AFP's Top 20 Articles of 2019

Did you miss any AFP articles published last year? Read the ones that were most popular with AFP readers, according to page views on the website, in 2019. The following 20 articles are in order of most views.

Treatment of the Common Cold

Katharine C. DeGeorge, Daniel J. Ring, and Sarah N. Dalrymple
Acute upper respiratory tract infection, also called the common cold, is the most common acute illness in the United States. Informing patients about the self-limited nature of this illness can help manage expectations, limit antibiotic use, and avoid over-the-counter purchases that are unlikely to help. Treatments with proven effectiveness for cold symptoms in adults include over-the-counter analgesics, zinc, nasal decongestants with or without antihistamines, and intranasal ipratropium. The only safe and effective treatments for children are analgesics, acetylcysteine, honey, nasal saline irrigation, intranasal ipratropium, and menthol rub.

September 1, 2019

Type 2 Diabetes Therapies: A STEPS Approach

Joshua Steinberg and Lyndsay Carlson
Several recent large randomized controlled trials have significantly improved physicians’ knowledge about the impact of medications for type 2 diabetes mellitus on patient-oriented outcomes. A concise and organized way to evaluate pharmacotherapy options is to use the five patient-oriented STEPS criteria: safety, tolerability, effectiveness, price, and simplicity. The first-line treatment option, metformin, is safe and fairly well-tolerated, has excellent long-term effectiveness on patient-oriented outcomes, is moderately priced, and has a simple dosing regimen. However, most patients with type 2 diabetes require more than one medication. The STEPS approach can help choose subsequent medications if metformin does not provide adequate glycemic control.

February 15, 2019

Migraine Headache Prophylaxis

Hien Ha and Annika Gonzalez
Many patients with episodic migraine headaches would benefit from preventive therapy, which reduces frequency, severity, and distress from migraines; preventive therapy could improve quality of life and prevent chronic migraines. Indications for preventive therapy include four or more headaches a month, eight or more headache days a month, debilitating headaches, and medication-overuse headaches. Several first- and second-line medications are available for treatment; identifying and managing environmental, dietary, and behavioral triggers can also be useful. Relaxation training, thermal biofeedback, electromyographic feedback, and cognitive behavior therapy have good evidence as nonpharma­cologic ways to prevent episodic migraines.

January 1, 2019

Anticoagulation: Updated Guidelines for Outpatient Management

Patricia Wigle, Brad Hein, and Christopher R. Bernheisel
Vitamin K antagonists, unfractionated heparin, low-molecular-weight heparin, and direct oral anticoagulants are commonly used for the prevention and treatment of systemic embolism associated with atrial fibrillation, stroke, and venous thromboembolism. Low-molecular-weight heparin and select direct oral anticoagulants can be used for anticoagulation therapy initiation on an outpatient basis. Indications for anticoagulation therapy, direct oral anticoagulant therapy, and recommendations from guidelines are addressed in this article.

October 1, 2019

Patellofemoral Pain Syndrome

David Y. Gaitonde, Alex Ericksen, and Rachel C. Robbins
Patellofemoral pain syndrome, a common cause of knee pain in adolescents and adults younger than 60 years, can cause limitations in daily physical activity and ability to exercise if undiagnosed. The cardinal feature of patellofemoral pain syndrome is pain in or around the anterior knee that intensifies when the knee is flexed during weight-bearing activities. The diagnosis is clinical, and pain with squatting is the most sensitive physical examination finding. Treatment includes rest, a short course of nonsteroidal anti-inflammatory drugs, and physical therapy with strengthening exercises.

January 15, 2019

Plantar Fasciitis

Thomas Trojian and Alicia K. Tucker
Plantar fasciitis is common in runners but can also affect sedentary people. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Symptoms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs. Many conservative treatments have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures.

June 15, 2019

Acne Vulgaris: Diagnosis and Treatment

Linda K. Ogé, Alan Broussard, and Marilyn D. Marshall
Typical acne lesions involve the pilosebaceous follicles and the inter­related processes of sebum production, Cutibacterium acnes colonization, and inflammation. Treatment is based on severity and usually includes topical agents such as retinoids, benzoyl peroxide, and antibiotics. Oral antibiotics and isotretinoin may be used for severe, recalcitrant acne. Combination oral contraceptives and spironolactone are also used in some patients. Further study is needed to determine the effectiveness of complementary therapies and physical modalities such as laser therapy and light therapy.

