Am Fam Physician. 1998;57(9):2260
Management of Alcohol Abuse
(Great Britain—The Practitioner, January 1998, p. 16.) Excessive use of alcohol may be undiagnosed or may present as a range of physical conditions (irritability, insomnia, diarrhea, nausea) or social consequences (broken relationships, “accidents,” lawbreaking). The assessment of alcohol use may be difficult since the patient's history may be unreliable. A raised gamma-glutamyl transferase level reflects recent heavy drinking, and an increased mean corpuscular volume suggests prolonged alcohol intake. Although these tests are useful, only 65 percent of alcoholics show abnormalities in one or both of these values. Brief interventions by a family physician, combined with the use of printed patient education materials, may be very effective and may reduce the number of problem drinkers by one half. Other drinkers may respond to multidisciplinary community-based interventions, participation in Alcoholics Anonymous, or benzodiazepines, either as single strategies or in combination. All patients with alcohol dependence require encouragement, support, close monitoring and nutritional support, including vitamin B1, as part of an individualized monitoring plan.
Childhood Screening for Strabismus
(Canada—Canadian Family Physician, February 1998, p. 337.) Strabismus is abnormal ocular alignment that occurs in approximately 4 percent of children younger than six years of age. If strabismus is left untreated, amblyopia or loss of vision develops in the misaligned eye in up to one half of cases. Most cases of childhood strabismus are idiopathic and many patients have a family history of the condition, but since strabismus is occasionally secondary to ocular disease, refractive errors or muscle paralysis, all patients should be carefully examined. Children with risk factors for strabismus should be referred to an ophthalmologist for screening. Screening includes inspection and ophthalmoscopy as well as assessment of visual acuity, pupillary reactions, ocular alignment and eye movements. Recommendations usually specify that screening should take place in neonates and in children at six months, three years and five to six years of age. At the six-month screening, pupillary reactions and the ability to follow objects should be tested. In children three years of age and older, visual acuity can be tested and the cover test applied to detect abnormal eye alignment.
Chronic Obstructive Pulmonary Disease
(Great Britain—The Practitioner, January 1998, p. 57.) Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Since over 90 percent of cases of COPD are attributable to cigarette smoking, the most important aspect of management is smoking cessation. In over 60 percent of patients, an improvement in forced expiratory volume in one second (FEV1) of more than 200 mL may be achieved with the use of bronchodilators. Approximately 20 percent of patients also respond to oral corticosteroids (30 mg of prednisone daily for two weeks). Patients who do not respond to steroids may benefit from the use of either a single bronchodilator or a combination of beta-agonist and anticholinergic drugs. The role of long-acting theophylline has not been clarified by research. Exercise, weight loss and other measures to improve general health may greatly improve the quality of life in patients with COPD. Long-term oxygen therapy is only beneficial for patients with demonstrated hypoxia as measured by the partial pressure of oxygen in arterial blood (PaO2).
(Australia—Australian Family Physician, August 1997, p. 937.) Up to 500,000 cases of pneumococcal pneumonia and 2,600 to 6,200 cases of pneumococcal meningitis occur in the United States each year. Twenty-three of the 90 known pneumococcal serotypes are targeted in the current vaccine. These serotypes are believed to account for almost 90 percent of cases of pneumococcal disease. An antibody level of 300 μg per mL after vaccination has been assumed to be protective. Antibody response is usually poor in children under two years of age and in immunosuppressed persons. Patients who are infected with human immunodeficiency virus but are otherwise healthy generally respond well to the vaccine. Vaccination is currently recommended for patients with reduced splenic function (particularly following splenectomy), elderly persons, patients with HIV infection, immunocompetent patients with chronic disease, patients with chronic cerebrospinal fluid leak and certain indigenous populations at high risk for pneumococcal disease. Although a single immunization is usually recommended, antibody levels generally decline within 10 years, and revaccination should be considered in vulnerable patients.