Depression

A 69-year-old woman was hospitalized with fever, chills, and nausea. Three weeks earlier, she had received a 2-week course of oral levofloxacin for pneumonia, which resolved. Her history included rheumatic heart disease; diabetes mellitus; depression; a hysterectomy; 2 mitral commissurotomies; nonrepairable mitral valve regurgitation, for which she received a St Jude Medical bileaflet valve; a left-sided cerebrovascular accident; and paroxysmal atrial fibrillation. Her medications included verapamil, furosemide, metoprolol, potassium chloride, metformin, nortriptyline, and warfarin. She denied tobacco and alcohol use.

ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.

Until recently, celiac diseasewas considered a rare disorder.However, new evidencesuggests that about1% of Americans are affected.As serologic tests that detect autoantigensinvolved in celiac diseasebecome more widely used, morecases will likely be identified.1

ABSTRACT: When you approach a patient with a neurologic complaint, look for abnormal postures and bodily asymmetries. Careful history taking puts the patient's complaint in context and gives direction to the clinical investigation. Remember that a change in the character of an existing condition requires assessment as a new complaint. The mental status evaluation, at a minimum, considers the patient's level of alertness and orientation, including speech and comprehension. Distinguish among delirium, dementia, and psychosis, and avoid making a psychiatric diagnosis until organic causes have been excluded. Cranial nerves II to VIII are the most pertinent to the neurologic screening examination. The evaluation of cranial nerves II, III, IV, and VI is particularly important in patients with headache or visual disturbances and suspected intracranial lesions.

ABSTRACT: The complexities of chronic nonmalignant pain and the contributions of psychosocial and environmental factors require assessment and treatment strategies that may go far beyond the use of analgesics. The first step is to rule out serious underlying conditions; determine the chronicity, quality, location, and intensity of the pain; assess aggravating environmental factors; and evaluate the patient's level of functioning. The pharmacologic regimen may include oral or topical analgesics, antidepressants, muscle relaxants, nerve stabilizers, and/or opioids. A comprehensive plan includes alternative modalities, such as physical and occupational therapy, stress management, relaxation techniques, and the treatment of comorbid conditions, including anxiety, depression, and sleep disorders. The optimal opioid regimen consists of methadone or a sustained-release opioid combined with a short-acting opioid for breakthrough pain.

Until recently, practitioners focused on the timing of initiation of renal replacement therapy (dialysis) and transplantation once advanced kidney disease had developed. However, a new CKD classification system now provides an action plan for the earlier stages of the disease.

During his last routine pediatric visit, a 4-month-old boy with a large head circumference (98th percentile for his age) was referred for radiographic evaluation. The infant had been delivered by cesarean birth because of cephalopelvic disproportion; his head size had gradually increased since birth. There was a family history of this condition.

ABSTRACT: The prevalence of erectile dysfunction (ED) is higher among men with hypertension than among normotensive men. Sexual dysfunction is a common side effect of many antihypertensive medications and can lead to noncompliance. Treatment-related ED is more often associated with diuretics and ß-blockers and is less common with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. If ED complicates therapy, consider switching to an antihypertensive agent with fewer sexual side effects. However, if compelling reasons exist for the use of a particular antihypertensive agent (eg, a ß-blocker in a patient with previous myocardial infarction), several options for the treatment of ED are available. Phosphodiesterase-5 inhibitors have been shown to be safe and effective in men who are receiving antihypertensive therapy.

ABSTRACT: Prompt treatment of herpes zoster with an antiviral such as acyclovir does not prevent post-herpetic neuralgia, but it can reduce the pain and duration of the disorder, particularly in older patients. Agents used to treat post-herpetic neuralgia include gabapentin, tricyclic antidepressants, lidocaine patches, capsaicin, and opioids. Effective treatment often requires the use of multiple medications. When you select a regimen, consider whether your patient is at heightened risk for adverse drug effects and whether he or she has comorbid disorders, such as depression, that might be amenable to treatment with the same medication used for post-herpetic neuralgia. Patients with intense pain and dysfunction are more likely to have a protracted disease course; early, aggressive intervention is warranted in this setting. For patients who continue to have disabling pain despite treatment, consider intrathecal corticosteroid or lidocaine injections or referral to a pain management center or specialist.