October 15, 2019

Current Concepts in Concussion: Initial Evaluation and Management

Keith A. Scorza and Wesley Cole
Concussion results from trauma to the head; it affects individuals physically, cognitively, and emotionally/behaviorally and is a major health concern. Headache is the most common symptom. Spine and serious brain injuries should be ruled out before diagnosis. Symptom checklists, neuropsychological tests, balance tests, and sideline assessment tools are used for diagnosis and monitoring recovery. Athletes with suspected concussion should not return to play until medically cleared. Brief cognitive and physical rest is the preferred management. Individuals should gradually return to activities, but those with risk factors, such as more severe symptoms immediately following injury, may require longer recovery periods.

April 1, 2019

Urinary Incontinence in Women: Evaluation and Management

Jocelyn S. Hu and Elyse Fiore Pierre
Urinary incontinence (UI) is a common problem in women, resulting in economic burden and decreased quality of life. The Women’s Preventive Services Initiative is the only major organization that recommends annual screening for UI in all women. Initial evaluation should determine whether incontinence is transient or chronic, the subtype of the incontinence, and whether any findings warrant subspecialist referral. Pelvic floor strengthening and lifestyle modifications are first-line recommendations for all UI subtypes. No medications are approved by the U.S. Food and Drug Administration for treatment of stress incontinence; antimuscarinic medications may be prescribed for urge incontinence. Patients with refractory symptoms should be referred for more invasive management.

September 15, 2019

Hand-Foot-and-Mouth Disease: Rapid Evidence Review

Aaron Saguil, Shawn F. Kane, Rebecca Lauters, and Michael G. Mercado
Hand-foot-and-mouth disease is most commonly caused by enterovirus 71 and coxsackievirus A16. Clinical diagnosis is based on the presentation of a low-grade fever with a maculopapular or papulovesicular rash on the hands and soles of the feet, and by painful oral ulcerations. The largest incidence of the disease is within the first five years of life, and most cases occur in patients younger than 10 years. Handwashing, specifically after diaper changes and toileting, and before eating, helps stop the spread of the disease.

October 1, 2019

Abnormal Uterine Bleeding in Premenopausal Women

Noah Wouk and Margaret Helton
Abnormal uterine bleeding is a common symptom in reproductive-aged women. The acronym PALM-COEIN facilitates the classification of bleeding, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Evaluation includes a detailed history and pelvic examination, as well as laboratory testing to rule out anemia and pregnancy. Endometrial sampling should be performed in patients 45 years and older, and in younger patients with a significant history of unopposed estrogen exposure. To avoid surgical risks and preserve fertility, medical management is the preferred initial approach for most hemodynamically stable patients.

April 1, 2019

Kidney Stones: Treatment and Prevention

Leonardo Ferreira Fontenelle and Thiago Dias Sarti
In patients with suspected kidney stones, the first priority is to rule out conditions requiring immediate referral to an emergency department, then to alleviate pain. The diagnostic workup consists of urinalysis, urine culture, and imaging to confirm the diagnosis and assess for conditions requiring active stone removal. Conservative management consists of pain control, medical expulsive therapy with an alpha blocker, and follow-up imaging to monitor stone position and assess for hydronephrosis. Asymptomatic kidney stones should be followed with serial imaging and should be removed if they become larger or if symptoms, urinary obstruction, or infection occurs. All patients with kidney stones should be screened for risk of stone recurrence.

April 15, 2019

Otitis Media: Rapid Evidence Review

Heidi L. Gaddey, Matthew Thomas Wright, and Tracy N. Nelson
Acute otitis media, the most common diagnosis in childhood acute sick visits, can cause ear pain, fever, irritability, otorrhea, anorexia, and sometimes vomiting and lethargy. Acute otitis media is diagnosed in children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by acute otitis externa, and in children with mild bulging and recent-onset ear pain or intense erythema of the tympanic membrane. Treatment usually consists of pain management and antibiotics. However, observation with deferment of initial antibiotics is an option in some children without severe symptoms. Pneumococcal and influenza vaccines and exclusive breastfeeding until at least six months of age can reduce the risk of acute otitis media.

September 15, 2019

Gastroenteritis in Children

Scott Hartman, Elizabeth Brown, Elizabeth Loomis, and Holly Ann Russell
Acute gastroenteritis, defined as a diarrheal disease of rapid onset, with or without nausea, vomiting, fever, or abdominal pain, is not a major cause of death in the United States but leads to significant morbidity. Physical examination is the best way to assess hydration. Mild to moderate dehydration can be treated with oral rehydration therapy. Half-strength apple juice followed by preferred fluids may be used for mild dehydration, and an oral rehydration solution with or without an antiemetic should be used for moderate dehydration. Hospitalization and intravenous rehydration are recommended for children who do not respond to oral rehydration therapy plus an antiemetic and patients with severe dehydration.

