Items in AFP with MESH term: Evidence-Based Medicine
ABSTRACT: Cutaneous warts are a common presenting complaint in children and adolescents. Common, plantar, or flat warts are cutaneous manifestations of the human papillomavirus. The treatment of warts poses a therapeutic challenge for physicians. No single therapy has been proven effective at achieving complete remission in every patient. As a result, many different approaches to wart therapy exist. These approaches are discussed to demonstrate the evidence supporting common therapies and provide a guideline for physicians. Evidence supports the at-home use of topical salicylic acid and physician-administered cryotherapy. Intralesional immunotherapy for nongenital cutaneous warts may be an option for large or recalcitrant warts.
Diagnosis and Treatment of Hypothermia - Article
ABSTRACT: Although hypothermia is most common in patients who are exposed to a cold environment, it can develop secondary to toxin exposure, metabolic derangements, infections, and dysfunction of the central nervous and endocrine systems. The clinical presentation of hypothermia includes a spectrum of symptoms and is grouped into the following three categories: mild, moderate, and severe. Management depends on the degree of hypothermia present. Treatment modalities range from noninvasive, passive external warming techniques (e.g., removal of cold, wet clothing; movement to a warm environment) to active external rewarming (e.g., insulation with warm blankets) to active core rewarming (e.g., warmed intravenous fluid infusions, heated humidified oxygen, body cavity lavage, and extracorporeal blood warming). Mild to moderate hypothermia is treated easily with supportive care in most clinical settings and has good patient outcomes. The treatment of severe hypothermia is more complex, and outcomes depend heavily on clinical resources. Prevention and recognition of atypical presentations are essential to reducing the rates of morbidity and mortality associated with this condition.
Diabetic Nephropathy: Common Questions - Article
ABSTRACT: Diabetic nephropathy, or diabetic kidney disease, affects 20 to 30 percent of patients with diabetes. It is a common cause of kidney failure. Diabetic nephropathy presents in its earliest stage with low levels of albumin (microalbuminuria) in the urine. The most practical method of screening for microalbuminuria is to assess the albumin-to-creatinine ratio with a spot urine test. Results of two of three tests for microalbuminuria should be more than 30 mg per day or 20 mcg per minute in a three- to six-month period to diagnose a patient with diabetic nephropathy. Slowing the progression of diabetic nephropathy can be achieved by optimizing blood pressure (130/80 mm Hg or less) and glycemic control, and by prescribing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Patients with diabetes and isolated microalbuminuria or hypertension benefit from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In the event that these medications cannot be prescribed, a nondihydropyridine calcium channel blocker may be considered. Serum creatinine and potassium levels should be monitored carefully for patients receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. These medications should be stopped if hyperkalemia is pronounced.
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.
ABSTRACT: Plantar fasciitis causes heel pain in active as well as sedentary adults of all ages. The condition is more likely to occur in persons who are obese or in those who are on their feet most of the day. A diagnosis of plantar fasciitis is based on the patient's history and physical findings. The accuracy of radiologic studies in diagnosing plantar heel pain is unknown. Most interventions used to manage plantar fasciitis have not been studied adequately; however, shoe inserts, stretching exercises, steroid injection, and custom-made night splints may be beneficial. Extracorporeal shock wave therapy may effectively treat runners with chronic heel pain but is ineffective in other patients. Limited evidence suggests that casting or surgery may be beneficial when conservative measures fail.
ABSTRACT: All pregnant women should be offered screening for asymptomatic bacteriuria, syphilis, rubella, and hepatitis B and human immunodeficiency virus infection early in pregnancy. Women at increased risk should be tested for hepatitis C infection, gonorrhea, and chlamydia. All women should be questioned about their history of chickenpox and genital or orolabial herpes. Routine screening for bacterial vaginosis is not recommended. Influenza vaccination is recommended in women who will be in their second or third trimester of pregnancy during flu season. Women should be offered vaginorectal culture screening for group B streptococcal infection at 35 to 37 weeks' gestation. Colonized women and women with a history of group B streptococcal bacteriuria should be offered intrapartum intravenous antibiotics. Screening for gestational diabetes remains controversial. Women should be offered labor induction after 41 weeks' gestation.
