Update on Community-Acquired Pneumonia

(Great Britain—The Practitioner, February 2001, p. 108.) British studies estimate the incidence of community acquired pneumonia to be between five and 10 per 1,000 population. Among patients consulting a family physician because of an acute respiratory problem, approximately one in 10 has pneumonia and up to 40 percent of these require hospital admission. The cause is never identified in about 45 percent of cases. Of the remainder, 36 percent are caused by Streptococcus pneumoniae, 10 percent by Haemophilus influenzae and most of the rest by viruses. Organisms such as Chlamydia, Legionella, Mycoplasma and Staphylococcus each account for fewer than 1.5 percent of cases. The etiology of the condition cannot be deduced from the clinical presentation. Most patients present with fever, cough, sputum, malaise and pleuritic pain, but the presentation may be nonspecific in elderly patients. Management consists of rest, analgesia and antibiotic therapy. Antibiotics are selected based on the most likely causative organism and local patterns of antibiotic resistance. In many areas, amoxicillin remains the best empiric choice for patients who have no contraindications to the drug. Dosages of 500 to 1,000 mg three times daily are recommended. Hospital admission should be considered in patients 50 years of age and older, and in those with coexisting chronic illnesses, rapid respiratory rates, low blood pressure and adverse prognostic features.

Thrombosed External Hemorrhoids

(Australia—Australian Family Physician, January 2001, p. 29.) External hemorrhoids arise from the vessels in the dermis of the lower anal canal distal to the dentate line. Pathologically, hemorrhoidal tissue has the appearance of dilated vascular channels with longstanding inflammatory changes. While many symptoms of external hemorrhoids are minor, thrombosis can produce moderate to severe pain, a worrying mass and, occasionally, dark red bleeding. If symptoms are mild, the first episode of thrombosed external hemorrhoid may respond to a conservative treatment strategy of sitz baths (immersion in warm water for 15 to 20 minutes twice daily), stool softening and oral analgesia. Patients with severe or prolonged symptoms generally require excision of thrombosed hemorrhoidal tissue under local anesthetic. The thrombosed hemorrhoidal vein and overlying skin are excised using elliptical excision, but care must be taken to avoid damaging the anal verge. Sutures may not be required because most excisions heal well using the conservative measures described above. Simple incision and clot evacuation are not recommended because of the high recurrence rate of thrombosis.

Lattice Corneal Dystrophy

(Canada—Canadian Family Physician, February 2001, p. 265.) Corneal dystrophies are slowly progressive degenerations of the cornea classified by which one of the five corneal layers is predominately affected. The three types of lattice dystrophies all affect the stromal layer. The most common lattice dystrophy is type I, which presents in children as recurrent corneal erosions characterized by painful, red eyes and decreased visual acuity. Types II and III occur in adults and type II is associated with systemic amyloidosis. The principal differential diagnosis of lattice corneal dystrophy is traumatic corneal abrasion. The slit-lamp examination will reveal a branching pattern of amyloid deposits that interlace across the cornea. Increasing opacification usually leads to corneal transplantation by 40 or 50 years of age.

Management of Obstructive Sleep Apnea

(Great Britain—The Practitioner, February 2001, p. 117.) Obstructive sleep apnea occurs when complete or partial obstruction of the upper airway during sleep leads to sleep fragmentation and consequent symptoms. Up to 4 percent of men have more than five apneic episodes per hour during sleep, accompanied by daytime symptoms. The most important consequence of obstructive sleep apnea is daytime somnolence, which is related to the amount of sleep fragmentation rather than the degree of hypoxemia. Studies relating sleep apnea to heart disease are complicated by the high prevalence of obesity and hypertension in these patients. The relationship of sleep apnea to these conditions (cause or effect) is obscure, but losing weight significantly improves symptoms. Evaluating obstructive sleep apnea generally requires full polysomnographic testing, because oximetry alone is not an adequate screening tool. Patients may also be treated with nasal continuous airway positive pressure therapy. More recently, devices to stabilize the mandible have been suggested. Patients with significant snoring may benefit from ear, nose and throat referral and surgery.