Items in AFP with MESH term: Early Diagnosis
Screening for Osteoporosis: Recommendation Statement - U.S. Preventive Services Task Force
ABSTRACT: The management of early pregnancy loss used to be based largely in the hospital setting, but it has shifted to the outpatient setting, allowing women to remain under the care of their family physician throughout the miscarriage process. Up to 15 percent of recognized pregnancies end in miscarriage, and as many as 80 percent of miscarriages occur in the first trimester, with chromosomal abnormalities as the leading cause. In general, no interventions have been proven to prevent miscarriage; occasionally women can modify their risk factors or receive treatment for relevant medical conditions. Unless products of conception are seen, the diagnosis of miscarriage is made with ultrasonography and, when ultrasonography is not available or is nondiagnostic, with measurement of beta subunit of human chorionic gonadotropin levels. Management options for early pregnancy loss include expectant management, medical management with misoprostol, and uterine aspiration. Expectant management is highly effective for the treatment of incomplete abortion, whereas misoprostol and uterine aspiration are more effective for the management of anembryonic gestation and embryonic demise. Misoprostol in a dose of 800 mcg administered vaginally is effective and well-tolerated. Compared with dilation and curettage in the operating room, uterine aspiration is the preferred procedure for early pregnancy loss; aspiration is equally safe, quicker to perform, more cost-effective, and amenable to use in the primary care setting. All management options are equally safe; thus, patient preference should guide treatment choice.
Guillain-Barre Syndrome - Article
ABSTRACT: Guillain-Barré syndrome consists of a group of neuropathic conditions characterized by progressive weakness and diminished or absent myotatic reflexes. The estimated annual incidence in the United States is 1.65 to 1.79 per 100,000 persons. Guillain-Barré syndrome is believed to result from an aberrant immune response that attacks nerve tissue. This response may be triggered by surgery, immunizations, or infections. The most common form of the disease, acute inflammatory demyelinating polyradiculoneuropathy, presents as progressive motor weakness, usually beginning in the legs and advancing proximally. Symptoms typically peak within four weeks, then plateau before resolving. More than one-half of patients experience severe pain, and about two-thirds have autonomic symptoms, such as cardiac arrhythmias, blood pressure instability, or urinary retention. Advancing symptoms may compromise respiration and vital functions. Diagnosis is based on clinical features, cerebrospinal fluid testing, and nerve conduction studies. Cerebrospinal fluid testing shows increased protein levels but a normal white blood cell count. Nerve conduction studies show a slowing, or possible blockage, of conduction. Patients should be hospitalized for multidisciplinary supportive care and disease-modifying therapy. Supportive therapy includes controlling pain with nonsteroidal anti-inflammatory drugs, carbamazepine, or gabapentin; monitoring for respiratory and autonomic complications; and preventing venous thrombosis, skin breakdown, and deconditioning. Plasma exchange therapy has been shown to improve short-term and long-term outcomes, and intravenous immune globulin has been shown to hasten recovery in adults and children. Other therapies, including corticosteroids, have not demonstrated benefit. About 3 percent of patients with Guillain-Barré syndrome die. Neurologic problems persist in up to 20 percent of patients with the disease, and one-half of these patients are severely disabled.
ABSTRACT: Sepsis is a complication of severe infection characterized by a systemic inflammatory response. Mortality rates from sepsis range between 25% to 30% for severe sepsis and 40% to 70% for septic shock. The clinical presentation of sepsis is highly variable depending on the etiology. The most common sites of infection are the respiratory, genitourinary, and gastrointestinal systems, as well as the skin and soft tissue. Fever is often the first manifestation of sepsis, with pneumonia being the most common presentation leading to sepsis. Early goal-directed therapy completed within the first six hours of sepsis recognition significantly decreases in-hospital mortality. Initial management includes respiratory stabilization followed by aggressive fluid resuscitation. Vasopressor therapy is indicated when fluid resuscitation fails to restore adequate mean arterial pressure and organ perfusion. Early antibiotic therapy can improve clinical outcomes, and should be given within one hour of suspected sepsis. Blood product therapy may be required in some cases to correct coagulopathy and anemia, and to improve the central venous oxygen saturation. Insulin therapy may be required to maintain serum glucose levels less than 180 mg per dL. Initiation of low-dose corticosteroids may further improve survival in patients with septic shock that does not respond to vasopressor therapy. Timely initiation of evidence-based protocols should improve sepsis outcomes.
ABSTRACT: Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited cause of kidney disease. Enlarging cysts within the kidneys are the clinical hallmark of the disease. Renal manifestations include varying degrees of kidney injury, urinary tract infections, kidney stones, and hematuria. Extrarenal manifestations can include pain, hypertension, left ventricular hypertrophy, hepatic cysts, intracranial aneurysm, diverticulosis, and abdominal and inguinal hernias. The progression of ADPKD cannot be reversed with current treatment modalities; therefore, therapies target the resulting clinical manifestations. Early detection and management of hypertension are important to delay the progression of renal dysfunction and development of cardiovascular complications. Pain management includes evaluation of concomitant illnesses, use of analgesics, and adjuvant therapy. Fluoroquinolones may be the most useful class of antibiotics for the treatment of urinary tract infections because of their lipophilic properties and bactericidal action against gram-negative pathogens. Nephrolithiasis is twice as common in persons with ADPKD compared with the general population and is suggested by flank pain with or without hematuria. Cystic hemorrhages usually resolve within one week, although microscopic hematuria may still be present. Because of the proliferative effect of estrogen on hepatic cysts, oral contraceptives containing estrogen and menopausal estrogen therapy should be administered at the lowest effective dose or avoided in patients with ADPKD. Intracranial aneurysms are at least twice as common in patients with ADPKD than in the general population. Renal ultrasonography is the diagnostic modality of choice to screen at-risk individuals for ADPKD.