be used. Inhaled corticosteroids should be considered before initiating a long-acting beta2 agonist. Caution should be used if a long-acting beta2 agonist is discontinued before initiation of an inhaled corticosteroid because this may precipitate exacerbations. Evidence to support the use of mucolytics, oral theophylline, and oral corticosteroids is limited. Patients with severe hypoxemia (i.e., arterial oxygen pressure less than 55 mm Hg or oxygen saturation less than 88 percent) should be given continuous oxygen.
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.
ABSTRACT: Keloids and hypertrophic scars represent an exuberant healing response that poses a challenge for physicians. Patients at high risk of keloids are usually younger than 30 years and have darker skin. Sternal skin, shoulders and upper arms, earlobes, and cheeks are most susceptible to developing keloids and hypertrophic scars. High-risk trauma includes burns, ear piercing, and any factor that prolongs wound healing. Keloid formation often can be prevented if anticipated with immediate silicone elastomer sheeting, taping to reduce skin tension, or corticosteroid injections. Once established, however, keloids are difficult to treat, with a high recurrence rate regardless of therapy. Evidence supports silicone sheeting, pressure dressings, and corticosteroid injections as first-line treatments. Cryotherapy may be useful, but should be reserved for smaller lesions. Surgical removal of keloids poses a high recurrence risk unless combined with one or several of these standard therapies. Alternative postsurgical options for refractory scars include pulsed dye laser, radiation, and possibly imiquimod cream. Intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections appear to be beneficial for treatment of established keloids. Despite the popularity of over-the-counter herb-based creams, the evidence for their use is mixed, and there is little evidence that vitamin E is helpful.
Henoch-Schönlein Purpura - Article
ABSTRACT: Henoch-SchÃ¶nlein purpura is an acute, systemic, immune complex-mediated, leukocytoclastic vasculitis. It is characterized by a triad of palpable purpura (without thrombocytopenia), abdominal pain, and arthritis. Most patients have an antecedent upper respiratory illness. More than 90 percent of Henoch-SchÃ¶nlein purpura cases occur in children younger than 10 years; however, adults with this condition are more likely to experience complications than children. All patients with Henoch-SchÃ¶nlein purpura develop a purpuric rash, 75 percent develop arthritis, 60 to 65 percent develop abdominal pain, and 40 to 50 percent develop renal disease. Because Henoch-SchÃ¶nlein purpura spontaneously resolves in 94 percent of children and 89 percent of adults, supportive treatment is the primary intervention. Oral prednisone at 1 to 2 mg per kg daily for two weeks has been used to treat abdominal and joint symptoms. A meta-analysis found that corticosteroid use in children reduced the mean time to resolution of abdominal pain and decreased the odds of developing persistent renal disease. Early aggressive therapy with high-dose steroids plus immunosuppressants is recommended for patients with severe renal involvement. Long-term prognosis depends on the severity of renal involvement. End-stage renal disease occurs in 1 to 5 percent of patients.
Corticosteroid Injections for Trigger Finger - Cochrane for Clinicians
NAEPP Updates Guidelines for the Diagnosis and Management of Asthma - Practice Guidelines
Linear Lesions on the Face - Photo Quiz
Glucocorticoids for Treatment of Croup - Cochrane for Clinicians
Intra-articular Corticosteroid for Treating Osteoarthritis of the Knee - Cochrane for Clinicians