CARDIOLOGY HYPERTENSION Treatment in African Americans Thiazide diuretics should be the drugs of choice for initial treatment of HTN

TN in most pts requiring drug therapy B/C of their ability to prevent one or more forms of CVD and their low cost. Most pts will require more than drug to control BP; diuretics should be included in these regimens. Weight control, low sodium/high potassium eating and increased physical activity and smoking cessation should all be encouraged. In pts unable to tolerate diuretics, therapy can be started with ACE inhibitors, CCBs or BBs, all of which have demonstrated ability to prevent or lessen CVD. Alpha-blockers should not be used for initial therapy. Monotherapy is appropriate if BP is <155/100, combination therapy should be used as first line if BP is 155/100. In patients with Diabetes and/or renal disease, combination therapy should be instituted at lower BP levels (145/90). African Americans as a group, have a lower BP response to monotherapy with BBs, ACE inhibitors, or ARBs compared with diuretics or CCBs. These reductions in responsiveness can be eliminated by using combinations of drugs, one of which is a diuretic. Obesity and high BP are part of a complex condition known as metabolic syndrome. The Dx of metabolic syndrome is based on the presence of at least three of a cluster of risk factors: obesity, high BP, elevated TGs, low HDL and elevated fasting blood glucose. Predisposing factors for the metabolic syndrome include type 2 diabetes mellitus, obesity and inactivity. African Americans are more likely to be sensitive to dietary sodium, a condition called salt sensitivity. DERMATOLOGY ACNE CURRENT PERSPECTIVES on the TREATMENT of ACNE Topical retinoids have a potent effect on both inflammatory and noninflammatory lesions while antibiotics affect primarily inflammatory lesions. Clinical trials of combination therapies involving topical retinoids and antimicrobial agents have consistently shown that this approach yields faster and better results verses monotherapy (i.e. retinoids plus doxycycline). Oral antibiotic therapy should be kept to a minimum of 2-4 months. To optimize Acne Therapy: o Use gentle non-soap cleaners pH 4.5 to 6.5 no more than twice a day o Apply a moisturizer with low irritation potential

o Minimize the use of irritating products aftershave, alcohol-based cleaners, exfoliating washes, and abrasive sponges o Avoid tanning salons and sun lamps o DO NOT PICK AT SKIN DRY SKIN Common causes, effective treatments Diseases that can cause dry skin and mild generalized pruritus include end-stage renal disease, obstructive hepatobiliary DO, diabetes, thyroid disease, hyperparathyroidism, and Hodgkins disease. Treatment centers on retaining moisture and avoiding irritants limiting showers and baths, using only luke-warm or cool water, relying on mild soaps such as Tone or Dove, wearing only cotton clothing, using only mild, nonperfumed detergents, and avoid dryer sheets. Key component of treatment is the use of both an emollient, which softens and smoothes the skin, and a moisturizer, which adds moisture, together immediately after bathing. Effective moisturizers and emollients include OTC products such as urea-based creams and lotions (Carmol, Eucerin), petrolatum (Vaseline Petroleum Jelly), and mineral oil, as well as Rx products that contain ammonium lactate (Lac-Hydrin). ERYTHRASMA Moist, reddish brown macules or patches, with irregular borders and sharp margins, that extend to the skin fold edges. Maceration of the skin is also evident. E.N.T. ALLERGIC RHINITIS Focus on Intranasal Corticosteroids Rhinitis is an inflammation of the mucous membranes of the nose and is characterized by one or more nasal SS congestion, rhinorrhea, sneezing and/or itching. May be allergic or non-allergic in nature. Often a predisposing factor in the development or exacerbation of asthma, rhinosinusitis and nasal polyps. Considerable improvement in asthma SS can be observed after pts receive appropriate medical or surgical treatment for sinusitis and nasal polyps. Use of intranasal corticosteroids as first-line therapy, with oral antihistamines as adjunctive therapy for patients with moderate or severe intermittent allergic rhinitis and those with mild to severe persistent rhinitis. Monotherapy with oral antihistamines is appropriate only for pts with mild intermittent SS. Nasal congestion is the most bothersome SS.

