AFP Journal Review

1. AFP Journal Review Lianne Beck, MD Emory Family Medicine May 15, 2008 Issue

2. Articles • Diagnosis and Management of Benign Prostatic Hyperplasia • Common Tinea Infections in Children • Primary Brain Tumors in Adults • The Visually Impaired Patient

3. Diagnosis and Management of Benign Prostatic Hyperplasia • Prevalence: 20 % in 40-year-old men; 90 % in men in their seventies. • Half of all men with histologic BPH experience moderate to severe lower urinary tract symptoms • Common symptoms are hesitancy, weak stream, nocturia, and incontinence. • May be complicated by recurrent UTI or bladder stones. • Acute urinary retention is uncommon, annual risk of < 1 %. • Irreversible renal damage is rare.

4. Diagnosis • History • Establish the severity of symptoms – AUA symptom index • Evaluate for causes other than BPH • Identify contraindications to potential therapies • Physical • DRE • Labs • UA – R/O bladder cancer, bladder stones, UTI, or urethral strictures • PSA - Measure in men who have at least a 10-year life expectancy and who would be a candidate for prostate cancer treatment; Correlate with prostate volume • Urine cytology (smokers, irritative sx’s, hematuria)

6. Differential Diagnosis of Lower Urinary Tract Symptoms in Men • Neurogenic bladder – abnormal sphincter tone • Prostatitis – fever, tender prostate • Bladder CA – hematuria • Prostate CA – nodule or induration • UTI – dysuria, frequency, pyuria, bacteruria

8. Treatment • Watchful Waiting • Recommended for mild symptoms (AUA Symptom Index score of 7 or less) • Those who do not perceive their symptoms to be particularly bothersome. • Patients who choose this approach should be monitored annually for symptom progression.

10. Alternative Therapies • Saw palmetto • Cochrane review concluded that saw palmetto produces mild to moderate improvement in urinary symptoms and flow measures, which is comparable to finasteride. • More recent high-quality, randomized controlled trial found no benefit with saw palmetto in symptom relief or urinary flow measures after one year of therapy. • Rye grass pollen extract (Cernilton) and Pygeum • Cochrane reviews small studies found evidence that each agent provides modest symptomatic improvement. • The AUA does not recommend the use of phytotherapy.

13. Common Tinea Infections in Children • Tinea is also called ringworm. • Caused by a group of fungi that infect only the outer keratinous layer of skin, hair, and nails. • Dermatophytes are aerobic fungi that are divided into three genera (Trichophyton, Microsporum, and Epidermophyton). • These fungi cannot survive on mucosal surfaces. • Infection is acquired directly from contact with infected humans (anthropophilic organisms), animals (zoophilic organisms) or indirectly from exposure to contaminated soil or fomites (geophilic organisms).

16. Diagnostic Tests • KOH microscopy is useful for the office-based diagnosis of tinea infections. • Directly shows hyphae and confirms infection. • Sensitivity 76.5 % vs 53.2% for fungal culture in diagnosing tinea unguium. NPV 81.6% vs 69% • Culture is expensive and time consuming, but appropriate for: • long-term oral therapy • infection seems resistant to standard topical therapy • diagnosis is unclear.

17. KOH Microscopy

18. Tinea capitis - M. audouinii and M. canis fluoresces ( < 5%) blue-green. Tinea (pityriasis) versicolor - Malassezia furfur fluoresces pale yellow to white Erythrasma - Corynebacterium minutissimum bacterium fluoresces bright coral red. Wood's lamp

19. Diagnosis Circumscribed alopecia, broken hairs, pruritus, scaling, adenopathy > 90 % caused by Trichophyton tonsurans Direct KOH microscopy or fungal culture can confirm. Treatment Must use oral agents to penetrate the affected hair shafts. Micronized oral griseofulvin 20 mg/kg/day for at least 8 weeks. Terbinafine (Lamisil) 62.5 mg (<20kg), 125 mg or 250 mg (> 40kg) daily x 4 weeks approved for use in children > 2yrs. Check LFT’s at baseline Selenium sulfide 2.5% shampoo 2-3x/week Tinea Capitis

20. Diagnosis Annular patch or plaque with an advancing, raised, scaling border and central clearing. +/- pruritis Most often caused by Trichophyton species. Confirmation with KOH microscopy Treatment Topical antifungal agent applied to the lesion and a 2-cm area surrounding the lesion once or twice daily until one week after the lesion appears to resolve. (2-4 wks) Newer fungicidal agents, Butenafine (Mentax) and terbinafine therapies are more effective than older fungistatic, miconazole (Micatin) and clotrimazole therapies. Oral medications reserved for patients with severe infection or for infections that do not respond to topical therapy. Avoid combination antifungal/corticosteroid Tinea Corporis

