AJCM Summer2012

American Journal of Clinical Medicine®

Owned and Published by the American Association of Physician Specialists, Inc. Peer Reviewed. Listed in Google Scholar and BioMedLib

Summer 2012 • Volume Nine, Number Two

Featured in this issue 70

Curriculum Factors Predicting Family Medicine Specialty Choice: An Exploratory Study Among Rural Medical Scholars

80

Urgent Care Centers: An Overview

88

Acute Infectious Mononucleosis: A Review for Urgent Care Physicians

92

Review of Important ECG Findings in Patients with Syncope

102 Wellens’ Syndrome: A Case Report

104 Medical Ethics

Without the Rhetoric

AJCM

®

URGENT CARE SECTION

80

Urgent Care Centers: An Overview Sean McNeeley, MD

82

Urinary Tract Infection Update

88

Acute Infectious Mononucleosis: A Review for Urgent Care Physicians

In This Issue Curriculum Factors Predicting Family Medicine Specialty Choice: An Exploratory Study Among Rural Medical Scholars

Mark E. Rogers, MD

70

Thomas Horowitz, DO

92

Review of Important ECG Findings in Patients with Syncope Joseph Toscano, MD

Daniel M. Avery, Jr., MD John R. Wheat, MD, MPH James D. Leeper, PhD Jerry T. McKnight, MD, MPH Brent G. Ballard, MD Jia Chen, MA

The Physician’s Role in a Disaster Our Place in the Community is Greater Than Just in our Offices

Kim Gibson, MD Joseph Toscano, MD

98

Rhinosinusitis: An Urgent Care Perspective Sean M. McNeeley, MD

78

102

Wellens’ Syndrome: A Case Report Joseph Toscano, MD

104

Medical Ethics Without the Rhetoric Mark Pastin, PhD

American Association of Physician Specialists, Inc.® 5550 West Executive Drive Suite 400 Tampa, Florida 33609-1035 Phone: 813-433-2277 Fax: 813-830-6599 www.aapsus.org

AAPS Board of Directors William G. Anderson, DO Scott G. Barnes, DO Terrance Lee Baker, MD, MS A. Robert Cerrato, DO, JD Michael A. Cohen, DO Joseph M. Damiani, MD, FAAPRS Brian J. Feaver, MD, FAASFP Kenneth M. Flowe, MD, FAAEP Joseph C. Gallagher, DO, FAASOS William J. Garrity, DO, FAASFP Surinder K. Kad, MD, FAAIM, MPH, MBA Jerry R. Majers, DO, FAAIM, FAAGM Douglas L. Marciniak, D.O, FAAIM Stephen A. Montes, DO, FAASOS Thomas G. Pelz, DO, FAAIM Asaf R. Qadeer, MD Anthony P. Russo, Jr., DO Susan M. Sarracino, MD Craig S. Smith, MD Louis W. Sullivan, MD Martin E. Thornton, DO

AAPS Staff William J. Carbone Chief Executive Officer Nadine B. Simone Executive Assistant Andrea N. Balboa Assistant Director of Certification Christina Stebbins Manager of Test Development Susan LoBianco Certification Coordinator Marilyn D. Whitfield Certification Coordinator Maria F. Valente Certification Coordinator Esther L. Berg Director of CME, Meetings & Membership Keely M. Clarke CME, Meetings & Membership Coordinator Anthony J. Durante Director of Finance & Operations Sandra E. Martin Finance & Operations Coordinator Debi S. Colmorgen Communications Coordinator Lauren E. Withrow Governmental Affairs Coordinator James G. Marzano Director of Public Relations & Marketing Jeffery L. Morris, Jr., JD Director of Communications & External Affairs

W

elcome to the American Journal of Clinical Medicine® (AJCM®). This issue is focused on urgent care. The Journal is dedicated to improving the practice of clinical medicine by providing up-to-date information for today’s practitioners.

The AJCM is the official journal of the American Association of Physician Specialists, Inc. (AAPS), an organization dedicated to promoting the highest intellectual, moral, and ethical standards of its members, and whose diversity incorporates physicians that represent a broad spectrum of specialties including anesthesiology, dermatology, diagnostic radiology, disaster medicine, emergency medicine, family medicine obstetrics, family practice, geriatric medicine, hospital medicine, internal medicine, obstetrics and gynecology, ophthalmology, orthopedic surgery, plastic and reconstructive surgery, psychiatry, radiation oncology, general surgery, and urgent care medicine.

Part of the mission of the AAPS is to provide education for its members and to promote study, research, and improvement of its various specialties. In order to further these goals, the AJCM invites submissions of high-quality review articles, clinical reports, case reports, or original research on any topic that has potential to impact the daily practice of medicine. Publication of a peer-reviewed article in the AJCM is one of the criteria needed to qualify for the prestigious Degree of Fellow in the Academies of Medicine of the AAPS. Articles that appear in the AJCM are peer reviewed by members with expertise in their respective specialties. Manuscripts submitted for publication should follow the guidelines in The International Committee of Medical Journal Editors: “Uniform requirements for manuscripts submitted to biomedical journals” (JAMA, 1997; 277:927-934). Studies involving human subjects must adhere to the ethical principals of the Declaration of Helsinki, developed by the World Medical Association. By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of their article that might create any potential conflict of interest.

More detailed information is included in the AJCM Manuscript Criteria and Information on pages 106 and 107.

All articles published, including editorials, letters, and book reviews, represent the opinions of the authors and do not reflect the official policy of the American Association of Physician Specialists, Inc., or the institution with which the author is affiliated, unless this is clearly specified. ©2012 American Journal of Clinical Medicine® is published by the American Association of Physician Specialists, Inc. All rights reserved. Reproduction without permission is prohibited. Although all advertising material is expected to conform to ethical standards, acceptance does not imply endorsement by the American Journal of Clinical Medicine® and the American Association of Physician Specialists, Inc.

Editor-In-Chief

Wm. MacMillan Rodney, MD, FAAFP, FACEP

Senior Editor

Kenneth M. Flowe, MD, FAAEP

Managing Editor

Esther L. Berg, MEd

Editorial Board

Harold M. Bacchus, Jr., MD, FAAFP Gilbert Daniel, MD, FAAR Michael K. Garey, MD Surinder K. Kad, MD, FAAIM, MPH, MBA Leslie Mukau, MD, FAAEP, FACEP Thomas G. Pelz, DO, FAAIM

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AJCM is peer reviewed and listed in Google Scholar and BioMedLib

AJCM

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Welcome to the American Journal of Clinical Medicine® (AJCM®)As editor-in-chief of the American Journal of Clinical Medicine®, published by the American Association of Physician Specialists, Inc. (AAPS), let me introduce myself. Recently, AAPS became a sponsoring partner of the National Rural Health Association (NRHA) because our goals for rural health are intertwined.

Two particular specialties within the American Board of Physician Specialties (ABPS), the certifying body of the AAPS, seem to have gained favorable attention for underserved communities where platoons of internists, pediatricians, and obstetricians cannot be sustained financially. Building on a residency in primary care – but mainly family medicine – physicians can obtain one more year of training and become board certified in emergency medicine (BCEM) or obstetrics (BCFMOB).

In support of these efforts, which seem to be orphaned in most USA medical schools, we are publishing evidence-based research relevant to our goals of providing high quality health care at a lower cost.

As with most rural physicians, BCEM and BCFMOB physicians: • cover the hospital • encounter unexpected trauma • deliver babies • care for newborns and children • and more In addition there are numerous needs for skills in various diagnostic and surgical procedures.

The American Journal of Clinical Medicine has started a series of case reports in specific areas helpful to rural and mission hospital physicians. These include the following: • Ultrasound Case of the Month – Trauma • Ultrasound Case of the Month – OB-Gyn • Fractures You Can and Should Manage • Office Surgery Cases including the use of office anesthesia • IV Sedation Analgesia-Ketamine when general anesthesia is not available • Chest X-ray Case of the Month • ECG Case of the Month Each case requires a series of board simulation questions. At the end of the cases suggested answers are given and backed up with scientific literature. Each case should be an exercise combining the procedure and the subsequent management/ follow-up of the patient. Readers will, over the course of ten issues, accumulate skills not readily available in most current ACGME residencies. Your comments are appreciated.

Wm. MacMillan Rodney MD, FAAFP, FACEP Editor, American Journal of Clinical Medicine® Member, American Board of Family Medicine Obstetrics

A recent review of the article, Heterotaxy Syndrome in a Young Adult, that appeared in the American Journal of Clinical Medicine®, Winter 2012, Volume 9, Number 1, revealed that parts of this article had been used without acknowledgment from an article entitled, Situs revisited: Imaging of the heterotaxy syndrome, in Radiographics,1999;19:837-852. The author has issued an apology for this oversight, and the electronic version of AJCM will insert this attribution of credit to Radiographics at the top of the AJCM article.

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American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

Curriculum Factors Predicting Family Medicine Specialty Choice:

An Exploratory Study Among Rural Medical Scholars Daniel M. Avery, Jr., MD John R. Wheat, MD, MPH James D. Leeper, PhD Jerry T. McKnight, MD, MPH Brent G. Ballard, MD Jia Chen, MA

Abstract

Introduction

Family medicine is central to medical education strategies that produce rural physicians. In 1996, the Rural Medical Scholars Program was created to produce rural family physicians in Alabama. The literature suggests that curriculum can play a supporting role with special admissions in the production of rural family physicians. This study seeks to determine if curriculum factors were associated with family medicine specialty choice among Rural Medical Scholars. A questionnaire was sent to 112 students who had completed the Rural Medical Scholars Program and had either entered or completed residency. Eighty responded to the survey. Several curriculum factors are associated with choosing family medicine specialty among medical students in the Rural Medical Scholars Program; i.e., positive attitudes toward Family Medicine by clinical faculty in OB/ GYN, Pediatrics, Psychiatry, and Neurology, and viewing Family Medicine faculty, Family Medicine residents, and community-based family physician preceptors as stronger than other faculty in terms of being clinicians, teachers, and mentors.

An educational research interest of faculty of the University of Alabama School of Medicine-Tuscaloosa (UASOM-T) is to understand why some students choose the specialty of Family Medicine. A regional clinical campus of the University of Alabama School of Medicine, UASOM-T, has several programmatic components to address its mission focus of providing primary care physicians to serve rural Alabama. The third and fourth years of clinical medical sciences include a required two-month rotation in rural Alabama studying Family and Community Medicine. There is an unopposed family medicine residency, an institute for rural health research, and an affiliated Master’s Degree program in Rural Community Health.

A pipeline program recruits and nurtures rural students from high school and college into these programs and culminates in the Rural Medical Scholars Program (RMSP),1 which specifically admits rural Alabama students into a five-year MS-MD program in rural community health and medicine. Ten Rural Medical Scholars (RMSs) per year make up one-third of each class at UASOM-T.

Curriculum Factors Predicting Family Medicine Specialty Choice . . .

American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

Rescinding of interest in primary care has been observed in students entering the regional campus through both usual admissions conducted at the main campus in Birmingham and special admissions to the RMSP conducted at the branch campus. The RMSP admissions committee seeks to discern primary care interest and rural practice intent among students with at least eight years of residence in rural Alabama. Whereas all RMSs must impress the committee with their interest in rural primary care to be selected into the program, unpublished program data indicate that 20-30% end up in non-primary care specialties.

Ongoing efforts to study the effectiveness of the RMSP provided opportunity to address the research interest with data.

The study was initiated with a literature review that identified admissions, curriculum, and structural factors influencing students’ choices of residency training, especially family medicine.2 This review was followed with a survey of RMSs who had completed their five-year course of training and had chosen residencies. The survey study was designed to pilot test a questionnaire for determining the effects of admission, curriculum, and structural factors on student choice of family medicine specialty. The results relative to admission factors influencing RMSs to choose family medicine have been reported elsewhere.3 In this paper, curriculum factors that influenced them to choose family medicine are reported.

Literature Review Six recent reviews or systemic analyses of rural medical education programs4,5,6,7,8,9 comment on the importance of curriculum in the production of primary care physicians for rural practice.

There is a consensus that curriculum follows admissions in its impact on rural primary care career choice. However, each of the reviews gave credence to various aspects of curriculum. All six note the importance of rural experience in the curriculum.

