Community Acquired Pneumonia

(Australia—Australian Family Physician, July 2000, p. 639.) The incidence of community acquired pneumonia (CAP) is about two per 1,000 adults per year. CAP causes about 2 percent of overnight hospital admissions for adult patients and has a mortality rate of up to 10 percent. Risk factors for CAP and the resulting mortality include advanced age, immunosuppression, residence in a nursing home and chronic disease (especially diabetes, cardiovascular, respiratory, cerebrovascular, liver and non-skin malignancies). The typical symptoms of cough with sputum, fever, shortness of breath and malaise may not occur in elderly patients or in persons with other chronic conditions. The most common organism to cause CAP may vary, but in one study in Australia, Streptococcus pneumoniae was responsible for 42 percent of cases, Haemophilus influenzae for 9 percent and Mycoplasma pneumoniae for 8 percent. Species of Chlamydia and Legionella also are significant pathogens in CAP. The radiograph and clinical findings on admission have been used to identify high-risk patients as those with opacity in more than one lobe, abnormal laboratory indices, tachypnea, confusion and extremes of blood pressure or temperature (either too high or too low). Patients with few risk factors and low severity on clinical examination may respond well to oral antibiotics. Patients at higher risk may require intravenous antibiotics, supportive care and monitoring for complications. Sputum should be cultured to identify the organism to guide intensive antibiotic therapy. All patients at risk for CAP should be counseled about smoking cessation and general health and should receive influenza and pneumococcal immunization.

Primary Open Angle Glaucoma

(Great Britain—The Practitioner, July 2000, p. 654.) Primary open angle glaucoma is a common chronic eye condition affecting up to 7 percent of adults older than 75 years. Many cases are detected through screening for raised intraocular pressure or cupping of the optic disc. The key for effective control is early identification. If diagnosis is delayed until vision deteriorates, more than 40 percent of retinal nerve fibers may be destroyed. The traditional treatment using the drug pilocarpine lacked systemic side effects but produced pinpoint pupils and was unpopular with patients. Timolol and, more recently, other beta blockers have become the mainstay of medical therapy. These new agents are expensive and have surprising side effects. For example, latanoprost darkens eye color and stimulates growth of eyelashes and eyebrows. Traditional surgical approaches, such as trabeculectomy, have been expanded with the introduction of laser techniques.

Alopecia Areata

(Canada—Canadian Family Physician, July 2000, p. 1469.) Approximately 2 percent of the population has alopecia areata. This autoimmune condition presents as a well-circumscribed oval bald patch or as patches with “exclamation mark” hairs (short hairs with proximal tapering) at the edges of each patch. One half of all cases of alopecia areata resolve spontaneously within one year, but about 10 percent of patients progress to complete baldness and 1 percent lose all body hair, including eyebrows and eyelashes (alopecia universalis). If local treatment of alopecia areata is desired, injections of triamcinolone acetate every four to six weeks for three months may be successful. Topical steroids, minoxidil and anthralin have also been used. If 50 percent or more of the scalp is involved, treatment options include topical immunotherapy, systemic steroids or phototherapy. Patients should be counseled about general health and encouraged to contact support groups as part of the management of this condition.

Headaches in Children

(Great Britain—The Practitioner, July 2000, p. 618.) Acute headaches in children are often caused by viral infections, while headaches in older children may be provoked by exercise. Even young children can provide information about their headache and the associated symptoms by using gestures and pictures to indicate location, severity and other characteristics. The child's history is the key diagnostic tool, because the physical examination may be normal in many cases. In the absence of trauma or physical findings, acute recurrent headaches are most likely to be migraine and chronic nonprogressive headaches are probably tension headaches. Chronic progressive headaches may be symptoms of brain tumor or other intracranial pathology. Headache alone is reported in only 1 percent of children with brain tumors, but headaches that worsen when the patient bends over or with the Valsalva maneuver should be investigated to exclude a serious progressive disorder.