Chest pain (or chest discomfort) is a common symptom that can occur as a result of cardiovascular, pulmonary, pleural, or musculoskeletal disease, esophageal or other gastrointestinal disorders, or anxiety states. The frequency and distribution of life-threatening causes of chest pain, such as acute coronary syndrome (ACS), pericarditis, aortic dissection, pulmonary embolism, pneumonia, and esophageal perforation, vary substantially between clinical settings. Systemic lupus erythematosus, rheumatoid arthritis, and HIV are conditions that until only recently have been recognized as conferring a strong risk for coronary artery disease. Because pulmonary embolism can present with a wide variety of symptoms, consideration of the diagnosis and rigorous risk factor assessment for venous thromboembolism (VTE) is key. Classic risk factors include cancer, trauma, recent surgery, prolonged immobilization, pregnancy, oral contraceptives, and family history and prior history of VTE. Other conditions associated with increased risk of pulmonary embolism include CHF and COPD. Although uncommon in the office setting, delays in diagnosing life-threatening causes of chest pain can result in serious morbidity and mortality.
A. Symptoms
Myocardial ischemia is usually described as dull, aching sensation of “pressure,” “tightness,” “squeezing,” or “gas”, rather than as sharp or spasmodic. Ischemic symptoms usually subside within 5–20 minutes but may last longer. Progressive symptoms or symptoms at rest may represent unstable angina due to coronary plaque rupture and thrombosis. Prolonged chest pain episodes might represent myocardial infarction, although one-third of patients with acute myocardial infarction do not report chest pain. When present, the pain is commonly accompanied by a sense of anxiety or uneasiness. The location is usually retrosternal or left precordial. Because the heart lacks somatic innervation, precise localization of pain due to cardiac ischemia is difficult; the pain is commonly referred to the throat, lower jaw, shoulders, inner arms, upper abdomen, or back. Ischemic pain may be precipitated or exacerbated by exertion, cold temperature, meals, stress, or combinations of these factors and is usually relieved by rest. However, many episodes do not conform to these patterns; and atypical presentations of ACS are more common in the elderly, women, and persons with diabetes. Other symptoms that are associated with ACS include shortness of breath; dizziness; a feeling of impending doom; and vagal symptoms, such as nausea and diaphoresis.
In the elderly, fatigue is a common presenting complaint of ACS. Likelihood ratios for cardinal symptoms considered in the evaluation of acute myocardial infarction. Hypertrophy of either ventricle or stenotic aortic valvular disease may also give rise to chest pain with less typical features. Pericarditis may produce pain that is greater supine than upright and may increase with respiration, coughing, or swallowing. Pleuritic chest pain is usually not ischemic, and pain on palpation should signal a musculoskeletal cause. Aortic dissection classically produces an abrupt onset of tearing pain of great intensity that often radiates to the back; however, this classic presentation occurs in a small number of cases. Anterior aortic dissection can also lead to myocardial or cerebrovascular ischemia. Pulmonary embolism has a wide range of clinical presentations, with chest pain present in only 75% of cases. The chief objective in evaluating patients with suspected pulmonary embolism is to assess the patient's clinical risk for VTE based on medical history and associated signs and symptoms. Esophageal perforation of the thoracic region is another cause of chest pain, with most cases resulting from medical procedures of the esophagus.
B. Physical Examination
Findings on physical examination can occasionally yield important clues to the underlying cause of chest pain; however, a normal physical examination should never be used as the sole basis for ruling-out ACS or aortic dissection. Vital sign measurement, including pulse oximetry, is always the first step for assessing the urgency and tempo of the subsequent examination and diagnostic work-up. Findings that increase the likelihood of ACS include diaphoresis, hypotension, S3 or S4 gallop, pulmonary crackles, or elevated jugular venous pressure. Although chest pain that is reproducible or worsened with palpation strongly suggests a musculoskeletal cause, up to 15% of patients with ACS will have reproducible chest wall tenderness. Pointing to the location of the pain with one finger has been shown to be highly correlated with nonischemic chest pain. Aortic dissection can result in differential blood pressures (> 20 mm Hg), pulse amplitude deficits, and new diastolic murmurs. Although hypertension is considered the rule in patients with aortic dissection, systolic blood pressure <> 10 mm Hg) and inspection of jugular venous pulsations. Subcutaneous emphysema is common following cervical esophageal perforation but present in only about one-third of thoracic perforations (ie,those most commonly presenting with chest pain).
The absence of physical examination findings in patients with suspected pulmonary embolism usually serves to increase the likelihood of pulmonary embolism, although a normal physical examination is also compatible with the much more common conditions of panic/anxiety disorder and musculoskeletal disease.