Family medicine or primary care preceptors were found to be important by three,4,5,6 as was a rural focus within the curriculum.5,6,8 Family medicine faculty was emphasized by two.6 A family medicine focus in the curriculum6 and problem-based learning5 were each noted by one. Five of the reviews4,5,6,8,9 recommended that multiple interventions be bundled to influence students to choose to become rural primary care physicians; special admissions rated highest among those interventions, but curriculum was next. Ranmuthugala7 found the support for special admissions to be compelling and assessed special rural curriculum as influential but did not find sufficient outcomes data accompanied by control of potential confounders to fully endorse expenditures on a special rural curriculum.

Further literature review disclosed an emphasis on three aspects of a curriculum to promote rural family medicine: special family medicine focus, clinical family medicine emphasis, and curriculum content.

Special family medicine focus. A special family medicine focus throughout medical school helps attract medical students into family medicine. There is a direct relationship between amount of exposure to family medicine that students experience

and the likelihood of choosing family medicine as a career. Required time in family medicine,9,10 a required family medicine clerkship,9,11,12 involvement of family physicians throughout medical school,13,14 and family medicine mentors throughout all four years of medical school9,11,15 support the choice of family medicine. Exposure to ambulatory family medicine16 and rural family medicine rotations10,14,17 also play a part.

Clinical family medicine emphasis. Clinical family medicine exposure attracts medical students to family medicine as a career. Students respond positively to family medicine patient care during the preclinical years.18 The literature discloses advocates for medical curricula to produce family physicians through clinical rotations in family medicine to “exemplify the personal rewards and health care benefits of the family practice approach to care.”11 Medical students respond to the opportunity to interact with patients and family medicine attendings including medical school faculty and community-based physicians.11 To adequately portray the discipline, the curriculum should expose students to the wide diversity of patients, problems, and activities that family physicians deal with each day.11,15 Curriculum content. Curriculum content plays an integral part in effectiveness of the medical school in attracting medical students to family medicine. Family medicine emphasizes care of the entire patient or holism.15 Curricula that promote family medicine as a career demonstrate enduring relationships with patients, continuity of care, and preventive medicine.15 Likewise, community-based primary care experiences and rural preceptor exposure are key curriculum components.17 This literature review provides the basis for testing hypotheses relating medical education curriculum to student choice of family medicine for residency training. It would appear that a special focus on family medicine indicates its priority in the school, a clinical emphasis demonstrates its practicality, and its content appeals to students with generalist interests. This study was conducted to test the utility of a questionnaire to discriminate among targeted students who do and do not make this choice. For this pilot study with a small number of participants, the statistical testing is considered to be hypothesis generating, searching for associations that bear further study in less uniform and larger populations of students.

Methods The methods for this cross-sectional survey of the 80 Rural Medical Scholars who had progressed beyond medical school are described elsewhere.3 The survey pilot tested a 32-question survey containing 12 questions (with multiple parts) related to medical education curriculum; five of these questions shown in Table 1 appear to discriminate between Rural Medical Scholars who did and did not choose family medicine. Three rounds of mailings were conducted. After the first mailing that generated responses from 40 RMSs, the questionnaire was shortened and Question 2 added, accounting for its fewer responses. This research was approved by the Institutional Review Board of The University of Alabama.

Curriculum Factors Predicting Family Medicine Specialty Choice . . .

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Variables. The dependent variable was choice of a family medicine residency (yes or no). Independent variables related to curriculum were derived from the questions shown in Table 1.

with RMSs who chose family medicine training. We are encouraged about its potential for use in a more diverse population of medical students.

Analyses. Univariate and bivariate statistical methods were used to evaluate the responses to the questionnaires using chisquare, Fisher’s exact test, logistic regression, and two independent sample t-tests. P-values of .05 or smaller were considered statistically significant. Odds ratios were calculated for factors reaching this level of significance.

As a hypothesis-generating study, we must first consider its limitations. The study is cross-sectional, thus the time sequence between characteristic and choice of family medicine training cannot be assumed. For example, perhaps attitudes and perceptions were preselected in the admission process or perhaps the choice of family medicine conditioned the attitudes and perceptions that were reported. The sample restricts applicability of the findings to Rural Medical Scholars only. The uniformity of the selective group of respondents could be expected to limit variability in responses and, thus, the power of the questions to detect differences that might be more easily demonstrated in a more natural grouping of students. The limited number of participants made for unstable statistics in some cases and limited our ability to explore for an association among variables while controlling for others. Hence, bivariate analysis was as far as we could go.

Findings This study included 64 respondents from the 80 Rural Medical Scholars who graduated from the UASOM-T between the years 2000 and 2008, making an 80% response rate (except for Question 2, which was answered by 24 of 40 RMSs who viewed it). As reported before,3 characteristics of respondents were similar to the surveyed group on race (3.1% vs. 2.5% African Americans), gender (39.1% vs. 31.2% females), and percentage choosing family medicine residency (56.2% vs. 48.9%).

The Table demonstrates the five questions related to medical curriculum that correlated with family medicine residency choice at the .05 level. Question 2 indicates that those who perceived the first two years of medical school to not place primary care at high priority were more likely to choose family medicine. Question 7 shows that during clinical clerkships, students who perceived positive attitudes toward students choosing a family medicine career among clinical faculty in other specialties, such as OB/GYN, Pediatrics, Psychiatry, and Neurology, were more likely to choose family medicine. Question 8 indicates that students who reported being exposed least to Internal Medicine residents during the first three years of medical school were more likely to choose Family Medicine. In Question 10, students who reported having a family medicine experience in a medical school clinic were less likely to choose family medicine. From Question 11, students were more likely to have chosen family medicine if they perceived their family medicine instructors, both faculty and preceptors, to be strong clinicians and mentors, and if they perceived their preceptors and residents to be strong teachers.

Discussion The literature suggests that curriculum follows admissions among the tools at hand to influence medical students to choose to become rural family physicians. The purposes of this study were: 1) to pilot test the utility of a survey questionnaire to detect student characteristics (e.g., attitudes, opinions, selfdescribed attributes) related to curriculum that distinguishes medical students who choose to train in family medicine vs. other specialties and 2) to generate hypotheses about these characteristics to be tested in subsequent studies. The sample used in this pilot study was comprised of Rural Medical Scholars whose variability was limited by a highly selective common admission process. Still, within this cohesive group, the questionnaire produced item responses that more commonly appear

Despite these weaknesses, the questionnaire did provide items whose responses aggregated according to choice of family medicine or not; 13 of 54 items performed at the .05 level of significance. These data provide a reasonable basis to study a larger and more diverse population of students in anticipation of validating the presence of these associations (and finding others) and to consider additional factors that might influence such relationships.

One might consider which of these generated hypotheses should take priority in subsequent study. As demonstrated in the literature review, there is no mystery about the importance of family medicine as the principle feature of a curriculum to prepare rural physicians. Thus, we expected the findings suggesting that RMSs choosing family medicine had positive attitudes and opinions about family medicine faculty, residents, and community practitioners during the clinical years of medical school. A more compelling case for study might be found among the questions that reflect the educational environment and setting. In these data, students selecting family medicine found the basic medical sciences years of medical school to afford primary care and family medicine low priority. They more often noted positive support for their intention to practice family medicine during the clinical years of medical school from non-family medicine faculty, while finding strength in the family medicine departmental faculty, residents, and community physicians as clinicians, mentors, teachers, and role models in comparison to other departments. They reported less exposure to internal medicine residents, lending support for unopposed family medicine residencies. Finally, they were less likely to report having experienced family medicine in a medical school clinic (as opposed to their required experience in a rural preceptor’s office).

Consistent with the literature reviewed, these data speak to the positive aspects of conducting medical education to produce rural family physicians in a context where family medicine is high-

Curriculum Factors Predicting Family Medicine Specialty Choice . . .

American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

Table 1: Questionnaire Items related to Curriculum (Independent Variables) 1. Indicate whether or not each phrase describes the medical school you attended during the first two years: a. It has a primary care track

 Yes  No (Primary Care Track 1) b. It has a rural medicine track

 Yes  No (Rural Medicine Track 1) 2. How accurately does each phrase describe your medical school environment during the first two years? a. Primary Care has high priority

 Not at all  Moderately Highly (Primary Care Priority 1) b. Family Medicine has high priority

 Not at all  Moderately Highly (Family Medicine Priority1) c. Family physicians had visible roles in administration and teaching

 Not at all  Moderately Highly (Family Physician Visibility 1) 3. During pre-clinical medical school courses, what were the attitudes of clinical faculty to whom you were exposed toward you or peers choosing Family Medicine as a career? a. Obstetrics-Gynecology faculty

 Very positive  Neutral  Very negative (OB-GYN Attitudes 1) b. Internal Medicine faculty

 Very positive  Neutral  Very negative (IM Attitudes 1) c. Surgery faculty

 Very positive  Neutral  Very negative (Surgery Attitudes 1) d. Pediatric faculty

 Very positive  Neutral  Very negative (Pediatric Attitudes 1) e. Psychiatry faculty

 Very positive  Neutral  Very negative (Psychiatry Attitudes 1) f. Family Medicine faculty

 Very positive  Neutral  Very negative (FM Attitudes 1) g. Neurology faculty

 Very positive  Neutral  Very negative (Neurology Attitudes 1) h. Community Medicine faculty

 Very positive  Neutral  Very negative (Comm Med Attitudes 1) 4. Indicate whether or not each phrase describes the medical school you attended during the last two years: a. It has a primary care track

 Yes  No (Primary Care Track 2) b. It has a rural medicine track

 Yes  No (Rural Medicine Track 2) 5. How accurately does each phrase describe your medical school environment during the last two years? a. Primary care was high priority

 Not at all  Moderately  Highly (Primary Care Priority 2) b. Family Medicine was high priority

 Not at all  Moderately  Highly (Family Medicine Priority 2) 6. On a continuum of medical education clinical emphasis during the last two years from 100% specialty-subspecialty-based to 100% primary care-based, where would you place your medical education experience:  100% specialty  50% specialty 100% primary care  subspecialty 50% primary care  1  2  3 4 5 6 7 8 9  10 (Primary Care Emphasis) 7. During clinical clerkships at medical school, what were the attitudes of clinical faculty to whom you were exposed toward you or peers choosing Family Medicine as a career? a. Obstetrics-Gynecology faculty

 Very positive  Neutral  Very negative (OB-GYN Attitudes 2) b. Internal Medicine faculty

 Very positive  Neutral  Very negative (IM Attitudes 2) c. Surgery faculty

 Very positive  Neutral  Very negative (Surgery Attitudes 2) d. Pediatric faculty

 Very positive  Neutral  Very negative (Pediatric Attitudes 2) e. Psychiatry faculty

 Very positive  Neutral  Very negative (Psychiatry Attitudes 2)

Curriculum Factors Predicting Family Medicine Specialty Choice . . .

