(Australia—Australian Family Physician, November 1998, p. 1041.) The cough reflex generates blasts of air with a velocity of up to 800 km per hour to clear the trachea and large bronchi. The reflex is activated by mechanical or chemical irritation of the respiratory epithelium, increased sputum production or increased sensitivity of the normal reflex. Bronchoconstriction may trigger cough or may be induced by cough in susceptible individuals. A review article concludes that antitussive therapy is seldom appropriate for a productive cough, but patients may benefit from an expectorant such as guaifenesin or a mucolytic to facilitate sputum clearance. If nasal congestion is suspected as a major contributor to productive cough, therapy with systemic or local decongestants may be appropriate. Distressing nonproductive cough may be suppressed with opiates such as codeine or dextromethorphan, or nonopiates including diphenhydramine. Studies have shown inconsistent results in the efficacy of these compounds, and it has been suggested that much of the antitussive activity may be due to the syrup rather than the pharmacologic agent. Mucolytics and expectorants are widely used but little evidence validates their effectiveness. In high dosages, expectorants may cause significant gastric irritation and nausea. Patients with chronic bronchitis are reported to benefit from antitussive therapy with ipratropium, and patients with asthma are reported to benefit from beta-adrenoreceptor agonists and nedocromil sodium in reducing cough. Cough that is related to the use of angiotensin-converting enzyme inhibitors may be relieved by a reduction in dosage and suppressed by the use of nifedipine, cromolyn sodium, sulindac or indomethacin.
Low Back Pain
(Great Britain—The Practitioner, November 1998, p. 770.) More than one half of all adults report low back pain, but most patients recover spontaneously, and fewer than 20 percent seek medical care. A history of recent trauma, such as a fall or a motor vehicle accident, should prompt investigation for fracture. A history of pain that increases when the patient is supine or pain that is severe at night should raise suspicion of tumor or infection, especially in patients with risk factors such as extremes of age, recent infection, immunosuppression or intravenous drug use. Saddle anesthesia, bladder problems and progressive neurologic defects in the pelvis and legs are typical signs of cauda equina syndrome. If no serious cause for back pain is apparent, management is based on simple analgesics and an early return to normal activities. Prolonged bed rest and muscle relaxants have not been shown to be effective therapy for back pain.
Pediatric Hip Conditions
(Great Britain—The Practitioner, November 1998, p. 785.) Several hip conditions may cause gait problems and deformities of the lower limb in children. Approximately one in 400 children has significant hip instability, known as developmental dysplasia of the hip (DDH). DDH most commonly occurs on the left side, in first-born children and in girls, and risk factors include family history, breech delivery and the presence of other congenital abnormalities. If left untreated, DDH results in shortening of the leg with external rotation, painless limp and restricted abduction in flexion. Perthes' disease (idiopathic avascular necrosis of the capital femoral epiphysis) is most common in boys and is bilateral in 10 percent of cases. This disorder occurs most commonly in children four to 10 years of age and presents as pain in the hip or knee, limping and fixed flexion deformity. Slipped upper femoral epiphysis also presents as pain and limp and is also more common in males but occurs during adolescence, between the ages of 10 and 15 years.
(Australia—Australian Family Physician, October 1998, p. 947.) Inflammation of the lacrimal duct produces pain and swelling below the medial canthus of the eye, and local tenderness, excessive lacrimation and fever. The condition occurs when both the proximal and distal ends of the lacrimal duct are partially or completely obstructed because of trauma, infection or concretions of natural secretions. Sarcoidosis is also a cause of chronic or acute dacryocystitis. Symptomatic relief should be provided with warm compresses and analgesics. Antibiotic coverage should be selected to treat the most likely pathogens, which include Staphylococcus aureus, Streptococcus species and Haemophilus influenzae. Systemic dicloxacillin or flucloxacillin are frequently used to treat dacryocystitis. Once the acute inflammation is controlled, patients should be taught lacrimal massage. Surgery is indicated only for severe, chronic infections, epiphora or problems in tear drainage.