Acute altitude illnesses

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.

What do extreme athletes who can summit the peaks of Mt. Everest have in common with people with heart failure? This Mayo Clinic video explains it:



References:

Clinical Review: Acute altitude illnesses. BMJ 2011; 343:d4943 doi: 10.1136/bmj.d4943
High-Altitude Medicine http://buff.ly/UGjp6Q

Acute pyelonephritis in women (2011 review)

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

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

Acute low back pain: What to do? What works and what doesn't?

Here is an excerpt from a recent review article in the official AFP journal American Family Physician:

Acute low back pain is one of the most common reasons for adults to see a physician. Most patients recover quickly with minimal treatment.

"Red flags"

Serious "red flags" include:

- significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis)
- major or progressive motor or sensory deficit
- new-onset bowel or bladder incontinence or urinary retention
- loss of anal sphincter tone
- saddle anesthesia
- history of cancer metastatic to bone
- suspected spinal infection

Diagnosis

Without signs of serious pathology, imaging and laboratory testing often are not required.

Treatment

Patient education, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and muscle relaxants are beneficial.

Bed rest should be avoided, if possible.

Exercises directed by a physical therapist, such as the McKenzie method and spine stabilization exercises, may decrease recurrent pain.

Spinal manipulation and chiropractic techniques are no more effective than established medical treatments.

No substantial benefit has been shown with:

- oral steroids
- acupuncture
- massage
- traction
- lumbar supports
- regular exercise programs

References:

Diagnosis and treatment of acute low back pain. Casazza BA. Am Fam Physician. 2012 Feb 15;85(4):343-50.

Image source: Different regions (curvatures) of the vertebral column, Wikipedia, public domain.

Acute otitis externa

What is Acute otitis externa?

Acute otitis externa is a common condition involving inflammation of the ear canal. It is caused by bacteria such as Pseudomonas aeruginosa and Staphylococcus aureus. Acute otitis externa often occurs following swimming or minor trauma from inappropriate cleaning.

What are the symptoms of Acute otitis externa?

The rapid onset of ear canal inflammation leads to otalgia (earache), itching, canal edema, erythema, and otorrhea. Tenderness with movement of the tragus or pinna is a classic finding.

What is the treatment for Acute otitis externa?

For uncomplicated cases, use topical antimicrobials or antibiotics such as acetic acid, aminoglycosides, polymyxin B, and quinolones. Some of these agents come in preparations with topical corticosteroids which may help resolve symptoms more quickly.

There is no evidence that any one antimicrobial or antibiotic preparation is clinically superior to another. Here two suggested approaches:

- Neomycin/polymyxin B/hydrocortisone preparations are a reasonable first-line therapy when the tympanic membrane is intact.

- Oral antibiotics are used when the infection has spread beyond the ear canal or in patients at risk of a rapidly progressing infection.

References:

Acute otitis externa: an update. Schaefer P, Baugh RF. Am Fam Physician. 2012 Dec 1;86(11):1055-61.
Image source: Wikipedia, a GNU Free Documentation License.

Acute bronchitis: Many patients expect to be treated with antibiotics and cough meds but this differs from guidelines

Mind map of differential diagnosis of cough. See more Allergy and Immunology mind maps here.

Cough is the most common symptom bringing patients to the primary care physician's office. The most common diagnosis in these patients is acute bronchitis, according to a recent review in the official journal of AFP, American Family Physician.

Acute bronchitis should be differentiated from other common causes of cough such as pneumonia and asthma - because the therapies are clearly different.

Symptoms of acute bronchitis typically last 3 weeks. As we already know, the presence of colored (e.g., yellow or green) sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections. This conclusion was contradicted by a recent study: Green or yellow phlegm likely to be bacterial - confirming beliefs by doctors and patients alike (http://goo.gl/zff8X and http://goo.gl/cwKGs).

Viruses cause more than 90% of acute bronchitis, and therefore, antibiotics are generally not indicated. They should be used only if pertussis is suspected to reduce transmission or if the patient is at increased risk of developing pneumonia (e.g., patients 65 years or older).

The typical therapies that have been traditionally used for managing acute bronchitis symptoms have been shown to be ineffective. The U.S. Food and Drug Administration recommends against using cough and cold preparations in children younger than 6 years.

The supplement pelargonium may help reduce symptom severity in adults.

Many patients expect to be treated with antibiotics and cough medications but this differs from evidence-based recommendations.

The CNN video below tries to decipher what hides behind the names of common cough and cold medications:

References:

Diagnosis and treatment of acute bronchitis. Albert RH. Am Fam Physician. 2010 Dec 1;82(11):1345-50.