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American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

f. Family Medicine faculty

 Very positive  Neutral  Very negative (FM Attitudes 2) g. Neurology faculty

 Very positive  Neutral  Very negative (Neurology Attitudes 2) h. Community Medicine faculty

 Very positive  Neutral  Very negative (Comm Med Attitudes 2) 8. During the first three years of medical school, to what degree were you exposed to the following residents? a. Pediatric residents

 None  Moderate  Great (Ped Resident Exposure) b. Internal Medicine residents

 None  Moderate  Great (IM Resident Exposure) c. Family Medicine residents

 None  Moderate  Great (FM Resident Exposure) d. Surgery residents

 None  Moderate  Great (Surg Resident Exposure) e. Orthopedic residents

 None  Moderate  Great (Orth Resident Exposure) f. Emergency Medicine residents

 None  Moderate  Great (EM Resident Exposure) g. OB/GYN residents

 None  Moderate  Great (OB-GYN Resident Exposure) 9. Indicate how much time you spent in a required or elective Family Medicine course during medical school. a. Year 1  None  1-7 days  8-14  15-21  22-28  29-56  57 or more (Time in FM 1) b. Year 2  None  1-7 days  8-14  15-21  22-28  29-56  57 or more (Time in FM 2) c. Year 3  None  1-7 days  8-14  15-21  22-28  29-56  57 or more (Time in FM 3) d. Year 4  None  1-7 days  8-14  15-21  22-28  29-56  57 or more (Time in FM 4) 10. Indicate the settings of the Family Medicine experiences you had during medical school (Circle all that apply): a. Hospital (Hospital Setting) b. Medical school clinic (Med Sch Clinic Setting) c. Urban community doctor’s office (Urban Office Setting) d. Rural community doctor’s office (Rural Office Setting) e. Community health center (CHC Setting) f. Public health department (PHD Setting) 11. In your opinion, how do these aspects of the Family Medicine Department at your medical school compare to the other clinical departments? a. FM faculty as clinicians

Stronger  Equal  Weaker (Faculty Clinicians) b. FM faculty as teachers

Stronger  Equal  Weaker (Faculty Teachers) c. FM faculty as mentors

Stronger  Equal  Weaker (Faculty Mentors) d. FM residents as teachers

Stronger  Equal  Weaker (Resident Teachers) e. FM residents as role models

Stronger  Equal  Weaker (Resident Role Models) f. FM community physicians as teachers

Stronger  Equal  Weaker (Community Teachers) g. FM community physicians as mentors

Stronger  Equal  Weaker (Community Mentors) h. FM community physicians as clinicians

Stronger  Equal  Weaker (Community Clinicians) 12. At the time of medical school graduation, how important was each influence in determining your specialty decision? a. Medical school teacher

 Not  Moderately  Highly (Teacher Influence) b. Residents

 Not  Moderately  Highly (Resident Influence) c. Medical school clerkships  Not  Moderately  Highly (Clerkship Influence)

Curriculum Factors Predicting Family Medicine Specialty Choice . . .

American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

Table 2: Curriculum Factors* Associated with Choice of Family Medicine Residency among Rural Medical Scholars

Factor (see Table 1)

Total (N)

FM Choice (%)

P-value

Odds Ratio

2.a. Primary Care Priority 1

Not at all Moderate+

16 8

62.5 12.5

0.03

11.6

2.c. Family Medicine Priority 1

Not at all Moderate+

17 7

58.8 14.3

0.08

10.0

7.a.

OB/GYN Attitudes 2

Positive Neutral/Negative

45 18

66.7 33.3

0.02

4.0

7.c.

Surgery Attitudes 2

Positive Neutral/Negative

31 32

67.7 46.9

0.09

2.4

7.d. Pediatrics Attitudes 2

Positive Neutral/Negative

43 19

67.4 36.8

0.02

3.5

7.e.

Psychiatry Attitudes 2

Positive Neutral/Negative

38 24

73.7 33.3

< .01

5.6

7.f.

FM Attitudes 2

Positive Neutral/Negative

57 6

61.4 16.7

0.08

8.0

7.g. Neurology Attitudes 2

Positive Neutral/Negative

44 19

68.2 31.6

< .01

4.7

8.b. IM Resident Exposure

None Moderate+

48 16

68.8 18.8

<.01

9.5

8.e. Orth Resident Exposure

None Moderate+

57 6

61.4 16.7

0 .08

8.0

10.b. Med Sch Clinic Setting Yes No

52 12

50.0 83.3

0.04

5.0

10.f. PHD Setting Yes No

16 48

75.0 50.0

0.08

3.0

11.a. Faculty Clinicians Stronger Equal/Weaker

15 47

86.7 44.7

<0.01

8.1

11.b. Faculty Teachers Stronger Equal/Weaker

16 46

75.0 47.8

0.06

3.3

11.c. Faculty Mentors Stronger Equal/Weaker

31 32

77.4 34.4

<0.01

6.5

Curriculum Factors Predicting Family Medicine Specialty Choice . . .

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American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

Factor (see Table 1)

Total (N)

FM Choice (%)

P-value

Odds Ratio

11.d. Resident Teachers Stronger Equal/Weaker

19 44

84.2 43.2

<0.01

7.0

11.e. Resident Role Models Stronger Equal/Weaker

23 40

69.6 47.5

0.09

2.5

11.f.

Community Teachers Stronger Equal/Weaker

22 40

72.7 45.0

0.04

3.3

11.g. Community Mentors Stronger Equal/Weaker

33 29

69.7 37.9

0.01

3.8

11.h. Community Clinicians Stronger Equal/Weaker

21 40

76.2 42.5

0.01

4.3

*We show factors that were associated in these data at P-value < 0.05 and calculated Odds Ratios to show the relative size of the effects. Because of the small numbers in this hypothesis-generating pilot study, we also show factors that demonstrated an associational trend at 0.05 < P < 0.10.

ly valued and effectively demonstrated – among family medicine physicians and residents who are strong in their art, in clinics, and community locales. With these findings, the data also suggest an important influence of associated specialist instructors who reinforce the importance of primary care as a career. At the same time, the Rural Medical Scholars in this study, who followed the training path of family medicine for which they were selected, found that preclinical sciences at the urban health sciences center did not place priority on primary care.

There is a growing literature about the “hidden curriculum” of medical education and its influence on students in terms of developing professional attitudes and making career choices.18 The values and beliefs of those surrounding students in training impact students. There is a growing movement toward dissemination of medical education into communities whose cultures (and hidden curriculums) are less that of the academic health science center and more that of the native community.18 Does variation in the contexts and settings of medical education not only influence student outcomes beyond specialty choice but also their comfort to practice in nonurban communities and their perceptions of self-worth in doing so? These are questions that can be approached and are timely as this country seeks to address primary care needs of all citizens, many of whom share a context and culture foreign to medical education. Our next use of this questionnaire will expand beyond RMSs to include their classmates and to test the hypotheses that were suggested.

We will also seek to hear and respond to what the participants are telling us about the contexts and settings of medical education relative to their intentions to practice medicine that engages with community need.

Daniel M. Avery, Jr., MD, Professor and Chair of OB/GYN, University of Alabama School of Medicine, Tuscaloosa, AL.

John R. Wheat, MD, MPH, Professor of Community & Rural Medicine, University of Alabama School of Medicine, Tuscaloosa, AL. James D. Leeper, PhD, Professor of Community & Rural Medicine, University of Alabama School of Medicine, Tuscaloosa, AL. Jerry T. McKnight, MD, MPH, Professor of Family Medicine, University of Alabama School of Medicine, Tuscaloosa, AL. Brent G. Ballard, MD, Resident in Family Medicine, Tuscaloosa Family Medicine Residency, Tuscaloosa, AL. Jia Chen, MA, Research Coordinator, Baylor College of Medicine, Houston, TX. ACKNOWLEDGEMENTS: Financial Support: Grant in the amount of $2,000 from the Research Council Council of the College of Community Health Sciences of the University of Alabama.

Institutional Board Approval: University of Alabama IRB# 09-OR-042.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. ®

References 1.

Wheat JR, Brandon JE, Leeper JD, Boulware DW. Rural Health Leaders Pipeline, 1990-2005: Case Study of a Second-Generation Rural Medical Education Program. J Agromed. 12:51-61,2007.

2.

Avery DM, Wheat JR, McKnight JT, Leeper JD. Factors associated with choosing Family Medicine as a career specialty: What can we use?

American Journal of Clinical Medicine. 6:54-58;2009.

3.

Avery DM, Wheat JR, Leeper JD, McKnight JT, Ballard BG, Chen

Curriculum Factors Predicting Family Medicine Specialty Choice . . .

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J. Admission factors predicting Family Medicine specialty choice: A literature review and exploratory study among students in the Rural Medical Scholars Program. Journal of Rural Health, no. doi: 10.1111/ j.1748-0361.2011.00382.x (on-line 25 May 2011; print version pending).

4.

Geyman JP, Hart GL, Norris TE, Coombs JB, Lishner DM. Educating generalist physicians for rural practice: how are we doing? J Rural Health. 2000;16:56–80.

5.

Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Med Teach. 2004;26:265–272.

6.

Hsueh W, Wilkinson T, Bills J. What evidence-based undergraduate interventions promote rural health? N Z Med J. 2004;117:U1117.

7.

Ranmuthugala G, Humphreys J, Solarsh B, et al. Where is the evidence that rural exposure increases uptake of rural medical practice? Aust J Rural Health. 2007;15:285–8.

8.

Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physicians supply: a systematic review and projected impact of widespread replication. Acad Med. 2008;83:235–43.

9.

Henry JA, Edwards BJ, Crotty B. Why do medical graduates choose rural careers? Rural Remote Health. 2009;9:1083. Available at: http:// www.rrh.org.au/articles/subviewnew.asp?ArticleID=1083. Accessed November 11, 2010.

11. Godkin M, Quirk M. Why Students Chose Family Medicine: State Schools Graduate the Most Family Physicians. Family Physician. Vol. 23, #7, Sept.-Oct.1991, p521-526.

12. Whitcomb ME. The Challenge of Providing Doctors for Rural America.

Acad Med. 80:715-6;2005.

13. Pugno PA, Schmittling GT, McGaha AL et al. Entry of US Medical School Graduates Into family Medicine Residencies: 2006-2007 and a 3 Year Summary. Family Medicine. Vol. 39, #8, Sept. 2007.

14. Hobbs J, Rosenthal TC, Newton WP et al. Difficult Choices in Medical Student Education. Annals of Family Medicine. 4:564-565(2006).

15. Burack JH, Irby DM, Carline JD et al. A Study of Medical Students Specialty-Choice Pathways: Trying on Possible Selves. Academic Medicine. Vol. 72, #6, June 1997, p534-541.

16. Schafer S, Shore W, Hearst N. Is Medical School the Right Place to Choose a Specialty ? JAMA. 2001;285:2782-2783.

17. Grayson MS, Klein M, Franke K. Impact of a First Year Primary Care Experience on Residency Choice. J Gen Intern Med. 2001 Dec.16(12)860-863.

18. Campos-Outcalt D, Senf J, Kutob R. Comments Heard by US Medical Students about Family Medicine. Fam Med. 2003,35:573-8.

10. Simmonds AC, Robbins JM, Brinker MR, et al. Factors Important in Selecting a Residency Program. Academic Medicine. Vol. 65, #10, Oct.1990.

F O R T O D AY ’ S H O S P I TA L I S T

SM

For Further Information Please Contact: American Board of Hospital Medicine 5550 West Executive Drive • Suite 400 Tampa, Florida 33609-1035 (813) 433-2277 www.abhmus.org

A B H M is a primary board of certification dedicated only to hospital medicine .

I t is not a s u bspecialty board .

Curriculum Factors Predicting Family Medicine Specialty Choice . . .

®

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The Physician’s Role in a Disaster

Our Place in the Community is Greater Than Just in our Offices Thomas Horowitz, DO

Los Angeles County has one of the most sophisticated disaster systems of any county in the United States. There is one weak link that we need to strengthen, however. The physician community is ill trained and poorly equipped for the type of event we can expect here. We know there are earthquakes coming. There are train and other vehicle accidents. We are on the terrorist’s radar. Yet few outside of the emergency medicine specialty prepare.

There are practical reasons why. Most of us are dependent on offices that have no emergency power and we do not keep redundant tools of our trade and supplies at home. In fact, few physicians even have first aid kits in their cars. We need to anticipate where and how we may be needed. We need to plan on how we can be of the most value to our community.

And we must train. In spite of free training programs in medical emergency preparedness, sponsored by FEMA and our county health department, few of us take classes in dealing with the type of catastrophic event we know is coming. We need to learn field-level care, how to deal with crush and blast victims, and how to deal with the emotional issues of patients, their loved ones, our co-workers, and ourselves. In reality, this is some of the most interesting CME you can imagine. It can help you save friends, family, and others in the community.

We have a community of key players in a disaster. We need to train and equip ourselves. Our place in the community is so much greater than just our office and hospital work.

Thomas Horowitz, DO, is a family practitioner in Los Angeles.

Reprinted with permission from Southern California Physician magazine, Volume 143, Issue 2, February 2012.