 Intermittent allergic rhinitis is defined as the occurrence of symptoms for less than 4 days a week or for fewer than 4 weeks. Persistent rhinitis is defined as the occurrence of SS for 4 days a week and for more than 4 weeks. Nasonex most rapid onset of action, low systemic bioavailability, can be used as low as age 2, is the only intranasal steroid indicated for use as prophylactic therapy. Guidelines for the Tx of acute bacterial maxillary sinusitis (ABMS) suggests the use of a broad spectrum ABO in those Uris that do not clear or that worsen after 5-7 days. Otitis Media Dx and Management Dx must meet three criteria: 1) rapid onset; 2) presence of middle ear effusion (MEE); and 3) signs or symptoms of middle ear inflammation. MEE fluid can remain in the ear for as long as 90 days after an acute infection has resolved. Observation Option deferring antibacterial treatment for 48 72 hours in selected children with uncomplicated AOM without severe symptoms and limiting management to symptomatic relief. This option should be limited to otherwise-healthy children between the ages of six months to 2 years with nonsevere illness at presentation and uncertain diagnosis, and to children two years and older without severe symptoms at presentation or an uncertain Dx. It may be acceptable to give reliable parents a safety net ABO Rx to be filled in case the illness does not improve. An expiration date of 5-6 days should be included on the Rx. First-line Tx is usually Amoxil because of its general effectiveness, safety, low cost and acceptable flavor 80 to 90 mg/kg/day in 2 doses. Patients with severe illness (moderate to severe otalgia or fever equal to or greater than 39C) who are deemed by the clinician to require immediate coverage for B lactamase-positive Haemophilus influenzae and Moraxella catarrhalis should receive high-dose Augmentin. Pts who are allergic to Amoxil but who do not exhibit a Type I hypersensitivity should be treated with Cefdinir - Omnicef, Cefpodoxime - Vantin or Cefuroxime Ceftin. Patients with Type I allergic reactions should be treated with either Clarithromycin, Azithromycin, Erythromycin/Sulfisoxazole or TMP/Sulfamethoxazole. Children who are vomiting or those who have a compliance problem should receive IM Ceftriaxone (50 mg/kg). Up to 70% may improve after one dose. Standard 10 day therapy for children < 6 years. Kids > 6 years with mild to moderate disease may receive a 5-7 day course of Tx. Pts who fail to improve while receiving Amoxil or Augmentin should not receive TMP/Sulfamethoxazole or Erythromycin/Sulfisoxazole because they have been associated with high levels of resistance.

 Acetaminophen or Ibuprofen is suggested as a first-line analgesic, while topical agents show only modest benefits in patients over the age of five (for benzocaine) or six (for naturopathic agents). Prevention mothers should be encouraged to breast-feed infants for at least the first six months, limit or eliminate pacifier use in children older than six months, avoid exposure to secondhand tobacco smoke, avoid supine bottle-feeding (bottlepropping), children older than 2 years immunoprophylaxis with killed and liveattenuated influenza vaccines has shown greater than 30% efficacy in preventing AOM during cold-flu season. OB/GYN BACTERIAL VAGINOSIS Treatment of Recurrent BV is the most common cause of vaginal D/C and odor among women of reproductive age. 15 30% of women treated for BV can develop a recurrence in the first 1 to 3 months following treatment. Women with multiple sexual partners or those who engage in frequent sexual intercourse are more likely to develop BV. Routine douching doubles the risk for developing BV, may inhibit the restoration of H2O2 producing Lactobacilli. Counseling women with recurrent BV to eat yogurt or take probiotic supplements to restore the vaginal microflora is probably of little value. Metronidazole is not active against anaerobic bacteria including Lactobacilli, so use of metronidazole spares the lactobacilli. Oral metronidazole 500mg twice daily and metronidazole gel show similar efficacy, the single 2-gram oral metronidazole is less efficacious. Best strategy for the management of recurrent BV: treat longer initially and then to provide suppressive therapy with metro-gel to prevent recurrence. Initial therapy should be increased to 10-14 days. Pts should have their male partners use condoms during the period of therapy and the month thereafter to help reestablish H2O2-producing vaginal microflora. STDs(STIs) HIV Pts with an untreated STI may be 2-3 times more susceptible to HIV infection than are noninfected persons. HIV infected persons with an STI may transmit HIV infection more easily than does one with HIV alone.

