My Medicine Notes

Good article: Botulinum toxin in facial plastic surgery

General Techniques:

• Inject while retracting
• Patient in a 60 degree recline
• Touch up 2 weeks later if needed
• Use white eyeliner to mark safety zones
• Compress injection sites firmly away into safety zone
• Wipe area with EtOH swab
• Inject with muscles contracted (Frown and Forehead)

USE epinephrine!

• Corticosteroids and diphenhydramine help stave off rebound anaphylaxis

• Empiric 6 food elimination diet (SFED) resolves inflammation in 66% of patients
  • Milk, Wheat, Soy, Eggs, Treenuts/peanuts, and fish/shellfish
• Food elimination based on allergy testing resolves esophageal inflammatiton in 50% of patients
  • Often (69%), patients are able to identify a single food trigger
• Medication options for eosinophilic esophagitis include
  • Topical steroids delivered via an asthma inhaler and then swallowed
  • PPI
• Dysphagia with eosinophilic esophagitis is often secondary to esophageal strictures, which can be treated with endoscopic dilation

Causes:

• Dairy: 50%
• Wheat: 31%
• Soy
• Egg: 36%
• Nuts
• Fish/Shellfish

References:

• AFP Vol 103 No 9 May 2021
• Zalewski A, Doerfler B, Krause A, Hirano I, Gonsalves N. Long Term Outcomes of the Six Food Elimination Diet and Food Reintroduction in a Large Cohort of Adults with Eosinophilic Esophagitis. Am J Gastroenterol. 2022 Aug 12. doi: 10.14309/ajg.0000000000001949. Epub ahead of print. PMID: 35971213.

Risk factors (OR):

• Latex allergy (7.9)
• Asthma (3.2)
• Urticaria (2.9)
• Insect venom allergy (2.50
• Allergic rhinitis (2.3)
• Atopic dermatitis (1.9)
• Medication allergy (1.9)

Reduce risk:

• Early introduction of peanuts, cow's milk, wheat, and cooked eggs between 4-6 mo decreases risk of developing food allergies
• Early introduction of peanuts and cooked eggs at 4-6 mo is safe and effective for reducing risk of food allergy

Reference:

• AFP Vol 108 No 2 Aug 2023

IgM

• IgM antibodies are produced by the body immediately after the exposure to a specific antigen
• Mainly found in blood and lymph fluid
• Quantity produced upon exposure to the antigen is nearly 6 times as much of IgG
• IgM antibodies usually also have 10 binding sites (compared to only 2 in IgG)
  • Only about half of the binding sites can actually be used to bind IgM to an antigen
• IgM is multivalent: Multiple monomers are bonded together
• Temporary - disappear within 2 to 3 weeks following infection

IgG

• IgG refers to an immunity for a particular disease
• A late stage response as compared to IgM
• Abundant in the body
• Protects against various disease causing foreign agents
• IgM antibodies are replaced by IgG antibodies that last for life time

1. Evaluate patients with skin testing
2. If positive: treat with venom immunotherapy

Reference:

• AFP Vol 106 No 6 Dec 2022

5As for Adults

The 5A's provide health practitioners with five steps to better manage their patients' health issues (such as smoking cessation or weight loss):

• ASK for permission to discuss weight and explore readiness
• ASSESS obesity related risks and 'root causes' of obesity
• ADVISE on health risks and treatment options
• AGREE on health outcomes and behavioral goals and followup
• ASSIST in accessing appropriate resources and providers

References:

• http://www.obesitynetwork.ca/5As

1. Catastrophizing: Imagining the worst possible outcome. "I will get fired if the presentation has any glitches."
2. Mind reading: Imagining what others are thinking. "I know he doesn’t like working with me because he thinks I’m dumb."
3. Fortune telling: Imagining what the future holds, but without data. "They will all hate me in the new group because I’m the only one who isn’t a physicist."
4. Black-and-white thinking: Considering only two possible outcomes. "I’ll either hit a home run or get fired."
5. Overgeneralizing: Painting all situations with a generalized outcome. "I presented to the CEO last year, and it didn’t go well. I never get things right or always fail when it comes to executive audiences."

How to get out of the traps:

• Pause the pattern.
• Name the trap.
• Separate FUD from fact. Create a two-column list. On one side list all your fears, uncertainties, and doubts, or FUD. The second column is for verified facts.
• Tell more stories. When we’re anxious, we tend not only to believe our own stories, we believe the most extreme and negative forms of them. Instead of curbing this reflexive habit, indulge it. Compose three separate stories and ensure they’re very different from each other.
• Walk your talk. Ask yourself what you’d advise others to do.

BATHE for Primary Care Counselling

• Background
• Affect
• Trouble
• Handling
• Empathy

Children's Medication Clinic - Serious behavioral and emotional problems not requiring inpatient

• Up to 17yo
• Princeton Plaze
• 1800 Mercy dr
• Orlando, FL 32808
• 507-875-3700

• Focuses on the identification and modification of dysfunctional thoughts to improve affect
• Cognitive restructuring
  • Help patients change the way they think about themselves
  • Address catostrophic thinking
  • Treach patients to view a setback as a temporary lapse
  • Teach positive thinking (like replace thoughts that undermine weight management efforts)

Behavior Therapy:

• Change behavior and the feelings will follow
• Reinforce or extinguish a behavior (rewards, aversive stimuli, restructured environment)
• Relaxation training (music, progressive body relaxation, yoga, deep breathing, walks, etc)

Components of Behavioral Therapy:

1. Self-monitoring
   • Daily records of food intake, physical activity, weight
2. Stimulus control
   • Avoidance, narrowing, use of inhibitory stimuli to reduce triggers
3. Problem solving
   • Define the problem; brainstorm solutions; implement strategy
4. Goal setting
   • Establish dietary and weight goals
5. Contingency management
   • Develop recovery methods from overeating or weight gain
6. Enlist social support
   • Recruit family/friends to help modify lifestyle behaviors
7. Relapse prevention training
   • Expect setbacks; be prepared; view as temporary
8. Stress management
   • Decrease negative impact of stress on positive behavior patterns
9. Rewards
   • Congratulate self on successes, not mistakes; plan rewards for achieving goals
10. Ongoing contact
    • To maintain progress, most programs require short interval appointments

Reference:

• OMA Review Course 2016

• Regularly practice relaxation techniques
  • Deep breathing
  • Muscle relaxation
• Make a list of worries in the evening before bedtime and give yourself permission to address them tomorrow
• Enlist or accept emotional support from others
• Reduce caffeine consumption gradually (FDA recommends <400 mg for adults)
• Adopt effective sleep hygiene practices
• Use a digital application to promote self-help
  • Search in app store for: wellness, sleep, stress, etc

References:

• JFP Vol 69, No 7 Sep 2020

STOPP is CBT in a nutshell.

• Learn this ONE KEY SKILL and you can start to take control of your emotions and your life.
• "Between stimulus and response there is a space. In that space lies our freedom to choose our response. In our response lies our growth and our freedom". Viktor Frankl.

STOPP

1. STOP !
   • Just pause for a moment
2. TAKE A BREATH
   • Notice your breathing as you breathe in and out. In through the nose, out through the mouth.
3. OBSERVE
   • What thoughts are going through your mind right now?
   • Where is your focus of attention?
   • What are you reacting to?
   • What sensations do you notice in your body?
4. PULL BACK - PUT IN SOME PERSPECTIVE
   • DON'T BELIEVE EVERYTHING YOU THINK!
   • What's the bigger picture?
   • Take the helicopter view.
   • What is another way of looking at this situation?
   • What advice would I give a friend?
   • What would a trusted friend say to me right now?
   • Is this thought a fact or opinion?
   • What is a more reasonable explanation?
   • How important is this? How important will it be in 6 months time?
   • It will pass.
5. PRACTISE WHAT WORKS - PROCEED
   • What is the best thing to do right now?
   • What is the most helpful thing for me, for others, for the situation?
   • What can I do that fits with my values?
   • Where can I focus my attention right now?
   • Do what will be effective and appropriate.

HOW TO USE STOPP:

• Practise the first two steps often for a few days - many times every day at any time.
• Read through the steps often.
• Carry written reminders with you (use the printable resources below).
• Practise STOPP by running through all the steps several times a day, every day…when you don't need it.
• Start to use it for little upsets.
• Gradually, you will find that you can use it for more distressing situations. Like any new habit or skill, it will become automatic over time.

References:

• https://www.getselfhelp.co.uk/stopp.htm
• https://www.youtube.com/watch?v=3NHZkQ57wzE

Apps:

• https://play.google.com/store/apps/details?id=stopp.submarine.gg&hl=en
• https://itunes.apple.com/us/app/stopp-app/id1242381115?mt=8

How to have EMPATHY

• Eye contact - establish
• Muscles of facial expression
• Posture (open/closed)
• Affect - recognize
• Tone of voice - recognize
• Hear the whole person (understand the context)
• Your response

References:

• TED. (2013, December 12). Dr. Helen Riess: The power of empathy [Video file]. Retrieved from https://www.youtube.com/watch?v=baHrcC8B4WM

Learning to gradually face your fears is one of the most effective ways to break the OCD cycle. For OCD, the technique for facing fears is called exposure and response prevention (ERP).

ERP is done by:

• Exposing (E) yourself to situations that bring on obsessions (triggers)
• Not engaging in the unhelpful coping strategies that include compulsions or rituals, and avoidance (Ritual Prevention- RP)

Steps:

1. Step 1: Get to know your OCD better
   • To face your fears, it is helpful to know what you are thinking (your obsessions) and identify the triggers that bring on your obsessions and compulsions.
   • You can do this by keeping track of the triggers on a daily basis for 1 week by using the Obsessive Fear Monitoring Form. (see end)
   • Because obsessions can happen frequently, writing down 3 triggers per day (e.g. 1 in the morning, 1 in the afternoon, and 1 in the evening) will be enough to give you a good overview of your obsessions and compulsions.
   • In the column labeled ¡§Fear¡¨, rate how intense the fear was in the specific situation. Use a 0-10 rating scale, where 0 = no fear and 10 = extreme fear.
   • Finally, record all the compulsions/coping strategies you used in response to the obsession. Be sure to include both behavioural and/or mental strategies you used to manage the obsession and fear.
2. Step 2: Build a fear ladder
   • After about 1 week of tracking your obsessions and compulsions, you will be ready to make a list of all the different situations that you fear.
   • Build a fear ladder by rank, ordering your triggers from least scary to most scary. For example, if you have contamination fears, being at a friend¡¦s apartment may be a situation that is low on the fear ladder because it only evokes a fear of 1/10. But using the bathroom in a shopping mall may be a situation that is very high on the ladder because it evokes a 9/10 fear. See Examples of Fear Ladders for some ideas about building your fear ladder.
     • TIP: Build a separate ladder for each of your obsessive fears. For example, you may need a separate hierarchy for all situations related to your fear of contamination. You may also need a separate ladder for all situations related to your fear of causing something terrible to happen.
3. Step 3: Climb the fear ladder ¡V ERP
   • Once you have built a fear ladder, you are ready to face your fears by putting yourself in situations that bring on your obsessions (exposure), while resisting doing anything to control the obsessions and the anxiety associated with them (response prevention).