The Physician’s Role in a Disaster

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Urgent Care Medicine

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Urgent Care Centers: An Overview Sean McNeeley, MD 

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Urinary Tract Infection Update Kim Gibson, MD Joseph Toscano, MD 

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Acute Infectious Mononucleosis: A Review for Urgent Care Physicians Mark E. Rogers, MD 

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Review of Important ECG Findings in Patients with Syncope Joseph Toscano, MD 

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Rhinosinusitis: An Urgent Care Perspective Sean M. McNeeley, MD 

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Wellens’ Syndrome: A Case Report Joseph Toscano, MD 

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Urgent Care Centers: An Overview Sean McNeeley, MD

Although there are currently more than 9,000 urgent care centers in the United States alone, they continue to be an almost underground success. Perhaps the roller coaster history of urgent care has contributed to the quiet but sustained second surge in centers. Although sources are not definitive, the concept of urgent care began as early as 1970, with entrepreneurial physicians opening individual clinics to serve patients’ needs for acute but non-emergent medical care. It had a peak in the mid-1980s before a precipitous decline. Several causes have been proposed for this sudden decline. Many of the earlier urgent care centers were staffed by physicians who were not optimally trained to provide the type of care requested; quality issues became well know. It went so far that derogatory terms such as “doc in a box” were commonly used to describe this care arrangement. As these types of centers grew, they also challenged the hospitals’ revenue and market share. Hospitals responded by purchasing them or providing better options in their emergency departments.

Although that looked like the end of the story, it has proven to be just a false start. Over the last two decades urgent care centers have been appearing all over the country, and the number continues to increase. The gap between patients’ access to primary care and emergency care has widened. Urgent care has expanded to fill it. Shortages of primary care providers and changes in how primary care is provided (less evening and weekend availability) have left a gap in the provision of care, causing patients to move towards urgent care. The high cost of emergency department care for non-emergent issues also has likely increased the number of patient seeking an alternative.

Insurance plans and employers who pay the premiums have gone so far as to assist patients with finding urgent care centers rather than directing them to local emergency rooms. Also, as

more of the cost of care is borne by the patient, a lower cost option of urgent care is the obvious choice.

The definition of urgent care varies, but most centers have a few things in common. These include provision of unscheduled care, after-hours access, expanded services compared to primary care, and a lower cost than emergency care. Urgent care provides acute episodic care to patients who are unscheduled.

Some provide scheduled appointments and primary care, but these are not always present and represent a variation from typical urgent care practice. Expanded access is a key to the definition of urgent care. Most urgent care centers are open at least twelve hours a day on weekdays. It is not unusual to find centers opening as early as 7 a.m. and closing as late as 12 p.m. for patient convenience. Weekend hours are also the norm. Weekend hours vary from six to more than twelve hours a day. Expanded services when compared to primary care offices also characterize urgent care. On-site x-ray, intravenous medications and fluids, repair of lacerations, foreign body removal, basic fracture care, and treatment of abscess are most common. Beyond simple CLIA-waived tests, such as strep throat and urinalysis, urgent care centers often perform blood work. This includes complete blood counts and basic metabolic panels. CT scans, ultrasound, and even MRI are occasionally available as well. Several sources have reported that the cost of care for comparable medical problems in urgent care, although slightly more than primary care, is usually between one-third and one-tenth the cost of emergency care. Copays vary from zero to as much as $100. Usually they are less than $50.

The issue of quality has also been become an important factor in the current “Phase 2” of urgent care centers’ growth.

With improved standards and higher regard among the other

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specialties, urgent care medicine has become more of a career choice than a final alternative for physicians unable to practice elsewhere. Groups, such as the Urgent Care Association of America (UCAOA), have been offering training in many forms. Online webinars, biennial national conventions and conferences provide a great resource for those looking to learn.

UCAOA pioneered several one-year postgraduate fellowship programs, which have been in existence for several years and are dedicated to training physicians who desire to practice urgent care. In 2010 the Urgent Care College of Physicians (UCCOP) formed with the support of UCAOA. UCCOP is dedicated to inspiring excellence and advancing the specialty in urgent care practice. The Journal of Urgent Care Medicine (JUCM), the official journal of UCAOA and UCCOP, provides another method to share the practical and clinical knowledge relating to the resurgence of urgent care. The American Association of Physician Specialties (AAPS) recently recognized the importance of urgent care as a separate knowledge base by adding Urgent Care Medicine to its list of certifications offered.

The new Board of Certification of Urgent Care Medicine (BCUCM) was developed to help define that knowledge base and create a process for urgent care physicians to be tested and recognized for their proficiency with it.

part of the answer to decreasing cost and improving quality.

Although predicting the future is difficult, it looks bright for the new specialty of Urgent Care Medicine.

With all the changes in medicine today and the increasing move toward value, urgent care is a definite and increasingly valuable

Sean McNeeley, MD, is a board-certified family physician who has been practicing urgent care medicine since 1997. He is a founding board member of the Urgent Care College of Physicians and the Board of Certification in Urgent Care Medicine.

Dr. McNeeley has lectured nationally over the last several years and teaches students, residents, and fellows in his position as Medical Director of University Hospitals Urgent Care Network in Cleveland.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

Interesting Reading 1.

Gray B, Janiak B. Urgent care centres. Archives of Emergency Medicine.

1985,2,197-199.

2.

Weinick R, Burns R, Mehrotra A. Many Emergency Department Visits Could Be Managed at Urgent Care Centers and Retail Clinics. Health Affairs. 29,9,2010;1630-1636.

3.

Weinick R, Bristol S, DesRoches C. Urgent care centers in the U.S.: Findings from a national survey. BMC Health Services Research. 2009 9:79.

BCUCM Offers Physician Board Certification in Urgent Care ®

The newly formed Board of Certification of Urgent Care Medicine® (BCUCM®) will certify board eligible physicians in the practice of urgent care medicine  Urgent care medicine is a rapidly growing medical specialty resulting from public demand for convenient and timely access to high-quality episodic health care.  Physician board certification in urgent care medicine is now available. BCUCM is a new Member Board of ABPS, a nationally recognized multi-specialty body that has certified allopathic and osteopathic physicians for over 50 years.  Contact BCUCM for application, eligibility requirements, certification standards, examination details, study references and other pertinent information.

813-433-2277 www.bcucm.org

BCUCM is a Member Board of the American Board of Physician Specialties®

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Urinary Tract Infection Update Kim Gibson, MD Joseph Toscano, MD

Abstract Urinary tract infections are commonly treated in urgent care practice. Clinicians need to be aware of the advantages and limitations of diagnostic tests, as well as the proper empiric antibiotic treatment of these infections, in order to effect the best outcomes for patients. Several recent articles and a published guideline provide the most up-to-date information and form the basis of this review.

Introduction Urinary tract infection (UTI) is a common problem diagnosed and treated in urgent care medicine practice. A 2010 report indicated that 3.1% of urgent care visits were for UTIs.1 An estimated eight million episodes of UTI occur in the US each year2 with one out of three women requiring treatment for UTI before age 24.3 Urinalysis and urine gram stain and culture may assist with diagnosis, but add to the cost of care and are not always necessary. UTIs can affect the lower urinary tract (cystitis) or upper tract (pyelonephritis). Similar to other acute infections, initial antibiotic treatment for cystitis is empiric. A variety of antibiotics is available for treating UTIs, but changing antibiotic sensitivities make appropriate empiric treatment a moving target over time. A recently published guideline4 by the Infectious Diseases Society of America and European Society for Microbiology and Infectious Diseases provides evidence-based recommendations for treating pre-menopausal, non-pregnant females with uncomplicated UTI. UTIs which occur in men, pregnant women, and patients with immunosuppression or urinary tract abnormalities, such as congenital malformations, uri-

nary calculi, recent urologic instrumentation, indwelling catheters, neurogenic bladder, and kidney transplant, are considered complicated and require more complex decision-making than will be reviewed in this update. Because the majority of UTIs are uncomplicated, however, this review should have broad application.

Symptomatology/Differential Diagnosis Diagnosis of UTI in young healthy patients can usually be made clinically. Patients with cystitis typically present with any or all of the following: cloudy urine; abnormal urine odor; dysuria; urinary frequency, hesitancy, or urgency; suprapubic discomfort; gross hematuria.5,6 More severe symptoms are more predictive of UTI than milder ones,5 as is the presence of combinations of symptoms rather than just a single symptom.6 Complaints of vaginal discharge or vaginal irritation and the absence of dysuria or back pain reduce the likelihood of UTI.6 Pyelonephritis typically causes fever, chills, malaise, flank discomfort, nausea/vomiting, and/or abdominal pain, with or without concomitant lower urinary tract signs.

With cystitis, there may be no physical exam abnormalities or only mild suprapubic tenderness to palpation, while pyelonephritis typically causes a patient to look systemically ill in general, with costovertebral angle tenderness to percussion on physical exam in most cases. These patients may also have mild tenderness of the anterior upper quadrants of the abdomen overlying the kidneys. Though UTI is more common in women than men, symptoms and physical exam findings are usually similar in both sexes.

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Older patients can present more of a diagnostic challenge and may have nonspecific symptoms such as malaise, fatigue, anorexia, or even fever or chills, without any of the more focal symptoms above to guide the clinician to the urinary tract as the source of the problem. UTI should be part of a fairly broad differential diagnosis for such patients.

Conversely, those with symptoms of UTI may uncommonly have other disorders. Patients with sexually transmitted infections, as well as urethritis, cervicitis, and vulvovaginitis from other causes, can present with symptoms similar to cystitis.

Some patients with ureterolithiasis may have only mild flank pain or lower urinary tract symptoms. Pelvic inflammatory disease, appendicitis, and sigmoid diverticulitis are among the entities which have been misdiagnosed as acute cystitis. Interstitial cystitis is uncommon but often initially indistinguishable from acute infectious cystitis.

Generating a reasonable differential diagnosis for each patient and performing a careful history and physical examination with focused testing is the time-honored approach. Diagnoses such as those above – in addition to infection with a resistant organism or UTI combined with some element of urinary tract obstruction – should be considered in patients who do not improve promptly with usual empiric therapy. Of course, nonspecific symptoms like malaise, fatigue, anorexia, fever or chills can have many causes. Even with an abnormal urinalysis in hand, the careful clinician should avoid premature diagnostic closure, because urinary tract colonization is not uncommon in older patients and may be unrelated to a patient’s presenting illness.

Diagnostic Testing Urinalysis (UA) is a relatively simple, office-based test that can be used to evaluate patients with urinary complaints. In urgent care settings where UA is available, dipstick results rather than microscopic analysis may be more likely to be utilized.

The different components of dipstick testing vary in their accuracy for predicting infection, with nitrite having the highest specificity (adjusted odds ratio of 6.36 in one study5) but poor sensitivity (i.e., it will be negative in many patients who have a UTI). The combination of dipstick-positive leukocyte esterase and blood may have the highest sensitivity (77%) and specificity (70%).5 Urinalysis results may also suggest diagnoses other than UTI or the need for additional history or examination, as when clue cells or trichomonads are found in a specimen.

Urine culture is traditionally the gold standard for diagnosing UTI, and, though a culture showing no growth essentially rules out UTI caused by the most common organisms, sensitivity and specificity will vary depending on the threshold colony count used and whether a specimen is obtained by catheterization or other methods. As well, the time required for culture results often exceeds the time to clinical cure with empiric treatment, and cultures can add significantly to the cost while not improving the quality of care in the majority of cases.

As with any clinical situation, diagnostic tests should be used when their results may improve management compared with not using them. The finding that, in patients with at least one UTI symptom, even a completely normal further history, physical exam, and dipstick UA cannot rule out UTI6 is often used as a rationale to not perform UA in patients with typical symptoms. Still, UA may have some use when there is diagnostic uncertainty, and, though it requires microscopy, findings of pyuria without bacteriuria increase the chance that a sexually transmitted infection rather than a UTI is present. An interesting study7 showed no significant difference in clinical outcomes whether patients were treated with antibiotics, in an immediate or delayed fashion, based on symptoms alone or based on UA results, though antibiotics were used less often if testing or delayed prescribing was employed. A cost effectiveness analysis8 showed that basing antibiotic treatment on dipstick testing was cost-effective, compared with treating immediately without testing, if avoiding a day of moderately severe symptoms was valued at $15 (10 British pounds) or more. Though the monetary cost may not be directly paid by them, this is probably the case for most patients!

Urine culture ideally obtained before and without delaying antibiotics is recommended in patients with acute pyelonephritis4 and in the management of pediatric UTIs. Culture is also recommended in patients with complicated UTIs (men, pregnant women, and patients with immunosuppression or urinary tract malformations, urinary tract stones, recent urologic instrumentation, indwelling catheters, neurogenic bladder, and kidney transplant) and may also be helpful, while starting empiric therapy, in patients with a previous history of known resistant infections, failure of empiric antibiotics, or multiple recurrent UTIs. The yield of culture is lower in patients who are taking antibiotics at the time of testing.

