Journal: American family physician
High-quality, office-based spirometry provides diagnostic information as useful and reliable as testing performed in a pulmonary function laboratory. Spirometry may be used to monitor progression of lung disease and response to therapy. A stepwise approach to spirometry allows for ease and reliability of interpretation. Airway obstruction is suspected when there is a decreased forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio, but there is no strong evidence to clearly define what constitutes a significant decrease in this ratio. A low FVC is defined as a value below the 5th percentile in adults or less than 80% of predicted in children and adolescents five to 18 years of age. The FEV1/FVC ratio and FVC are used together to identify obstructive defects and restrictive or mixed patterns. Obstructive defects should be assessed for reversibility, as indicated by an improvement of the FEV1 or FVC by at least 12% and 0.2 L in adults, or by more than 12% in children and adolescents five to 18 years of age after the administration of a short-acting bronchodilator. FEV1 is used to determine the severity of obstructive and restrictive disease, although the values were arbitrarily determined and are not based on evidence from patient outcomes. Bronchoprovocation testing may be used if spirometry results are normal and allergen- or exercise-induced asthma is suspected. For patients with an FEV1 less than 70% of predicted, a therapeutic trial of a short-acting bronchodilator may be tried instead of bronchoprovocation testing.
Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease in the United States, affecting up to 30% of adults. There are two forms of NAFLD: nonalcoholic fatty liver (NAFL), defined as 5% or greater hepatic steatosis without hepatocellular injury or fibrosis, and nonalcoholic steatohepatitis (NASH), defined as 5% or greater hepatic steatosis plus hepatocellular injury and inflammation, with or without fibrosis. Individuals with obesity are at highest risk of NAFLD. Other established risk factors include metabolic syndrome and type 2 diabetes mellitus. Although NAFLD is common and typically asymptomatic, screening is not currently recommended, even in high-risk patients. NAFLD should be suspected in patients with elevated liver enzymes or hepatic steatosis on abdominal imaging that are found incidentally. Once other causes, such as excessive alcohol use and hepatotoxic medications, are excluded in these patients, risk scores or elastography tests can be used to identify those who are likely to have fibrosis that will progress to cirrhosis. Liver biopsy should be considered for patients at increased risk of fibrosis and when other liver disorders cannot be excluded with noninvasive tests. Weight loss through diet and exercise is the primary treatment for NAFLD. Other treatments, such as bariatric surgery, vitamin E supplements, and pharmacologic therapy with thiazolidinediones or glucagon-like peptide-1 analogues, have shown potential benefit; however, data are limited, and these therapies are not considered routine treatments. NAFL typically follows an indolent course, whereas patients with NASH are at higher risk of death from cardiovascular disease, cancer, and end-stage liver disease.
Drugs are being prescribed with more frequency and in higher quantities. A serious adverse drug event from prescribed medications constitutes 2.4% to 16.2% of all hospital admissions. Many of the adverse drug events present intraorally or periorally in isolation or as a clinical symptom of a systemic effect. Clinical recognition and treatment of adverse drug events are important to increase patient adherence, manage drug therapy, or detect early signs of potentially serious outcomes. Oral manifestations of commonly prescribed medications include gingival enlargement, oral hyperpigmentation, oral hypersensitivity reaction, medication-related osteonecrosis, xerostomia, and other oral or perioral conditions. To prevent dose-dependent adverse drug reactions, physicians should prescribe medications judiciously using the lowest effective dose with minimal duration. Alternatively, for oral hypersensitivity reactions that are not dose dependent, quick recognition of clinical symptoms associated with time-dependent drug onset can allow for immediate discontinuation of the medication without discontinuation of other medications. Physicians can manage oral adverse drug events in the office through oral hygiene instructions for gingival enlargement, medication discontinuation for oral pigmentation, and prescription of higher fluoride toothpastes for xerostomia.