Treatment
Treatment of chest pain should be guided by the underlying etiology. The term “noncardiac chest pain” is used to describe patients who evade diagnosis after receiving extensive work-up. Although under-studied, one small trial found that about half of the patients fulfilled criteria for anxiety or depression and almost half reported symptom improvement with high-dose proton-pump inhibitor therapy.
Thursday, March 19, 2009
Friday, March 13, 2009
Cough Type And Treatment
A. Acute Cough
Chest radiography should be considered for any adult with acute cough who shows abnormal vital signs or in whom the chest examination is suggestive of pneumonia. The relationship between specific clinical findings and the probability of pneumonia is shown in. In patients with dyspnea, pulse oximetry and peak flow help exclude hypoxemia or obstructive airway disease. However, a normal pulse oximetry value (eg, > 93%) does not rule out a significant alveolar–arterial (A–a) gradient when patients have effective respiratory compensation. During documented influenza outbreaks, the positive predictive value of clinical diagnosis of influenza approaches 70% and usually obviates the usefulness of rapid diagnostic tests.
B. Persistent Cough
Chest radiography is indicated when ACE inhibitor therapy–related and postinfectious cough are excluded by history or further diagnostic testing. Testing for pertussis infection should be performed using polymerase chain reaction on a nasopharyngeal swab or nasal wash specimen. When the chest film is normal, postnasal drip, asthma, and GERD should be considered. The presence of typical symptoms of these conditions directs further evaluation or empiric therapy, though typical symptoms are often absent. Definitive procedures for determining the presence of each are available (Table 2–1). However, empiric treatment with a maximum-strength regimen for postnasal drip, asthma, or GERD for 2–4 weeks is the recommended approach since documenting the presence of postnasal drip, asthma, and GERD does not mean they are the cause of the cough illness. In about 25% of cases, persistent cough has multiple contributors. Spirometry may help identify large airway obstruction in patients who have persistent cough and wheezing and who are not responding to asthma treatment. When empiric therapy for postnasal drip syndrome, asthma, and GERD are not helpful, additional evaluation with pH manometry, endoscopy, barium swallow, sinus CT or high-resolution chest CT may be helpful.
Treatment
A. Acute Cough
Treatment of acute cough should target the underlying etiology of the illness, the cough reflex itself, and any additional factors that exacerbate the cough. When influenza is diagnosed, treatment with amantadine, rimantadine, oseltamivir, or zanamivir is equally effective (1 less day of illness) when initiated within 30–48 hours of illness onset. In the setting of Chlamydia or Mycoplasma documented infection or outbreaks, first-line antibiotics include erythromycin, 250 mg orally four times daily for 7 days, or doxycycline, 100 mg orally twice daily for 7 days. In patients diagnosed with acute bronchitis, inhaled agonist therapy reduces severity and duration of cough in some patients. Evidence supports a modest benefit of dextromethorphan, but not codeine, on cough severity in adults with cough due to acute respiratory tract infections. Treatment of postnasal drip (with antihistamines, decongestants, or nasal corticosteroids) or GERD (with H2-blockers or proton-pump inhibitors), when accompanying acute cough illness, can also be helpful. There is good evidence that vitamin C and echinacea are not effective in reducing the severity of acute cough illness after it develops; however, evidence does support vitamin C (at least 1 g daily) for prevention of colds among persons with major physical stress (eg,post-marathon) or malnutrition.
B. Persistent Cough
When pertussis infection is suspected or confirmed, treatment with macrolide antibiotics is appropriate to reduce shedding and transmission of the organism. When pertussis infection has lasted more than 7–10 days, antibiotic treatment does not affect the duration of cough, which can last up to 6 months. There is no evidence to guide how long treatment for persistent cough due to postnasal drip, asthma, or GERD should be continued. Recurrence of symptoms warrants further evaluation. The small percentage of patients with idiopathic persistent cough should be managed in consultation with an otolaryngologist; treatment options include nebulized lidocaine therapy.
However, empiric treatment with a maximum-strength regimen for postnasal drip, asthma, or GERD for 2–4 weeks is the recommended approach since documenting the presence of postnasal drip, asthma, and GERD does not mean they are the cause of the cough illness. In about 25% of cases, persistent cough has multiple contributors. Spirometry may help identify large airway obstruction in patients who have persistent cough and wheezing and who are not responding to asthma treatment. When empiric therapy for postnasal drip syndrome, asthma, and GERD are not helpful, additional evaluation with pH manometry, endoscopy, barium swallow, sinus CT or high-resolution chest CT may be helpful.