Basic blood work (CBC, chemistry panel, blood culture) rarely helps decision-making for patients with uncomplicated UTI, and no useful role has been shown for erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP). Patients with suspected concomitant urinary tract obstruction or who show signs of severe systemic infection usually require prompt imaging with ultrasound or CT, and typically blood work is obtained for these patients and anyone else requiring hospitalization. CT without contrast is preferred for diagnosing urinary calculi and obstruction. Intravenous (IV) contrast may be used for a “CT urogram” and both IV and oral contrast is typically used is inflammatory disorders such as appendicitis or diverticulitis need to be excluded, though more recent evidence shows that unenhanced CT may be adequate.

Treatment Considerations The main element of treatment for UTI in the United States is antibiotics; phenazopyridine may be prescribed as an adjunct to alleviate symptoms. An evidence-based guideline for the antimicrobial treatment of UTI in adults was published in March

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2011 by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases4 and included interesting considerations, balancing the positives of likely efficacy with negatives, termed “collateral damage,” relating to the “ecological adverse effects of antimicrobial therapy.” The following recommendations come from that guideline.

Table 1: Antibiotic Treatment for Uncomplicated Acute Cystitis4

ate in certain settings,” while not elaborating on what those settings might be.

Amoxicillin and ampicillin are not recommended for patients with cystitis.

Table 2: Outpatient Antibiotic Treatment for Uncomplicated Acute Pyelonephritis4

Three-day regimens of fluoroquinolones like ofloxacin, ciprofloxacin, and levofloxacin, are very effective but have higher rates of collateral damage, and the guideline authors recommend that these be reserved for more serious infections and only be considered alternates for uncomplicated acute cystitis.

If fluoroquinolone resistance prevalence is less than 10% Ciprofloxacin 500 mg BID for 7 days, with or without an initial 400-mg dose of IV ciprofloxacin or 1 g of IV ceftriaxone or a consolidated 24-hour IV dose of an aminoglycoside OR Ciprofloxacin XR 1000 mg once daily for 7 days OR Levofloxacin 750 mg once daily for 5 days If fluoroquinolone resistance prevalence is 10% or more, then use: Ciprofloxacin 500 mg BID for 7 days, plus initial 1 g dose of IV ceftriaxone or a consolidated 24-hour IV dose of an aminoglycoside OR Ciprofloxacin XR 1000 mg once daily for 7 days, plus initial 1 g dose of IV ceftriaxone or a consolidated 24hour IV dose of an aminoglycoside OR Levofloxacin 750 mg once daily for 5 days, plus initial 1 g dose of IV ceftriaxone or a consolidated 24-hour IV dose of an aminoglycoside If infecting organism is known to be susceptible Trimethoprim-sulfamethoxazole DS (160/800 mg) BID for 14 days, plus an initial 1 g dose of IV ceftriaxone or a consolidated 24-hour IV dose of an aminoglycoside Only if above regimens are contraindicated Oral beta-lactam (amoxicillin-clavulanate, cefdinir, cefaclor, or cefpodoxime-proxetil) for 10-14 days, plus an initial 1 g dose of IV ceftriaxone or a consolidated 24-hour IV dose of an aminoglycoside Abbreviations: BID, twice a day; DS, double strength; g, gram; IV, intravenous; XR, extended release

Beta-lactam agents, including amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil, in three- to sevenday regimens are appropriate choices if the other recommended agents cannot be used, though they have lower efficacy and a higher rate of adverse effects. There is less evidence to support the use of cephalexin and other beta-lactams than those above, though the guideline authors felt that they might be “appropri-

To be managed as outpatients, individuals with pyelonephritis should be able to maintain their hydration and take oral antibiotics; fluoroquinolones are the primarily recommended. Oral ciprofloxacin (500 mg twice daily for seven days), with or without an initial 400-mg dose of intravenous (IV) ciprofloxacin (or 1 g of IV ceftriaxone or a consolidated 24-hour dose of an

Nitrofurantoin 100 mg BID for 5 days OR Trimethoprim-sulfamethoxazole DS (160/800 mg) BID for 3 days (if prevalence of resistance is < 20%) OR Fosfomycin trometamol 3 gm single dose OR Pivmecillinam 400 mg BID for 5 days (not available in the United States) If availability or allergy history precludes these choices, then use: Fluoroquinolones for 3 days OR Beta-lactams (amoxicillin-clavulanate, cefdinir, cefaclor, or cefpodoxime-proxetil) for 3 to 7 days Abbreviations: BID, twice a day; DS, double strength Recommended treatment for patients with uncomplicated cystitis includes nitrofurantoin monohydrate macrocrystals (100 mg twice daily for five days) and trimethoprim-sulfamethoxazole (160/800 mg [1 double-strength tablet] twice-daily for three days) can be used when resistance prevalence to it is less than 20%. Fosfomycin trometamol (3 g in a single dose) is an option, though there is some evidence of decreased efficacy compared to the above regimens. Though not sold in the Unites States, pivmecillinam 400 mg twice a day for five days is an additional alternative, where available.

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aminoglycoside) can be used for outpatients if fluoroquinolone resistance prevalence is less than 10%. There is no rate of resistance at which a definite recommendation could be made to use something other than a fluoroquinolone. If, however, resistance is known or thought to exceed 10%, then a single initial dose of 1 g of ceftriaxone or a consolidated 24-hour dose of an aminoglycoside should be given IV prior to starting outpatient oral therapy with ciprofloxacin 500 mg twice daily. Other oral fluoroquinolone regimens (ciprofloxacin extended-release 1000 mg once a day for seven days or levofloxacin 750 mg for five days) are alternatives and may be given without consideration of an initial IV dose unless fluoroquinolone resistance prevalence exceeds 10%. In this case, as with the above situation, a single initial IV dose of 1 g of ceftriaxone or a consolidated 24-hour dose of an aminoglycoside should start treatment.

Oral trimethoprim-sulfamethoxazole (160/800 mg [1 doublestrength tablet] twice-daily for 14 days) may be used, but only if the infecting organism is known to be susceptible. Patients receiving this regimen should all receive a starting IV dose of a long-acting antibiotic, e.g., 1 g of ceftriaxone or a consolidated 24-hour dose of an aminoglycoside. The guideline authors give a weaker recommendation to use oral beta-lactams (e.g., amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoximeproxetil) due to lower effectiveness. These should be taken for 10-14 days and may be considered in situations where there are contraindications to the other treatment options. All patients with pyelonephritis treated with oral beta-lactams should receive a starting IV dose of a long-acting antibiotic as above.

Disposition Decisions Patients with uncomplicated infections and normal, stable vital signs, who can maintain good oral intake and who are capable of taking oral antibiotics and reliable follow-up are candidates for outpatient management. Men, pregnant women, and patients with immunosuppression, urinary tract malformations, renal/ureteral stones, recent urologic instrumentation, indwelling catheters, neurogenic bladder, and kidney transplant who otherwise fit the above criteria may be treated as outpatients, if urine cultures can be obtained, and after consultation and close, scheduled follow-up with the appropriate specialty can be arranged. Urgent care clinicians should consider sending all other patients to the emergency department for extended observation, with IV hydration and symptom management (as well as consideration of admission), if such is not available in the clinician’s setting.

Resolution of symptoms is adequate proof of cure in cases of uncomplicated UTI, and testing for cure is not necessary. Patients should be advised that symptoms may persist for several days, but that adequate treatment should result in progressively decreasing symptoms. If symptoms fail to improve steadily or are not resolved by the time the antibiotic course is finished, then patients should seek re-evaluation.

Conclusion UTI is a common disorder seen in urgent care practice. The clinician should use history, physical examination, and focused testing to confirm the diagnosis and evaluate, when appropriate, for other diagnoses or more complicated situations. Most patients with uncomplicated UTI can be effectively managed as outpatients using empiric antibiotics in accordance with the most recent guidelines and appropriate discharge instructions.

Review Highlights •

Urinalysis adds little information for patients with typical cystitis symptoms or when there is otherwise little diagnostic uncertainty.

•

Consider a broader differential diagnosis as well as resistant infections or associated urinary tract obstruction in patients who do not improve promptly with usual empiric therapy.

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Be wary of the “slam dunk”: Before diagnosing a urinary tract infection and discharging an elderly patient who presents with nonspecific symptoms, evaluate for other important potential causes with a thorough history and physical exam and focused testing.

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Urine culture is not necessary for non-pregnant, premenopausal women with uncomplicated, acute cystitis.

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Urine culture is recommended for pediatric urinary tract infections, acute pyelonephritis, and complicated UTIs.

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Pre-treatment urine culture may be helpful when there is a previous history of known resistant infections, failure of empiric antibiotics, or multiple recurrent UTIs.

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Use recommended antibiotics to maximize the chance of cure and minimize “collateral damage.”

Kimberly Gibson, MD, has been practicing and managing urgent care in the Tampa Bay area since 2001. She is a founding board member of both the Urgent Care College of Physicians and the Board of Certification in Urgent Care Medicine.

Joseph Toscano, MD, has been practicing urgent care and emergency medicine in the San Francisco Bay area for more than 15 years. He develops and reviews continuing medical education material in urgent care and emergency medicine for a variety of publications and presents regularly at urgent care conferences. Dr. Toscano is a founding board member of both the Urgent Care College of Physicians and the Board of Certification in Urgent Care Medicine.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

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References 1.

Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Affairs.

2010;29(9)1630-36.

2.

National Institutes of Health. The National Kidney and Urologic Diseases Advisory Board 1990 Long-Range Plan -- Window on the 21st Century.

Bethesda, MD: National Institutes of Health; 1990;90:583.

3.

4.

David RD, DeBlieux PM, Press R. Rational antibiotic treatment of outpatient genitourinary infections in a changing environment. Am J Med. 2005;118(Suppl)7A:7S-13S. Gupta K, Hooton TM, Naber KG, et al. Infectious Diseases Society of America, European Society for Microbiology and Infectious Diseases.

International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;Mar;52(5):e103-20.

5.

Little P, Turner S, Rumsby K, et al. Developing clinical rules to predict urinary tract infection in primary care settings: sensitivity and specificity of near patient tests (dipsticks) and clinical scores. Br J Gen Pract. 2006 Aug;56(529):606–612.

6.

Bent S, Nallamothu BK, Simel DL, et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA. 2002;287:2701-10.

7.

Little P, Moore MV, Turner S, et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ. 2010;340:c199.

8.

Turner D, Little P, Raftery J, et al. Cost effectiveness of management strategies for urinary tract infections: results from randomised controlled trial. BMJ. 2010;340:c346.

9.

Ripkey M. Urgencies of the Genitourinary System. In: Biros MH, Sterner S, Vogel EC (eds): Handbook of Urgent Care Medicine. 2nd ed.

Philadelphia: Hanley and Belfus, Inc. 2002;57-60.

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Acute Infectious Mononucleosis: A Review for Urgent Care Physicians Mark E. Rogers, MD

Abstract

History and Pathophysiology

Acute infectious mononucleosis (IM) is a common illness that presents to urgent care facilities. The presenting symptoms of acute IM can range from the obvious, such as persistent exudative tonsillitis and marked cervical lymphadenopathy, to the more vague symptoms of fatigue and malaise. Although most cases of acute IM are either subclinical or require only supportive care, some cases can have severe and life-threatening complications. Arrival at the correct diagnosis can be complicated by the timing of the patient’s presentation, since the sensitivities and specificities of the various laboratory and diagnostic tests change as the illness evolves. Even those patients without any complications can have prolonged symptoms and difficulty returning to school, work, or physical activities.

Infectious mononucleosis was first described in the 19th century as Drüsenfieber, or “glandular fever,” owing to its clinical presentation of fever with lymphadenopathy and splenomegaly.