KEY POINTS TO MANAGING YOUR OCD (see Facing your Fears: Exposure for more tips):

• Bottom up. Start with the easiest item on the fear ladder first (i.e. fear=2/10) and work your way up.
• Track progress. Track your anxiety level throughout the exposure exercise in order to see the gradual decline in your fear of a particular situation. Use the Facing Fears Form to help you do this.
• Feeling anxious when you try these exercises is a sign that you are on the right track. If you¡¦re not anxious you might be too low on your ladder, and if you are feeling flooded with excessive anxiety, chances are you started too high up on the ladder. Remember that regardless of how intense your fear is, it will peak and then level off. What goes up must come down! Even if you do nothing about it the fear will eventually go away on its own.
• Don¡¦t avoid. During exposure, try not to engage in subtle avoidance (e.g. thinking about other things, talking to someone, touching the doorknob only with one finger instead of the whole hand, making mental promises to de-contaminate later on, etc.). Avoidance actually makes it harder to get over your fears in the long term.
• Don¡¦t rush. It is important to try to stay in the situation until your fear drops by at least half (e.g. from 6/10 to 3/10), or until you notice a significant reduction from your fear at the start (e.g. from 7/10 to 4/10). Also, focus on overcoming 1 fear at a time. It is a good idea to do the exposure repeatedly until the first item on the hierarchy no longer causes much of a problem for you.

Engaging in Response Prevention

• Resist the urge. In order for exposure to work, it is important that you try to resist, as much as possible, carrying out your compulsions during or after the exposure. The whole point of ERP is to learn to face your fear without having compulsions.
• Modeling. If you have been performing compulsions for some time, it may be difficult to know how to face a feared situation without doing them. In this case, it can be helpful to ask a family member or a close friend who does not have OCD to show you how to, for example, wash hands quickly or leave home without rechecking appliances, and then model, or copy, their behaviour.
• Delaying and reducing ritualizing as an alternative. You might find it very difficult to completely resist a compulsion, especially the first time you are facing your fears. In that case, you can try to delay acting on the compulsion rather than not doing it at all. For example, after touching the floor (exposure), wait for 5 minutes before washing your hands, and wash for 1 minute instead of 3 minutes. Try to gradually prolong the delay, so that you can eventually resist the compulsion altogether.
• Re-exposure. If you do end up performing a compulsion, try to re-expose yourself to the same feared situation immediately, and repeat the practice until your fear drops by half. For example, Practice 1: touch the floor and wait for 5 minutes before washing hands for 1 minute. Practice 2: touch the floor again immediately after washing, and wait for another 5 minutes before washing for 1 minute. Repeat this process until your anxiety drops from, say, 6/10 to 3/10.

How to move on.

• Once you experience only a little anxiety when completing an exercise, you can move on to the next one.
  • For example, after several practices, you might feel very little anxiety when you wait 5 minutes to wash your hands after touching the floor. You can then challenge yourself to wait for 8 minutes before washing your hands after touching the floor. Again, repeat this practice until your anxiety drops by half or is significantly reduced from where it was at the start.

References:

• https://www.anxietycanada.com/adults/exposure-therapy-ocd-erp
• https://www.getselfhelp.co.uk/ocd.htm

#+Obsessive Fear Monitoring Form

#+Example Fear Ladder

#+Daily Exposure Practice Form Task:_________________________ Ritual prevention (or delay)_____________________________ Expected Initial Distress rating % (before starting Exposure)________________________ Goal: Distress level % (after Exposure) _ Frequency of Exposures _ times per __ (day/week)

Distress Rating 0-100 (No or minimal/Moderate/Severe/Worst ever distress) Use this form when undertaking Exposure & Response Prevention (ERP), when NOT responding to the urge to perform a ritual or compulsion. It is normal to feel very anxious and distressed at the thought of either delaying or not doing the ritual

Extreme in theater:

• Separate / Hold / Monitor until able to address
• Judiciously restrain
• Neurolepticize if needed with caution

Not as extreme in theater: (PIE)

• P - Proximity - Start treatment as far forward as possible
• I - Immediacy - Treatment begins ASAP
• E - Expectancy - Instill expectancy in SM that they will return to duty

4 Steps:

1. H&P
2. BATHE
   • Background: What happened?
   • Affect: How does it make you feel?
   • Troubles: What troubles you about _ ?
   • Handle: How are you handling _ ?
   • Empathy: Demonstrate empathy
3. Mental Status Exam / SIG E CAPS
4. Eval though content/process, ego mechanisms (impulses, coping skills, etc)
5. Disposition

• Acknowldege
• Notice triggers
• Remember why

Example:

• Acknoledge pain when it occurs
• Notice whether something is making it worse in the moment
• Remember the top 3 reasons that you want to stay off opioids:
  • My kids
  • I do not want to be dependent on something
  • My health

NAME it to Tame it:

• Notice
  • Notice the strong emotions that are occurring and name them (anger, fear, unease, etc)
  • Choose a word to describe the emotional reaction
• Acknowledge
  • Acknowledge this emotion and calmly hover over it to allow your executive brain to filter and organize it
• Make room
  • Make room for the emotion. Be with the anger, fear, and unease without explaining it.
• Expand awareness
  • Expand awareness and monitor strong emotions so that the emotions do not take over when they return

Reference:

• AFP Nov 2023 Vol 108, No 5

• Spirit of MI: Emphasizes personal choice and control
  • Collaborative: Partnership between patient and clinician
  • Evocative: Reasons to change come from the patient rather than the doctor
  • Autonomy supporting: Ultimately the patient decides what to do
• Four Guiding Principles: (RULE)
  1. R - Resist the righting reflex
  2. U - Understand your patient's motivation
  3. L - Listen (actively) to your patient
  4. E - Empower your patient
• Guiding Principles: (GRACE)
  1. G - Generate a gap (develop discrepancy)
  2. R - Roll with resistance
  3. A - Avoid arguments
  4. C - Can do (support self efficacy)
  5. E - Express empathy
• Key Processes:
  • Engagement
    • Set the agenda collaboratively
    • Non-judgemental
    • Patient-centered
  • Focusing
    • Develop the conversation around a single issue
  • Evoking (DARN)
    • Move the conversation toward a prepatory change talk
    • D - Desire to change (want, like, wish..)
    • A - Ability to change (can, could..)
    • R - Reasons to change (if..then)
    • N - Need to change (need, have to, got to..)
    • Importance ruler (scale 1-10)
  • Planning
    • Explore barriers to change
    • Fascilitate change
    • Explore commitment
• Practitioner Approach: (OARS)
  • O - Open questions
  • A - Affirmations
  • R - Reflections
  • S - Summaries
• Motivational Interviewing:
  1. Agenda setting - Would you mind if I talked with you about your weight?
  2. Exploration
     • Patient's desire - Are you interested in being more active?
     • Patient's ability - Would you be able to walk for 30min each day?
     • Patient's reasons - You mentioned you are now more open to exercising. What makes you open to it now?
     • Patient's need - How important is it that you get more fit?
  3. Providing information - Obesity has been linked to a greater risk of DM. Losing even a modest amount of weight can lower your risk. There are several options available to help you.
  4. Listening and summarizing - It sounds like you are interested in seeing a dietition for nutrition advice but are worried about finding the right one.
  5. Generating options and contracting - It sounds like you have several good ideas about how to reduce your calorie intake. Which one do you think would work best? I look forward to hearing about it at our next appointment.

References:

• CME Bulletin - Diagnosis and Management of Obesity
• FPM Sep/Oct 2016
• OMA Review Course 2016

Act opposite to the emotional urge in the service of pursuing values or goals.

• Many often become obsessively focused on pain or anxiety that they allow it to limit their participation in activities
• They can instead engage in counteractivities, within reason, despite pain or anxiety being present.
• They can engage in activities (physical and mental) as tolerated despite feeling pain or anxiety

PLISSIT

• Permission
• Limited Information
• Specific Suggestions
• Intensive Therapy

1. Identify percieved risks and benefits
2. Address percieved risks and benefits
3. Establish ease of use
4. Make a plan

References:

• JFP 2013;62(12 suppl CME):S20-S26

1. Pre-contemplation (Start MI here)
2. Contemplation (MI)
3. Preparation (use CBT here)
4. Action (CBT)
5. Maintenance (CBT)

Reference:

• OMA Review Course 2016

Catastrophize:

• On hearing uncertain news, you imagine the worst possible outcome

Catastophizers learn to choose the worst possible outcome because it allows for the greatest sense of relief when they are reassured.

Catastrophizers rush to external sources to calm themselves down:

• checking whether anyone else has "come through" the same problem;
• matching symptoms online to obtain a diagnosis and treatment options;
• asking a professional to tell them that they will survive.

Once they are reassured, they feel better, they have "rewarded" this seeking behavior. The next time they feel uncertain or threatened, they will ratchet up their anxiety with a catastrophic thought, then look outwards for reassurance even faster than before.

In this way, catastrophizing soon becomes a well-entrenched habit. The greatest problem with seeking others to alleviate anxiety is that it offers only temporary relief.

Plan for tackling anxiety:

1. Accept yourself.
   • Anxiety is energy. Look for enjoyable ways to challenge yourself and use your energy more positively:
     • Taking regular aerobic exercise.
     • Learning something new.
     • Taking up a creative passion.
2. Take control.
   • Establish a regular "worry time".
     • Start by setting aside half an hour every day. Write down all your concerns in specific terms
     • Assign a score on a scale of 0 to 100% to estimate how distressed this possibility makes you feel
     • List all the possible explanations for your concern, then rank each one according to how likely it is to be correct
     • Score your worry for the level of distress it is causing you now. Gradually, you will be able to reduce the amount and frequency of worry time.
3. Use the "best friend test".
   • Ask yourself what you would advise your best friend to do about each concern, and take that action
4. Learn to self-soothe.
   • Whenever you are overwhelmed by anxiety and feel you must seek reassurance, give yourself permission to do so – but not straight away.
     • Start with 2 min.
       • Breathing slowly in through your nose and out through your mouth, or taking some gentle exercise, will help.
       • Gradually, you will find you can wait longer.
       • When you get to the point where you can wait more than 20 minutes, most people find they no longer need to be reassured by others.

1. Rate
2. Blood Pressure
3. Preload
4. Contractility

1. Herpertrophic Cardiomyopathy
2. WPW
3. Long QT
4. Congenital Aortic Stenosis
5. Anomalous coronary

Reference:

• AFP Aug 2022 Vol 106 No 2

This simple, seven step list has been developed to deliver on the hope we all have–to live a long, productive healthy life.

1. High blood pressure
2. Cholesterol
3. Blood Sugar
4. Diet
5. Physical Activity
6. Weight
7. Smoking

References:

• https://www.ncbi.nlm.nih.gov/pubmed/25908393
• http://heartinsight.heart.org/Lifes-Simple-7/

Increase Factors that enhance risk:

• FH of premature ASCVD (M<55, F<65)
• Primary HLD (LDL 160-189, non-HDL 190-219)
• Metabolic syndrome
• CKD
• Chronic inflammatory condition
• Premature menopause (<40) or h/o pre-eclampsia
• High risk race or ethnicity (South Asian ancestry)
• Lipid levels and other biomarkers associated with incresaed 10y ASCVD:
  • Persistent hypertriglyceridemia (>175)
  • High sensitivity CRP >=2
  • Lipoprotein A >=50
  • Apolipoprotein B >= 130
  • Ankle-brachial index < 0.9

Anticoagulation

• Anticoagulation is recommended for AF at a CHA2DS2-VASc score of 2 for men and 3 for women without moderate or severe mitral stenosis or a mechanical valve.
  • The score has not been validated for mitral stenosis or mechanical valves.
• Direct oral anticoagulants are recommended over warfarin for AF without moderate or severe mitral stenosis or a mechanical valve.
  • Warfarin is still recommended for mitral stenosis and mechanical valves.
• Although CHA2DS2-VASc scores of 0 for men and 1 for women do not require treatment, scores of 1 for men and 2 for women are indeterminate and anticoagulation may be considered by shared decision-making.