Chest radiography should be considered for any adult with acute cough who shows abnormal vital signs or in whom the chest examination is suggestive of pneumonia. The relationship between specific clinical findings and the probability of pneumonia is shown in. In patients with dyspnea, pulse oximetry and peak flow help exclude hypoxemia or obstructive airway disease. However, a normal pulse oximetry value (eg, > 93%) does not rule out a significant alveolar–arterial (A–a) gradient when patients have effective respiratory compensation. During documented influenza outbreaks, the positive predictive value of clinical diagnosis of influenza approaches 70% and usually obviates the usefulness of rapid diagnostic tests.
B. Persistent Cough
Chest radiography is indicated when ACE inhibitor therapy–related and postinfectious cough are excluded by history or further diagnostic testing. Testing for pertussis infection should be performed using polymerase chain reaction on a nasopharyngeal swab or nasal wash specimen. When the chest film is normal, postnasal drip, asthma, and GERD should be considered. The presence of typical symptoms of these conditions directs further evaluation or empiric therapy, though typical symptoms are often absent. Definitive procedures for determining the presence of each are available (Table 2–1). However, empiric treatment with a maximum-strength regimen for postnasal drip, asthma, or GERD for 2–4 weeks is the recommended approach since documenting the presence of postnasal drip, asthma, and GERD does not mean they are the cause of the cough illness. In about 25% of cases, persistent cough has multiple contributors. Spirometry may help identify large airway obstruction in patients who have persistent cough and wheezing and who are not responding to asthma treatment. When empiric therapy for postnasal drip syndrome, asthma, and GERD are not helpful, additional evaluation with pH manometry, endoscopy, barium swallow, sinus CT or high-resolution chest CT may be helpful.
Treatment
A. Acute Cough
Treatment of acute cough should target the underlying etiology of the illness, the cough reflex itself, and any additional factors that exacerbate the cough. When influenza is diagnosed, treatment with amantadine, rimantadine, oseltamivir, or zanamivir is equally effective (1 less day of illness) when initiated within 30–48 hours of illness onset. In the setting of Chlamydia or Mycoplasma documented infection or outbreaks, first-line antibiotics include erythromycin, 250 mg orally four times daily for 7 days, or doxycycline, 100 mg orally twice daily for 7 days. In patients diagnosed with acute bronchitis, inhaled agonist therapy reduces severity and duration of cough in some patients. Evidence supports a modest benefit of dextromethorphan, but not codeine, on cough severity in adults with cough due to acute respiratory tract infections. Treatment of postnasal drip (with antihistamines, decongestants, or nasal corticosteroids) or GERD (with H2-blockers or proton-pump inhibitors), when accompanying acute cough illness, can also be helpful. There is good evidence that vitamin C and echinacea are not effective in reducing the severity of acute cough illness after it develops; however, evidence does support vitamin C (at least 1 g daily) for prevention of colds among persons with major physical stress (eg,post-marathon) or malnutrition.
B. Persistent Cough
When pertussis infection is suspected or confirmed, treatment with macrolide antibiotics is appropriate to reduce shedding and transmission of the organism. When pertussis infection has lasted more than 7–10 days, antibiotic treatment does not affect the duration of cough, which can last up to 6 months. There is no evidence to guide how long treatment for persistent cough due to postnasal drip, asthma, or GERD should be continued. Recurrence of symptoms warrants further evaluation. The small percentage of patients with idiopathic persistent cough should be managed in consultation with an otolaryngologist; treatment options include nebulized lidocaine therapy.
However, empiric treatment with a maximum-strength regimen for postnasal drip, asthma, or GERD for 2–4 weeks is the recommended approach since documenting the presence of postnasal drip, asthma, and GERD does not mean they are the cause of the cough illness. In about 25% of cases, persistent cough has multiple contributors. Spirometry may help identify large airway obstruction in patients who have persistent cough and wheezing and who are not responding to asthma treatment. When empiric therapy for postnasal drip syndrome, asthma, and GERD are not helpful, additional evaluation with pH manometry, endoscopy, barium swallow, sinus CT or high-resolution chest CT may be helpful.
Sunday, March 8, 2009
Alcohol & Illicit Drugs
Substance abuse is a major public health problem in the United States and is estimated to be a factor in 41% of highway fatality accidents. The lifetime prevalence of alcoholism is estimated to be between 12% and 16%. Approximately two-thirds of high school seniors are regular users of alcohol. Underdiagnosis of alcohol abuse is substantial, both because of patient denial and lack of detection of clinical clues. A substantial decline in alcohol-related fatalities testifies to the success of educational and law-enforcement efforts to stop drinking and driving. Even so, alcohol-impaired driving remains prevalent, especially among men aged 18–34 years.