Later, in the 1920s it was found to be associated with a “mononuclear leukocytosis” by Sprunt and Evans. However, it was not until the 1960s that the link between infectious mononucleosis (IM) and Epstein-Barr virus (EBV), a human herpes type 4 virus, was established.1,2

Introduction Sore throat and fever are among the most common complaints presenting to an urgent care facility. One common cause of a sore throat, Group A Streptococcus, can often be reliably diagnosed with rapid antigen testing and/or culture. On the contrary, acute infectious mononucleosis (IM) is not always considered early in the course of a sore throat and can often be diagnostically challenging. However, a better understanding of the pathophysiology, clinical course, and limits of laboratory testing of acute IM can help the urgent care clinician to become proficient with the diagnosis, treatment, and prognosis of this illness.

Spread of the virus occurs from oral secretions. Shedding of EBV has also been detected from the cervix and seminal fluid, which raises concern for the possibility of transmission through sexual contact.3 The incubation period between exposure and presentation of symptoms can range between 30 to 60 days, making identification of the initial exposure difficult.

Human exposure and infection with EBV is ubiquitous, with 50% of children by the age of five having detectable EBV antibodies. This increases to 90% by the age of 25, with the majority of these adults having had asymptomatic or subclinical infection. The most common age group presenting with acute infectious mononucleosis is between the ages of 15 to 24.4

Clinical Presentation Fatigue and malaise are the most frequent complaints, followed by sore throat and fever. Exam often reveals enlarged, erythematous, and exudative tonsils, but these findings are not always present later in the course of the illness. A thin, grey

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membrane covering the tonsils can sometimes be seen and is associated with acute infectious mononucleosis. Posterior cervical lymphadenopathy can be suggestive of acute infectious mononucleosis but is not always seen. On the contrary, anterior cervical lymphadenopathy can be quite marked and is usually found more easily than the posterior chain enlargement.

Enlarged cervical lymph nodes should also prompt the clinician to check for other areas of lymphadenopathy (axillary, inguinal) that can be associated with IM as well as other infections and malignancies. Also, findings of splenomegaly or hepatomegaly can be suggestive of acute IM. In fact, the initial presenting symptom could be abdominal pain from hepatitis or spontaneous rupture of the spleen, requiring rapid recognition. The clinician should also perform a thorough examination of the skin and sclera checking for jaundice or a diffuse, erythematous, maculopapular rash. These skin manifestations may also be the presenting complaint, especially the latter in a patient who may have been prescribed amoxicillin for presumed Group A streptococcal pharyngitis.

Diagnostic Testing Over the decades following the discovery of the Epstein-Barr virus’s association with infectious mononucleosis, various diagnostic tests have been developed, beginning with the heterophile antibody agglutination (monospot) test. After infecting B-cell lymphocytes in the oral epithelium, the virus is then spread by these B-cells throughout the reticulo-endothelial system. This, in turn, induces the B-cells to produce IgM antibodies against EBV. In the presence of these antibodies, sheep and horse red blood cells will agglutinate, which indicates a positive test. The IgM antibodies peak within two to six weeks after the onset of symptoms, so testing in the first week of illness has a lower (50%) sensitivity. However, by the third week, the sensitivity increases to over 80%, and the specificity is nearly 100%.5,6 Therefore, when clinical suspicion for IM is high, it is recommended to repeat the heterophile antibody testing every two weeks, for a period six weeks from the onset of symptoms. It should be noted that if the heterophile antibody test is positive, it can remain so for up to a year before the antibodies decline. Also, false positive tests are rare but can be caused by some malignancies (lymphoma and leukemia), infections (HIV, HSV, toxoplasmosis, rubella), and autoimmune disorders (rheumatoid arthritis and systemic lupus erythematosis).6 In particular, in the adolescent and young adult age group that most frequently presents with acute mono-like symptoms, acute HIV/retroviral syndrome should also be considered as it can mimic acute IM. Testing for more specific EBV antibody serologies has been developed and is also available to most practitioners. The drawbacks of these serologies compared to the heterophile antibody test are their higher cost and complexity, the latter often leading to frequent misinterpretation.

During the initial three to four weeks of acute IM, EBV early antigen (EA) antibodies will begin to rise but then will quickly decrease over the next three months or so. Also, early in the course of the illness, EBV viral capsid antigen (VCA) IgM antibody will begin to peak during the first two to six weeks of symptoms. It will then slowly decline over the following two to three months as well.4 Therefore, if repeat VCA IgM and EA levels remain low during the course of the illness, the diagnosis of acute IM is unlikely.

After two to three months from the onset of symptoms, VCA IgG antibodies begin to appear and will remain elevated for life.

Also, around this time EBV nuclear antigen (EBNA) antibodies will begin to be detected. EBNA will also remain elevated for the remainder of one’s life, and the presence of these antibodies likely excludes acute IM within the last year.5 In summary, VCA IgM and EA antibodies appear in the first few months of symptoms and are indicative of acute IM, while VCA IgG and EBNA antibodies appear much later in the course and during convalescence (Table 1). If serologic results are equivocal or do not agree with the clinical picture, the serologies should be rechecked in two to four weeks.

Table 1: Progression of Epstein Barr Virus Serological Markers

Infection status

EA VCA IgM

VCA IgG EBNA

No prior infection

-

-

-

-

Early infection

+

+

+/-

-

Late infection

-

+/-

+

+/-

-

+

+/-

Past/latent infection -

In ascending order of appearance (left to right): early antigen (EA) antibody, viral capsid antigen IgM antibody (VCA IgM), viral capsid antigen IgG antibody (VCA IgG), and Epstein Barr nuclear antigen antibody (EBNA).

Besides specific EBV antibody testing, there is other non-specific laboratory testing that may support the diagnosis of acute IM. During the initial two to six weeks of symptoms the patient will often have leukocytosis with an elevated number of atypical lymphocytes (greater than 10%) and may also have a mildly decreased platelet count. Up to 10% of patients may also have mildly elevated liver transaminases that usually normalize within three months.

Treatment and Complications Treatment of acute IM is mostly supportive with analgesics, increased fluid intake, and rest. The vast majority of patients are treated as outpatients. Since EBV is spread by oral secretions or intimate contact, there is no risk of transmission when returning to work or school.

However, in cases of extreme tonsillar hypertrophy and dehydration, hospital admission or observation for intravenous fluid therapy may be required. Although corticosteroids (prednisone) have been shown to be effective in decreasing the pain

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from acute tonsillitis, there is a concern that suppressing the body’s cellular response could lead to further proliferation of EBV.8 EBV complications can include other sites of infection (meningitis, encephalitis, Guillain-Barré Syndrome), and EBV is also involved with the development of some malignancies (lymphomas). Corticosteroids should, therefore, be used with some caution. In severe cases requiring corticosteroids, the recommended dosage is 0.5mg -1.0mg/kg per day of prednisone for seven days, followed by a taper.9 The fatigue and malaise from acute IM varies widely from mild symptoms lasting only a few weeks to more severe symptoms of fatigue that can persist for several months, or even up to a year or more in up to 10% of patients. The persistence of fatigue that is seen in some patients after acute IM would seem to implicate EBV as the causative agent of chronic fatigue syndrome (CFS). However, no convincing link has been found between EBV and CFS. Acyclovir has been used against other herpes viruses (herpes simplex and varicella zoster) with some success, and in vitro studies of acyclovir have shown it to be effective against EBV. However, to date, there are no convincing clinical studies to show that it improves the course in patients with acute IM. Nevertheless, acyclovir (along with IVIG) could be considered in those with serious complications or immunodeficiencies.10 Complications of EBV during the active infection can affect a variety of systems (Table 2). Localized spread of infection around the tonsils can lead to the development of peritonsillar cellulitis or abscess. This complication can occur in any patient with suppurative tonsillitis, including Group A streptococcal infections. Therefore, in patients presenting with a peritonsillar abscess, both acute IM and Group A Streptococcus should be considered. A peritonsillar abscess necessitates incision or aspiration with drainage as well as intravenous antibiotics and corticosteroids.

Table 2: Complications of Acute Infectious Mononucleosis

Common

Rare

Dehydration

Splenic rupture

Massive splenomegaly

Necrotic hepatitis

Hepatitis

CNS infections

Maculopapular rash

Hemolytic anemia

Prolonged fatigue/malaise* Hemophagocytic Syndrome Peritonsillar abscess

Myocarditis

*Post-infection fatigue and malaise can continue for one to two years in some patients with acute IM. This should not to be confused with chronic fatigue syndrome.

Acute IM is commonly associated with splenomegaly and mildly increased liver transaminases. Although a rare complication – splenic rupture – can occur. Splenic rupture is more often spontaneous rather than traumatic and is most likely to occur within the first three to four weeks of symptoms.11 There-

fore, it is recommended that all patients with acute IM be educated about this possibility as well as its associated symptoms.

Since the majority of the cases of splenic rupture occur in the first three to four weeks of symptoms, this is often used as a guideline as to how long the patient should refrain from contact sports or vigorous activity. Determination of splenic size by ultrasound does not seem to be a very reliable prognostic indicator, since spleen sizes vary considerably among the population, and the patient’s baseline spleen size was not likely to have been imaged prior to infection. Also, the degree of splenic enlargement does not necessarily correlate with the likelihood of rupturing.12 Exam findings of splenomegaly and left upper quadrant tenderness are certainly more cost-effective than ultrasound but may not be reliable indicators themselves.13 Other, more rare complications can involve the central nervous system, such as aseptic meningitis, encephalitis, optic neuritis, cranial nerve palsies, transverse myelitis, and Guillain-Barré syndrome.9 Additional rare complications include fulminant or necrotic hepatitis as well as hematologic emergencies, such as hemolytic anemia and hemophagocytic syndrome. The latter is a devastating syndrome that is highly associated with EBV. Clinical findings of hemophagocytic syndrome (also known as hemophagocytic lymphohistiocytosis, or HLH) are fever, jaundice, splenomegaly, and lymphadenopathy. Activated macrophages (histiocytes) consume leukocytes, red blood cells, and platelets in the bone marrow and spleen. This leads to a pancytopenia and can mimic T-cell lymphoma. The result is subsequent and profound immunodeficiency. HLH has a high rate of mortality, often from overwhelming secondary infections.14

Closing Remarks Patients with acute infectious mononucleosis will frequently present to an urgent care facility. Therefore, urgent care providers must have acute IM in their differential when evaluating patients for fatigue, sore throat, lymphadenopathy, splenomegaly, and fever. In particular, in those patients with prolonged or vague symptoms (fatigue and malaise), the diagnosis of acute IM can be easily missed. Being on the lookout for acute IM and understanding the importance of the timing of laboratory testing as well as its limitations can assist the clinician in arriving at the correct diagnosis. Also, familiarizing oneself with the complications of acute IM can aid in arriving at the correct diagnosis in those patients with atypical presentations, such as hepatitis or splenic rupture. Lastly, urgent care clinicians should ensure that they are well-versed about the expected course, its potential complications, and prognosis, so that they can effectively educate their patients.

Mark E. Rogers, MD, is Assistant Professor of Emergency Medicine, West Virginia University, Department of Emergency Medicine, Morgantown, WV. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might ®

American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

create any potential conflict of interest. The author has stated that no such relationships exist.

References 1.

Sprunt TP, Evans FA. Mononucleosis leukocytosis in reaction to acute infections (infectious mononucleosis). Johns Hopkins Hosp Bull.

1920;31:409.

2.

Evans AS. The history of infectious mononucleosis. Am J Med Sci. 1974;267:189.

3.

Silver MI, Paul P, Sowjanya P, Ramakrishna G, Vedantham H, Kalpana B, Shah KV, Gravitt PE. Shedding of Epstein-Barr virus and cytomegalovirus from the genital tract of women in a periurban community in Andhra Pradesh, India. J Clin Microbiol. 2011 Jul;49(7):2435-9.

4.

Heath CW Jr, Brodsky AL, Potolsky AI. Infectious mononucleosis in a general population. Am J Epidemiolo. 1972;95:46.

5.

Bruu AL, Hjetland R, Holter E, Mortensen L, Natås O, Petterson W, Skar AG, Skarpaas T, Tjade T, Asjø B. Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies. Clin Diagn Lab Immunol. 2000 May;7(3):451-6.

6.

Gray JJ, Caldwell J, Sillis M. The rapid serological diagnosis of infectious mononucleosis. J Infect. 1992 Jul;25(1):39-46.

7.