Rate Control

• Ventricular rate control is accepted as alternative to rhythm control for first-line management of chronic AF
• Lenient rate control (<110bpm) is as effective as strict (<80bpm)
• A beta-blocker is preferred for rate control in those with CAD or systolic dysfunction
• Verapamil or diltiazem may be preferred in those with asthma
• Amiodarone may be effective if other drugs have failed

Rhythm Control

• Treatment of choice for urgent conversion is DC cardioversion

References:

• AFP Vol 101 No 2 Jan 2020
• JAMA Vol 322 No 18 Nov 2019

Risk for Major Cardiac Complications following surgery

Assign a point for each:

1. High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular)
2. H/o MI or pos GXT, or current chest pain secondary to myocardial ischemia, current nitrate therapy, or EKG with pathologic Q wave
3. H/o CHF, pulmonary edema, r paroxysmal nocturnal dyspnea; or current bilateral rales, S3, or CXR with pulmonary vascular redistribution
4. H/o cerebrovascular disease
5. Preoperative treatment with insulin
6. Preoperative serum creatinine >2.0mg/dL

Surgical risk category

• High (Cardiac risk >5%)
  • Aortic or other major vascular surgery
  • Peripheral vascular surgery
• Intermediate (Cardiac risk 1-5%)
  • Carotid endarterectomy
  • Head and neck surgery
  • Intraperitoneal or intrathoracic surgery
  • Orthopedic surgery
  • Prostate surgery
• Low (Cardiac risk <1%)
  • Superficial procedures
  • Breast surgery
  • Cataract surgery
  • Endoscopic procedures
  • Most ambulatory surgeries

References:

• AFP Vol 85 No 3 Feb 2012

• ACE Inhibitors
  • Indications
    • Patients with hypertension, diabetes mellitus, chronic kidney disease, abnormal left ventricular function, systolic heart failure, or recent MI
  • Comments
    • Decrease mortality rates Use caution in pregnant women and in patients with angioedema, renovascular disease, or hyperkalemia
• Angiotensin receptor blockers
  • Indications
    • Patients in whom ACE inhibitors are not tolerated
  • Comments
    • No additional benefit vs. ACE inhibitors Use caution in pregnant women and in patients with angioedema, renovascular disease, or hyperkalemia
• Beta blockers
  • Indications
    • First-line therapy in patients with history of MI, acute coronary syndrome, systolic heart failure, angina pectoris, atrial fibrillation, or atrial flutter Consider for patients with essential tremor, hyperthyroidism, or migraine
  • Comments
    • Decrease mortality rates Use caution in older patients (may increase stroke risk) and in those with bronchospastic disease, second- or third-degree heart block, symptomatic bradycardia, or depression
• Calcium channel blockers
  • Indications
    • Consider for patients whose symptoms are not controlled with or who cannot tolerate beta blockers, and for patients with Raynaud disease Can be used in patients with angina pectoris, atrial fibrillation, or atrial flutter
  • Comments
    • Use long-acting nondihydropyridines; avoid short-acting nifedipine Use caution in patients with second- or third-degree heart block
• Nitrates
  • Indications
    • Patients with angina whose symptoms are not controlled with beta blockers or calcium channel blockers can use long-acting nitrates; short-acting nitrates can be used for quick relief of symptoms
  • Comments
    • Evidence lacking on mortality benefit Use caution in patients with hypotension
• Ranolazine (Ranexa)
  • Indications
    • Patients with recent MI or stable coronary artery disease Adjunctive therapy in patients whose symptoms are not controlled with beta blockers or calcium channel blockers, or in whom beta blockers are not tolerated
  • Comments
    • Does not lower blood pressure Use caution in patients with impaired liver function and in those taking QT-prolonging medications

References:

• AFP Vol 97 No 6 Mar 2018

1. Coronary circulation
2. Arrhythmia
3. Valves
4. Myocardium
5. Pericardium

Changes in Cardiorespiratory Fitness and Survival in Patients With or Without Cardiovascular Disease

• During a median follow-up of 6.3 years (IQR: 3.7-9.9 years), 18,302 participants died with an average yearly mortality rate of 27.6 events per 1,000 person-years.
• In general, changes in CRF ≥1.0 MET were associated with inverse and proportionate changes in mortality risk regardless of baseline CRF status.
  • For example, a decline in CRF of >2.0 METS was associated with a 74% increase in risk (HR: 1.74; 95% CI: 1.59-1.91) for low-fit individuals with CVD, and 69% increase (HR: 1.69; 95% CI: 1.45-1.96) for those without CVD.

Reference:

• Kokkinos P, Faselis C, Samuel IBH, et al. Changes in Cardiorespiratory Fitness and Survival in Patients With or Without Cardiovascular Disease. J Am Coll Cardiol. 2023;81(12):1137-1147. https://doi.org/10.1016/j.jacc.2023.01.027
• https://www.jacc.org/doi/pdf/10.1016/j.jacc.2023.01.027

Risk Factors:

• Age
• Smoking
• Diabetes
• HLD
• HTN

Surgical candidates:

• Patients with 50% stenosis of the artery and symptoms
• Patients with 70% or more stenosis

Risk of stroke during procedure:

• Open surgery: 2%
• Trans-Carotid Artery Revascularization (TCAR): between 2-4%
• Carotid Artery Stenting: 4%

After procedure: ASA or clopidogrel

Decision rule for likelihood of CAD as cause of Chest Pain

Likelihood of CAD as cause of Chest Pain

References:

• AFP Vol 96 No 5 Sep 2017

The following definitions are used to relate the CAC score to the extent of underlying coronary artery disease (3):

• Coronary calcium score 0: No identifiable coronary artery disease.
• Coronary calcium score 1-99: Mild coronary artery disease.
• Coronary calcium score 101-400: Moderate coronary artery disease.
• Coronary calcium score > 400: Extensive coronary artery disease.

When interpreting the CAC score, it is essential to consider age and gender. Women, in general, have lower calcium scores than men.

A calcium score calculator is available here that provides CAC score distribution based on age, gender, and ethnicity.

CAC score increases with age. Hence, at a certain age, we will be expected to have a specific CAC score that would be considered normal for that age. This score would then reflect the age of our arteries or the arterial age.

If everything is normal, we would expect our arterial age to be the same as our observed age.

However, if the CAC score is high, our arterial age may be higher than our observed age. Conversely, if our CAC score is low, the arterial age may be lower than our observed age.

The table below shows how arterial age can be predicted from the CAC score

Estimated Arterial Age and 95% Confidence Intervals by Coronary Artery Calcium Score

Guidelines for coronary calcium scoring by 2010 ACCF task force

These guidelines are latest at time of writing (July 2016):

• intermediate cardiovascular risk and asymptomatic adults (class IIa)
• low-to-intermediate risk and asymptomatic adults (class IIb)
• low risk and asymptomatic (class III)
• asymptomatic adults with diabetes mellitus, 40 years of age and older (class IIa)

Reference:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621006/
• https://radiopaedia.org/articles/agatston-score
• AJM Vol 134 No 9 Sep 2021

Stable coronary artery disease:

• Reversible supply/demand mismatch related to ischemia, a history of MI, or the presence of plaque documented on catheterization or CTA
• Stable if asymptomatic or controlled by medications or revascularization
• No evidence PCPI provides better outcomes than medical therapy for stable mod-severe CAD
  • ISCHEMIA Trial NEJM 4/2020

Treatment:

• Lifestyle changes
  • 30-60 min of mod-intensity aerobic activity (Reduces cardiovascular mortality - RR=0.74; 95% CI 0.64-0.86)
• Risk factor modification
• Antiplatelet and antianginal therapy
  • If NO recent stent placement
    • If no contraindication to ASA -> ASA 75-162mg daily
    • If contraindication to ASA -> Clopidogrel 75mg daily
  • If recent stent placement
    • Dual antiplateley therapy: ASA + P2Y12 (clopidogrel, ticagrelor, or prasugrel)
      • Drug eluting stent -> Continue for 6-12 mo
      • Bare-metal stent -> Continue for 1-12 mo
• Angina
  • Sublingual NG
  • B-blockers
  • If symptoms not controlled:
    • CCB
    • Long acting nitrate
    • Ranolazine
  • If persistent angina -> Consider CABG or PCI
• Heart Failure
  • Preserved EF -> Lifestyle modifications
  • Reduced EF:
    • Diuretics
    • B-Blockers
    • ACE inhibitors
    • Angiotensin receptor blockers
    • Lifestyle modifications

References:

• AFP Vol 97 No 6 Mar 2018

Post-CVA

• BP Goal: <130/80
• High dose statin (secondary prevention)

• Plasma acts on Fibrin breaking it into Fibrin Degradation Products (FDPs).
• One FDP is D-Dimer, which is 2 D domains of fibrin monomeres crosslinked by activated factor XIII.
• D-dimer is generated from fibrin (NOT fibrinogen) and thus its increase indicates recent or ongoing intravascular coagulation

Associated Disorders:

1. Arterial thromboembolic disease:
   • Myocardial infarction
   • Stroke
   • Acute limb ischemia
   • Atrial fibrilation
   • Intracardiac thrombus
2. Venous thromboembolic disease:
   • Deep vein thrombosis
   • Pulmonary embolism
3. Disseminated intravascular coagulation
4. Preeclampsia and eclampsia
5. Abnormal fibrinolysis; use of thrombolytic agents
6. Cardiovascular disease; congestive failure
7. Severe infection/sepsis/inflammation
8. Surgery/Trauma (eg: tissue eschemia, necrosis
9. Systemic inflammatory response syndrome
10. Vasoocclussive episode of sickle cell disease
11. Severe Liver disease (decreased clearance)
12. Malignancy
13. Renal disease
14. Normal pregnancy
15. Venous malformations

References:

• UptoDate.com Graphic 60881

References:

• Am Fam Physician. 2021 Jul ;104(1):73-78.

Egg consumption is not associated with the occurrence of cardiovascular events over an average of 12 years.

A meta-analysis found that eating more than one egg per day, on average, was associated with a decreased likelihood of coronary artery disease (approximately 11%). This decrease may be due to a healthy user bias; that is, eating eggs may be associated with healthy habits. (Level of Evidence = 2b)

Reference:

• Am Fam Physician. 2021 Jun 1;103(11):695.