ONCOLOGY MULTIPLE MYELOMA

Multiple myeloma (MM) is a monoclonal B-cell malignancy originating from lymph node follicle-center B lymphocytes, which transform into neoplastic plasma cells. They infiltrate the bone marrow and cause either multiple osteolytic lesions or diffuse bone demineralization Incidence is 3-4 cases per 100,000 population, male-to-female ratio of 1.5:1, mean age of Dx is 65 years, median survival in the 36-month range. Hallmark of MM that is seen in 75% of patients is Bence Jones protein (monoclonal paraprotein light chains), excreted in the urine. Bone pain from lytic bone disease is a common presenting symptom in MM, occurring in more than two thirds of patients. Tumor growth, activated osteoclasts cause devastating bone destruction often leading to vertebral collapse (possible reduction of height by several inches) and pathologic fractures of long bones. Nerve compression from vertebral lesions or bone collapse often results in radiculopathy. Normocytic normochromic anemia and thrombocytopenia are frequent findings and result from the replacement of bone marrow hematopoietic tissue by neoplastic plasma cells. 15% of all patients present with hypercalcemia at Dx, which is primarily due to the release of bone-resorbing cytokines Hyperviscosity syndrome can obstruct blood flow to the distal extremities, causing acrocyanosis and Raynauds phenomenon. Coagulation abnormalities are often seen and result from thrombocytopenia (from mm bone marrow infiltration). These may lead to GI and pulmonary hemorrhages. The main infectious complications in MM are pneumonia and pyelonephritis. Renal insufficiency develops in up to 50% of patients with MM, it is caused by Bence Jones proteinuria. Peripheral smear may show stacked and clumped erythrocytes (rouleaux). Bone marrow examination is required to Dx MM. Baseline radiographic studies of the skull, spine, pelvis, humeri and femora should be performed early and repeated every 6 months. To Dx MM, three simultaneous findings are required: 1. Bone marrow Bx shows more than 10% plasma cells, neoplastic plasma cell aggregates, or plasmacytoma 2. Bone lytic lesions are found, or diffuse demineralization (involving mainly the flat bones such as the skull, spine and ribs) is found. 3. Clinical presentation is typical of MM. Asymptomatic patients should not be started on chemotherapy b/c some of them will remain stable over time. For pts younger then 70 yo autologous hematopoietic stem cell transplantation following chemotherapy with vincristine, adriamycin and dexamethasone.

For pts >70 yo recommended therapy remains melphalan and prednisone in 7-day courses repeated every 6 weeks. Prognosis in MM depends on two major factors: renal function and total body tumor burden. Pts survive an average of 6 months if the disease is untreated. Chemotherapy prolongs survival to 3 years (8.6 months in the presence of renal failure) Cause of death is usually infection, renal failure or lung hemorrhage. PREVENTATIVE MEDICINE VACCINATIONS

Influenza New Influenza Vaccine Recommendations AAP May 2004 o Influenza immunizations for all healthy children between 6 and 24 months of age o Household contacts and out-of-home caregivers for all children < 24 months of age o Health-care professionals Two Influenza Vaccine Types o Trivalent influenza vaccine (TIV) IM o Live attenuated, cold adapted influenza vaccine (LAIV) - intranasal Current recommendations for TIV o Priority High-risk children and adolescents Pregnant women in the 2nd and 3rd trimesters Persons in close contact with high-risk children Health-care professionals o All children between the ages of 6 months and 24 months o Any person who wishes to prevent influenza Dosing Schedule for TIV by age o 6-35 mos 0.25mL 1-2 doses IM o 3-8 yrs 0.5mL 1-2 doses IM o >9 yrs 0.5mL 1 dose IM Current recommendations for LAIV o Healthy individuals 5-49 yrs who want protection from influenza o Dosed at 0.25 mL given into each nostril using the AccuSpray device o First-time recipients younger than 9 yrs should receive 2 doses of vaccine 6 weeks apart Peak influenza activity is in the month of Feb PULMONOLOGY ASTHMA 4 Key components for long term asthma control o Assessment and monitoring

o Pharmacologic therapy o Control of factors contributing to asthma severity o Patient education for a partnership General goals for all treatment plans o Prevent chronic asthma SS and exacerbations during daytime and nighttime o Maintain normal activity levels (including physical activity) o Achieve normal or near-normal lung function o Be satisfied with asthma care o Have no or minimal side effects with optimized therapy o Pharmacologic treatment for asthma consists of two components: quick relief and long-term control

PSYCHOLOGY DEPRESSION CHILDHOOD o Dx can be made only if 5 or more of the following SS are present during the same 2 week period and represent a change from previous functioning: o Decreased concentration, indecisiveness o Depressed or irritable mood o Diminished pleasure or interest in activities o Failure to make expected weight gains o Fatigue o Feelings of guilt or worthlessness o Insomnia or hypersomnia o Morbid thoughts, suicidal ideation or attempt o Psychomotor retardation or agitation SS must occur every day or nearly every day. SS cannot be attributed to a substance (e.g., a medication), general medical condition, or bereavement. o Both genetic and psychosocial factors have a role in depression, and family dysfunction appears to be particularly influential. o Other factors include peer problems, chronic illness, prior depressive episodes and a first-degree relative with a Hx of depression. o 60% of patients with depression who are younger than 20 years have a firstdegree relative with a Hx of depression. o Key information obtained during the Hx include: Onset, duration, intensity, frequency, severity and pervasiveness of the SS. o Developmental, social and FHx should also be obtained along with an account of potential stressors in the childs environment. o Appropriate baseline tests may include a CBC with diff, electrolytes, creatinine, BUN, LFTs, TSH, ECG, MRI, or EEG.