Binge drinking among college students has recently increased. As with cigarette use, clinician identification and coun seling about alcoholism may improve the chances of recovery. About 10% of all adults seen in medical practices are problem drinkers. An estimated 15–30% of hospitalized patients have problems with alcohol abuse or dependence, but the connection between patients’ presenting complaints and their alcohol abuse is often missed. The CAGE test is both sensitive and specific for chronic alcoholism. However, it is less sensitive in detecting heavy or binge drinking in elderly patients and has been criticized for being less applicable to minority groups or to women. Others recommend asking three questions:
(1) How many days per week do you drink (frequency)?
(2) On a day when you drink alcohol, how many drinks do you have in one day (quantity)?
(3) On how many occasions in the last month did you drink more than five drinks (binge drinking)?
The Alcohol Use Disorder Identification Test (AUDIT) consists of questions on the quantity and frequency of alcohol consumption, on alcohol dependence symptoms, and on alcohol-related problems.It has been found to accurately detect hazardous drinking, harmful drinking, and alcohol dependence and does not seem to be affected by ethnic or gender bias. Choice of therapy remains controversial. However, use of screening procedures and brief intervention methods can produce a 10–30% reduction in longterm alcohol use and alcohol-related problems. However, brief advice and counseling without regular follow-up and reinforcement cannot sustain significant long-term reductions in unhealthy drinking behaviors.
Several pharmacologic agents are effective in reducing alcohol consumption. In acute alcohol detoxification, standard treatment regimens use long-acting benzodiazepines, the preferred medications for alcohol detoxification, because they can be given on a fixed schedule or through “frontloading” or “symptom-triggered” regimens. Adjuvant sympatholytic medications can be used to treat hyperadrenergic symptoms that persist despite adequate sedation. Three drugs are FDA approved for treatment of alcohol dependence—disulfiram, naltrexone, and acamprosate. Disulfiram, an aversive agent, has significant adverse effects and consequently, compliance difficulties have resulted in no clear evidence that it increases abstinence rates, decreases relapse rates, or reduces cravings. Persons who receive shortterm treatment with naltrexone have a lower chance of Reproduced, with permission, from the United States Department of Health Human Services, U.S. Public Health Service, Office of Disease Prevention Health Promotion. Clinician’s Handbook of Preventive Services: Put Prevention Into Practice. U.S. Government Printing Office, 1994. alcoholism relapse. Compared with placebo, naltrexone can lower the risk of treatment withdrawal in alcohol-dependent patients. Compared with placebo, long-acting intramuscular formulation of naltrexone has been found to be well-tolerated and to reduce drinking significantly among treatment seeking alcoholics over a 6-month period. In a randomized, controlled trial, patients receiving medical management with naltrexone, a combined behavioral intervention, or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy with or without combined behavioral intervention.
Use of illegal drugs—including cocaine, methamphetamine, and so-called “designer drugs”—either sporadically or episodically remains an important problem. Disturbing trends include an increase in use of marijuana and inhalants among eighth graders and high school students and an increase in abuse of prescription pain medications. Many drug users are employed, and many use drugs during pregnancy. Cocaine or tobacco use during early pregnancy substantially increases the risk of miscarriage.Abuse of anabolic-androgenic steroids has been associated with use of other illicit drugs, alcohol, and cigarettes and with violence and criminal behavior. As with alcohol abuse, the recognition of drug abuse presents special problems and requires that the clinician actively consider the diagnosis.
Currently, evidence does not support the use of carbamazepine, disulfiram, mazindol, phenytoin,nimodipine, lithium, antidepressants, or dopamine agonists in the treatment of cocaine dependence. In a methadone maintenance population, the combination of contingency management with bupropion is more effective than bupropion alone for the treatment of cocaine addiction.
Buprenorphine has potential as a medication to ameliorate the symptoms and signs of withdrawal from opioids and has been shown to be effective in reducing concomitant cocaine and opiate abuse. Slow tapering with temporary substitution of methadone and buprenorphine—accompanied by medical supervision and ancillary medications—can reduce withdrawal severity, but most patients relapse to heroin use. Cessation of methadone maintenance is possible using buprenorphine by transfer from methadone to buprenorphine and subsequent buprenorphine reductions. Evidence does not support the use of naltrexone in maintenance treatment of opioid addiction.