All EKG interpretations should address:

• Rate
• Rhythm
• Intervals (PR, QRS, ST, QT)
• Axis
• P waves
• Q waves
• R wave progression
• T waves
• Any pathological findings

How I read:

1. Look at rhythm strip at bottom and count across
   • Gives me: rate, regular vs not, clue into interval abnormalities
2. Look at I and aVF
   • Gives me: axis deviation
3. Look at V1 and II
   • gives me atrial pathology - RAE/LAE

3b) If regular rate, look at aVR

• Gives me sinus vs ectopic focus (with caveats)

1. Scan for Q waves (not abnormal if only in III)
2. Look at R wave progression in V1-V6
   • Gives me: clues to LVH/RVH, BBB's, ideas extent of injury if actual MI
3. Scan for T wave abnormalities (not unusual to find odd T's in III)

Other thoughts:

• Sinus vs not sinus: sinus rhythm implies from sinus node - should be negative in aVR, positive everywhere else, not changing in morphology
• Regular vs sinus arrhythmia: While no widely accepted standard values exist, I was taught there should be less than 0.04 beat-to-beat variability and that is what I use to determine regular or not regarding heart rate variability

Favorite learning resources:

• ECG Wave-Maven: http://ecg.bidmc.harvard.edu/maven/mavenmain.asp (I have used this for years)
• Learn The Heart: http://www.learntheheart.com/EKGreview.html (Fun ECG quizzes)

1. Step 1: Rule out hypothyroidism
2. Step 2: Management
   • First line:
     • Metoprolol succinate (longer acting than tartrate)

Framingham Diagnostic Criteria (Need 2 Major or 1 Major and 2 Minor):

• Major
  • Acute pulmonary edema
  • Cardiomegaly
  • Hepatojugular reflex
  • Neck vein distension
  • Paroxysmal nocturnal dyspnea or orthopnea
  • Rales
  • Third heart sound gallop
• Minor
  • Ankle edema
  • Dyspnea on exertion
  • Hepatomegaly
  • Nocturnal cough
  • Pleural effusion
  • Tachycardia >120bpm

Stages of Heart Failure

Stage A - (At risk of HF)

• At high risk of heart failure, but without structural heart disease or symptoms of HF
• Therapy Goals:
  • Treat HTN / Lipids
  • Smoking cessation
  • Regular Excercise
  • Discourage EtOH intake and illicits
  • Control metabolic syndrome
• Therapy Management:
  • ACE I or ARB in appropriate patients for vascular disease or diabetes
  • Statins when indicated

Stage B (At risk of HF)

• Sturctural heart disease, but without signs or symptoms of HF
• Therapy Goals:
  • Prevent HF symptoms and worsening of cardiac remodeling
• Therapy Management:
  • ACE I or ARB in appropriate patients
  • B-Blocker in appropriate patients
  • Select patients:
    • ICD
    • Revascularization or valvular surgery

Stage C (HF)

• Structural heart disease with prior or current symptoms of HF
• Therapy Goals:
  • Control symptoms
  • Patient education
  • Prevent hospitalization
  • Prevent mortality
• Therapy Management:
  • Diuretics for fluid retention
  • ACE I or ARB
  • B-Blocker
  • Aldosterone antagonists
  • In selected patients:
    • Angiotensin receptor-neprilysin inhibitor
    • Digitalis
    • Isosorbide dinitrate/hydralazine
    • Cardiac resynchronization therapy
    • ICD
    • Revascularization or valvular surgery

Stage D (HF)

• Refractory HF requireing specialized intervention
• Therapy Goals:
  • Control symptoms
  • Improve quality of life
  • Reduce hospital admissions
  • Establish end-of-life goals
• Therapy options:
  • Compassionate end-of-life care/hospice
  • Deactivate ICD
  • Extraordinary measures:
    • Heart transplantation
    • Chronic inotropes
    • Temporary or permanent mechanical support
    • Experimental surgery or drugs

References:

• AFP Vol 96 No 10 Nov 2017
• AFP Vol 96 No 9 Nov 2017

Diagnostic Criteria

• At least 2 of the following:
  • Palpable purpura (mandatory)
  • Age =< 20y at disease onset
  • Abdominal pain or GI bleeding
  • Vessel wall granulocytes on biopsy
• Plus 1 of the following
  • Abdominal pain
    • Diffuse and colicky
  • Histopathology
    • Leukocytoclastic vasculitis or proliferative glomerulonephritis with predominant IgA deposition
  • Arthritis or arthralgia
    • Acute-onset joint pain or swelling
  • Kidney involvement
    • Proteinuria or hematuria

References:

• Consultant Oct 2016

• BP targets of 140/90 mmHg offer similar reduction in CV and all-cause mortality as lower targets and have fewer adverse effects
• Lower BP targets lead to a reduction in MI with NNT of 137 over 3.7 years
• Based on mortality - primary goal is < 140/90
• Lower BP leads to fewer MI, so might be beneficial trade for some

Reference:

• AFP Vol 106 No 6 Dec 2022

Statin intensity:

4 Reasons for statin initiation:

1. Secondary prevention (MI)
2. DM - 40-75yo and LDL - 70-189
3. LDL > 190
4. ASCVD >7.5%

In adults without history of CVD:

• Use a low to moderate statin for primary prevention of CVD events if the have all 3:
  1. Age 40-75yo
  2. At least 1 CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking)
  3. A calculated 10-yr ASCVD score >10%
• Adults 40-75yo with ASCVD 7.5%-10% and 1 CVD risk factor could benefit but it is much lower

References:

• JFP Vol 66 No 5 May 2017
• AFP Vol 97 No 9 May 2018

See: JNC 8

BP Goal:

• AAFP/ACP:
  • Treatment recommended for Adults 60+ with SBP >150 mmHg with target <150 mmHg to reduce risk of stroke, cardiac events, and possibly mortality (strong evidence)
  • Remember: 60-150-140
    • Patients >60yo, consider treatment is SBP is >150mmHg or >140mmHg if they have a history of stroke or in a high cardiovascular risk
• ACC/AHA:
  • Treatment recommended for noninstitutionalized, ambulatory, community-dwelling adults 65+ with avg SBP of 130+ mmHg with target < 130
  • No statistically significant benefit to all-cause mortality, CVD mortality, heart failure, or renal events when the lower BP cutoff was used (130/80) and the difference for fatal or nonfatal myocardial infarction was borderline nonsignificant.

Timing of anti-hypertensives:

• Take a bedtime as significant reduction in mortality and morbidity for once-daily anti-hypertensives (LOE = 1b-)
  • NNT 20.3

Targets:

• Acute intrecerebral hemorrhage
  • If SBP >220 within 6 hrs of event - continuous drug infusion and close BP monitoring
  • If SBP 150-220 within 6 hrs of event - immediate lowering below 140 mmHg is potentially harmful
• Acute ischemic stroke
  • <185/110 before administration of IV tPA
  • <185/105 for at least 24 hrs after initiating drug therapy
• Post CVA
  • <130/80
• Chronic kidney disease
  • <130/80
• Diabetes mellitus
  • <130/80
  • ACE-I or ARB
• Heart failure
  • With preserved EF: <130 systolic
  • With reduced EF: <130/80
• Kidney transplant
  • <130/80
• Stable ischemic heart disease
  • <130/80

Key Elements of Office BP Assessment:

• Patient should avoid caffeine, exercise, and smoking for at least 30min before the visit
• Patient should relax, sitting in a chari, with feet on floor and back supported for at least 5 min
• Patient should have empty bladder
• There should be no talking during the rest period and measurement
• No clothing covering the area where the cuff is placed
• Correct cuff size
• Patient arm should be supported
• Middle of the cuff should be on the patient upper arm at the level of the right atrium
• Seperate repeaated meaurements by 1 to 2 min
• Take the average of at least 2 measurements

Resources:

• https://www.aafp.org/patient-care/clinical-recommendations/all/hypertension-over-60.html

References:

• AFP Vol 97 No 6 Mar 2018
• AFP Vol 97 No 9 May 2018

Formulas:

• Max heart rate = 220 - age
• Target heart rate = 50-85%

See also: METS in Physical Activity

References:

• AFP Vol 85 No 3 Feb 2012
• J Musc Med Mar 2012

Describing

• Timing:
  • systolic
    • midsystolic (systolic ejection murmurs, or SEM)
      • AS
      • PS
      • ASD
      • HOCM
    • holosystolic (pansystolic)
      • MR
      • TR
      • VSD
    • late systolic
      • MVP
  • diastolic
    • Early
      • AR
      • PR
      • Austin-Flint
    • Mid/Late
      • MS
      • TS
  • Continuous throughout systole and diastole
    • Patent ductus arteriosus
    • Combination murmurs
• Grading
  • Systolic on a scale of 6
  • Diastolic on a scale of 4
• Shape
  • crescendo, decrescendo, crescendo-decrescendo or uniform
• Pitch
  • high pitched if there is a large pressure gradient across the pathologic lesion and low pitched if the pressure gradient is low.
  • high-pitched sounds are heard with the diaphragm of the stethoscope, whereas low-pitched sounds are heard with the bell.
• Location
  • A = aortic valve post (right upper sternal border or RUSB)
  • P = pulmonic valve post (left upper sternal border or LUSB)
  • T = tricuspid valve post (left lower sternal border or LLSB)
  • M = mitral valve post (apex)

• Use the ankle-brachial index for diagnosis in patients with history/physical exam findings suggestive of peripheral arterial disease (PAD). A
• Strongly encourage smoking cessation in patients with PAD as doing so reduces 5-year mortality and amputation rates. B
• Use structured exercise programs for patients with intermittent claudication prior to consideration of revascularization; doing so offers similar benefit and lower risks. A
• Recommend revascularization for patients who have limb ischemia or lifestyle-limiting claudication despite medical and exercise therapy. B

ABI

• A resting ABI is performed with the patient in the supine position, with measurement of systolic blood pressure in both arms and ankles using a Doppler ultrasound device

Management

• Smoking cessation
• Exercise
• Diet
• Medication
  • HTN Management
  • High-dose statin
  • Antiplatelet agent - preferably cloidogrel

References:

• JFP Dec 2020 Vol 69 No 10

• Antiplatelet agent (like ASA 81mg/d or clopidogrel 75mg/d)
• RAAS blockers (like lisinopril 20mg/d or losartan50mg/d)
• B-blockers (like motoprolol 100mg bid)
• Statins (like atorvastatin 80mg/d)

References:

• JFP Vol 59 No 9 Sep 2010

• Alcohol moderation
  • Abstain from binge drinking
  • Limit to moderate daily consumption (i.e., 1.5 standard drinks per day for women and 2 for men)
• Diet
  • Increase consumption of dairy, fruits, polyunsaturated fats, vegetables, and whole grains
  • Increase consumption of foods high in calcium, magnesium, and potassium (e.g., avocados, legumes, nuts, seeds, tofu)
  • Increase consumption of vegetables high in nitrites (e.g., leafy vegetables, beetroot)
  • Reduce consumption of foods high in sugar, and saturated or trans fats
• Healthy drinks
  • Consider hibiscus tea, pomegranate juice, beetroot juice, and cocoa
  • Moderate consumption of coffee, and green and black tea
• Physical activity
  • Add strength or resistance training 2 to 3 days per week
  • Moderate intensity aerobic activity (e.g., walking, jogging, cycling, yoga, swimming) at least 5 days per week
• Salt reduction
  • Avoid adding salt when cooking or dining
  • Limit consumption of high salt foods, including fast foods, processed foods, and soy sauce
  • Many breads and cereals are high in salt
• Smoking cessation
  • Smoking cessation programs and adjuncts are recommended
• Stress reduction
  • Daily mindfulness or meditation appears to improve blood pressure measurements
• Weight loss
  • Evaluate obesity by waist-to-height ratio less than 0.5, or by ethnic-specific body mass index targets
  • Limit obesity, particularly truncal obesity

Reference:

• AFP Jun 2021 Vol 103 No 12

Triggers:

• Alcohol
• Anemia
• Caffeine
• Drugs
  • Antipsychotics
  • Bronchodilattors
  • Cannabinoids
  • Catecholamines
  • Corticosteroids
  • Decongestants
  • Inotropes
  • Loop diuretics
  • Stimulants
  • Vasodilators
• Electrolyte abnormalitis
• Exercise
• Fever
• Hyperthyroidism
• Hypovolemia

Vagal Meneuvers:

• Carotid sinus massage (5-10 sec)
• Diving reflex (up to 30s): patient submerges face in cold water or bags of ice paced on nose and forehead
• Valsalva (10-15 sec): Patient bears down against a closed glottis or blows through a straw or 10-ml syringe

Reference:

• AFP Vol 107 No 6 Jan 2023

• Patients with elevated troponin levels and chronic renal disease, pulmonary hypertension, pulmonary embolism, chronic obstructive pulmonary disease, sepsis, or acute ischemic stroke have a 2- to 5-fold increased risk of death, even in the absence of known cardiovascular disease (strength of recommendation: B, meta-analysis, multiple prospective and retrospective observational studies.)
• Elevated troponin raises risk of death 5-fold in pulmonary embolism patients.
• Elevated troponin I is an independent predictor of mortality in severe sepsis.
• Elevated troponin predicts increased death risk in up to 20% of stroke patients.

