Beat the heat: Identification and Tx of heat-related illness

The prompt identification and treatment of heat-related illnesses and expedited transport to a higher level of care can be lifesaving. This article serves as a go-to guide.

Acute Bronchitis

Cough is the most common illness-related reason for ambulatory care visits in the United States. Acute bronchitis is a clinical diagnosis characterized by cough due to acute inflammation of the trachea and large airways without evidence of pneumonia. Pneumonia should be suspected in patients with tachypnea, tachycardia, dyspnea, or lung findings suggestive of pneumonia, and radiography is warranted. Pertussis should be suspected in patients with cough persisting for more than two weeks that is accompanied by symptoms such as paroxysmal cough, whooping cough, and post-tussive emesis, or recent pertussis exposure. The cough associated with acute bronchitis typically lasts about two to three weeks, and this should be emphasized with patients. Acute bronchitis is usually caused by viruses, and antibiotics are not indicated in patients without chronic lung disease. Antibiotics have been shown to provide only minimal benefit, reducing the cough or illness by about half a day, and have adverse effects, including allergic reactions, nausea and vomiting, and Clostridium difficile infection. Evaluation and treatment of bronchitis include ruling out secondary causes for cough, such as pneumonia; educating patients about the natural course of the disease; and recommending symptomatic treatment and avoidance of unnecessary antibiotic use. Strategies to reduce inappropriate antibiotic use include delayed prescriptions, patient education, and calling the infection a chest cold.

Vertebroplasty for osteoporotic fracture? Think twice

Think twice before recommending vertebroplasty (VP) for symptomatic osteoporotic compression fractures. New studies suggest that it has little benefit; thus, VP should be considered only after other, more conservative options fail.

Cultural competence teaching in U.S. pediatric clerkships in 2006

PURPOSE

Cultural sensitivity may be especially important in the care of children, and national pediatric associations have issued policy statements promoting cultural competence in medical education. The authors conducted a national survey to investigate the current state of cultural competence teaching and learning within U.S. pediatric clerkships.

METHOD

The authors surveyed 125 U.S. pediatric clerkship directors concerning the presence or absence of cultural curricula, content, teaching methods, and evaluation. Question types were multiple-choice single/best answer, checklists, five-point Likert-type scales, and free-text responses.

RESULTS

Of 100 respondents (80% response rate), most agreed or strongly agreed that teaching culturally competent care is important (91%), enhances the physician/patient/family relationship (99%), and improves patient outcomes (90%). Twenty four of 98 respondents (25%) reported cultural competence teaching. The most common teaching methods were lectures (63%), experiential learning through community activities (58%), and small-group discussions (54%). Only 14 respondents reported any curricular evaluation, the commonest methods being student surveys, clinical case presentations, and standardized patient experiences. Top factors facilitating curriculum development were culturally diverse populations of patients, students, faculty, and hospital staff, and faculty interest and expertise. Top challenges included lack of protected time for program development, funding, and faculty expertise.

CONCLUSIONS

Few U.S. pediatric clerkships currently provide cultural competence curricula. The authors' suggestions to promote cultural competence teaching include providing faculty development opportunities and developing and disseminating teaching materials and evaluation tools. Such dissemination is important to graduate physicians, who can provide culturally sensitive pediatric care to the changing U.S. population.

Evaluation and treatment of acute low back pain

Acute low back pain with or without sciatica usually is self-limited and has no serious underlying pathology. For most patients, reassurance, pain medications, and advice to stay active are sufficient. A more thorough evaluation is required in selected patients with "red flag" findings associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require closer follow-up and, in some cases, urgent referral to a surgeon. In patients with nonspecific mechanical low back pain, imaging can be delayed for at least four to six weeks, which usually allows the pain to improve. There is good evidence for the effectiveness of acetaminophen, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physical therapy, and advice to stay active. Spinal manipulative therapy may provide short-term benefits compared with sham therapy but not when compared with conventional treatments. Evidence for the benefit of acupuncture is conflicting, with higher-quality trials showing no benefit. Patient education should focus on the natural history of the back pain, its overall good prognosis, and recommendations for effective treatments.

A snapshot of the status of problem-based learning in U. S. medical schools, 2003-04

PURPOSE

Although the use of problem-based learning (PBL) is widespread in U.S. medical schools, its true prevalence is unknown. This study examined the prevalence of PBL in preclinical curricula.

METHOD

In 2003, a Web-based questionnaire was sent to education deans or directors of medical education at the 123 Liaison Committee on Medical Education-accredited medical schools in the United States. The respondents indicated whether or not they were using PBL and what percentage of faculty-student contact hours in the preclinical years used PBL.

RESULT

All 123 schools responded. Of them, 70% used PBL in the preclinical years. Of schools using PBL, 45% used it for less than 10% of their formal teaching, while 6% used it for more than half of their formal teaching. Of the 30% of schools not using PBL, 22% had used it in the past, and 2% had plans to incorporate it in the future.

CONCLUSIONS

Use of PBL is widespread in the preclinical curricula of U.S. medical schools. That use is limited, however, since fewer than 6% of programs use it for more than 50% of their instruction.

How much effort is needed to keep up with the literature relevant for primary care?

OBJECTIVES

Medicine must keep current with the research literature, and keeping current requires continuously updating the clinical knowledge base (i.e., references that provide answers to clinical questions). The authors estimated the volume of medical literature potentially relevant to primary care published in a month and the time required for physicians trained in medical epidemiology to evaluate it for updating a clinical knowledge base.

METHODS

We included journals listed in five primary care journal review services (ACP Journal Club, DynaMed, Evidence-Based Practice, Journal Watch, and QuickScan Reviews). Finding little overlap, we added the 2001 "Brandon/Hill Selected List of Print Books and Journals for the Small Medical Library." We counted articles (including letters, editorials, and other commentaries) published in March 2002, using bibliographic software where possible and hand counting when necessary. For journals not published in March 2002, we reviewed the nearest issue. Five primary care physicians independently evaluated fifty randomly selected articles and timed the process.

RESULTS

The combined list contained 341 currently active journals with 8,265 articles. Adjusting for publication frequency, we estimate 7,287 articles are published monthly in this set of journals. Physicians trained in epidemiology would take an estimated 627.5 hours per month to evaluate these articles.

CONCLUSIONS

To provide practicing clinicians with the best current evidence, more comprehensive and systematic literature surveillance efforts are needed.

Testicular cancer

Although testicular cancer accounts for only 1 percent of all tumors in males, it is the most common malignancy in males between 15 and 34 years of age. Cryptorchidism is the most significant risk factor for testicular cancer, increasing the risk up to 11-fold. A painless testicular mass is the classic presentation for testicular cancer, although a number of patients present with diffuse pain or swelling. Ultrasonography may be helpful in confirming the presence of a scrotal mass within the testicle. Intratesticular masses are considered malignant until proved otherwise. Radical orchiectomy is the treatment for the primary tumor. Staging of disease is based on tumor histology, serum tumor markers and presence of lymph-node or other metastatic disease. Depending on the stage of disease, further treatment may include observation, radiotherapy, chemotherapy or surgery. Survival rates in patients with testicular cancer have improved dramatically in the past 20 years and now exceed 90 percent overall.