Management of acute asthma exacerbations.

Am Fam Physician. 2011 Jul 1;84(1):40-7

Authors: Pollart SM, Compton RM, Elward KS

Asthma exacerbations can be classified as mild, moderate, severe, or life threatening. Criteria for exacerbation severity are based on symptoms and physical examination parameters, as well as lung function and oxygen saturation. In patients with a peak expiratory flow of 50 to 79 percent of their personal best, up to two treatments of two to six inhalations of short-acting beta2 agonists 20 minutes apart followed by a reassessment of peak expiratory flow and symptoms may be safely employed at home. Administration using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized beta2 agonist therapy in children and adults. In the ambulatory and emergency department settings, the goals of treatment are correction of severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the risk of relapse. Multiple doses of inhaled anticholinergic medication combined with beta2 agonists improve lung function and decrease hospitalization in school-age children with severe asthma exacerbations. Intravenous magnesium sulfate has been shown to significantly increase lung function and decrease the necessity of hospitalization in children. The administration of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization, with the most pronounced effect in patients with severe exacerbations. Airway inflammation can persist for days to weeks after an acute attack; therefore, more intensive treatment should be continued after discharge until symptoms and peak expiratory flow return to baseline.

PMID: 21766754 [PubMed - in process]

Usefulness of procalcitonin measurement in reducing antibiotic use and identifying serious bacterial illness.

Am Fam Physician. 2011 Jul 15;84(2):177-9

Authors: Graber MA, Dachs R, Darby-Stewart A

PMID: 21766767 [PubMed - in process]

A diagnostic approach to pruritus.

Am Fam Physician. 2011 Jul 15;84(2):195-202

Authors: Reamy BV, Bunt CW, Fletcher S

Pruritus can be a symptom of a distinct dermatologic condition or of an occult underlying systemic disease. Of the patients referred to a dermatologist for generalized pruritus with no apparent primary cutaneous cause, 14 to 24 percent have a systemic etiology. In the absence of a primary skin lesion, the review of systems should include evaluation for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes mellitus. Findings suggestive of less serious etiologies include younger age, localized symptoms, acute onset, involvement limited to exposed areas, and a clear association with a sick contact or recent travel. Chronic or generalized pruritus, older age, and abnormal physical findings should increase concern for underlying systemic conditions. Initial evaluation for systemic disease includes complete blood count and measurement of thyroid-stimulating hormone, fasting glucose, alkaline phosphatase, bilirubin, creatinine, and blood urea nitrogen. Hodgkin lymphoma is the malignant disease most strongly associated with pruritus, which affects up to 30 percent of patients with the disease. Chest radiography is needed when lymphoma is suspected. A wheal and flare response indicates histamine-induced pruritus in patients with urticaria or an allergic dermatitis. These patients benefit from continuous dosing of a long-acting antihistamine. Second-generation antihistamines, such as cetirizine, loratadine, and fexofenadine, may be more effective because of improved patient compliance.

PMID: 21766769 [PubMed - in process]