References:

• J Fam Pract. 2013 October;62(10):585-586, 598.

Myocardial ischemia

1. Acute coronary syndrome
   • STEMI
   • NSTEMI
2. Other coronary ischemia
   • Arrhythmia: tachy- or brady-
   • Cocaine/methamphetamine use
   • Coronary intervention (PCI or cardiothoracic surgery)
   • Stable coronary atherosclerotic disease in setting of increased O2 demand (eg tachycardia)
   • Severe hypertension
   • Coronary embolus
   • Aortic dissection
   • Coronary artery vasculitis (SLE, Kawasaki's)
3. Non-coronary ischemia
   • Shock (hypotension)
   • Hypoxia
   • Hypoperfusion
   • Pulmonary embolism
   • Global ischemia
   • CT Surgery

Myocardial injury with no ischemia

1. Comorbidities
   • Renal failure
   • Sepsis
   • Infiltrative diseases
   • Acute respiratory failure
   • Stroke
   • Subarachnoid hemorrhage
2. Specific identifiable precipitants
   • Extreme exertion
   • Cardiac contusion
   • Burns >30% BSA
   • Cardiotoxic meds: anthracyclines, herceptin
   • Electrical shock
   • Carbon monoxide exposure
3. Other
   • Apical ballooning (Takotsubo)
   • Myocarditis
   • Myopericarditis
   • Rhabdomyolysis involving cardiac muscle
   • Hypertrophic cardiomyopathy
   • Peripartum cardiomyopathy
   • Heart failure, malignancy, stress cardiomyopathy

References:

• UptoDate Graphic 54910

[2023-07-07 Fri 10:28]

Abstract:

Blood pressure (BP) recordings often differ between arms, but the extent to which these differences are reproducible and whether the differences have prognostic importance is unknown. We enrolled 421 consecutive patients from a medicine and a renal clinic at a veterans’ hospital. Three BP recordings were obtained in each arm using an oscillometric device in a sequential manner and repeated in 1 week. Patients were followed for all-cause mortality ≤7 years. The right arm had 5.1-mm Hg higher systolic BP that attenuated by ≈2.2 mm Hg a week later. Systolic BP dropped 6.9 mm Hg over 1 week and by an additional 5.3 mm Hg in patients with chronic kidney disease. Accounting for the visit and arm effect improved the reproducibility of the BP measurements. The intraclass correlation coefficient was 0.74, which improved to 0.88 after accounting for visit and 0.93 after accounting for arm. The crude mortality rate was 6.33 per 100 patient-years. Every 10-mm Hg difference in systolic BP between the arms conferred a mortality hazard of 1.24 (95% CI: 1.01 to 1.52) after adjusting for average systolic BP and chronic kidney disease. BP differences between arms are reproducible and carry prognostic information. Patients should have evaluation of BP in both arms at the screening visit.

• In this study we found that in veterans attending a renal clinic or a general medicine clinic, there were consistent differences in BP between arms.
• At each of the visits, ≈30% of the patients had between-arm systolic BP differences that exceeded 10 mm Hg, and between 30% and 40% of the patients had between-arm diastolic BP differences that exceeded 5 mm Hg. On average, the right arm had ≈5-mm Hg higher systolic BP that attenuated by ≈2 mm Hg a week later.
• Systolic BP dropped ≈7 mm Hg from over 1 week and by an additional ≈5 mm Hg in CKD patients. Accounting for the visit and arm effect reduced the residual variance and improved the reproducibility of the measurements.
• Finally, every 10-mm Hg difference in systolic BP conferred a 24% higher mortality hazard after accounting for average systolic BP at baseline and CKD.

Reference:

• Agarwal R, Bunaye Z, Bekele DM. Prognostic significance of between-arm blood pressure differences. Hypertension. 2008 Mar;51(3):657-62. doi: 10.1161/HYPERTENSIONAHA.107.104943. Epub 2008 Jan 22. PMID: 18212263.
• https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.107.104943

Self-help measures to reduce leg swelling in diabetics:

• Twice a day, lie down with pillows under your legs to bring them above your heart levels.
• Make sure you get regular exercise to reduce risks of fluid build-up in legs.
• Wear compression stockings if you are prone to leg swellings.
• Eating a low-sodium diet will help symptoms of leg swellings.
• For diabetic women, wearing low-heeled or flat shoes is the best way to avoid leg swelling.
• Don’t stand in one spot for too long. Take breaks to sit down. If your job requires you to stand for long hours, keep one leg bent at the knee and then repeat the same with the other leg to keep them moving.
• Get regular leg massages to improve blood circulation in the entire leg. Start with the lower legs and move downwards to the toes. This will redistribute any accumulated fluids throughout the leg.
• Wear well-fitted shoes that are never tight, even when your feet feel slightly swollen. If you must, buy shoes one size bigger. It is better to buy shoes with ties to be adjusted as per foot condition.
• Never sit cross-legged because it stops circulation of blood to the lower leg.
• If you smoke, consider quitting because a diabetic who smokes is at increased risk of leg swelling.

[2023-09-12 Tue 10:47]

Reference:

• Rokicki W, Rokicki M, Rydel M. What do we know about Tietze's syndrome? Kardiochir Torakochirurgia Pol. 2018 Sep;15(3):180-182. doi: 10.5114/kitp.2018.78443. Epub 2018 Sep 24. PMID: 30310397; PMCID: PMC6180027.

PRACTICE RECOMMENDATIONS

• Use an excisional biopsy for a melanocytic neoplasm. (SOR C)
• Choose a punch biopsy over a shave biopsy for rashes. (SOR B)
• Properly photograph and document the location of all lesions before biopsy. (SOR A)
• Provide the pathologist with a sufficient history, including the distribution and appearance of the lesion, and how long the patient has had it. (SOR A)

The 9 tips:

1. Choose your biopsy type wisely.
   • The most common biopsy types are shave, punch, and excisional
   • Shave biopsy: lesions that are solitary, elevated, and give the impression that a sufficient amount of tissue can be sampled using this technique
   • Punch biopsy: most "rashes" (inflammatory skin disorders)
   • Excisional biopsy: melanocytic neoplasms or larger lesions.
   • Videos of biopsies: http://www.jfponline.com/multimedia/video.html
2. When performing a shave biopsy, avoid obtaining a sample that's too superficial.
   • The advantage of the shave biopsy is that it is minimally invasive and quick to perform
3. Choose punch over shave biopsy for rashes.
   • Punch biopsy is the preferred technique for almost all inflammatory skin conditions (rashes)
   • A punch biopsy size of 4 mm is commonly used for rashes
4. Choose an excisional biopsy for a melanocytic neoplasm, when possible.
   • The purpose of an excisional biopsy (which typically includes a 1 to 3 mm rim of normal skin around the lesion) is to completely remove a lesion.
   • The excisional biopsy generally is the preferred technique for clinically atypical melanocytic neoplasms (lesions that are not definitively benign)
5. Be careful with curettage.
   • Curettage is a biopsy technique in which a curette—a surgical tool with a scoop, ring, or loop at the tip—is used in a scraping motion to retrieve tissue from the patient.
6. Remember the importance of proper fixation and processing.
   • Promptly place sampled tissue in an adequate amount of formalin so that the tissue is submersed in it in the container
   • Failure to do so can result in improper fixation and will make it difficult to render an appropriate diagnosis.
7. Properly photograph and document the biopsy location.
   • To properly record the site of a biopsy for future dermatologic exams, take pictures of the lesion at the time of biopsy. The photographs should clearly document the lesion in question, and should be taken far enough from the site that surrounding lesions and/ or other anatomic landmarks are also visible.
8. Give the pathologist a pertinent history.
   • Providing the pathologist with a sufficient history, including the distribution and appearance of the lesion, and how long the patient has had it
9. Know when to refer.

Refernces:

• J Fam Pract. 2014 October;63(10):559-564.

Disease of sebaceous follicles - multifactorial (abn keratonization, excessive sebum, Propionibacterium acnes, and hormones)

• Open Comedones: flat or slightly raised with dark substance in cental orifice
• Closed Comedones: pale white papules with no visible orifice

Therapy is based on lesion type and severity (mild, mod, severe):

• Noninflammatory
  • First line: topical tretinoin (predominance of comedones) if not effective -> topical antimicroials like benzoyl peroxide (preferred with inflammation) (Level 1 evidence).
  • Second line - adapalene (I)
• Papular or pustular (Topical retinoid + benzoyl peroxide + topical antibiotic) (Oral Abx if severe)
  • First line: topical erythromycin (I), clindamycin (I), clindoxyl (I), or benzamycin (I)
  • Second line: Oral tetracycline (I), minocycline (I), or doxycycline 100mg/d(I), also erythromycin, clindamycin, ampicillin, amoxicillin (all Level 1)
  • Third line: Oral antibiotics plus topical retinoids (I)
  • Fourth line Trimethoprim-sulfamethoxazole (III)
• Nodulocystic or treatment resistant acne or scarring (Topical retinoid + benzoyl peroxide + oral antibiotic)
  • First line: steroid injection if sparse (I), isotretinoin if severe (I)
  • Second line: antiandrogens (OCP or spironolactone)

Major recommendations from guidelines:

• Topical retinoids are recommended as monotherapy for comedonal acne or in combination with topical or oral antimicrobials in patients with mixed or primarily inflammatory acne (LOE 1)
• Benzoyl peroxide is an effective topical agent (LOE 1)
• Topical antibiotic therapy is recommended only in combination with benzoyl peroxide (LOE 1)
• Systemic antibiotic therapy is recommneded for management of moderate and severe inflammatory acne and acne resistant to topical treatments (LOE 1)
  • Preferred oral antibiotic are tetracyclines with doxycycline and minocycline more effective than tetracycline
• Systemic antibiotic use should be limited to the shortest possible duration, typically 3 months. Concomitant and ongoing topical therapy with benzoyl peroxide or topical retinoid is recommended for maintenance. (LOE 1)
• Combined oral contraceptives are effective in treating inflammatory acne in girls and women (LOE 1)
  • Consider spirinolactone 25 mg to 100 mg for women - safe, inexpensive, and effective
• Oral isotretinoin is recommended for treatment of severe nodular acne, moderate recalcitrant acne, or acne that produces scarring or psychosocial distress (LOE 1)

First line treatment options:

• May be prescribed as a fixed combination product or as separate component.