Rapid opioid detoxification with opioid antagonist induction using general anesthesia has emerged as an approach to treat opioid dependence. However, a randomized comparison of buprenorphine-assisted rapid opioid detoxification with naltrexone induction and clonidine-assisted opioid detoxification with delayed naltrexone induction found no significant differences in rates of completion of inpatient detoxification, treatment retention, or proportions of opioid-positive urine specimens, and the anesthesia procedure was associated with more potentially lifethreatening adverse events. Finally, cognitive behavior therapy, contingency management, couples and family therapy, and other types of behavioral treatment have been shown to be effective interventions for drug addiction.
Binge drinking among college students has recently increased. As with cigarette use, clinician identification and coun seling about alcoholism may improve the chances of recovery. About 10% of all adults seen in medical practices are problem drinkers. An estimated 15–30% of hospitalized patients have problems with alcohol abuse or dependence, but the connection between patients’ presenting complaints and their alcohol abuse is often missed. The CAGE test is both sensitive and specific for chronic alcoholism. However, it is less sensitive in detecting heavy or binge drinking in elderly patients and has been criticized for being less applicable to minority groups or to women. Others recommend asking three questions:
(1) How many days per week do you drink (frequency)?
(2) On a day when you drink alcohol, how many drinks do you have in one day (quantity)?
(3) On how many occasions in the last month did you drink more than five drinks (binge drinking)?
The Alcohol Use Disorder Identification Test (AUDIT) consists of questions on the quantity and frequency of alcohol consumption, on alcohol dependence symptoms, and on alcohol-related problems.It has been found to accurately detect hazardous drinking, harmful drinking, and alcohol dependence and does not seem to be affected by ethnic or gender bias. Choice of therapy remains controversial. However, use of screening procedures and brief intervention methods can produce a 10–30% reduction in longterm alcohol use and alcohol-related problems. However, brief advice and counseling without regular follow-up and reinforcement cannot sustain significant long-term reductions in unhealthy drinking behaviors.
Several pharmacologic agents are effective in reducing alcohol consumption. In acute alcohol detoxification, standard treatment regimens use long-acting benzodiazepines, the preferred medications for alcohol detoxification, because they can be given on a fixed schedule or through “frontloading” or “symptom-triggered” regimens. Adjuvant sympatholytic medications can be used to treat hyperadrenergic symptoms that persist despite adequate sedation. Three drugs are FDA approved for treatment of alcohol dependence—disulfiram, naltrexone, and acamprosate. Disulfiram, an aversive agent, has significant adverse effects and consequently, compliance difficulties have resulted in no clear evidence that it increases abstinence rates, decreases relapse rates, or reduces cravings. Persons who receive shortterm treatment with naltrexone have a lower chance of Reproduced, with permission, from the United States Department of Health Human Services, U.S. Public Health Service, Office of Disease Prevention Health Promotion. Clinician’s Handbook of Preventive Services: Put Prevention Into Practice. U.S. Government Printing Office, 1994. alcoholism relapse. Compared with placebo, naltrexone can lower the risk of treatment withdrawal in alcohol-dependent patients. Compared with placebo, long-acting intramuscular formulation of naltrexone has been found to be well-tolerated and to reduce drinking significantly among treatment seeking alcoholics over a 6-month period. In a randomized, controlled trial, patients receiving medical management with naltrexone, a combined behavioral intervention, or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy with or without combined behavioral intervention.
Use of illegal drugs—including cocaine, methamphetamine, and so-called “designer drugs”—either sporadically or episodically remains an important problem. Disturbing trends include an increase in use of marijuana and inhalants among eighth graders and high school students and an increase in abuse of prescription pain medications. Many drug users are employed, and many use drugs during pregnancy. Cocaine or tobacco use during early pregnancy substantially increases the risk of miscarriage.Abuse of anabolic-androgenic steroids has been associated with use of other illicit drugs, alcohol, and cigarettes and with violence and criminal behavior. As with alcohol abuse, the recognition of drug abuse presents special problems and requires that the clinician actively consider the diagnosis.
Currently, evidence does not support the use of carbamazepine, disulfiram, mazindol, phenytoin,nimodipine, lithium, antidepressants, or dopamine agonists in the treatment of cocaine dependence. In a methadone maintenance population, the combination of contingency management with bupropion is more effective than bupropion alone for the treatment of cocaine addiction.
