Management of Bite Wounds
(Canada—Canadian Family Physician, April 2001, p. 769.) Even apparently minor bite wounds should be thoroughly investigated, because external features may not reliably indicate the extent of internal damage. High-pressure irrigation (8 lb per square inch) is recommended to clean bite wounds and ensure removal of contaminants. This may be achieved using a 30- to 35-mL syringe equipped with an 18- to 20-gauge plastic catheter or needle. The tip of the syringe should be placed approximately 2 cm above the wound. At least 200 mL of saline is required to irrigate small bite wounds. Goggles and protective shields should be used by physicians to avoid self-contamination from splashing debris. Devitalized tissue should be excised; however, blunt probing of wounds is discouraged because this can damage tissue and increase the risk of infection. Rabies and tetanus prophylaxis should be considered on an individual basis, depending on the type of animal involved, local risk factors and patient status. Secondary closure may reduce the risk of infection and provide better long-term cosmetic results than primary closure in most patients. Primary closure is most frequently used in recent, low-risk, uninfected wounds. The use of prophylactic antibiotics depends on the extent of tissue damage and the circumstances of the bite. Dog and cat bites are most likely to cause infection by a mixture of organisms, and amoxicillin-clavulanic acid is the antibiotic of choice. Bite wounds should be evaluated within 48 hours to assess for signs of infection and to reevaluate wounds that were initially left open.
Nutritional Advice in Type 2 Diabetes
(Great Britain—The Practitioner, March 2001, p. 231.) The most important dietary advice for patients with type 2 diabetes and their families is to control their weight. Type 2 diabetes is extremely rare in patients with a body mass index (BMI) of 21, but the risk increases fivefold with a BMI of 25 and 40-fold with a BMI of 30. About 80 percent of all cases of diabetes are attributed to weight gain. Conversely, a weight loss of 10 kg increases life expectancy by 25 percent and a weight loss of 15 to 18 kg can normalize glucose tolerance. Patients need advice about diet and exercise that can be used in the context of their families, community and daily activities. Good evidence supports restricting saturated fat to less than 10 percent of caloric intake. Depending on comorbidities and complications, patients may also benefit from advice to lower their intake of salt and cholesterol, and to increase consumption of dietary fiber and specific micronutrients, such as magnesium and antioxidants, that may be significant in preventing microvascular and other complications.
Screening for Lung Cancer
(Canada—Canadian Family Physician, March 2001, p. 537.) Approximately 20 percent of persons who smoke eventually develop lung cancer and the overall five-year survival rate is 14 percent. The principal reason for the dismal survival rate is late detection of neoplasms, but expert opinion has been divided on the potential benefits of screening. A review by Canadian experts concludes that chest radiography and sputum cytology are indicated in symptomatic current and former smokers older than 45 years with a smoking history of 30 pack-years or more and airflow obstruction. The definition of airflow obstruction is the ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FVC) of 70 percent or less and a FEV1 of less than 70 percent. In the future, more extensive screening may be recommended because of improved testing technologies, especially spiral computed tomography, and innovations in treatment.
Recurrent Aphthous Stomatitis
(Great Britain—The Practitioner, March 2001, p. 215.) Up to 25 percent of the population has recurrent aphthous stomatitis at some time, and the condition is especially prevalent in students and young adults. Recurrent aphthous stomatitis typically starts in childhood as recurrent, small round or ovoid oral ulcers with surrounding inflammation. The condition has spontaneous remissions and relapses for several years, but eventually resolves. The differential diagnosis includes several serious conditions such as infection with human immunodeficiency virus or cytomegalovirus, states of vitamin deficiency and inflammatory bowel diseases. Treatment of recurrent aphthous stomatitis is often unsatisfactory, but patients may benefit from the use of antiseptic mouthwashes and scrupulous oral/dental hygiene, tetracycline mouth rinses, topical steroids and topical anesthetics. Systemic corticosteroids or other immunosuppressants are occasionally indicated.