February 1, 2019

Influenza: Diagnosis and Treatment

David Y. Gaitonde, Faith C. Moore, and Mackenzie K. Morgan
The hallmark of influenza infection is abrupt onset of fever, cough, chills or sweats, myalgias, and malaise. For most patients in the outpatient setting, the diagnosis is made clinically, and laboratory confirmation is not necessary. Laboratory testing may be useful in hospitalized patients with suspected influenza and in patients for whom a confirmed diagnosis will change treatment decisions. Rapid molecular assays are the preferred diagnostic tests. Treatment with one of four approved anti-influenza drugs may be considered if the patient presents within 48 hours of symptom onset. Annual influenza vaccination is recommended for all people six months and older who do not have contraindications.

December 15, 2019

Gas, Bloating, and Belching: Approach to Evaluation and Management

John M. Wilkinson, Elizabeth W. Cozine, and Conor G. Loftus
Gas, bloating, and belching are most often caused by functional gastrointestinal disorders. Psychological distress often makes the symptoms worse. Exhaustive testing is not necessary for diagnosis. Most patients are classified as having gastric or small bowel bloating, bloating with constipation, or belching disorders, with functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation being the most common causes. Patients with symptoms of irritable bowel syndrome should be tested for celiac disease, and patients with chronic constipation should have a rectal examination to evaluate for dyssynergic defecation.

March 1, 2019

Acute Hand Infections

Caitlyn M. Rerucha, John T. Ewing, Kathryn E. Oppenlander, and Wesley Charles Cowan
Any trauma to the hand, particularly a penetrating trauma, may introduce damaging pathogens. Superficial infections occur in the skin and subcutaneous tissues, whereas deep infections can involve the tendon sheaths, adjacent anatomic compartments, deep fascial planes, bursae, joint spaces, and bones. Superficial hand infections are more common than deep infections and are typically managed with elevation, warm soaks, splinting in the position of function, analgesics, and empiric antibiotics when indicated. Clenched-fist bite wounds result from direct contact of the fist on incisor teeth and are associated with polymicrobial infections. Empiric antibiotics and prompt surgical consultation are indicated to reduce long-term morbidity.

February 15, 2019

Erythema Multiforme: Recognition and Management

Kathryn P. Trayes, Gillian Love, and James S. Studdiford
Erythema multiforme is an immune-mediated reaction that involves the skin and sometimes the mucosa. Erythema multiforme lesions can be isolated, recurrent, or persistent, and are classically described as target-like with three concentric segments: a dark center, surrounded by a lighter pink ring, both of which are surrounded by a red ring. Infections, especially herpes simplex virus and Mycoplasma pneumonia, and medications constitute most of the causes of erythema multiforme. Management of erythema multiforme depends on the underlying etiology and the disease severity.

July 15, 2019

Health Maintenance in School-Aged Children: Part I. History, Physical Examination, Screening, and Immunizations

Margaret Riley, Leigh Morrison, and Anna McEvoy
The goals of the health maintenance visit in school-aged children (five to 12 years) are promoting health, detecting disease, and counseling to prevent injury and future health problems. The visit should include a history (e.g., hospital care since the previous visit, living situation, lifestyle habits, school performance, social determinants of health); physical examination; and appropriate screening, such as depression, dyslipidemia, hypertension, hearing, and vision assessments. Immunizations should be given based on the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices immunization schedule.

August 15, 2019

Toilet Training: Common Questions and Answers

Drew C. Baird, Michael Bybel, and Adam W. Kowalski
Most U.S. children achieve the physiologic, cognitive, and emotional development necessary for toilet training by 18 to 30 months of age, although some children require more time. Markers of readiness for toilet training include being able to walk, don and remove clothing, and follow parental instruction; expressive language; awareness of a full bladder or rectum; and demonstrated dissatisfaction with a soiled diaper. Physicians should provide anticipatory guidance to parents beginning at about 18 to 24 months of age, noting the signs of toilet training readiness, and setting realistic expectations for parents. Complications of toilet training include stool toileting refusal, stool withholding, encopresis, hiding to defecate, and enuresis. These problems typically resolve with time.

October 15, 2019