Hopkins RF 3rd, Witmer TJ, Neubauer RH, Rabin H. Detection of antibodies

to Epstein-Barr virus antigens by enzyme-linked immunosorbent assay. J Infect Dis. 1982 Dec;146(6):734-40.

8.

Gulley ML. Molecular diagnosis of Epstein-Barr virus-related diseases. J Mol Diagn. 2001 Feb;3(1):1-10.

9.

American Academy of Pediatrics. Epstein-Barr Virus Infections (Infectious Mononucleosis). In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:289-292.

10. Rafailidis PI, Mavros MN, Kapaskelis A, Falagas ME. Antiviral treatment for severe EBV infections in apparently immunocompetent patients. J Clin Virol. 2010 Nov;49(3):151-7.

11. Safran D, Bloom GP. Spontaneous splenic rupture following infectious mononucleosis. Am Surg. 1990 Oct;56(10):601-5.

12. Hosey RG, Mattacola CG, Kriss V, Armsey T, Quarles JD, Jagger J. Ultrasound assessment of spleen size in collegiate athletes. Br J Sports Med. 2006 Mar;40(3):251-4.

13. Waninger KN, Harcke HT. Determination of safe return to play for athletes recovering from infectious mononucleosis: a review of the literature. Clin J Sport Med. 2005 Nov;15(6):410-6.

14. Fisman DN. Hemophagocytic Syndromes and Infection. Emerging Infectious Diseases. Centers for Disease Control and Prevention.

2000;6(6).

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Review of Important ECG Findings in Patients with Syncope Joseph Toscano, MD

Abstract Guidelines recommend 12-lead ECG as an important test to perform in patients with syncope. Though the incidence of ECG abnormalities is quite low, urgent care clinicians must be knowledgeable about the findings which portend the highest risk for these patients. Having a structured approach to interpreting these patients’ ECGs, and acting appropriately when abnormalities are found, should minimize morbidity and mortality in this patient group.

cope of 6.2 cases per 1000 patient-years.2 Patients with cardiac syncope have a worse prognosis than those with noncardiac syncope,2 and 12-lead ECG is an important test to be used Table 1: Important ECG findings in patients with syncope

•

Paroxysmal or sustained dysrhythmia on monitoring in clinic

•

Non-sinus rhythm of any sort

•

Nonspecific intraventricular conduction delay (QRS > 100 ms without left or right bundle branch pattern)

•

Left bundle branch block or left anterior or posterior hemiblock

•

ECG signs of coronary ischemia

•

Long QT syndrome - QTc > 440-450 msec in men or > 460 msec in women

•

Brugada sign - right bundle branch block and anterior ST elevation

•

Left ventricular hypertrophy in someone with no reason to have it and/or Q waves in II, III, aVF, V5, and V6

•

Pre-excitation syndromes (PR interval < 120 msec) with or without delta wave

Introduction Syncope is an uncommon problem seen in urgent care practice, and most cases of syncope are self-limited and benign.

Transient loss of consciousness is, however, occasionally a harbinger of a more severe underlying problem. Coronary ischemia, cardiac dysrhythmia and the potential for dysrhythmia, and cardiac outflow obstruction are among the cardiac causes of syncope that need to be considered when a patient presents after syncope, regardless of the healthcare setting. The following review summarizes the major conditions that need to be excluded by ECG for patients who present after having passed out (see Table 1).

Epidemiology/Pathophysiology There is little information about how frequently patients present to urgent care settings after syncope; however, it has been reported that up to 1.5% of emergency department visits1 and 6% of hospital admissions are for this problem.1,2 Data from the Framingham study showed an occurrence rate of first syn-

for cardiac diagnoses. Because the large trials combine ECG abnormalities with other potentially important determinants of outcome (e.g., lab results, vital signs, age, comorbidities), it is hard to determine the independent effect of “picking-up” an

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abnormal finding, and, to the author’s knowledge, this has not been quantified. Although the number is surely small overall, for those affected it is obviously very important. Such “lowincidence, high-stakes” situations are common in acute care practice, and the basic principle of minimizing morbidity and mortality by appropriately interpreting ECGs is inferred from the overall date and case studies.

Syncope has many potential causes, with a common pathophysiology of transient, globally decreased cerebral blood flow.

There are many disorders that need to be considered, including syncope mimics. The complete evaluation of these patients requires more complex decision-making than will be explained in this review. On the other hand, several authoritative guidelines2,3,4 recommend ECG as the primary, and in most cases only, diagnostic tool for these patients, and along with a history and physical examination, a complete initial evaluation can be provided at most urgent care clinics. Clinicians need to be cognizant of the ECG findings that place patients at higher risk for ongoing or recurrent problems after syncope.

The cardiac causes of syncope, which may be apparent on ECG, include conditions which lead to coronary ischemia, cardiac outflow obstruction, dysrhythmias, and conduction system problems severe enough to decrease cardiac output. Paroxysmal dysrhythmias may rarely be observed in clinic. When these are not present, it is vital to look for ECG changes, which are known to predispose to recurrent dysrhythmia or other problems. Patients with non-sinus rhythm of any sort, conduction disorders of the left bundle (left bundle branch block, left anterior or posterior hemiblock), or nonspecific intraventricular conduction delay (prolonged QRS without left or right bundle pattern) are more likely to suffer significant adverse cardiac outcomes after syncope.5

Coronary Ischemia Syncope associated with coronary ischemia can have many causes, including paroxysmal dysrhythmia, left ventricular pump failure, and acute mitral regurgitation. Careful cardiac and pulmonary physical exam may be revealing in these cases. As well, the clinician should review the 12-lead ECG for signs of ischemia. These include new and evolving ST segment changes, T wave inversions, and/or Q waves (see Figures 1 and 2). Comparison with any prior ECGs can increase the specificity of any abnormal findings for an acute problem, as can obtaining a second ECG in clinic 10 to 15 minutes after the first for stable patients. The sensitivity of ECG is less than perfect, however, so patients with a presentation that is clinically suspicious for ischemia should be promptly and safely transferred to a higher level of care, even with a normal or unchanged ECG.

Brady- and Tachydysrhythmias Bradycardia results in syncope due to directly decreased cardiac output (cardiac output = stroke volume x heart rate). A slow heart rate should be obvious on ECG and may be due to sinus bradycardia or first-, second-, or third-degree heart block.

Sinus bradycardia and lower grade heart block (first- or type I second-degree heart block) may be transient and generally carry a lower risk of adverse outcomes than higher grade heart block (type II second- or third-degree heart block). Sinus bradycardia or even lower grade heart block may be seen as part of a “vagal” response, and any slow heart rate may be due to intrinsic conduction system disease, medication (calcium channel blockers and beta blockers), or hyperkalemia.

Patients with persistent, symptomatic bradycardia of any sort or high-grade heart block even without symptoms generally require transfer to a higher level of care and may be candidates Figure 1: ST Segment Elevation Myocardial Infarction – STEMI. The pattern of ST segment elevations in contiguous inferior leads (II, III, aVF) with ST segment depressions in the reciprocal anteroseptal leads has a high specificity for acute myocardial infarction. Syncope in this patient, who otherwise complained only of left arm pain, may have been related to paroxysmal bradycardia or other dysrhythmia, but did not recur.

Emergency transfer to the emergency department was followed by emergency cardiac catheterization showing a 100% right coronary artery lesion, which was successfully stented.

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Figure 2: Cardiac Ischemia. This 41-year-old male presented after passing out while playing basketball. ST segment depressions in the lateral leads (I, aVL, V4, V5, V6) were subtle but persistent on serial ECG. He was transferred to the ED and admitted. His cardiac enzymes became positive, and cardiac catheterization revealed a 99% circumflex lesion.

Figure 3: Long QT syndrome. It is important to measure the QT interval and the QTc (or at least verify the computerized reading), but a general impression of whether the QTc is prolonged can be obtained by looking for the end of the T wave (white arrow). It if it occurs over halfway between the R-R interval (from one black arrow to the other, above), then the QTc will be prolonged. An alternative method using the peaks of the R and T waves is easier to “train your eye to see” but may be less accurate. This 16-year-old patient presented after syncope. She had inducible ventricular tachycardia during electrophysiology study and had an automated internal cardioverter/ defibrillator placed at the same time.

for pacemaker placement; associated symptoms are a more important criterion for pacemaker placement than heart rate, though documented periods of asystole for three or more seconds or any escape rate below 40 beats per minute are significant in asymptomatic patients. Those with asymptomatic sinus bradycardia or low grade heart block should be managed in consultation with a cardiologist, and most can have outpatient follow-up.

Tachycardia results in syncope when the heart rate reaches a threshold above which inadequate time for ventricular filling lowers stroke volume below a critical, brain-perfusing level.

This threshold rate will be lower for patients with many types of underlying cardiac disease. Ventricular tachycardia or very rapid supraventricular tachycardia cause syncope more often than atrial fibrillation, atrial flutter, or multifocal atrial tachycardia do. Of course, any culprit dysrhythmia may have resolved by the time the patient presents for care to an urgent care clinic.

It may recur paroxysmally and be captured with monitoring in clinic, but more often, the clinician must examine the ECG for conditions that predispose to tachydysrhythmia (see below).

As with ischemia, ECG sensitivity is too low for it to be relied upon to completely “rule-out” a potential rhythm problem, particularly in an asymptomatic patient after syncope has resolved.

Therefore, for patients with worrisome presentations, such as syncope during exercise or prominent palpitations preceding their syncopal episodes, the urgent care clinician should coordinate disposition and follow-up with a cardiologist, even if the 12-lead ECG in clinic is normal.

Though the heart rate in sinus tachycardia will usually not rise to the level where a patient will have syncope as a result of the elevated rate alone, it may more often indicate an underlying non-cardiac problem that needs evaluation, for example, blood loss, dehydration, infection, etc.

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Conditions Which Predispose to Dysrhythmia Several conditions, in healthy patients without structural heart disease, are associated with a predisposition to tachydysrhythmias and syncope. These conditions are also associated with sudden cardiac death, so clinicians should look for the ECG findings of these disorders in all patients who present after syncope. Clinicians should immediately consult a cardiologist for any patient with any of these ECG findings after syncope.

Hospital admission for telemetry and electrophysiology study is often advised. Any of these may be found on routine ECG as well, and without a history of recent or prior syncope, an outpatient workup can be pursued. The occurrence of syncope, however, portends higher risk, and these patients need immediate, or at least extremely close, specialty follow-up. These conditions are reviewed in greater depth elsewhere,6 but the following section summarizes the most important details.

Long QT syndrome (LQTS) Several abnormalities of delayed ventricular repolarization are characterized by prolongation of the QT interval on ECG. These abnormalities include congenital membrane-ion-channel defects and some acquired causes related to medications, toxins, and neuropathies. Any of them may result in spontaneous or provoked (e.g., at the sound of a loud noise or physical or emotional stress) ventricular tachycardia, which can degenerate to fibrillation. The median age of those who die from LQTS is 32 years old.

Delayed ventricular repolarization is defined relative to heart rate (QTcorrected, or QTc) and LQTS is characterized by a QTc interval > 440-450 msec in men and > 460 msec in women.

Though the correct formula to calculate QTc is part of most ECG units, computerized assessment of the QT interval may be unreliable and will result in a miscalculation. Any reading in a

syncope patient should be checked with a set of calipers. As a general “gestalt,” look for the end of the T wave to occur after the halfway point between the R-R interval (see Figure 3) if the patient has LQTS.

Brugada syndrome Patients with Brugada syndrome have a defective sodium membrane channel due to an inherited chromosomal mutation. The defective channel predisposes to ventricular tachycardia and fibrillation. The ECG hallmark of this disorder is a right bundle branch pattern with anterior ST segment elevation in either a coved-downsloping or saddle-shaped pattern (see Figure 4).

Figure 4: Brugada Sign. The pattern of right bundle branch block (RBBB) and “coveddownsloping” ST segment elevation in leads V1 (top) and V2 (bottom) comprise one form of Brugada sign. In a patient with syncope, this is suspicious for Brugada syndrome due to self-terminating ventricular tachycardia. A second form of Brugada sign includes more of a saddle-shape (coved but not downsloping) to the elevated ST segment. The basic abnormal pattern to remember for Brugada is “RBBB and ST elevation” which should not normally occur together.

