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Am Fam Physician. 2000;61(7):2232-2234

Management of Exercise-Induced Asthma

(Great Britain—The Practitioner, November 1999, p. 830.) Exercise triggers symptoms in up to 80 percent of persons with asthma. Several studies have reported that 3 to 13 percent of children and young adults have exercise-induced asthma. Although exercise-induced asthma causes distressing symptoms, many athletes with the condition are highly successful. In 1984, 11.2 percent of Olympic participants reported having episodes of exercise-induced asthma and more than 60 percent of these athletes went on to win Olympic medals. The pathogenesis of exercise-induced asthma may be related to changes induced by inspiration of cool, dry air. Symptoms of wheezing and breathlessness usually peak within 10 minutes of exercise cessation and resolve spontaneously within 20 to 60 minutes, depending on the severity of the attack. The diagnosis is generally based on history with a challenge test if necessary. The diagnosis is confirmed if forced expiratory volume in one second or peak expiratory flow after 10 minutes of exercise fall by at least 15 percent. The treatment of choice is with an inhaled β2 agonist 15 minutes before exercise. Inhaled steroids may be necessary in more severe cases. Physicians and athletes should be aware of sporting regulations; the International Olympic Committee currently bans epinephrine, most steroids and certain β2 agonists.

Helping Children Deal with the Grieving Process

(Canada—Canadian Family Physician, December 1999, p. 2914.) Although the basic process of grieving is similar in children and adults, children have unique features that complicate their adjustment following death of a close friend or family member. Psychologists believe that the disruption caused by a death may be more upsetting for children than the death itself. Therefore, families should try to avoid dramatic changes in living arrangements. Children also have a strong need to support surviving family members and should be allowed to do so. The concept of death and the reaction to it depend on the child's stage of emotional development. Very young children react to the distress of family and friends and experience separation anxiety from the deceased. Children of about two to seven years of age may harbor fears that they caused the death or have fantasies about the dead person. The reaction of older children may be dominated by fear of abandonment and concerns about personal safety. Assisting children in the grieving process requires understanding of the psychologic defenses and evolving developmental issues.

Effectiveness of Head Lice Treatment

(Great Britain—The Practitioner, November 1999, p. 824.) Head lice infestation is most common in children four to 11 years of age, and girls are more susceptible than boys. Lice require close head-to-head contact for at least 30 seconds to spread from one infected person to a new host. The infestation usually develops over several weeks before detection, so all close contacts over the previous month should be considered at risk. The infestation can be surprisingly difficult to confirm; live lice must be found for the diagnosis to be made. Common treatments for head lice include permethrin and lindane. In evidence-based reviews of three trials, no differences were found in effectiveness between the standard treatments. Resistance to common agents is increasing and concerns have been raised about the safety of these medications. Frequently, apparent treatment failure may be the result of misdiagnosis or inappropriate use of medication. This review calls for treatment with two applications of the selected agent seven days apart. If this treatment is unsuccessful, treatment with an agent from a different chemical group should be applied.

Effusions in Rheumatic Disease of the Hand

(Australia—Australian Family Physician, December 1999, p. 1223.) Joint effusions are detected by fluctuance—a fluid impulse generated by compression of the affected joint. Large effusions may be easily detected, but smaller effusions require techniques specific to the joint being examined. For interphalangeal joints, the “four-finger” technique is recommended. The thumb and index finger of each hand are placed around the joint so that the fingers of one examining hand are at a right angle to those of the other examining hand. One finger-thumb pair acts as compressor and the other as sensor, and they are pressed and released alternately. The “two-thumb” technique is advocated for metacarpophalangeal joints. The examiner holds the patient's hand with the metacarpophalangeal joints flexed to 20 degrees and fluctuations are detected by the examiner's thumbs placed lateral to the joint.

Diagnosing and Controlling Hyperuricemia

(Great Britain—The Practitioner, December 1999, p. 886.) Hyperuricemia may occur as a primary metabolic disorder or it may be the result of conditions that increase purine synthesis and catabolism by increasing cell turnover. Conditions that cause secondary hyperuricemia include psoriasis, hemolytic anemia, myeloproliferative disease and certain neoplasms. Conversely, renal failure with underexcretion of uric acid can also cause hyperuricemia. Joint damage in hyperuricemia causes classical attacks of gout but tophi may also develop in cartilage, tendons and other tissues. Acute gouty monoarthritis may be diagnosed clinically and confirmed by finding crystals on aspirate from the joint. Blood chemistries usually show elevated uric acid, sedimentation rate and leukocytosis. Acute attacks may respond to indomethacin or another nonsteroidal anti-inflammatory drug in adequate dosages. Alternative therapies are colchicine or steroids. Steroids may be injected into the affected joint or given as a short tapering course of oral medication. Diet and medication may play a role in long-term control of hyperuricemia. Alcohol intake should be reduced and foods high in purines should be avoided. Allopurinol can lower uric acid levels by inhibiting urate synthesis. Probenecid and uricosuric agents may be ineffective if renal function is compromised.

Management of Upper Arm Pain

(Great Britain—The Practitioner, December 1999, p. 880.) Tendonitis of the rotator cuff is the most common cause of upper arm pain. The condition is almost always unilateral and about one third of patients report a recent injury. In some patients, there is a traumatic bursitis with or without tendonitis. The pain is most severe at mid-abduction and may be exacerbated by reaching up, outward or backward. Pain may also occur at night. Secondary spasm of the trapezius muscle causes the arm to be held to the side with the shoulder elevated. Analgesics, physical therapy or injection of a corticosteroid are all effective treatments for rotator cuff tendonitis.

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