Alternative options:

Reference:

• Cheung M, Taher M, Lauzon G., Acneiform facial eruptions, Canadian Fam Phys, Vol 51; April 2005; 527-533
• AFP Vol 86 No 8 Oct 2012
• JAMA Vol 316 No 13 Oct 2016
• AFP Vol 95 No 11 Jun 2017
• https://www.aad.org/member/clinical-quality/guidelines/acne
• FPN Apr 2023

Tretinoin is associated with photosensitivity, so nighttime application is recommended. Can apply benzoyl peroxide in the morning if used in combination.

Chronic vascular facial disorder of 20-60yo northern/eastern european descent

• Pathogenesis: unknown but implicated factors include bacteria, Demodex mites, vasomotor and connective tissue dysfunction, and topical steroids
• Triad:
  1. Symmetrical erythema,
  2. papules and pustules, and
  3. telangiectasia on cheeks, forehead, and nose (absence of comedones)

Often exacerbated by sun, wind, hot drinks

Treatment:

• Avoid triggers
• First line: topical metronidazole (Daily 1% or bid 0.75%) (I) plus oral tetracycline (tapered from starting dose of 1000mg/d) (I) or minocycline (100-200mg/d) (I)
• Second line: Sulfacetamide (III) plus oral Abx as above
• Third line: Isotretinoin (II)

References:

• Cheung M, Taher M, Lauzon G., Acneiform facial eruptions, Canadian Fam Phys, Vol 51; April 2005; 527-533

Non-pharmacologic treatment options:

• Moisturizers:
  • Use liberally, combine with bathing, patient preferences on type
• Bathing practices:
  • Minimum perform daily
  • Soak in warm water 10-15 minutes
  • Followed by quick pat drying and immediate application (2-3 minutes) of topical moisturizer/medications.
• Bleach baths:
  • Once or twice weekly bleach (sodium hypochlorite) is effective in clinically improving moderate-to-severe AD in children.
  • May also help adults
  • Thought to reduce skin inflammation and decrease S. Aureus colonization.
• Wet wrap therapy (wwt):
  • Using layers of bandage, guaze, clothing, etc with topical medications. Evidence supports improvement of symptoms in children.

Pharmacologic treatment options:

• Topical corticosteroids
• Topical calcineurin inhibitors
• Dupilumab
• Phototherapy
• Systemic immunosuppresents: cyclosporine, azathioprine, mycophenolate, methotrexate

Pregression of bites:

1. Initial reaction
   1. Erythematous, pruritis macules with central hemorrhagic puncta in linear or grouped distribution
2. Subsequent reactions
   1. Wheals, papules, vesicles

Differential Diagnosis:

• Bedbugs
• Fleas
• Lice
• Mosquitoes
• Scabies
• Spiders
• Ticks

Treatment:

• Vacuuming
• Heat or cold treatment
• Trapping - use plastic encasements to trap bedbugs and prevent migration to and from hiding spots
• Pesticides
• Can use petroleum jelly on legs of furnature to prevent ascending

References:

• AFP Vol 86 No 7 Oct 2012

1. adapalene/benzoyl peroxide (EpiDuo)
2. clindamycin/benzoyl peroxide (Neuac)
3. adapalene (Differin)

Reference:

• AFP Vol 106 No 6 Dec 2022

Refer to a Burn Center:

• Burns to the face, hands, feet, major joints, genitalia, or perineum
• Children in health care facilities without staff trained to treat children or appropriate equipment for children
• Concurrent trauma
• Electrical or chemical burns
• Full-thickness (third-degree) burns at any age
• Greater than 10% total body surface area involved
• Inhalation injuries
• Need for special support (social, emotional, rehabilitative)
• Preexisting medical issues that may complicate treatment or recovery or increase mortality risk

Topical Agents:

• Bacitracin
• Impregnated nonadherent gauze (Xeroform, Vaseline gauze)
• Mafenide acetate (Sulfamylon)
• Medical grade honey
• Mupirocin
• Silver sulfadiazine (Silvadene)

References:

• AFP Vol 101 No 8 Apr 2020

Comparison of Basal Cell and Cutaneous Squamous Cell Carcinoma

Biopsy:

• Initial tissue sampling is typically performed using a shave technique if the lesion is raised
• Can alternatively use a punch biopsy of the most abnormal-appearing skin
• Pigmented lesions and those with any features concerning for melanoma risk should always be evaluated using a full-thickness technique

Risk Stratification of Low- vs. High-Risk Basal Cell Carcinoma

Low-risk location = trunk and extremities excluding hands, feet, nail units, pretibia, and ankles; Moderate-risk location = cheeks, forehead, scalp, neck, and pretibia; High-risk location = central face, eyelids, eyebrows, periorbital skin, nose, lips, chin, mandible, preauricular and postauricular skin/sulci, temple, ear, genitalia, hands, and feet.

Management (National Cancer Care Network guidelines)

• BCC:
  • Excision of low-risk primary BCC with a 4-mm margin of uninvolved skin around the tumor
  • Incomplete excision of the primary tumor (i.e., pathology demonstrating tumor at the surgical margin) should be followed by immediate re-excision or Mohs micrographic surgery
• CSCC:
  • Excision of low-risk primary CSCC with a 4-mm to 6-mm margin of uninvolved skin around the tumor
  • Mohs micrographic surgery is an appropriate option for high-risk tumors or tumors in sensitive anatomic locations

Post Diagnosis Management:

• Annual screening of the patient for new primary skin cancers, including BCC, CSCC, and melanoma

References:

• AFP Sep 2020 Vol 102, No 6

Treatment:

• Start second generation H1 antihistamine
• If insufficient do one of the following:
  • Titrate second generation H1 antihistamine to 2 to 4 times normal dose
  • Add a different second generation H1 antihistamine
  • Add H2 antihistamine
  • Add first-generation H1 antihistamine at night
  • Add leukotriene receptor antagonist
• If insufficient
  • Add high-potency antihistamine hydroxyzine or doxepin and titrate as tolerated
• If insufficient
  • Consider referral for immunomodulatory therapy such as omalizumab or cyclosporine

Urticaria Causes:

• Immunoglobulin E mediated (IgE)
  • Aeroallergens
  • Contact allergen
  • Food allergen
  • Insect venom
  • Medications
  • Parasitic infections
• Non-IgE immunologically mediated
  • Aeroallergens (proteases)
  • Autoimmune disease
  • Bacterial infections
  • Cryoglobulinemia
  • Fungal infections
  • Lymphoma
  • Vasculitis
  • Virla infections
• Nonimmunologically mediated
  • Contact allergen
  • Elevation of core body temperature
  • Food pseudoallergens
  • Light
  • Mastocystosis
  • Medications (direct mast cell degranulation)
  • Physicla stimuli (cold, heat, pressure, vibration)
  • Water

Conditions confused with urticaria

• Arthropod bites
  • Lesions lasting several days, insect exposure history
• Atopic dermatitis
  • Maculopapular, scaling, characteristic distribution
• Bullous pemphigoid
  • Lesions lasting >24hrs, blistering, Nikolsky sign (light friction causes erosion or vesicle)
• Contact dermatitis
  • Indistinct margins, papular, persistent lesions, epidermal component present
• Erythema multiforme
  • Lesions lasting several days, iris-shaped papules, target appearance, may have fever
• Fixed-drug reactions
  • Offending drig exposure, not pruritic, often bullous, hyperpigmentation
• Henoch-Schonlein purpura
  • Lower extremity, purpuric lesions, systemic symptoms
• Mastocytoma
  • Yellow to orange pigmentation, Darier sign (a wheal and flare up reaction with stroking the lesion), flushing, bullae, most common in children
• Mastocytosis, diffuse cutaneous
  • Normal to yellow-brown skin color, diffuse thickening, bullae
• Morbilliform drug reactions
  • Maculopapular, associated with medication use
• Pityriasis rosea
  • Lesion lasting weeks, herald patch, Christmas tree pattern, often not pruritic
• Urticaria pigmentosa
  • Smaller lesions (1-3 mm), orange to brown pigmentation, Darier sign
• Viral exanthem
  • Not pruritic, prodrome, fever, maculopapular, individual lesions lasting days

References:

• AFP Vol 95 No 11 Jun 2017

See also:

• Aesthetics

The Two-Step Algorithm

1. Step 1 - Determine if lesion is melanocytic or not
   1. Determine if lesion is benign or malignant
2. Step 2 - Determine if lesion is a Nevus, Suspicious, or Melanoma
   1. Determine if need to biopsy or not
   2. Determine if digital monitoring (never for raised lesions)

A lesion is Melanocytic if it:

1. Has a network (Except in the following:)
   • Dermatofibroma (fine network surrounding central scar)
   • Solar lentigo (fine interrupted lines and moth eaten border)
   • Ink blot lentigo
2. Aggregated or peripheral rim of globules
   • Usually in growing nevi
3. Streaks
   • Usually = bad
   • Think biopsy
   • Spitz nevus - juvenile melanoma
4. Homogenous blue pigment
   • Blue nevus

Example images:

• Dermoscopic Structures

References:

• AFP Article on Dermoscopy
• FMX 2016
• https://www.ncbi.nlm.nih.gov/pubmed/25714607

Definition:

• Inflammation of the hair follicle 2/2 mechanical trauma, irritation, or infection
• Usual infectious organism is S aureus, also gram neg (after prolonged topical Ax) and pitysporum (saprophytic yeast) as well
• Pustules in clusters on hair-bearing areas of body.

Treatment:

• Pityrosporum:
  • First Line: Topical econazole (III), selenium sulfide shampoo (III), or 50% propylene glycolor etoconazole  (III) - 3 weeks treatment
  • Second line: Oral fluconazole (II), itraconazole (I), or ketoconazole (II) - 10-14 days
  • Third line: Oral antifungal plus topical agents (II)
• Bacterial:
  • First line: Topical mupirocin (I), erythromycin (III), clindamycin (III), or benzoyl peroxide (III) - treat until lesions resolvedd
  • Second line: Oral antistaphylococcal antibiotics (flouroquinolones(I), first gen cephalosporins (III), or macrolides (III))
• Gram negatives:
  • First line: Isotretinoin (II)
  • Second line: Ampicillin (III) or trimethoprim-sulfamethoxazole (III)

References:

• Cheung M, Taher M, Lauzon G., Acneiform facial eruptions, Canadian Fam Phys, Vol 51; April 2005; 527-533

Hair loss is a common problem that may be improved with vitamin and mineral supplementation. Vitamins and minerals are important for normal cell growth and function and may contribute to hair loss when they are deficient. While supplementation is relatively affordable and easily accessible, it is important to know which vitamins and minerals are helpful in treating hair loss.

Androgenetic alopecia (AGA), telogen effluvium (TE) are two common types of hair loss. Studies show that supplementing the diet with low levels of vitamin D can improve symptoms of these diseases. If a patient with AGA or TE has low iron levels (more commonly seen in females), supplementation is also recommended. These iron-deficient patients should also ensure their vitamin C intake is appropriate. At the present time there is insufficient data to recommend zinc, riboflavin, folic acid, or vitamin B12 supplementation in cases of deficiency. Neither vitamin E or biotin supplementation are supported by the literature for treating AGA or TE; in addition, biotin supplementation can also lead to dangerous false laboratory results. Studies show that too much vitamin A can contribute to hair loss, as can too much selenium, although more studies are needed to establish the latter relationship.

Alopecia areata (AA) occurs when the immune system attacks the hair follicle. Studies have shown a relationship between AA and low vitamin D levels. Vitamin D should be supplemented if levels are low. However, more studies are needed to determine the effect of iron and zinc supplementation on AA patients. There is currently not enough data to recommend supplementation of folate or B12. Biotin supplementation is not supported by available data for the treatment of AA. It is unclear if selenium plays a role in this disease; therefore, supplementation with this mineral is not recommended.