Buprenorphine has potential as a medication to ameliorate the symptoms and signs of withdrawal from opioids and has been shown to be effective in reducing concomitant cocaine and opiate abuse. Slow tapering with temporary substitution of methadone and buprenorphine—accompanied by medical supervision and ancillary medications—can reduce withdrawal severity, but most patients relapse to heroin use. Cessation of methadone maintenance is possible using buprenorphine by transfer from methadone to buprenorphine and subsequent buprenorphine reductions. Evidence does not support the use of naltrexone in maintenance treatment of opioid addiction.
Rapid opioid detoxification with opioid antagonist induction using general anesthesia has emerged as an approach to treat opioid dependence. However, a randomized comparison of buprenorphine-assisted rapid opioid detoxification with naltrexone induction and clonidine-assisted opioid detoxification with delayed naltrexone induction found no significant differences in rates of completion of inpatient detoxification, treatment retention, or proportions of opioid-positive urine specimens, and the anesthesia procedure was associated with more potentially lifethreatening adverse events. Finally, cognitive behavior therapy, contingency management, couples and family therapy, and other types of behavioral treatment have been shown to be effective interventions for drug addiction.
Thursday, March 5, 2009
Prevention Of Injuries & Violence
Injuries remain the most important cause of loss of potential years of life before age 65. Road traffic injuries, selfinflicted injuries, falls, and interpersonal violence are the major sources of injuries. Injuries affect mostly older women and young men, often causing long-term disability. Although there has been a steady decline in motor vehicle accident deaths per miles driven, road traffic injuries remain the tenth leading cause of death and the ninth leading cause of the burden of disease. Although seat belt use protects against serious injury and death in motor vehicle accidents, at least one-fourth of adults and one third of teenagers do not use seat belts routinely.
Air bags are protective for adults but not for small children. Each year in the United States, more than 500,000 people are nonfatally injured while riding bicycles. The rate of helmet use by bicyclists and motorcyclists is significantly increased in states with helmet laws. By the end of 2000, bicycle helmet use in 15 communities monitored by the CDC’s National Center for Injury Prevention and Control had risen from 40% to 55%, exceeding the Healthy People 2000 goal. Young men appear most likely to resist wearing helmets. Clinicians should try to educate their patients about seat belts, safety helmets, the risks of using cellular telephones while driving, drinking and driving—or using other intoxicants or long-acting benzodiazepines and then driving—and the risks of having guns in the home.
Long-term alcohol abuse adversely affects outcome from trauma and increases the risk of readmission for new trauma. Alcohol and illicit drug use are associated with an increased risk of violent death. There is a causal link between alcohol intoxication and injury due to assault.
Harm reduction can be achieved through practical measures, such as using plastic glasses and bottles in licensed premises; controlling prices of drinks; and targeted policing based on police, accident, and emergency data.
Males aged 16–35 are at especially high risk for seriousinjury and death from accidents and violence, with blacks and Latinos at greatest risk. For 16- and 17-year-old drivers, the risk of fatal crashes increases with the number of passengers. Deaths from firearms have reached epidemic levels in the United States and will soon surpass the number of deaths from motor vehicle accidents. Having a gun in the home increases the likelihood of homicide nearly threefold and of suicide fivefold. In 2002, an estimated 877,000 individuals successfully committed suicide.
Educating physicians to recognize and treat depression as well as restricting access to lethal methods have been found to reduce suicide rates. In elderly patients, the risk of hip fracture when falling can be reduced by as much as 80% by wearing hip protectors, but only about half of patients use them regularly. Oral vitamin D supplementation with 700–800 IU/d appears to reduce the risk of hip and other nonvertebral fractures in both ambulatory and institutionalized elderly persons, but 400 IU/d is not sufficient for fracture prevention.
Finally, clinicians have a critical role in detection, prevention, and management of physical or sexual abuse in particular, routine assessment of women for risk of domestic violence. In a trial, the 12-month prevalence of intimate partner violence ranged from 4% to 18% depending on the screening method, instrument, and health care setting. Rates of current domestic violence on exit questionnaire were 21% in suburban emergency department and 26% in urban emergency department settings. Inclusion of a single question about domestic violence in the medical history—“At any time, has a partner ever hit you, kicked you, or otherwise physically hurt you?”—can increase identification of this common problem. Another screen consists of three questions: (1) “Have you ever been hit, kicked, punched, or otherwise hurt by someone within
the past year? If so, by whom?” (2) “Do you feel safe in your current relationship?” (3) “Is there a partner from a previous relationship who is making you feel unsafe now?”
Women seem to prefer written, self-completed screening questionnaires to face-to-face questioning. Alternatively, computer prompts to clinicians may serve as useful reminders to inquiry. Assessment for abuse and offering of referrals to community resources creates potential to interrupt and prevent recurrence of domestic violence and associated trauma.
