Acute pyelonephritis in women (2011 review)

Posted on by

This is a 2011 review from the official journal of the AAFP, American Family Physician:

Acute pyelonephritis is a bacterial infection of the renal pelvis and kidney most often seen in young women.

Symptoms of acute pyelonephritis

Most patients have fever, although it may be absent early in the illness. Flank pain is nearly universal.

Tests for acute pyelonephritis

A positive urinalysis confirms the diagnosis.

Urine culture should be obtained in all patients to guide antibiotic therapy if the patient does not respond to initial empiric antibiotic regimens.

Escherichia coli is the most common pathogen in acute pyelonephritis. In the past decade, there has been an increasing rate of E. coli resistance to extended-spectrum beta-lactam antibiotics.

Imaging, usually with contrast-enhanced CT is not necessary unless there is:

- no improvement in the patient's symptoms
- symptom recurrence after initial improvement

Treatment of acute pyelonephritis

Outpatient treatment is appropriate for most patients.

Oral fluoroquinolone is the initial outpatient therapy if the rate of fluoroquinolone resistance in the community is less than 10%. If the resistance rate exceeds 10%, an initial IV dose of ceftriaxone or gentamicin should be given, followed by an oral fluoroquinolone regimen.

Oral beta-lactam antibiotics and trimethoprim/sulfamethoxazole (TMP-SMX (Bactrim) are inappropriate for therapy because of high resistance rates.

References:

Diagnosis and treatment of acute pyelonephritis in women. Colgan R, Williams M, Johnson JR. Am Fam Physician. 2011 Sep 1;84(5):519-26.
Nephrology Cases

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Source:
http://feeds.feedburner.com/CasesBlog

Factors that Promote Positive Adaptation to Stress and Adversity

Posted on by

The phenomenon of resilience reflects positive adaptation despite contexts of risk, adversity, or trauma.

Factors that promote positive adaptation to stress and adversity include the following:

- self-esteem
- optimism
- internal control
- coping aimed at acceptance
- coping aimed at seeking emotional support
- social contacts

Tips for managing stress (2-minute BBC video):

- Take a few deep breaths
- Get plenty of exercise
- Socialize - don't stress alone, talk to someone and have a laugh
- Get out - go to the park

Read more: http://www.bbc.co.uk/scotland/brainsmart

References:

Psychological and Social Factors that Promote Positive Adaptation to Stress and Adversity in the Adult Life Cycle. M. Guadalupe Jiménez Ambriz, María Izal and Ignacio Montorio. Journal of Happiness Studies, 2011.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Source:
http://feeds.feedburner.com/CasesBlog

Best Tweets – Selection of Twitter Favorites

Posted on by

Being a SuperHero has its drawbacks RT @Bongi1: Just about to fly to cape town just to turn around and fly back.

— GruntDoc (@gruntdoc) December 13, 2011

This is amusing: Amy Chua's "Battle Hymn of the Tiger Mother" was sold in China as "Being an American Mom." bit.ly/vI0zNo #hardcore

— Heidi N. Moore (@moorehn) December 11, 2011

Chickens' water keeps freezing. I propose adding vodka to it. I have been overruled. Something about killing them.

— Robert Silge, MD (@DoctorMac) December 10, 2011

Walked by a minor car accident earlier & a cop said to passersby: "Nothing to TWEET here, move along now."

— Nick Bilton (@nickbilton) December9, 2011

Study shows people can guess personality via body odor. From inkblot to stinkblot? j.mp/v6DDNX

— Dr John Weiner (@AllergyNet) December5, 2011

I attended a really long talk today.The only thing I learned from it is the flash-drive-around-the-neck is not a good look for lecturers.

— Jonathan,DO,MS,NCC (@DrJonathan) December1, 2011

Dental assistant (before I met dentist): "Ok I'm going to do the routine 14 x-rays." Me: "Uhhh, no that's ok."Her:"But, but-we always do!"

— Jonathan,DO,MS,NCC (@DrJonathan) December1, 2011

The inclusion of a Twitter update (tweet) in Best Tweets - Selection of Twitter Favorites does not represent endorsement or agreement of any kind. If you are included in this post but you would like to have your tweet removed for any reason, please email me and will comply with your request the same day.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Source:
http://feeds.feedburner.com/CasesBlog

UpToDate is the most read medical reference tool – how did Harrison’s, Cecil’s, etc. manage to lose that war?

Posted on by

This the summary of my Twitter discussion with an academic nephrologist (by the way, the founding editor of UpToDate is also a nephrologist):

@DrVes: UpToDate is likely the most read medical reference tool, at least in the U.S. - how did Harrison's, Cecil's, etc. manage to lose that war?

