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Am Fam Physician. 1999;59(10):2910

Recurrent UTIs in Children

(Australia—Australian Family Physician, December 1998, p. 1095.) Recurrent lower urinary tract infections (UTIs) can be difficult to treat in older (toilet-trained) children. Infrequent episodes, up to three per year, can usually be managed by a five-day course of an antibiotic. Long-term suppressive therapy using a six-month course of an antibiotic given in a low dosage at bedtime is useful unless antibiotic resistance develops. Although popular, no dietary, herbal or alternative therapies have proved effective in the management of recurrent childhood UTIs. A micturating cystourethrogram is usually necessary to investigate the cause of recurrent UTIs in children, although it can be a distressing procedure. If results are negative, bladder dysfunction is usually the cause of recurrent UTIs, especially detrusor instability and bladder spasms. Boys with recurrent UTIs may benefit from circumcision.

Approach to Schizophrenia Management

(Ireland—Forum, December 1998, p. 47.) Although the etiology of schizophrenia remains obscure, family history and environmental factors such as a history of head injury, urban childhood and complications of pregnancy have been identified as risk factors. Schizophrenia usually develops insidiously in late adolescence or early adulthood and may be preceded by a prodrome lasting several months. Early symptoms include loss of interest in work and social activities, deterioration of personal appearance and hygiene, increased anxiety, mild depression and mood swings. Patients also frequently report disturbances of sleep and appetite, increased irritability, and problems with concentration and memory before developing frank psychosis. The psychosis of schizophrenia may take several forms but generally has both negative features (apathy, blunted affect, emotional remoteness) and positive features (delusions, hallucinations, thought disorders). Early diagnosis and intervention have been shown to improve outcome, but one half of all patients have a prolonged illness with multiple relapses and remissions. Newer medications provide effective treatment with lower rates of side effects but are not yet available in depot preparations, making compliance an important issue. Although medications can assist in symptom control, the management of schizophrenia requires extensive family and community support. Patients require rehabilitation, assistance in rebuilding social networks, and counseling to cope with what is a terrifying and demoralizing illness. Families require considerable support to adjust to caring for the patient and managing the implications of the diagnosis.

Hereditary Breast Cancer

(Canada—Canadian Family Physician, January 1999, p.114.) About 5 percent of new cases of breast cancer occur in women with a predisposing genetic mutation. The two known genes associated with hereditary breast cancer, BRCA1 on chromosome 17q and BRCA2 on chromosome 13q, are believed to be tumor suppressors that act by binding to proteins important in DNA repair. In the general population, BRCA1 or BRCA2 mutations occur in about one per 1,000 population; however, in Ashkenazic Jews, the frequency of these mutations rises to more than one per 50 population. Women with BRCA1 mutation have an 80 to 90 percent risk of breast cancer and a 40 to 65 percent risk of ovarian cancer by the age of 70 years. These patients also have an increased risk of bilateral breast cancer and colon cancer. Women with the BRCA2 mutation have a similar risk for breast cancer, but their risk of ovarian cancer is lower—9 to 16 percent. Men who are carriers of either mutation appear to have increased risks of prostate cancer. Men who carry the BRCA2 mutation have an increased risk of breast cancer as well.

Chronic Blepharitis

(Great Britain—The Practitioner, December 1998, p. 844.) Chronic eyelid inflammation (blepharitis) may be caused by seborrhea or by staphylococcal infection and is often associated with other eye conditions such as styes, meibomian cysts and marginal keratitis. In seborrheic blepharitis, the eyelids appear greasy and the soft scales are easily removed. It is believed that eye irritation is caused by fatty acids produced by bacterial decomposition of excessive lipids. When staphylococcal infection occurs around the eyelashes, exotoxins and the buildup of scales can cause inflammation of the cornea, which may progress to corneal ulceration. Lid toilet is the mainstay of blepharitis therapy. Twice-daily cleansing using a weak solution of baby shampoo or bicarbonate of soda removes debris, scales and excess oils. Antibiotic ointment may be applied to the lid margins if staphylococcal infection is apparent. Eye drops containing corticosteroids and antibiotics can be prescribed for rapid relief of discomfort and inflammation, but these should only be used in severe cases for a limited time because of the risk of iatrogenic cataract and glaucoma.

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