Iron, vitamin D, folate, vitamin B12, and selenium are vitamins and minerals that may be involved in hair graying/whitening during childhood or early adulthood. Supplementing these deficient micronutrients can improve premature graying.

Reference:

• Almohanna, Hind M et al. "The Role of Vitamins and Minerals in Hair Loss: A Review." Dermatology and therapy vol. 9,1 (2019): 51-70. https://doi.org/10.1007/s13555-018-0278-6

Hair removal from shaving or using depilatories, deodorants, and irritation from anything rubbing against the affected area can worsen the condition.

The Hurley classification system is used to define severity and guide treatment.

• Stage I: single or multiple abscesses without sinus tracts or scarring
  • Medical
    • First line: Topical clindamycin
    • Second line: Topical resorcinol
  • Surgical
    • Punch debridement
    • Drain painful abscess
    • Intralesional triamcinolone
• Stage II: abscess recurrence with sinus tracts and scarring; widely separated lesions
  • Medical (Topical Clindamycine AND)
    • First line: Tetracycline Abx
    • Second line: Adalimumab (Humira)
    • Third line: Acitretin, oral clindamycin plus rifampin
  • Surgical
    • Local excision for larger, chronic lesions or sinus tracts
• Stage III: diffuse skin involvement with multiple sinus tracts and widespread abscess formation
  • Medical (Topical Clindamycine AND)
    • First line: Adalimumab
    • Second line: Infliximab (Remicade), anakinra (Kineret), oral clindamycin plus rifampin

Reference:

• Am Fam Physician. 2019;100(9):562-569

See also: Cutaneous Larva Migrans

There are also risk factors for a systemic sting reaction:

• A sting reaction < 2 months earlier increases the risk of a subsequent systemic sting reaction by ≥ 50%.
  • Pucci S, Antonicelli L, Bilò MB, et al. Shortness of interval between two stings as risk factor for developing Hymenoptera venom allergy. Allergy.1994;49:894-896.
• Among beekeepers, paradoxically, the risk of a systemic reaction is higher in those stung < 15 times a year than in those stung > 200 times.
  • Müller UR. Bee venom allergy in beekeepers and their family members. Curr Opin Allergy Clin Immunol. 2005;5:343-347.
• Patients with an elevated baseline serum level of tryptase (reference range, < 11.4 ng/mL), which is part of the allergenic response, or with biopsy-proven systemic mastocytosis are at increased risk of a systemic sting reaction.

Bee stings:

• Among beekeepers, the risk of a systemic reaction is higher in those stung < 15 times a year than in those stung > 200 times.
• Remove honey bee stingers by scraping the skin with a fingernail or credit card. Ideally, the stinger should be removed in the first 30 seconds, before the venom sac empties. Otherwise, intense local inflammation, with possible lymphangitic streaking, can result

Centipede

• The bite of a larger centipede can cause a painful reaction that generally subsides after a few hours but can last several days. Centipede bites are usually nonfatal to humans

Spiders

• brown recluse spider is described as having a violin-shaped marking on the abdomen; the body is yellowish, tan, or dark brown. A bite can produce tiny fang marks and cause dull pain at the site of the bite that spreads quickly; myalgia; and pain in the stomach, back, chest, and legs.28,29 The bite takes approximately 7 days to resolve.
• black widow spider is black; females exhibit a distinctive red or yellow hourglass marking on their ventral aspect.28,31 The pinprick sensation of a bite leads to symptoms that can include erythema, swelling, pain, stiffness, chills, fever, nausea, and stomach pain.

Fleas

• Flea bites, which generally occur on lower extremities, develop into a small, erythematous papule with a halo (FIGURE 4) and associated mild edema, and cause intense pruritus 30 minutes after the bite.
• Fleas are a vector for severe microbial infections, including bartonellosis, bubonic plague, cat-flea typhus, murine typhus, cat-scratch disease, rickettsial disease, and tularemia. Tungiasis is an inflammatory burrowing flea infestation—not a secondary infection for which the flea is a vector

Flies and biting midges

• include black flies, deer flies, horse flies, and sand flies
• Flies can transmit several infections, including bartonellosis, enteric bacterial disease (eg, caused by Campylobacter spp), leishmaniasis, loiasis, onchocerciasis, and trypanosomiasis.43
• Biting midges, also called "no-see-ums," biting gnats, moose flies, and "punkies,"44 are tiny (1-3 mm long) blood-sucking flies

Mosquitoes

• Advise patients to reduce their risk by using insect repellent, sleeping under mosquito netting, and wearing a long-sleeve shirt and long pants when traveling to endemic areas or when a local outbreak occurs

Ticks

• Ticks should be removed with fine-tipped tweezers. Grasp the body of the tick close to the skin and pull upward while applying steady, even pressure. After removing the tick, clean the bite and the surrounding area with alcohol or with soap and water. Dispose of a live tick by flushing it down the toilet; or, kill it in alcohol and either seal it in a bag with tape or place it in a container

Symptom control

• Symptomatic treatment of mild bites and stings includes washing the affected area with soap and water and applying a cold compress to reduce swelling.54 For painful lesions, an oral analgesic can be prescribed.
• For mild or moderate pruritus, a low- to midpotency topical corticosteroid (eg, hydrocortisone valerate cream 0.2% bid), topical calamine, or pramoxine can be applied,or a nonsedating oral antihistamine, such as loratadine (10 mg/d) or cetirizine (10 mg/d), can be used.14,55 For severe itching, a sedating antihistamine, such as hydroxyzine (10-25 mg every 4 to 6 hours prn), might help relieve symptoms; H1- and H2-receptor antagonists can be used concomitantly.
• Large local reactions are treated with a midpotency topical corticosteroid (eg, triamcinolone acetonide cream 0.1% bid) plus an oral antihistamine to relieve pruritus and reduce allergic inflammation. For a more severe reaction, an oral corticosteroid (prednisone 1 mg/kg; maximum dosage, 50 mg/d) can be given for 5 to 7 days
• Managing anaphylaxis
  • First-line therapy is intramuscular epinephrine, 0.01 mg/kg (maximum single dose, 0.5 mg) given every 5 to 15 minutes
  • Administration of O2 and intravenous fluids is recommended for hemodynamically unstable patients.
  • Antihistamines and corticosteroids can be used as secondary treatment but should not replace epinephrine

References:

• JFP Dec 2020 Vol 69 No 10

A few notes on lice treatment:

• Do not use a combination shampoo/conditioner, or conditioner before using lice medicine.
• Do not re–wash the hair for 1–2 days after the lice medicine is removed.
• After each treatment, checking the hair and combing with a nit comb to remove nits and lice every 2–3 days may decrease the chance of self–reinfestation. Continue to check for 2–3 weeks to be sure all lice and nits are gone.
• Machine wash and dry clothing, bed linens, and other items that the infested person wore or used during the 2 days before treatment using the hot water (130°F) laundry cycle and the high heat drying cycle. Clothing and items that are not washable can be dry–cleanedORsealed in a plastic bag and stored for 2 weeks.
• Soak combs and brushes in hot water (at least 130°F) for 5–10 minutes.
• Vacuum the floor and furniture, particularly where the infested person sat or lay. However, the risk of getting infested by a louse that has fallen onto a rug or carpet or furniture is very small. Head lice survive less than 1–2 days if they fall off a person and cannot feed; nits cannot hatch and usually die within a week if they are not kept at the same temperature as that found close to the human scalp. Spending much time and money on housecleaning activities is not necessary to avoid reinfestation by lice or nits that may have fallen off the head or crawled onto furniture or clothing.
• Do not use fumigant sprays; they can be toxic if inhaled or absorbed through the skin

Reference:

• https://www.cdc.gov/parasites/lice/head/treatment.html

• Topical Antibiotics
  • Clindamycin, Erythromycin, Metronidazole
  • Uses: Mild/Mod acne/rosacea
• Topical Keratolytics
  • Retinoids, Benzoyl peroxide, Salicylic acid, Azelaic acid
  • Uses: Acne, rosacea
• Topical Anti-inflammatory agents
  • Azelaic acid, Topical corticosteroids, Tars
• Topical Anti-fungals
  • Azoles, Allylamines, Benzoyl peroxide, Selenium sulfide, Pyrithione zinc
  • Uses: Seborrheic dermatitis, Malassezia folliculitis
• Topical Miscellaneous
  • Sodium sulfacetamide, sulfer, tar, Ivermectin, Brimonidine
• Systemic Antibiotics
  • Tetracyclines, Erythromycin, Sulfas
  • Uses: Mod/Severe acne/rosacea
• Systemic Retinoids
  • Isotretinoin
  • Uses: Nodulocystic, severe acne; select severe rosacea
• Oral contraceptives

References:

• Consultant Oct 2015

• https://medlineplus.gov/ency/article/000826.htm
• https://kidshealth.org/en/parents/molluscum-contagiosum.html

The "ABCDE" rule describes the features of early melanoma. These features are:

• Asymmetry - The shape of one half does not match the other half.
• Border that is irregular - The edges are often ragged, notched, or blurred in outline. The pigment may spread into the surrounding skin.
• Color that is uneven - Shades of black, brown, and tan may be present. Areas of white, gray, red, pink, or blue may also be seen.
• Diameter - There is a change in size, usually an increase. Melanomas can be tiny, but most are larger than 6 millimeters wide (about 1/4 inch wide)
• Evolving - The mole has changed over the past few weeks or months.
• Funny Looking - Ugly Duckling

Reference:

• Daniel Jensen J, Elewski BE. The ABCDEF Rule: Combining the "ABCDE Rule" and the "Ugly Duckling Sign" in an Effort to Improve Patient Self-Screening Examinations. J Clin Aesthet Dermatol. 2015 Feb;8(2):15. PMID: 25741397; PMCID: PMC4345927.
• https://moles-melanoma-tool.cancer.gov/#/

Labs: Obtain the following tests:

• Complete blood count with red blood cell indices (to assess for anemia)
• Complete metabolic panel (to assess for signs of underlying disease)
• Thyroid-stimulating hormone (to assess for a thyroid disorder) (see "Laboratory assessment of thyroid function", section on 'Evaluating for thyroid dysfunction')
• Ferritin (to assess iron storage) (see "Causes and diagnosis of iron deficiency and iron deficiency anemia in adults", section on 'Iron studies (list of available tests)')
• 25-hydroxyvitamin D levels (to assess for vitamin D deficiency) [17]

The selection of additional laboratory studies is guided by the need to rule out disorders in the differential diagnosis or to further investigate patients with signs or symptoms suggestive of a particular underlying disease, nutritional deficiency, heavy metal or other toxin exposure, or other causes of hair loss. As examples, a hormonal work-up to rule out hair loss related to hyperandrogenemia would be appropriate in women with signs of virilization, acne, and obesity, and further evaluation with antinuclear antibodies (ANAs) or other studies would be appropriate for a patient with signs or symptoms of an underlying autoimmune disease. In addition, dietary history may reveal nutritional deficiencies that should be evaluated.

• Telogen effluvium is a form of diffuse, nonscarring hair loss that presents as a transient or chronic loss of hair (picture 1A-C). Hair loss in telogen effluvium occurs as a result of an abnormal shift in follicular cycling that leads to the premature shedding of hair. A wide variety of endogenous and exogenous factors have been linked to the induction of telogen effluvium. Examples include major surgery, serious illness, childbirth, protein or caloric malnutrition, drugs, and severe emotional distress. In some cases, the inciting cause is unclear or multiple inciting triggers are identified.