@kidney_boy (Joel Topf): Reasons for UpToDate winning: Harrison's had no search, and an editorial style that told you about disease but not how to treat it

@DrVes: Exactly. It's amazing that those publishing companies didn't realize that they shipped "malfunctioning" product for years, and never fixed it.

@kidney_boy (Joel Topf): Harrison's is the great preclinical prof teaching pathophysiology, UpToDate is the smart clinician teaching you how to care for the patient with EBM.

@DrVes: UpToDate now has sections on pathophysiology, some of them quite good, check T-cells types, for example. Unfortunately, a lot of medical students get their basic pathology knowledge from Wikipedia nowadays. Just go to the library section where medical students are and have a look at the monitor screens during study time.

@kidney_boy (Joel Topf): Remember Harrison's is the youngest of the medical texts, it won by having regional approach (headache rather than CNS) to organization.

@DrVes: Classic-style textbooks (e.g. Harrisson's) feel like "half-book" nowadays. The doctors in training often find themselves asking "Where is the second part with treatment, updates, etc.?"

Related reading:

Review of the much anticipated UpToDate iPhone app, arguably the most read medical reference tool. iMedicalApps.com.
Are You Dependent on UpToDate for Your Clinical Practice?
"With UpToDate, students and interns may be as capable of teaching the resident (or attending) as visa versa"
Study: UpToDate More Likely than PubMed to Answer Patient Care Questions

Comments from Google Plus:

Neil Mehta - Ves one of the most useful aspects of Harrison's is/was the approach to symptoms. This is the first 100 or so pages of Harrison's. Understanding this can be a huge help in becoming a good clinician. It is pretty dense reading but internal medicine residents can benefit from spending time on this. Agree UpToDate is a tremendous resource. One thing to remember about U2D is that sections can be written by one author and this does run a risk of bias creeping in (no different than textbooks) but readers should learn to look at other sources/primary literature when necessary.
Ves Dimov - Right. UpToDate is far from perfect but it is very time efficient. It provides quick actionable info within 5-10 minutes of conducting a search. The depth of the content is limited by the person who wrote that particular article, of course.
Robert Silge - Yes, but by and large the people writing that content are qualified to do so. It is to medical textbooks what Wikipedia is to general reference books. Updates faster, to the point, and has info on (almost) everything. Its depth may be lacking, but for clinical practice I doubt the benefits of reading through primary literature is worth the time spent doing it for most endeavors.
And frankly for your first foray into a field, as a med student for example, Wikipedia is a darned useful place to start.
Ves Dimov - And that's why UpToDate is most users' favorite resource. One of the few drawbacks is the price though, $495 per year.
Robert Silge - Wonder how many people pay for it out of pocket vs use an institutional login?
Gary Levin - Up to date is like rounding with your attending or professor with instantaneous gratification. Harrison belongs in the library or for a second year med student to learn the language.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Source:
http://feeds.feedburner.com/CasesBlog

Hirsutism or Excess Hair

Posted on by

From NHS Choices YouTube channel: Hirsutism causes excess hair growth in women, such as on the face and chest. An expert explains the causes or hirsutism, treatments such as hair-removal and cosmetic techniques, and where to go for help if you're worried about excess hair growth.

The Cleveland Clinic Journal of Medicine published an Update on the management of hirsutism in 2010:

Hirsutism is a source of significant anxiety in women. While polycystic ovary syndrome (PCOS) or other endocrine conditions are responsible for excess androgen in many patients, other patients have normal menses and normal androgen levels (“idiopathic” hirsutism).
The finding of polycystic ovaries on ultrasound is not required for the diagnosis of polycystic ovary syndrome (PCOS). Gonadotropin-dependent ovarian hyperandrogenism is believed to cause PCOS. However, mild adrenocorticotropic-dependent adrenal hyperandrogenism also is a feature in many cases.
Even women with mild hirsutism can have elevated androgen levels, and thus, they may benefit from a laboratory evaluation.
Laser treatment does not result in complete, permanent hair reduction, but it is more effective than other methods such as shaving, waxing, and electrolysis. It produces hair reduction for up to 6 months. The effect is enhanced with multiple treatments. Interestingly, a portable laser hair removal device is currently available from Amazon (this post is not a recommendation or endorsement of the product).

References:

Update on the management of hirsutism. Cleveland Clinic Journal of Medicine June 2010 vol. 77 6 388-398.

A home hair removal laser device is available without prescription from Amazon.com (not a recommendation to buy any product, see the link below). A similar device is available from Costco.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Source:
http://feeds.feedburner.com/CasesBlog

Headache subtypes: 30-year prospective cohort study

Posted on by

This BMJ study included 590 people aged 19-20 from a cohort of 4,500 residents of Zurich, Switzerland, interviewed 7 times across 30 years of follow-up.