Acute pancreatitis is most commonly caused by gallstones or chronic alcohol use, and accounts for more than 200,000 hospital admissions annually. Using the Atlanta criteria, acute pancreatitis is diagnosed when a patient presents with two of three findings, including abdominal pain suggestive of pancreatitis, serum amylase and/or lipase levels at least three times the normal level, and characteristic findings on imaging. It is important to distinguish mild from severe disease because severe pancreatitis has a mortality rate of up to 30%. Contrast-enhanced computed tomography is considered the diagnostic standard for radiologic evaluation of acute pancreatitis because of its success in predicting disease severity and prognosis. The BALI and computed tomography severity index scores also can aid in determining disease severity and predicting the likelihood of complications. Treatment begins with pain control, hydration, and bowel rest. In the first 48 to 72 hours of treatment, monitoring is required to prevent morbidity and mortality associated with worsening pancreatitis. When prolonged bowel rest is indicated, enteral nutrition is associated with lower rates of complications, including death, multiorgan failure, local complications, and systemic infections, than parenteral nutrition. In severe cases involving greater than 30% necrosis, antibiotic prophylaxis with imipenem/cilastatin decreases the risk of pancreatic infection. In gallstone-associated pancreatitis, early cholecystectomy and endoscopic retrograde cholangiopancreatography with sphincterotomy can decrease length of hospital stay and complication rates. A multidisciplinary approach to care is essential in cases involving pancreatic necrosis.
Bell palsy is an acute affliction of the facial nerve, resulting in sudden paralysis or weakness of the muscles on one side of the face. Testing patients with unilateral facial paralysis for diabetes mellitus or Lyme disease is not routinely recommended. Patients with Lyme disease typically present with additional manifestations, such as arthritis, rash, or facial swelling. Diabetes may be a comorbidity of Bell palsy, but testing is not needed in the absence of other indications, such as hypertension. In patients with atypical symptoms, magnetic resonance imaging with contrast enhancement can be used to rule out cranial mass effect and to add prognostic value. Steroids improve resolution of symptoms in patients with Bell palsy and remain the preferred treatment. Antiviral agents have a limited role, and may improve outcomes when combined with steroids in patients with severe symptoms. When facial paralysis is prolonged, surgery may be indicated to prevent ocular desiccation secondary to incomplete eyelid closure. Facial nerve decompression is rarely indicated or performed. Physical therapy modalities, including electrostimulation, exercise, and massage, are neither beneficial nor harmful.
Lacerations, abrasions, burns, and puncture wounds are common in the outpatient setting. Because wounds can quickly become infected, the most important aspect of treating a minor wound is irrigation and cleaning. There is no evidence that antiseptic irrigation is superior to sterile saline or tap water. Occlusion of the wound is key to preventing contamination. Suturing, if required, can be completed up to 24 hours after the trauma occurs, depending on the wound site. Tissue adhesives are equally effective for low-tension wounds with linear edges that can be evenly approximated. Although patients are often instructed to keep their wounds covered and dry after suturing, they can get wet within the first 24 to 48 hours without increasing the risk of infection. There is no evidence that prophylactic antibiotics improve outcomes for most simple wounds. Tetanus toxoid should be administered as soon as possible to patients who have not received a booster in the past 10 years. Superficial mild wound infections can be treated with topical agents, whereas deeper mild and moderate infections should be treated with oral antibiotics. Most severe infections, and moderate infections in high-risk patients, require initial parenteral antibiotics. Severe burns and wounds that cover large areas of the body or involve the face, joints, bone, tendons, or nerves should generally be referred to wound care specialists.
Tinea infections are caused by dermatophytes and are classified by the involved site. The most common infections in prepubertal children are tinea corporis and tinea capitis, whereas adolescents and adults are more likely to develop tinea cruris, tinea pedis, and tinea unguium (onychomycosis). The clinical diagnosis can be unreliable because tinea infections have many mimics, which can manifest identical lesions. For example, tinea corporis can be confused with eczema, tinea capitis can be confused with alopecia areata, and onychomycosis can be confused with dystrophic toenails from repeated low-level trauma. Physicians should confirm suspected onychomycosis and tinea capitis with a potassium hydroxide preparation or culture. Tinea corporis, tinea cruris, and tinea pedis generally respond to inexpensive topical agents such as terbinafine cream or butenafine cream, but oral antifungal agents may be indicated for extensive disease, failed topical treatment, immunocompromised patients, or severe moccasin-type tinea pedis. Oral terbinafine is first-line therapy for tinea capitis and onychomycosis because of its tolerability, high cure rate, and low cost. However, kerion should be treated with griseofulvin unless Trichophyton has been documented as the pathogen. Failure to treat kerion promptly can lead to scarring and permanent hair loss.