ABSTRACT: To assess a child for overweight, begin by calculating his or her body mass index (BMI). Note that BMI is used differently in children than it is in adults. A child's BMI is plotted on a growth curve that reflects that child's age and gender. This yields a value-BMI-for-age-that provides a consistent measure across age groups. Children whose BMI-for-age is between 85% and 95% are at risk for becoming overweight. Any child whose BMI-for-age is 95% or more is considered overweight. The 2 main factors associated with overweight in children are poor eating habits and decreased physical activity. Recommend that children have at least 5 servings of fruits and vegetables a day. Children should engage in moderate physical activity for at least 60 minutes on most days of the week, and TV viewing and computer activities should be limited to no more than 2 hours a day.

A 43-year-old woman presented to the emergency department with a 4-day history of worsening erythema, swelling, and pruritus that developed on the face and progressed to the abdomen, back, and lower legs. In the past 2 to 3 days, fluid-filled blisters had arisen, followed by skin sloughing; the patient also reported subjective fevers. Another physician had prescribed naproxen for back pain 6 days earlier. The patient had a history of asthma, with rare inhaler use, and depression, for which she had taken citalopram for 2 years.

A 60-year-old woman with hypertension, diabetes mellitus, and intermittentatrial fibrillation presents with nausea, diaphoresis, dizziness, and globalweakness that has lasted 1 hour. She denies chest pain, dyspnea, syncope,vomiting, diarrhea, blood loss, and headache; there is no vertigo. Medicationsinclude acetaminophen, digoxin, diltiazem, glipizide, hydrochlorothiazide,irbesartan, metformin, pioglitazone, and warfarin.

ABSTRACT: Silent myocardial ischemia increases the risk of sudden death and other adverse events in patients with coronary artery disease (CAD). The simplest, least costly way to detect ischemia-whether silent or symptomatic-is exercise testing with ECG monitoring. However, if no symptoms are associated with ST-segment abnormalities during the test, these ECG changes may represent false-positive results and further testing (eg, Doppler echocardiography or radionuclide ventriculography) is required. The optimal management strategy for patients with CAD and silent myocardial ischemia remains unclear. However, current evidence suggests that risk factor modification, medical therapy and, in appropriate patients, revascularization interventions (eg, percutaneous coronary interventions, coronary artery bypass graft surgery) reduce the risk of adverse cardiac events.

ABSTRACT: Because of concerns raised by recent studies about the safety of hormone replacement therapy, attention has shifted to alternative therapies for prevention of osteoporosis. Resistance training has been shown to strengthen skeletal muscles, increase bone mineral density (BMD), and reduce fractures. Low-impact aerobic exercises, such as walking, improve cardiovascular fitness but do not create enough stress to increase BMD or muscle mass. A basic resistance training regimen consists of 5 or 6 weight-bearing exercises performed 2 or 3 times a week. Results can be seen in 4 to 6 weeks.

ABSTRACT: Consider prophylactic therapy for patients with frequent (5 or more per month), severe migraine attacks; commonly used agents include β-blockers, calcium channel blockers, antidepressants, and antiepileptic agents. Daily or alternate-day use of aspirin or an NSAID may also be helpful, and limited data suggest angiotensin II receptor blockers may provide effective migraine prophylaxis. For treatment of acute migraine attacks, triptans have emerged as the most effective agents. Controlled clinical trials have demonstrated that all the triptans have similar efficacy. The optimal strategy for an acute migraine attack is to initially administer a therapeutic agent at a dose sufficient to relieve symptoms. Intervention during the early, mild stages of an attack is more likely to alleviate pain than intervention after moderate to severe symptoms occur.

Many of the 9.5 million cancer survivors in the United States seek advice about food, physical activity, dietary supplements, and complementary nutritional therapies. Recently, the American Cancer Society (ACS) issued a guide that provides clinicians with information that can help these patients make informed choices.1 Highlights of the report follow.

The diagnosis and treatment of migraine as its own entity is a complicated and delicate balance between identification and management. The situation is more complex, however, when the patient with migraine presents with comorbid conditions (eg, mood, neurologic, or musculoskeletal pain disorders). These comorbid conditions have important clinical implications. In fact, the risk of these and other comorbid disorders is much higher for migraineurs than for persons without a history of migraine. Comorbid conditions can also complicate treatment in some patients because of the potential for drug interactions or exacerbation of one condition by therapy for the other. The onus is on the physician to consider migraine treatment regimens that include the potential to manage underlying comorbidities and, conversely, to consider treatment regimens when migraine itself may be secondary to other primary symptoms.

