Management of Hirsutism (Excess Hair)

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.

Image source: Skin layers. Wikipedia, public domain.

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.

Diagnosis and Management of COPD - Current Guidelines

WHO estimates that 210 million people have COPD worldwide. COPD is the 4th leading cause of death in the world, but by 2030 it is expected to be the 3rd, behind CAD and stroke (http://bit.ly/X5nje). COPD mortality is inversely correlated to the forced expiratory volume (FEV1) in 1 second (http://bit.ly/ZYIR7).

Here are the key recommendations from the recently published Guidelines for management of stable chronic obstructive pulmonary disease (COPD):

1. Spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms. Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms.

2. For stable COPD patients with respiratory symptoms and FEV1 between 60% and 80% predicted, treatment with inhaled bronchodilators may be used.

3. For stable COPD patients with respiratory symptoms and FEV1 <60% predicted, inhaled bronchodilators should be used.

4. Clinicians should prescribe monotherapy using either long-acting inhaled anticholinergics (LAMA) or long-acting inhaled β-agonists (LABA) for symptomatic patients with COPD and FEV1 <60% predicted.

5. Clinicians may administer combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled β-agonists, or inhaled corticosteroids, LABA/ICS) for symptomatic patients with stable COPD and FEV1<60% predicted.

6. Clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an FEV1 <50% predicted. Clinicians may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV1 >50% predicted.

7. Clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (PaO2 ≤55 mm Hg or SpO2 ≤88%).

References:

Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. ACP, 08/2011. Annals of Int Medicine, 2011.

Image source: Enlarged view of lung tissue showing the difference between healthy lung and COPD, Wikipedia, public domain.

Blood Management Summit and App - Transfuse 2012

Announcement: Blood Management Summit - Transfuse 2012 will be held on April 19-20, 2012 at the JW Marriott in Scottsdale, Arizona.

This conference has been developed with collaboration between Mayo Clinic and Hartford Hospital, building upon the success of three previous national conferences. "Transfuse 2012" is a unique multi-disciplinary conference focused on exploring the current state-of-the-art techniques and programs to reduce allogeneic blood utilization in hospitals. This international conference will feature national and international blood management experts from China, New Zealand and Australia along with a unique iPad app launch and one-of-a-kind hands-on animal lab.

Mayo Clinic's Mark H. Ereth, M.D. introduces the conference and the iPad app in this 3-minute video:



This conference is designed for all physicians, including surgeons and anesthesiologists, perfusionists, nurses and leaders in quality and patient safety. The conference is a CME accredited activity for physicians, nurses and perfusionists.

The Conference Website is: http://www.mayo.edu/cme/anesthesiology-2012r780

One of the course directors is Dr. Ajay Kumar, Chief of Division of Hospital Medicine at Hartford Hospital, and a good friend of mine. Another friend from the time I worked at Cleveland Clinic is also on faculty, Dr. Moises Auron.

It should be a great conference. Go check it out.

Mayo Clinic Offers Dietary Supplements, Stress Management, Massage and Acupuncture in the Mall of America

Cleveland Clinic has a Wellness Institute. In another push to the realm of wellness, Mayo Clinic now offers one-on-one consults with Complementary and Integrative Medicine physicians on campus and where the customers are - right in the Mall of the America. See this 3-part video series below:



Brent A. Bauer, M.D. Dr. Bauer is a physician in the Department of General Internal Medicine and supervisor of the Complementary and Integrative Medicine Research program at Mayo Clinic.



Nancy Drackley, a physical therapist, massage therapist, and supervisor of massage therapy at Mayo Clinic.



Tony Chon, M.D, a physician in the Department of General Internal Medicine and a member of the Complementary and Integrative Medicine team at Mayo Clinic, discusses acupuncture.

Guidelines for Management of Acute Bacterial Sinusitis by Infectious Diseases Society of America

A bacterial cause accounts for 2%-10% of acute rhinosinusitis cases.


Nose and nasal cavities. Image source: Wikipedia, public domain.

Recommendations for Management of Acute Bacterial Sinusitis by the Infectious Diseases Society of America (IDSA):

Bacterial rather than viral rhinosinusitis should be diagnosed when any of the following occurs:

- persistent symptoms lasting at least 10 days, without improvement
- symptoms or high fever and purulent nasal discharge or facial pain for 3–4 days at illness onset
- worsening symptoms after an initial respiratory infection, lasting 5–6 days, has started to improve.

Empirical therapy should be started as soon as acute bacterial rhinosinusitis is diagnosed clinically.

Amoxicillin-clavulanate, instead of amoxicillin alone, is recommended for both children and adults.

Macrolides and trimethoprim-sulfamethoxazole are not recommended as empirical therapy, because of high rates of antimicrobial resistance.

References:

Algorithm for the management of acute bacterial rhinosinusitis (figure)
Guideline Issued for Managing Acute Bacterial Rhinosinusitis - Physician's First Watch http://bit.ly/TGn6aM
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults http://bit.ly/TGnaHB

The management of ingrowing toenails - BMJ review

Ingrowing toenails are common, cause serious disability, and affect mainly young men. Most patients with ingrowing toenails are usually male, between the ages of 15 and 40 years.

There is a spectrum to the clinical presentation with pain progressing to infection, hypergranulation, and finally chronic infection.

Ingrowing toenails can occur in normal or abnormally shaped nails.

Cases in abnormally shaped nails are more difficult to manage conservatively and usually require surgery

Historically, a recurrence rate of 13-50% has been reported after surgical treatment, although more recent papers have reported recurrence rates of less than 5%.

Symptoms are less likely to recur after partial nail avulsion and segmental phenol ablation than after simple nail avulsion or wedge excisions alone.

Podiatrist Dr. Matthew Neuhaus explains what an ingrown toenail is (video):



Ingrown toenail surgery by Dr. Leo Krawetz (video). Warning: graphic content, do not try this at home:



References:

The management of ingrowing toenails. BMJ, 2012;344:e2089.
Nail Abnormalities: Clues to Systemic Disease - a good review from American Family Physician http://buff.ly/1irL0kQ

Approach to evaluation and management of syncope in adults - BMJ Review

Syncope is common in all age groups, and it affects 40% of people during their lifetime, usually described as a "faint" or "blackout".

Neurally mediated syncope, which is benign, is the most common cause

Cardiac syncope as a result of arrhythmias or structural cardiopulmonary disease is more common with increasing age. Cardiac syncope is associated with increased mortality and must be excluded.

Brain imaging, carotid Doppler ultrasound, electroencephalography, and chest radiography are often not needed in patients with syncope.

References:

An approach to the evaluation and management of syncope in adults. BMJ 2010;340:c880.
http://www.bmj.com/cgi/content/short/340/feb19_1/c880

Image source: Illustration of the human brain and skull. Wikipedia, Patrick J. Lynch, medical illustrator, Creative Commons Attribution 2.5 License 2006.