Physical and psychological abuse, exploitation, andneglect of older adults are serious underrecognized problems. Clues to elder mistreatment include the patient’s appearance, recurrent urgent-care visits, missed appointments, suspicious physical findings, and implausible explanations for injuries.
Air bags are protective for adults but not for small children. Each year in the United States, more than 500,000 people are nonfatally injured while riding bicycles. The rate of helmet use by bicyclists and motorcyclists is significantly increased in states with helmet laws. By the end of 2000, bicycle helmet use in 15 communities monitored by the CDC’s National Center for Injury Prevention and Control had risen from 40% to 55%, exceeding the Healthy People 2000 goal. Young men appear most likely to resist wearing helmets. Clinicians should try to educate their patients about seat belts, safety helmets, the risks of using cellular telephones while driving, drinking and driving—or using other intoxicants or long-acting benzodiazepines and then driving—and the risks of having guns in the home.
Long-term alcohol abuse adversely affects outcome from trauma and increases the risk of readmission for new trauma. Alcohol and illicit drug use are associated with an increased risk of violent death. There is a causal link between alcohol intoxication and injury due to assault.
Harm reduction can be achieved through practical measures, such as using plastic glasses and bottles in licensed premises; controlling prices of drinks; and targeted policing based on police, accident, and emergency data.
Males aged 16–35 are at especially high risk for seriousinjury and death from accidents and violence, with blacks and Latinos at greatest risk. For 16- and 17-year-old drivers, the risk of fatal crashes increases with the number of passengers. Deaths from firearms have reached epidemic levels in the United States and will soon surpass the number of deaths from motor vehicle accidents. Having a gun in the home increases the likelihood of homicide nearly threefold and of suicide fivefold. In 2002, an estimated 877,000 individuals successfully committed suicide.
Educating physicians to recognize and treat depression as well as restricting access to lethal methods have been found to reduce suicide rates. In elderly patients, the risk of hip fracture when falling can be reduced by as much as 80% by wearing hip protectors, but only about half of patients use them regularly. Oral vitamin D supplementation with 700–800 IU/d appears to reduce the risk of hip and other nonvertebral fractures in both ambulatory and institutionalized elderly persons, but 400 IU/d is not sufficient for fracture prevention.
Finally, clinicians have a critical role in detection, prevention, and management of physical or sexual abuse in particular, routine assessment of women for risk of domestic violence. In a trial, the 12-month prevalence of intimate partner violence ranged from 4% to 18% depending on the screening method, instrument, and health care setting. Rates of current domestic violence on exit questionnaire were 21% in suburban emergency department and 26% in urban emergency department settings. Inclusion of a single question about domestic violence in the medical history—“At any time, has a partner ever hit you, kicked you, or otherwise physically hurt you?”—can increase identification of this common problem. Another screen consists of three questions: (1) “Have you ever been hit, kicked, punched, or otherwise hurt by someone within
the past year? If so, by whom?” (2) “Do you feel safe in your current relationship?” (3) “Is there a partner from a previous relationship who is making you feel unsafe now?”
Women seem to prefer written, self-completed screening questionnaires to face-to-face questioning. Alternatively, computer prompts to clinicians may serve as useful reminders to inquiry. Assessment for abuse and offering of referrals to community resources creates potential to interrupt and prevent recurrence of domestic violence and associated trauma.
Physical and psychological abuse, exploitation, andneglect of older adults are serious underrecognized problems. Clues to elder mistreatment include the patient’s appearance, recurrent urgent-care visits, missed appointments, suspicious physical findings, and implausible explanations for injuries.
Saturday, February 28, 2009
Cancer Prevention
Mortality rates of cancer have begun to decrease in the past 2 years; part of this decrease results from reductions in tobacco use, since cigarette smoking is the most important preventable cause of cancer. Primary prevention of skin cancer consists of restricting exposure to ultraviolet light by wearing appropriate clothing and use of sunscreens. In the past 2 decades, there has been a threefold increase in the incidence of squamous cell carcinoma and a fourfold
increase in melanoma in the United States. Persons who engage in regular physical exercise and avoid obesity have lower rates of breast and colon cancer. Prevention of occupationally induced cancers involves minimizing exposure to carcinogenic substances such as asbestos, ionizing radiation, and benzene compounds. Chemoprevention has been widely studied for primary cancer prevention, but large trials in women taking aspirin, vitamin E, or calcium and vitamin D did not find reductions in cancer incidence or mortality. Use of tamoxifen, raloxifene, and aromatase inhibitors for breast cancer prevention. Hepatitis B vaccination can prevent hepatocellular carcinoma, and the development of an HPV vaccine holds promise for prevention of cervical cancer.