ABSTRACT: Before a diagnosis of subclinical hypothyroidism is made, other causes of elevated thyroid-stimulating hormone (TSH), such as recovery from a serious acute illness, must be ruled out. Diagnosis is based on at least 2 assays performed over a period of several weeks. If the screening TSH levels are abnormal, measurement of serum free thyroxine is needed to confirm the diagnosis. Although patients who have TSH levels in the upper limit of the traditional normal range may be at higher risk for progression to hypothyroidism, no evidence exists for adverse health consequences. For patients with serum TSH levels in the range of 5.1 to 10 mIU/L, consider such factors as age, comorbidities, symptoms of hypothyroidism, pregnancy or anticipation of pregnancy, and the presence of goiter or antithyroid antibodies in the decision to treat. Thyroxine therapy is recommended for patients with serum TSH levels above 10 mIU/L.

Anxiety is a common and troubling symptom in many patients with chronic obstructive pulmonary disease (COPD), even when their degree of respiratory impairment is only mild to moderate. Anxiety may also accompany other chronic, progressive pulmonary disorders, such as interstitial fibrosis and cystic fibrosis, and a wide variety of other, less common diseases that are characterized by progressive dyspnea on exertion.

Numerous factors put elderly patients at risk for adverse drug events. On average, they take at least 6 medications a day, which increases the likelihood of drug-drug interactions. In addition, many drugs that are safe and effective in younger patients are inappropriate for older persons because of age-related changes and comorbid conditions that affect absorption, distribution, metabolism, and elimination. First-pass metabolism decreases with age, which may increase systemic absorption of some oral nitrates, ß-blockers, estrogens, and calcium channel blockers. The age-related rise in body fat increases the volume of distribution of lipid-soluble compounds, such as diazepam, and prolongs clearance. About two thirds of elderly persons have impaired kidney function; in these patients, the dosage of renally excreted drugs-such as digoxin-needs to be reduced. Other strategies for avoiding adverse drug events are detailed here.

Millions of Americans suffer from anxiety disorders. Many with panic disorder, social anxiety disorder, and/or generalized anxiety disorder present initially to their primary care clinician. Effective treatment is possible in a busy primary care setting; therapy involves patient education and pharmacotherapy. Once other potential causes of symptoms of an anxiety disorder have been ruled out, the first step is to reassure the patient that he or she has a psychological condition-a very common one-and that symptoms are not the result of an undiagnosed disease or "going crazy" or "losing control." Educate and inform patients that complete clinical remission is achievable, often with medication alone. Begin treatment on day 1 with a long-acting benzodiazepine-such as alprazolam XR or clonazepam-or with the anxiolytic agent buspirone; at the same time, start a selective serotonin reuptake inhibitor (SSRI). The anxiolytic agent allays acute somatic symptoms until the full effects of the SSRI are manifest (often 4 to 6 weeks). The anxiolytic can then be gradually tapered. Referral to a psychiatrist for psychotherapy may be indicated when a patient refuses or cannot tolerate drug therapy, or when response to therapy is inadequate.

ABSTRACT: The basic screening studies for rheumatic diseases are a complete blood cell count, a determination of the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level, a rheumatoid factor assay, an antinuclear antibody (ANA) test, a measurement of serum uric acid level, and a urinalysis. Test results must be interpreted within a clinical context; for example, a positive ANA assay suggests the possibility of a rheumatic disorder, but it is not specific for any diagnosis. Tests that reveal the nature and extent of target-organ involvement, such as renal function studies in patients with systemic lupus erythematosus, can help guide the selection of therapy. Laboratory results also reflect disease activity; the ESR and CRP level are useful gauges of the activity of most inflammatory rheumatic disorders. Finally, laboratory monitoring can help you minimize the significant toxicity associated with many of the drugs used to manage rheumatic diseases.