The one-year prevalence of subtypes of headache were:

- 1% (female:male ratio of 2.8) for migraine with aura
- 11% (female:male ratio of 2.2) for migraine without aura
- 11% (female:male ratio of 1.2) for tension-type headache

The cumulative 30-year prevalence of headache subtypes were:

- 3% for migraine with aura
- 36% for migraine without aura
- 29% for tension-type headache

Despite the high prevalence of migraine without aura, most cases were transient and only 20% continued to have migraine for more than half of the follow-up period.

There was a substantial crossover among the subtypes and no specific pattern of progression.

The longitudinal overlap among subtypes of headache shows the developmental heterogeneity of headache syndromes.

References:

Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study. BMJ, 2011.

Image source: Openclipart.org, public domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Source:
http://feeds.feedburner.com/CasesBlog

Psychiatric and Neurologic comorbidities as systemic dysfunctions – Video

Posted on by

Highlights from the presentation of Dr Roswitha Goetze-Pelka at the 2011 Autoimmunity Congress Asia. She discusses the new data supporting Plato's observation that "the greatest mistake in the treatment of diseases is that there are physicians for the body, and physicians for the soul, although the two cannot be separated."

See more here:
Psychiatric and Neurologic comorbidities as systemic dysfunctions - Video

Acute altitude illnesses

Posted on by

This summary is based on a recent BMJ review:

Acute altitude illnesses include:

- high altitude headache
- acute mountain sickness
- high altitude cerebral edema
- high altitude pulmonary edema

Typical scenarios in which such illness occurs include:

- a family trek to Everest base camp in Nepal (5,360 m)
- a fund raising climb of Mount Kilimanjaro (5,895 m), shown in the map below
- a tourist visit to Machu Picchu (2,430 m)

View Larger Map

High altitude headache and acute mountain sickness often occur a few hours after arrival at altitudes over 3,000 meters.

Occurrence of acute mountain sickness is reduced by slow ascent. Severity can be modified by prophylactic acetazolamide.

Mild to moderate acute mountain sickness usually resolves with:

- rest
- hydration
- halting ascent
- analgesics

Occasionally people with acute mountain sickness develop high altitude cerebral oedema with confusion, ataxia, persistent headache, and vomiting.

Severe acute mountain sickness and high altitude cerebral edema require urgent treatment with:

- oxygen if available
- dexamethasone
- possibly acetazolamide
- rapid descent

High altitude pulmonary edema is a rare but potentially life threatening condition that occurs 1-4 days after arrival at altitudes above 2,500 meters. Treatment includes oxygen if available, nifedipine, and rapid descent to lower altitude.

References:

Clinical Review: Acute altitude illnesses. BMJ 2011; 343:d4943 doi: 10.1136/bmj.d4943

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Source:
http://feeds.feedburner.com/CasesBlog

Cleveland Clinic calls "Code Lavender" to improve patient satisfaction

Posted on by

From the WSJ:

How patients feel they were treated has always colored their opinions of a hospital. Now, those feelings are being factored into how hospitals get paid.

The Cleveland Clinic CEO, Dr. Cosgrove, says that in his own days as a top cardiac surgeon, he focused so intently on reducing complications from cardiac procedures that he gave little thought to the feelings or experiences of patients.

Times have changed dramatically since then. The Cleveland Clinic has launched a program known as HEART - for hear the concern, empathize, apologize, respond and thank—that empowers employees to handle patient concerns from the moment they arise.

It developed a Healing Services team to offer complimentary light massages, Reiki—a laying on of hands—aromatherapy, spiritual care from a clergy person or lay practitioner and other holistic services, and it will call a "Code Lavender" for patients or family members under stress who need immediate comfort.

Since 2008, the Cleveland Clinic's overall hospital ratings have increased by 89%.

"Code Lavender" has a Twitter account too (@CodeLavender), managed by the former Cleveland Clinic Chief Experience Officer who popularized the term.

From the Cleveland Clinic Twitter account: Efforts to improve patient satisfaction were featured in a NBC Nightly News story (see the video below).

References:

A Financial Incentive for Better Bedside Manner. WSJ.
Image source: Lavender Farm, Wikipedia, public domain.

Disclaimer: I was an Assistant Professor of Medicine at Cleveland Clinic from 2005 to 2008.

Comments from Twitter:

@TanyaPRpro (Tanya R. Walton): Clever and meaningful hospital care
@scottRcrawford: Brand medicine

@gruntdoc: How sad. Condolences. RT @DrVes: Cleveland Clinic calls "Code Lavender" to improve patient satisfaction goo.gl/X4Jtt
@MGastorf (Melissa Gastorf): concerns about satisfaction basis for payment- i.e. if you refuse to write narcotic and patient angry, physician payment suffers.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Source:
http://feeds.feedburner.com/CasesBlog