ABSTRACT: A large number of taxonomies are used to rate the quality of an individual study and the strength of a recommendation based on a body of evidence. We have developed a new grading scale that will be used by several family medicine and primary care journals (required or optional), with the goal of allowing readers to learn one taxonomy that will apply to many sources of evidence. Our scale is called the Strength of Recommendation Taxonomy. It addresses the quality, quantity, and consistency of evidence and allows authors to rate individual studies or bodies of evidence. The taxonomy is built around the information mastery framework, which emphasizes the use of patient-oriented outcomes that measure changes in morbidity or mortality. An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. Levels of evidence from 1 to 3 for individual studies also are defined. We hope that consistent use of this taxonomy will improve the ability of authors and readers to communicate about the translation of research into practice.
ABSTRACT: Hirschsprung's disease (congenital megacolon) is caused by the failed migration of colonic ganglion cells during gestation. Varying lengths of the distal colon are unable to relax, causing functional colonic obstruction. Hirschsprung's disease most commonly involves the rectosigmoid region of the colon but can affect the entire colon and, rarely, the small intestine. The disease usually presents in infancy, although some patients present with persistent, severe constipation later in life. Symptoms in infants include difficult bowel movements, poor feeding, poor weight gain, and progressive abdominal distention. Early diagnosis is important to prevent complications (e.g., enterocolitis, colonic rupture). A rectal suction biopsy can detect hypertrophic nerve trunks and the absence of ganglion cells in the colonic submucosa, confirming the diagnosis. Up to one third of patients develop Hirschsprung's-associated enterocolitis, a significant cause of mortality. Patients should be monitored closely for enterocolitis for years after surgical treatment of Hirschsprung's disease. With proper treatment, most patients will not have long-term adverse effects and can live normally.
ABSTRACT: The Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy provides guidelines for outpatient management of anticoagulation therapy. The ACCP guidelines recommend short-term warfarin therapy, with the goal of maintaining an International Normalized Ratio (INR) of 2.5 +/- 0.5, after major orthopedic surgery. Therapy for venous thromboembolism includes an INR of 2.5 +/- 0.5, with the length of therapy determined by associated conditions. For patients with atrial fibrillation, the INR is maintained at 2.5 +/- 0.5 indefinitely; for most patients with mechanical valves, the recommended INR is 3.0 +/- 0.5 indefinitely. Use of outpatient low-molecular-weight heparin (LMWH) is as safe and effective as inpatient unfractionated heparin for treatment of venous thromboembolism. The ACCP recommends starting warfarin with unfractionated heparin or LMWH for at least five days and continuing until a therapeutic INR is achieved. Because patients with venous thromboembolism and cancer who have been treated with LMWH have a survival advantage that extends beyond their venous thromboembolism treatment, the ACCP recommends beginning their therapy with three to six months of LMWH. When invasive procedures require the interruption of oral anticoagulation therapy, recommendations for bridge therapy are determined by balancing the risk of bleeding against the risk of thromboembolism. Patients at higher risk of thromboembolization should stop warfarin therapy four to five days before surgery and start LMWH or unfractionated heparin two to three days before surgery.
Peppermint Oil - Article
ABSTRACT: Peppermint leaf and peppermint oil have a long history of use for digestive disorders. Recent evidence suggests that enteric-coated peppermint oil may be effective in relieving some of the symptoms of irritable bowel syndrome. A combination product including peppermint oil and caraway oil seems to be moderately effective in the treatment of non-ulcer dyspepsia. Topical application of peppermint oil may be effective in the treatment of tension headache. Because of its relaxing effects on smooth muscle, peppermint oil given via enema has been modestly effective for relief of colonic spasm in patients undergoing barium enemas. Peppermint oil is well tolerated at the commonly recommended dosage, but it may cause significant adverse effects at higher dosages.