21. Diagnosis Occurs predominantly in adolescent and young adult men Often co-infection with tinea pedis, caused by same organisms, Trichophyton and Epidermophyton species. Lesion border is usually active with pustules or vesicles (unless the lesion is chronic). The background rash is red to reddish-brown and is usually a symmetric macule with fairly well-demarcated borders Usually spares the scrotum and is often pruritic; acute rashes also may have a burning quality. Treatment Always look at the feet!!! Topical therapy with terbinafine cream or spray applied once daily for one week and butenafine 1% cream applied once daily for two weeks. Tinea Cruris (Jock itch)

22. Diagnosis Predisposing factor: exposure to a moist environment and maceration of the skin Typically appears as a white macerated area between the toes A more diffuse dry scaling process often caused by T. rubrum ("moccasin type") may also occur Inflammatory vesiculobullous eruption occurring primarily on the soles of the feet Treatment Topical terbinafine applied once daily for 1 week or butenafine 1% applied once daily for 2 weeks. Oral terbinafine therapy 250 mg daily x 2 wks or fluconazole (Diflucan), 150 mg once weekly for 3 weeks, can be used to treat severe or refractory infections. Tinea Pedis (Athlete’s Foot)

23. Diagnosis Risk factors in adolescents include associated tinea pedis, improperly fitting shoes, and diabetes Nail scraping for KOH microscopy with or without a culture is recommended for confirmation. Periodic acid-Schiff (PAS) stain is the most accurate test, but costly. Treatment Best evidence supports continuous (as opposed to pulse tx) terbinafine for treatment in adoloscents. Griseofulvin usually used in children Low success rate: 35 to 50 % of patients disease-free at one year. Tinea Unguium

26. Primary Brain Tumors in Adults • 2 % of all cancers in U.S. adults • 18,000 new diagnoses of brain and nervous system cancers causing more than 12,000 deaths each year in the United States. • Peak incidence between 65 and 79 years of age • Most common malignant brain tumor is glioblastoma multiforme, which has a poor prognosis • Exposure to high-dose ionizing radiation is the only proven environmental risk factor.

27. Primary Brain Tumors • Typical symptoms include persistent headache, seizures, nausea, vomiting, neurocognitive symptoms, and personality changes • Any patient with chronic, persistent headache in association with protracted nausea, vomiting, seizures, change in headache pattern, neurologic symptoms, or positional worsening should be evaluated for a brain tumor. • Gadolinium-enhanced MRI is the preferred initial imaging study

32. The Visually Impaired Patient • Blindness or low vision affects 3.3 million Americans 40 years and older. • Ranks behind arthritis and CVD as the third most common chronic cause of impaired function in persons older than 70 years. • Patients with vision impairment are more likely to fall, make medication errors, have depression, or report social isolation. • Vision loss that accompanies the aging process has been associated with impaired postural stability and a resulting increase in the rate of falls.

33. The Visually Impaired Patient • AMD accounts for 54 % of all blindness and is the leading cause of blindness among white Americans. • Cataracts are the most prevalent eye disease in older persons and are the leading cause of blindness worldwide. • Diabetic retinopathy is the leading cause of new blindness in U.S. adults 20 to 74 years of age. • About one half of cases of visual impairment are correctable, and about one fourth are preventable.

34. Screening • The U.S. Preventive Services Task Force (USPSTF) is updating its 1996 screening recommendations (Insufficient evidence) for visual impairment. • The American Academy of Ophthalmology (AAO) suggests comprehensive medical eye evaluations: • every 2-4 yrs for patients 40 to 54 years of age • every 1-3 years for patients 55 to 64 years of age • 1 or 2 years for patients older than 65 years.

35. Evaluation • Check visual acuity using standard Snellen chart • An impairment of 20/50 or worse or a one-line difference between the eyes should warrant referral • Visual fields • Fundoscopic exam • Amsler Grid

37. Common Causes • Normal visual changes that occur with aging • presbyopia (the inability to focus on close objects) • decreased contrast sensitivity caused by retinal changes • decreased dark/light adaptation • delayed glare recovery. • In the U.S., the most prevalent etiologies of vision loss in persons 40 years and older are: • AMD (Age-Related Macular Degeneration) • Glaucoma • Cataracts • Diabetic retinopathy