Hirsutism is the excessive growth of terminal hair in a typical male pattern in a female. It is often a sign of excessive androgen levels. Although many conditions can lead to hirsutism, polycystic ovary syndrome and idiopathic hyperandrogenism account for more than 85% of cases. Less common causes include idiopathic hirsutism, nonclassic congenital adrenal hyperplasia, androgen-secreting tumors, medications, hyperprolactinemia, thyroid disorders, and Cushing syndrome. Women with an abnormal hirsutism score based on the Ferriman-Gallwey scoring system should be evaluated for elevated androgen levels. Women with rapid onset of hirsutism over a few months or signs of virilization are at high risk of having an androgen-secreting tumor. Hirsutism may be treated with pharmacologic agents and/or hair removal. Recommended pharmacologic therapies include combined oral contraceptives, finasteride, spironolactone, and topical eflornithine. Because of the length of the hair growth cycle, therapies should be tried for at least six months before switching treatments. Hair removal methods such as shaving, waxing, and plucking may be effective, but their effects are temporary. Photoepilation and electrolysis are somewhat effective for long-term hair removal but are expensive.
Acupuncture has been increasingly used as an integrative or complementary therapy for pain. It is well-tolerated with little risk of serious adverse effects. Traditional acupuncture and nontraditional techniques, such as electroacupuncture and dry needling, often result in reported pain improvement. Multiple factors may contribute to variability in acupuncture’s therapeutic effects, including needling technique, number of needles used, duration of needle retention, acupuncture point specificity, number of treatments, and numerous subjective (psychological) factors. Controlled trials have been published on pain syndromes, such as acupuncture for acute and chronic low back pain, knee osteoarthritis, headache, myofascial pain, neck pain, and fibromyalgia. For some conditions, enough data are available for systematic evaluations or meta-analyses. Acupuncture may provide modest benefits in the treatment of chronic low back pain, tension headache and chronic headache, migraine headache prophylaxis, and myofascial pain. Although patients receiving acupuncture for acute low back pain and knee osteoarthritis report less pain, the improvement with true (verum) acupuncture over sham acupuncture is not clinically significant for these conditions. These two conditions illustrate a recurring pattern in acupuncture trials, in which the additional improvement that can be attributed to verum over sham acupuncture, even when statistically significant, is of less clinical significance. This pattern supports the notion that acupuncture treatment has a notable placebo response, or meaning response, that may be responsible for much of its demonstrated benefits. For certain patients, especially those who are unresponsive or intolerant to standard therapies, acupuncture is a reasonable treatment option.
In 2018, through regular surveillance of more than 110 English-language research journals, 255 research studies met the criteria to become POEMs (patient-oriented evidence that matters). Using a validated tool, physician members of the Canadian Medical Association rated these POEMs for their relevance to patients in their practices. This article summarizes the clinical questions and bottom-line answers from the top 20 POEMs of 2018, as determined by these physicians. The top POEMs summarize potentially practice-changing research on the importance of accurate blood pressure measurement, the unclear benefits of lower blood pressure targets for hypertension, the lack of evidence regarding treatment of cough, advantages of shorter over longer courses of antibiotics for several common infections, the value of increased fluid intake for preventing recurrent urinary tract infections, and the benefit of nitrofurantoin over fosfomycin for the treatment of urinary tract infection. Other conclusions include the lack of benefit of anticonvulsants for low back pain, the value of nonopioid pain management compared with opioids, the risk of anxiety recurrence when an antidepressant is discontinued, the value of exercise for reducing the risk of depression, and the increased risk of fractures with the use of Z-drug hypnotics. Regarding clinical preventive services, adherence is better with fecal immunochemical tests than with older guaiac-based fecal occult blood tests for colon cancer screening; statins showed no benefit for patients 75 years or older; aspirin showed no benefit for cardiovascular disease prevention; and exercise, vision assessment, and environmental assessments may reduce the risk of falls. Finally, we identify the top POEMs summarizing clinical practice guidelines from the American College of Physicians, American College of Cardiology/American Heart Association, and the U.S. Preventive Services Task Force.