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Am Fam Physician. 1999;59(3):685

Hepatitis C Update

(Australia—Australian Family Physician, September 1998, p. 780.) The most common form of transmission of hepatitis C virus (HCV) is direct percutaneous inoculation, and up to 80 percent of persons who begin injecting drugs become positive for hepatitis C antibody within one year. Acute viral RNA can be detected in the serum within three weeks of infection, and anti-HCV antibody is detectable in 90 percent of patients within three months. The initial infection is usually asymptomatic, with only 15 to 20 percent of new patients reporting an associated illness characterized by malaise, anorexia and weakness. In approximately 85 percent of patients, the virus is not cleared and chronic hepatitis develops. In many patients, the chronic state is also asymptomatic, with widely fluctuating levels of alanine aminotransferase (ALT). In 20 to 30 percent of those with persistently elevated ALT levels (about one third of all patients), cirrhosis develops during the 20 to 30 years following infection. All patients with hepatitis C should be advised to avoid alcohol and hepatotoxic substances and to take measures to prevent spread of the disease. Immunization against hepatitis A and B should be considered. Selected patients may undergo therapy with interferon or interferon plus ribavirin. In cases of decompensated cirrhosis, liver transplantation should be considered.

Toxoplasmosis in Pregnancy

(Canada—Canadian Family Physician, September 1998, p. 1823.) Infection with the intracellular parasite Toxoplasma gondii usually occurs by eating raw meat but may also follow ingestion of unwashed raw vegetables or unpasteurized dairy products, or by exposure to oocysts from cat feces or contaminated soil. The initial infection is usually asymptomatic or accompanied by mild, non-specific symptoms. Women who become infected during pregnancy have a 30 to 40 percent risk of transmission to the fetus. The risk of transmission and severity of toxoplasmosis in the fetus depend on the time of gestation when infection occurs. In the first trimester, maternal infection is associated with a 15 percent rate of transmission to the fetus but, when fetal infection occurs, the consequences are severe—abortion, stillbirth, perinatal death and severe neurologic sequelae. Mothers infected during the third trimester have a 60 percent rate of transmission, but their fetuses tend to be only mildly affected by the disease. Infected fetuses have an increased risk of chorioretinitis, developmental delay and hearing loss. Pregnant women should be advised to eat only well-cooked meat, follow good hygiene practices and avoid unpasteurized dairy products. Hygiene should be particularly strict when handling cat litter or when in contact with soil.

Benign Prostatic Hypertrophy

(Great Britain—The Practitioner, September 1998, p. 638.) The prevalence of benign prostatic hypertrophy increases from about 615 cases per 1,000 men 40 to 49 years of age to 889 cases per 1,000 men 70 to 79 years of age. Assessment should include a complete medical history, symptom scoring, urinalysis, measurement of serum creatinine and digital rectal examination. In some patients, urine flow studies, prostate-specific antigen, postvoid residual urine assessment and pressure flow studies may be indicated. The three current approaches to treatment of benign prostatic hypertrophy are “watchful waiting,” medical therapy with alpha blockers, 5-alpha reductase inhibitors or herbal preparations, and surgical intervention. The choice of management strategy should be based on the patient's symptom score, the degree of urinary obstruction and the size of the prostate. Surgery is indicated for patients with repeated episodes of urinary retention, hematuria, recurrent infection, renal calculi or rising levels of urea or creatinine.

Treatment of Plantar Fasciitis

(Australia—Australian Family Physician, September 1998, p. 831.) A combination of several treatment modalities may be necessary to relieve the symptoms of plantar fasciitis. Ice should be applied for 10 minutes after any activity that exacerbates pain, and this treatment should be repeated after two hours. Optimal stretching is achieved by ankle dorsiflexion with the toes passively extended (against a wall or a block) for 20 seconds, repeated twice. Massage is also recommended twice daily, using a golf ball or a similar object rolled along the sole of the foot. Supportive taping of the midfoot is also beneficial, decreasing pressure on the plantar fascia. Anti-inflammatory medication may be given topically, orally or by local infiltration. For severe cases that are complicated by early-morning pain, custom-made night splints may be useful.

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