Treatment of fibromyalgia syndrome (FMS) is a challenge. However, most patients benefit from appropriate management. Essential to treatment are a physician's positive and empathetic attitude, continuous psychological support, patient education, patience, and a willingness to guide patients to do their part in management. Other important aspects involve addressing aggravating factors (eg, poor sleep, physical deconditioning, emotional distress) and employing various nonpharmacologic modalities (eg, regular physical exercise) and pharmacologic therapies. Drug treatment includes use of tricyclic medications alone or in combination with a selective serotonin reuptake inhibitor, and other centrally acting medications. Tender point injection is useful. It is important to individualize treatment. Management of FMS is both a science and an art.

ABSTRACT: The results of diagnostic tests do not correlate well with the presence and severity of pain. To avoid missing a serious underlying condition, look for "red flags," such as unexplained weight loss or acute bladder or bowel function changes in a patient with low back pain. Nonopioid medications can be more effective than opioids for certain types of pain (for example, antidepressants or anticonvulsants for neuropathic pain). When NSAIDs are indicated, cyclooxygenase-2 inhibitors are better choices for patients who are at risk for GI problems or who are receiving anticoagulants. However, if nonspecific NSAIDs are not contraindicated, consider using these far less expensive agents. The tricyclic antidepressants are more effective as analgesics than selective serotonin reuptake inhibitors. When opioids are indicated, start with less potent agents (tramadol, codeine, oxycodone, hydrocodone) and then progress to stronger ones (hydromorphone, fentanyl, methadone, morphine) if needed.

ain management is a commonand challenging aspect of caringfor elderly patients. The principlesthat guide therapeutic pain managementin these persons are differentfrom those used in the treatmentof younger persons.

Uncontrolled hypertension is a major health problem among African Americans. Obesity, high sodium and low potassium intake, and inadequate physical activity have been identified as barriers to cardiovascular health in many African Americans. Thus, it is important to educate and counsel patients about lifestyle modifications, such as a low-sodium, DASH (Dietary Approaches to Stop Hypertension)-type diet; regular aerobic exercise; moderation of alcohol consumption; and smoking cessation. All classes of antihypertensive agents lower blood pressure in African Americans, although some may be less effective than others when used as monotherapy. Most patients require combination therapy. Both patient barriers (such as lack of access to health care and perceptions about health and the need for therapy) and physician barriers (such as poor communication styles) contribute to the low rates of hypertension control in African Americans. Patient-centered communication strategies can help overcome these barriers and can improve compliance and outcomes. Such strategies include the use of open-ended questions, active listening, patient education and counseling, and encouragement of patient participation in decision making.

ABSTRACT: Once you have excluded a cardiac origin of chest pain, focus the evaluation on esophageal, psychiatric, musculoskeletal, and pulmonary causes. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are the most common causes of unexplained chest pain (UCP). If you suspect an esophageal disorder, empiric antisecretory therapy is the most cost-effective initial approach. If the patient remains symptomatic, order a 24-hour esophageal pH study with symptom analysis while the patient receives maximal acid suppression. Once GERD is excluded, the patient may be treated for visceral hyperalgesia with low-dose tricyclic antidepressants or standard doses of selective serotonin reuptake inhibitors. Panic disorder-the most common psychiatric disorder in patients with UCP-is often associated with atypical symptoms, such as palpitations and paresthesias, and other psychiatric disorders. If you suspect panic disorder, one approach is to give the patient a short-term, nonrefillable prescription for a benzodiazepine and refer him or her for psychiatric evaluation.

An examination the most recent data on the pharmacodynamics, efficacy, and safety of 5 commonly used herbs: echinacea, St John's wort, ginkgo biloba, saw palmetto, and black cohosh.

ABSTRACT: Fibromyalgia syndrome (FMS) is a common condition that causes chronic pain and disability. It should be diagnosed by its own clinical characteristics of widespread musculoskeletal pain and multiple tender points. American College of Rheumatology criteria guidelines are most helpful in diagnosing FMS. The major symptoms are pain, stiffness, fatigue, poor sleep, and those of other associated conditions, for example, irritable bowel syndrome, headaches, restless legs syndrome, chronic fatigue syndrome, and depression. The pathophysiology of FMS is thought to involve central sensitization and neuroendocrine aberrations, triggered or aggravated by genetic predisposition; trauma; psychosocial distress; sleep deprivation; and peripheral nociception.

n the United States, the number of cases and geographic range of West Nile virus infection have increased since 1999, when the virus first surfaced in the Western Hemisphere. This year, the virus is expected to spread to all states except Alaska and Hawaii.