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Am Fam Physician. 2000;61(8):2527-2528

Choosing a Prophylactic for the Prevention of Malaria

(Canada—Canadian Family Physician, January 2000, p. 121.) Changing patterns of chloroquine resistance make malaria prevention increasingly challenging. Chloroquine alone is now inadequate for prophylaxis in most areas. Mefloquine is the leading agent for many areas but concerns have arisen about serious neuropsychiatric side effects, which occur rarely, perhaps in one in 10,000 patients. Other side effects such as gastrointestinal and mild mood disorders prompt about 3 percent of patients to discontinue therapy. The leading alternative agent, doxycycline, is almost as effective as mefloquine but has a higher incidence of side effects. Primaquine can be used for prophylaxis of Plasmodium falciparum. Travelers should be advised that most prophylactic regimens require continuation of therapy for four weeks after leaving an endemic area. Physical measures such as use of insect repellant based on diethyltoluamide (DEET) and bed netting are also important in malaria prevention. Bed nets impregnated with permethrin have markedly reduced malaria transmission in endemic areas.

Triquetrum Fractures in Patients After a Fall

(Canada—Canadian Family Physician, January 2000, p. 70.) Fractures of the triquetrum, one of the eight bones of the wrist, are common in falls on the outstretched hand. The body of the triquetrum may be fractured by excessive direct force to the dorsum of the wrist, but “chip” fractures of the dorsal surface are much more common. Chip fractures may result from the ulnar styloid striking the triquetrum in a fall on the ulnar-deviated hand with the wrist extended. Swelling may be minimal, but tenderness is usually localized to the dorsum of the wrist immediately distal to the ulnar styloid (the triquetral point). Posteroanterior, lateral and oblique radiographic views are usually required to visualize triquetral fractures. Chip fracture may not be apparent on posteroanterior views. Additional fractures occur in up to 50 percent of cases; therefore, films must be carefully inspected. Because of the rich blood supply to the area, triquetral fractures usually heal well. Short arm casting for three to six weeks is usually required for union.

Skin Manifestations in Patients with Diabetes Mellitus

(Australia—Australian Family Physician, December 1999, p. 1217.) Approximately one third of persons with diabetes have cutaneous signs or symptoms. Peripheral vascular disease commonly leads to skin manifestations of hypoxia and poor perfusion. Microvascular disease in diabetes frequently results in atrophic hyperpigmented oval lesions (diabetic dermopathy) on the shins. Up to one half of patients with type 1 diabetes mellitus (formerly known as insulin-dependent diabetes mellitus) develop sclerodermatype changes in the hands and fingers. This is associated with microvascular complications in other body systems. Skin infections with bacteria or candida are more common and may be more severe in diabetic patients. A particular risk in the elderly diabetic patient is malignant otitis externa, which is usually caused by Pseudomonas aerugenosa and can progress to chondritis, osteomyelitis and cerebral infection. Although occurring in fewer than 1 percent of patients with diabetes, the circumscribed erythematous papules and plaques on the lower limbs known as necrobiosis lipoidica diabeticorum are an early marker for diabetes. Acanthosis nigricans, a dark velvety thickening of the skin in flexures, is associated with insulin resistance.

Support Patients Through Smoking Cessation

(Great Britain—The Practitioner, January 2000, p. 37.) In many countries, cigarette smoking remains the major preventable cause of illness and premature death. Regular smokers double their risk of dying before the age of 70 years. Recent surveys indicate that the prevalence of smoking may be increasing in certain population groups. A recent systematic review of 29 trials including more than 27,000 smokers concludes that even brief advice from a health professional increases the likelihood of sustained smoking cessation by about 60 percent. Smoking cessation requires a significant behavioral change in which the patient progresses through recognizable stages—precontemplation, contemplation, preparation, action and maintenance. Helping patients progress by just one stage can improve their chance of remaining smoke-free. The use of nicotine replacement therapy in a smoking cessation program can double sustained cessation. Family physicians should remind all smokers of the importance of cessation at every visit, assist smokers in making changes when they are ready and most likely to succeed, and support and reinforce continued smoking abstinence.

Tailoring Medical Advice for Prospective Travelers

(Canada—Canadian Family Physician, January 2000, p. 132.) The most common causes of death among overseas travelers are heart disease and trauma caused by accidents. The patient's medical history is essential to provide appropriate medical advice. The history must include the pre-existing health of the traveler and identification of health risks posed by the location, duration of stay and proposed activities. Travelers at particular risk are persons with cardiovascular or pulmonary disease, diabetes or immunodeficiency, and children and pregnant women. Advice should be offered to all travelers about avoiding infection from food, water and the environment as well as about safety and immunizations. Information on medical advice for travelers can be obtained from the Centers for Disease Control and Prevention (, the World Health Organization ( and other sites.

Identifying and Treating Patients with Anorexia Nervosa

(Great Britain—The Practitioner, February 2000, p. 129.) Anorexia nervosa carries a mortality rate of up to 20 percent. In addition to weight loss, patients may suffer from cachexia, cardiac dysfunction, leukopenia, osteoporosis and a variety of gastrointestinal and neuropsychiatric conditions. Patients usually have low self-esteem and may have obsessive tendencies. Many young women are believed to use food restriction as an outlet to escape demands of home, social group or academic environments. Refeeding, the cornerstone of care, is achieved by a variety of techniques. Treatments should be individualized for each patient. Patients must be screened for alternative explanations of weight loss and should also be tested for depression and other psychologic disorders. Medications are not the basis of therapy but may be used to treat concomitant depression.

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