o Psychiatric DO such as bereavement, adjustment DO with depressed mood, bipolar DO, and substance-induced mood DO should be considered. o Marijuana and alcohol use can cause depressive SS, as can other meds systemic corticosteroids, oral contraceptives, benzodiazepines, barbiturates, stimulants and anticonvulsants. o 70% of children who have depression also have at least one other psychiatric comorbidity substance abuse, anxiety DO and disruptive DO (ADHD, opposititional DO, or conduct DO). o Depressed kids are at increased risk for personality, eating, learning, and somatization DO. o Children who are depressed are more likely to experience academic difficulties, social impairment, and somatic complaints. They are also more likely to engage in risky behaviors, such as substance abuse, smoking, and promiscuity, and have higher rates of attempted and completed suicide COMMON MANIFESTATIONS OF MAJOR DEPRESSIVE DISORDER BY AGE <3 Feeding problems, temper tantrums, lack of playfulness and emotional expression 3-5 6-8 Phobias, enuresis, encopresis, being accident prone, being overly apologetic for minor infractions Vague somatic complaints (particularly chronic abdominal aches and headaches), aggressive behavior, resistance to new experiences and people Excessively morbid thoughts, worry about homework, self-blame

9-12

Adolescence Anger, irritable mood, moodiness, uncommunicativeness, hypersensitivity to criticism, anhedonia, hypersomnia, delinquency, preoccupation with body image o Immediate referral to a specialist and hospitalization is warranted for the child who has a plan to attempt suicide. o Prozac is the only drug approved by the FDA for use in pediatric MDD. o Tricyclic antidepressants are not effective in children o Antidepressant effects usually take about 3-6 weeks to manifest themselves. Improvement should be followed by maintenance therapy for 4-6 months to prevent a recurrent episode. o 40% of patients will have a recurrence of their MDD within 2 years and 70% recurrence within 5 years. o When terminating Tx gradually decrease in dosage to avoid SS of withdrawal. TRAUMA

ANIMAL/INSECT BITES Brown Recluse SS are not from infection but rather from the spiders dermatonecrotic venom Steroids are of very limited use with this condition. If areas continue to enlarge following a week consider Dapsone. Dapsone inhibits neutrophil function, which amplifies the necrosis. Dapsone 100mg/d x 1 week adults; 2 mg/kg/d x 1 week peds. Watch for hemolysis, check HCT prior to therapy. Contraindicated in pts with G6PD deficiency. UROLOGY OVERACTIVE BLADDER (OAB) Hallmark Symptom is urgency defined as a sudden, compelling desire to pass urine that is difficult to defer. Factors that contribute to OAB symptoms include: o Disorders of the lower urinary tract o Neurologic conditions o Behavior factors Caffeine intake Certain drugs o Systemic conditions Diabetes Parkinsons disease Prostate problems Vaginal atrophy Mast dramatic increase > 44 women, >64 - men Strong association between urge incontinence and depressive symptoms Comorbidities associated with OAB o UTIs o Disrupted sleep secondary to nocturia o skin ulceration in incontinent pts Dx o complete medical Hx o PE o UA and culture o focused pelvic/GU exam o appropriate cultures for D/C o complete review of pts medical and surgical history o pregnancy info vaginal vs caesarean section weight of the infant

 prolonged second stage of labor pelvic surgery o BPH symptoms in men > 65 o review of Rx and OTC meds, herbal products, food supplements, o caffeine and alcohol intake o bowel habits o patterns of urination and leakage o pain, blood or discomfort with urination o voiding dysfunction straining or incomplete emptying o neurologic status evaluation o PE of the abdomen, rectum, genitals and pelvis Medications o Contraindications and precautions apply to all antimuscarinic medications Contraindicated: uncontrolled narrow-angle glaucoma gastric reflux urinary retention Caution hepatic or renal impairment GI obstructive disorders bladder outflow obstruction ulcerative colitis intestinal atony myasthenia gravis GERD