increase in melanoma in the United States. Persons who engage in regular physical exercise and avoid obesity have lower rates of breast and colon cancer. Prevention of occupationally induced cancers involves minimizing exposure to carcinogenic substances such as asbestos, ionizing radiation, and benzene compounds. Chemoprevention has been widely studied for primary cancer prevention, but large trials in women taking aspirin, vitamin E, or calcium and vitamin D did not find reductions in cancer incidence or mortality. Use of tamoxifen, raloxifene, and aromatase inhibitors for breast cancer prevention. Hepatitis B vaccination can prevent hepatocellular carcinoma, and the development of an HPV vaccine holds promise for prevention of cervical cancer.
Thursday, February 26, 2009
Chemoprevention
As discussed, regular use of low-dose aspirin (81–325 mg) can reduce the incidence of myocardial infarction in men. Low-dose aspirin reduces stroke but not myocardial infarction in middle-aged women. Antioxidant vitamin (vitamin E, vitamin C, and beta-carotene) supplementation produced no significant reductions in the 5-year incidence of—or mortality from—vascular disease, cancer, or other major outcomes in high-risk individuals with coronary artery disease, other occlusive arterial disease, or diabetes mellitus.
Wednesday, February 25, 2009
Hypertension
Over 43 million adults in the United States have hypertension, but 31% are unaware of their elevated blood pressure; 17% are aware but untreated; 29% are being treated but have not
controlled their blood pressure (still greater than 140/90 mm Hg); and only 23% are well controlled. In every adult age group, higher values of systolic and diastolic blood pressure
carry greater risks of stroke and congestive heart failure.Systolic blood pressure is a better predictor of morbid events than diastolic blood pressure. Clinicians can apply specific blood pressure criteria, such as those of the Joint National Committee, to decide at what levels treatment should be considered in individual cases. Table 11–1 presents a classification of hypertension based on blood pressures.
Primary prevention of hypertension can be accomplished by strategies aimed at both the general population and special high-risk populations. The latter include persons with high-normal blood pressure or a family history of hypertension, blacks, and individuals with various behavioral risk factors such as physical inactivity; excessive consumption of salt, alcohol, or calories; and deficient intake of potassium. Effective interventions for primary prevention of hypertension include reduced sodium and alcohol consumption, weight loss, and regular exercise. Potassium supplementation lowers blood pressure modestly, and a diet high in fresh fruits and vegetables and low in fat, red meats, and sugar-containing beverages also reduces blood pressure.
Interventions of unproven efficacy include pill supplementation of potassium, calcium, magnesium, fish oil, or fiber; macronutrient alteration; and stress management.
Improved diagnosis and treatment of hypertension is a major cause of the recent decline in stroke deaths. Hypertension control, however, remains suboptimal. An intervention that included patient education and provider education was more effective than provider education alone in achieving control of hypertension, suggesting the benefits of patient participation in hypertension treatment.
controlled their blood pressure (still greater than 140/90 mm Hg); and only 23% are well controlled. In every adult age group, higher values of systolic and diastolic blood pressure
carry greater risks of stroke and congestive heart failure.Systolic blood pressure is a better predictor of morbid events than diastolic blood pressure. Clinicians can apply specific blood pressure criteria, such as those of the Joint National Committee, to decide at what levels treatment should be considered in individual cases. Table 11–1 presents a classification of hypertension based on blood pressures.
Primary prevention of hypertension can be accomplished by strategies aimed at both the general population and special high-risk populations. The latter include persons with high-normal blood pressure or a family history of hypertension, blacks, and individuals with various behavioral risk factors such as physical inactivity; excessive consumption of salt, alcohol, or calories; and deficient intake of potassium. Effective interventions for primary prevention of hypertension include reduced sodium and alcohol consumption, weight loss, and regular exercise. Potassium supplementation lowers blood pressure modestly, and a diet high in fresh fruits and vegetables and low in fat, red meats, and sugar-containing beverages also reduces blood pressure.
Interventions of unproven efficacy include pill supplementation of potassium, calcium, magnesium, fish oil, or fiber; macronutrient alteration; and stress management.
Improved diagnosis and treatment of hypertension is a major cause of the recent decline in stroke deaths. Hypertension control, however, remains suboptimal. An intervention that included patient education and provider education was more effective than provider education alone in achieving control of hypertension, suggesting the benefits of patient participation in hypertension treatment.
Subscribe to:
Posts (Atom)