• Anagen effluvium – Anagen effluvium is an acute loss of anagen hair fibers secondary to chemotherapy or toxin exposure and represents acute loss of greater than 80 percent of the scalp hair. Exclamation point hairs (short, 1 to 3 mm hairs with a tapered base) that result from dystrophic hair growth are a common finding. Microscopic evaluation of the proximal ends of hairs dislodged during a hair pull test demonstrates normal or dystrophic anagen hairs rather than telogen hairs. (See "Alopecia related to systemic cancer therapy".)
• Androgenetic alopecia (male or female pattern hair loss) – Features of androgenetic alopecia that are useful for distinguishing this condition from telogen effluvium include a clinical examination that demonstrates a characteristic pattern of hair loss and miniaturized hairs (picture 7A-C). A biopsy can be useful for differentiating between these diagnoses in difficult cases. Of note, the two conditions may coexist, and telogen hair shedding can occur early in the course of androgenetic alopecia. (See "Androgenetic alopecia in males: Pathogenesis, clinical features, and diagnosis" and "Female pattern hair loss (androgenetic alopecia in females): Pathogenesis, clinical features, and diagnosis".)
• Diffuse alopecia areata – Diffuse alopecia areata is an uncommon form of alopecia areata that is characterized by the diffuse loss of scalp hair, resulting in the appearance of generalized hair thinning (picture 8). Similar to anagen effluvium, exclamation point hairs may be present, and performance of the hair pull test may reveal dystrophic anagen hairs. A biopsy revealing an inflammatory infiltrate consistent with alopecia areata differentiates this condition from telogen effluvium. (See "Alopecia areata: Clinical manifestations and diagnosis".)
• Loose anagen syndrome – Loose anagen syndrome is a rare, nonscarring hair loss disorder that manifests with easily extracted anagen hairs from the scalp (picture 9). Young children are typically affected, particularly females with blond hair. Characteristically, examination of shed hairs reveals anagen hairs with ruffled cuticles (picture 10).
• Structural hair disorders – A variety of structural hair disorders causes weakening of the hair shaft that results in easily fractured hair. Unlike telogen effluvium, in which hair is shed from the follicle, these conditions result in increased breakage of hair. Close examination and 2x magnification of the loose hair will reveal broken hairs and may also reveal characteristic findings of a particular structural hair disorder.

Hair Cycle:

• 90% scalp hairs in anagen (growth) phase at any given time
• 10% scalp hairs in telogen (resting) or catagen (involution) phases

Evaluation Steps

• Is it scarring hair loss?
  • Scarring presents with:
    • pruritis
    • pain
    • erythema
    • scale
    • crust
    • obliteration of follicular pore markings leading to an abnormally smooth appearance of the skin
• If nonscarring, what is the Distribution of loss?
  • Patterned
    • Ex: Androgenic alopecia
      • Hairline recession, increased spacing between follicles, increased visibility of scalp, and miniturized follicles
      • Most common patterned hair loss
      • Minoxidil and finasteride
  • Diffuse
    • Ex: Telogen Effluvium
      • Most common diffuse hair loss
      • An inciting event disrupts hair cycle leading to loss > 200 scalp hairs a day (Decrease hair volume >10% but <50%)
    • severe illness
    • Major surgery
    • thyroid idsease
    • pregnancy
    • Fe def anemia
    • malnutrition
    • rpid weight loss
    • Vit D def
    • Medications:
      • Using: lithium, sodium valproate, fluoxetine, warfarin, metoprolol, propranolol, retinoids, isoniaxid
      • Discontinuing: estrogen containing OCPs
      • Occurs 2-4 months after inciting event
      • Labs:
    • TSH
    • ferritin
    • 25-OH Vit D2 and D3
      • Self-limited
      • Takes 6-9 months to normalize
  • Focal
    • Ex: Alopecia Areata
      • Hair loss patches with smooth borders
      • Autoimmune often in those with atopy
      • Spontaneous regrowth in 30% patients
      • Exclamation point hairs in active areas
      • Pigmented hairs preferentially lost with regrowth initially nonpigmented or white

References:

• JAMA Mar 2021 Vol 325 No 9

Location of hormonal acne:

• While typical teenage acne appears most of the forehead and cheeks, the most common areas for hormonal acne to pop up are on the lower sections of the face, including around the mouth, jawline, and neck.

Hormone levels:

• As a rule of thumb, birth control that contains a higher level of progesterone will have a stronger androgenic effect and have a higher risk of promoting acne breakouts.
• The reduction of androgen production will reduce the blackheads, whiteheads, and inflamed red pimples typical to acne.
• The estrogen that is used in birth control pills is almost always Ethinyl estradiol and rarely mestranol. The usual amount is 20–50 µg.

Estrogen effect provides some anti-androgenic effect through 3 mechanisms:

• Suppress secretion of pituitary gonadotropins, inhibit ovulation, and thus inhibit androgen production by the ovaries.
• Block the Androgen receptors
• Increase the liver production of SHBG and reducing circulating testosterone.

Women with acne need to avoid taking progestins with potent androgenic (acne-causing) effects, i.e., levonorgestrel and norgestrel. A better choice of progestins for women with acne would be drospirenone, norgestimate, gestodene, and desogestrel with a weaker androgenic effect.

The best birth control pills for women with Acne are pills that contain drospirenone and Ethinylestradiol. Examples of these pills are

• Yasmin,
• Yaz,
• Beyaz,
• Ocella,
• Safyral,
• Syeda,
• Gianvi,
• Loryna,
• Nikki,
• Vestura, and
• Zarah.

Lo Loestrin was found to cause more acne breakouts. Several other contraceptive options exacerbate or trigger acne in some women as they are higher in progestin (i.e., they increase testosterone-like activity) and low in estrogen. These include Depo-Provera (a shot), Skyla, Lylema, Implanon, and Nexplanon (a subdermal implant).

Indications of hormonal treatment in acne

• Severe flare-ups before menstruation
• When oral contraception is desirable
• Acne not responding to conventional treatment
• Polycystic ovary syndrome
• Late onset acne (acne tarda)
• Ovarian or adrenal hyperandrogenism

Summary of treatment recommendations from the European acne guidelines

Reference:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015761/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015761/

Confirmatory testing is generally unnecessary for clinically suspected onychomycosis.

• The most cost-effective approach to a patient with clinically suspected onychomycosis is empiric therapy with oral terbinafine.
  • Chance of liver injury is 1:50,000 to 1:120,000
  • If using a more expensive alternative medicine, than confirmatory testing with periodic acid-Schiff stain reduces cost

References:

• AFP Vol 97 No 9 May 2018

Treatment:

1. Drainage
   • Do not inject pulp and finger pad if using anesthesia
2. Antibiotics (typically not needed after drainage)

Risk factors:

• Accidental trauma
• Artificial nails
• Manicures
• Manipulating hangnails
• Occupational trauma
• Onychocryptosis (ingrown nails)
• Onychophagia (nail biting)

Prevention:

• Apply moisturizing lotion after washing
• Avoid chronic prolonged exposure to contact irritants and moisture
• Avoid nail trauma, biting, picking, manipulation, and sucking
• Avoid trimming cuticles or using cuticle removers
• Improve glycemic control in those with DM
• Keep affected areas clean and dry
• Keep nails short
• Use rubber gloves, preferably with inner cotton glove or liner, when exposed to moisture and/or irritants

Differential Diagnosis:

• Eczema
• Herpetic whitlow
• Psoriasis
• Dermatomyositis
• Granuloma annulare
• Hematomas from pulse oximetry
• Pyogenic granuloma
• Reiter syndrome
• Food hypersensitivity
• Melanoma
• Pemphigus vulgaris
• Squamous cell carcinoma

References:

• AFP Vol 96 No 1 Jul 2017

• Unknown etiology but flouronated topical corticosteroids, subclinical irritant contact dermatitis, and overmoisturization  of skin implicated.
• F > M
• Discrete, symmetric pinpoint papules and pustules but not on vermillion border - might have erythematous base.
• Treatment
  • Wean any topical steroids
  • First line: Oral tetracycline (II) (250mg bid-tid for several weeks)
  • Second line: Oral erythromycin (III)
  • Third line: Topical metronidazole (I) with or without above Abx

References:

• Cheung M, Taher M, Lauzon G., Acneiform facial eruptions, Canadian Fam Phys, Vol 51; April 2005; 527-533

Reference:

• AFP Vol 96 No 12 Dec 2017

Etiologies:

1. Dermatologic
   • Atopic dermatitis
   • Contact dermatitis
   • Lichen simplex chronicus
   • Psoriasis
   • Urticaria
   • Xerosis
2. Systemic
   • Autoimmune disorders
   • Chronic renal failure
   • Drug induced
   • Endocrine disorders
   • Hematologic (polycythemia vera) and HIV infection
   • Liver disease
   • Lymphoproliferative disorders
   • Malignancy
3. Neurologic
   • Brachioradial pruritis
   • Multiple sclerosis
   • Notalgia paresthetica
   • Postherpetic neuralgia
   • Poststroke
   • Small-fiber polyneuropathy (DM one of most common causes)
4. Psychogenic
   • Anxiety
   • Bipolar disorder
   • Delusional infestation
   • Depression
   • Obsessive-compulsive disorders
5. Mixed
   • More than 1 cause found
6. Other

Workup:

• Labs
  • CBC - hematologic or malignancy suspected
  • CMP - DM, liver, or renal disease suspected
  • ESR - autoimmune disease suspected
  • TSH - hyperthyroidism suspected
  • Hepatitis panel
  • HIV
• Imaging
  • CXR - lymphoma suspected
  • Spinal imaging (MRI) - secondary workup for brachioradial pruritis or notalgia paresthetica

Management:

• Non-Drug
  • Warm (not hot) water for bathing
  • Apply emollient to skin immediately after bathing
  • Use hypoallergenic body products
  • Humidify indoor spaces during winter
  • Avoid fabrics and other clothing materials that irritate the skin (like wool - use cotton)
  • Wear loose fitting clothes
  • Avoid vasodilators (caffeine, alcohol, spices, and activities that promote excessive sweating like strenuous exercise)
• Drugs
  • Antihistamines
    • Nocturnal itch, paraneoplastic itch, systemic mastocytosis
    • diphenhydramine 25-50 mg q4-6 prn
    • hydroxyzine 25 mg tid or qid
    • loratadine 10mg qd
  • Anticonvulsants
    • neuropathic itch, uremic itch
    • gabapentin 100-300mg /d
    • pregabalin 50-300 mg/d
  • Antidepressants
    • Cholestatic itch, nocturnal itch, paraneoplastic itch, pyschogenic itch, uremic itch
    • sertraline 75-100mg qd
    • paroxetine 20-40 mg qd
    • amitriptyline 10-25 mg qd to tid
    • doxepin 10mg qd or bid
    • mirtazapine 15 mg qd
  • Antipsychotics
    • Delusion of infestation
    • olanzapine 2.5-10 mg qd
    • risperidone 1-8 mg qd
  • Opioid-receptor agents
    • Cholestatic itch, uremic itch
    • naltrexone 50 mg qd
  • Bile-acid sequestrants
    • Cholestatic itch
    • cholestyramine 4-6 mg tid - 30 min before meals
    • ursodiol 13-15 mg/kg/d