The mortality of undiagnosed, untreated Brugada syndrome is reported to be 30% at two years; the average age at diagnosis is between 35 and 45. The ECG findings may be transient and are Figure 5: Wolf-Parkinson-White Syndrome (WPW). The pattern of shortening of the PR interval to less than 120 milliseconds, widening of the QRS complex, and a slurred upstroke of the initial part of the R wave, called the delta wave (black arrow), comprise WPW. Lown-GanongLevine syndrome appears similar but lacks the delta wave.

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reported to be unmasked by fever or some medications. A pseudo-Brugada sign can be produced by electrolyte disturbances, cocaine, cyclic antidepressants, class 1A or 1C antidysrhythmics, and right ventricular infarction or injury; however, all of these patients would require referral to a higher level of care in the setting of syncope.

Ventricular pre-excitations syndromes Several mechanisms of supraventricular tachycardia (SVT) exist, but those which incorporate conduction along an accessory pathway can permit SVT rates and other situations (e.g., very rapid conduction of atrial fibrillation) that are more likely to result in syncope. If the resting ECG captures conduction of the atrioventricular impulses along the accessory pathway, the classic pattern of Wolf-Parkinson-White (WPW) syndrome will be apparent. This includes shortening of the PR interval to less than 120 milliseconds, widening of the QRS complex, and a “delta wave,” which describes a slurred upstroke of the initial part of the R wave (see Figure 5). Patients with WPW will not have these findings if atrioventricular impulses are traveling along the normal conduction system at the time the ECG is performed. Lown-Ganong-Levine syndrome includes shortening of the PR interval to less than 120 milliseconds due to an accessory pathway, but there is no delta wave.

Table 2: Several, of many, systems used for diagnosing left ventricular hypertrophy on ECG

Cornell criteria

•

•

Height of the S wave in V3 plus height of the R wave in aVL > 24 mm for men

•

Height of the S wave in V3 plus height of the R wave in aVL > 20 mm for women

Commonly used •

Height of the R wave in V5 or V6 plus height of the S wave in V1 or V2 > 35mm

OR •

Sum of tallest R wave and deepest S wave in precordial leads > 40 mm

OR •

Height of R wave in aVL > 11 mm

Cardiac Outflow Obstruction Another genetic disorder, hypertrophic cardiomyopathy (HCM), comes in several forms, all involving abnormal left ventricular hypertrophy (LVH), either concentrically or including just a segment of the left ventricular wall. HCM has also been called idiopathic hypertrophic subaortic stenosis (IHSS) and hypertrophic obstructive cardiomyopathy and occurs in someone without the stressors of hypertension or valvular heart disease to produce the LVH. Many patients will never have symptoms, but there is potential for the hypertrophied segment to obstruct the outflow of blood from the left ventricle, particu-

larly during exercise. This can lead to syncope or worse: HCM is the most common cause of sudden death in young athletes.

Physical exam findings include a bisferiens pulse and systolic murmur heard along the left sternal border, which increases with Valsalva maneuver. ECG findings include LVH and/or prominent Q waves in leads II, III, aVF, V5 and V6. Though there are many schemes for predicting LVH (see Table 2) and these tend to be highly specific (computerized LVH algorithms are reliable if positive), sensitivity of these calculations for LVH in general ranges between 25 and 50%. Still, the ECG is reported to be abnormal in about 90% of patients with HCM, so examining for abnormal Q waves and/or “LVH in someone who has no reason to have it” is important when evaluating a patient post-syncope.

Conclusion Though of limited sensitivity, 12-lead ECG is inexpensive and is uniformly recommended in the evaluation of patients after syncope. Patients with ECG findings of obvious dysrhythmia or the potential for dysrhythmia, conduction disturbances, coronary ischemia, or cardiac outflow obstruction require cardiology consultation, and many will require transfer, admission, and electrophysiology or other evaluation. These are uncommon occurrences but truly represent a chance to potentially save a life, if appropriate diagnosis and referral is made.

Joseph Toscano, MD, has been practicing urgent care and emergency medicine in the San Francisco Bay area for more than 15 years. He develops and reviews continuing medical education material in urgent care and emergency medicine for a variety of publications and presents regularly at urgent care conferences. Dr. Toscano is a founding board member of both the Urgent Care College of Physicians and the Board of Certification in Urgent Care Medicine.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References 1.

Huff J, Decker WW, Quinn JV, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope. Ann Emerg Med. 2007;49:431-444.

2.

Morag R. Syncope. Available online at Medscape at: http://emedicine. medscape.com/article/811669-overview#a0101; last updated August 11, 2011; accessed December 14, 2011.

3.

Cooper PN, Westby M, Pitcher DW, et al. Synopsis of the National Institute for Health and Clinical Excellence guideline for management of transient loss of consciousness. Ann Intern Med. 2011;155:543-549.

4.

Reed MJ, Newby DE, Coull AJ, et al. The risk stratification of syncope in the emergency department (ROSE) pilot study: a comparison of existing syncope guidelines. Emerg Med J. 2007;24:270–275.

5.

Quinn J, McDermott D. Electrocardiogram findings in emergency department patients with syncope. Acad Emerg Med. 2011 Jul;18(7):714-718.

6.

Dovgalyuk J, Holstege C, Mattu A, et al. The electrocardiogram in the patient with syncope. Am J Emerg Med. 2007;25,688–701.

American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

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Rhinosinusitis: An Urgent Care Perspective Sean M. McNeeley, MD

Introduction Although sinusitis in one of the most common diagnoses in the acute care setting, controversy remains about how to diagnose and treat it. This is particularly evident when you compare practice patterns to the medical literature. Although less than 2% of acute sinusitis cases are likely bacterial, as many as 92% of patients receive antibiotics. Part of this disparity may be due to patients’ expectations. An understanding of the currently accepted methods of diagnosis and treatment as well as tools to assist providers in decreasing patients’ expectations for antibiotics may help providers narrow this gap. This article reviews current diagnostic and treatment patterns and methods to modify patient expectations with the goal of applying the information to the urgent care setting.

Background Sinusitis is one of the most common complaints in acute care.

Any provider of urgent care medicine knows that patients with some version of “sinus” complaint are a daily occurrence. The average adult has two to five illnesses involving the nose and contiguous sinus cavities.1 The number of days missed from work is similar to that reported for acute asthma.2 It is also the second most common infectious disease seen by generalist physicians in Canada.3 The economic burden may be as high as two billion dollars.1 The challenge for the acute care provider is to manage a patient’s expectation (usually antibiotics or immediate relief) while remaining consistent with current medical knowledge (most cases are viral or just need a tincture of time) without the benefit of a prior relationship. The literature also reports physicians’ prescribing patterns are not always consis-

tent with current understandings of the most effective means of diagnosis and treatment. While only 2% of sinusitis cases are likely bacterial, as high as 92% of patients seeking care are given an antibiotic.4 While not every patient with sinus symptoms seeks care, the disparity is shocking. These facts make it an important disease process for acute care providers to reconsider and assure that their practice is consistent with the information available to them. This article will concentrate on acute sinusitis from an urgent care perspective.

Definition The nose and paranasal sinuses represent a group of openings in the front of the skull decreasing its weight and helping to humidify and warm air before it enter the lungs. The sinuses open into the anterior nose through small apertures know as ostia. The entire area is layered with cilia that trap foreign bodies and bacteria and help to keep the small passages clear. Sinusitis is an inflammatory process affecting these areas, causing symptoms due to swelling and blockage of the ostia.5 Despite its common occurrence and years of investigation sinusitis is still not completely understood, and definitive diagnosis still remains a challenge. An accurate and practical diagnostic test for frontline physicians is lacking. Several guidelines have been proposed, but even they are not completely consistent.

The name sinusitis itself may be changing. Due to the high prevalence of anterior nasal passage blockage or congestion, the term rhinosinusitis has become more prevalent. Both terms relate to the same disease process of inflammation or infection of the sinuses and nasal mucosa. The main symptoms of this disease process include purulent rhinorrhea, nasal blockage, na-

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sal congestion, facial pressure, tooth pain, headache, ear pain, sneezing, malaise, and fever.

Most cases of sinusitis can be divided into viral and bacterial causes, although other more rare etiologies, such as fungal sinus infections, do occur. Acute viral rhinosinusitis (AVRS) has many etiologies. In most cases the etiology of the AVRS does not change management or prognosis and thus has little importance. Acute bacterial rhinosinusitis (ABRS) is most frequently cause by Streptococcus pneumoniae, Haemophilus influenza, or occasional Moraxella catarrhalis. Although some controversy exists about the definition of acute versus chronic sinusitis, symptoms present less than four weeks are most commonly used.

Diagnosis As with any other illness in the clinical setting specific diagnosis is only important if it alters the course of treatment or allows the clinician to provide an expected course of the disease process. Patient testing only makes sense in the clinical setting if the test results are available in a reasonable amount of time, the test has minimal or no risks, the test has reasonable cost versus benefit ratio, and the test is widely available. In the acute care setting, differentiating viruses is not practical. Differentiating bacterial etiologies also does not make sense unless a specific individual patient factor, such as treatment failure or immune status, is present. The key question is whether the etiology is viral or bacterial. It has been reported that less than 2% of sinusitis cases in a primary care office are bacterial in origin, but as much as 30% may be so in specialist offices.3 Several clinical guidelines and reviews have been proposed to help differentiate between AVRS and ABRS, but there are inconsistencies between them. New diagnostic tools are also still in the research phase.

As with any diagnostic consideration risk for the disease process is a good place to start. Several factors that predispose a patient to sinusitis include upper respiratory infections, anatomic variations, allergic rhinitis, nasal dryness, dental issues, immunodeficiency, and local irritation. The Task Force of Rhinosinusitis in 1997 developed symptom-based criteria for the diagnosis of rhinosinusitis. Two major or one major and two minor criteria were considered sufficient to make a clinical diagnosis. Major criteria included nasal drainage, nasal congestion, facial pain or pressure, postnasal drip, and anosmia. Fever, cough, fatigue, dental pain, and ear pressure or fullness were considered minor criteria.6 Today, this is a step in diagnosis but does not help define the etiology as bacterial or viral. Most of the recent guidelines do include nasal congestion or blockage, purulent rhinorrhea, and facial pain or pressure as defining symptoms.2 Sinus puncture is considered to be the gold standard for proving bacterial origin of rhinosinusitis.4 This procedure is rarely needed in clinical practice and not recommended in the primary care setting.7 Determining bacterial versus viral is best accomplished by considering duration, symptom pattern, and

severity. Duration of less than five days is generally considered viral. No improvement or worsening between five and ten days may be early bacterial disease, and greater than a ten-day duration points to a bacterial etiology. Most viruses peak between three and five days and resolve by seven in adults and ten days in children. Worsening after five days or initial improvement with subsequent worsening both lend to increased likelihood of a bacterial etiology. Severity has also become an important part of the decision between AVRS and ABRS. Although originally proposed and validated for chronic sinusitis, a good method for evaluating the severity of illness is a 10-point visual analog scale. The sinusitis scale uses the question “how troublesome are your sinusitis symptoms?” with 0 representing “not troublesome” and 10 being “worst thinkable.” Answers can be categorized as 0-3 mild, 4-7 moderate, and 8-10 severe.8 Other factors considered in severity include fever, localized pain, and swelling. Consistent findings of duration, course, or severity, alone or, more importantly, together, increase the likelihood of a bacterial etiology. A recent survey of pediatricians showed similar practice patterns in children age six and under.

The most important consideration was symptom duration. This was considered very important by 93%, followed by purulent rhinorrhea and nasal congestion, 55% and 43% respectively.9 In the past plain x-ray films were commonly used to diagnose sinusitis. Currently, imaging is not recommended in uncomplicated sinusitis cases. Plain radiography may even have a lower sensitivity than clinical diagnosis and does not help differentiate between viral and bacterial etiology. In patients who do require imaging plain radiography has been replaced by simple axial or coronal CT.6

Treatment Decongestants may provide symptomatic relief. Over-thecounter topical decongestants (phenylephrine, oxymetazoline, and xylometazoline) used in short durations shrink swelling and may relieve symptoms of sinus congestion. Use longer than 10 days has the risk of tachyphylaxis. Theoretically, because it does not decrease nasal blood flow, phenylephrine is the preferred agent.4 Oral decongestants have less effect on the nasal mucosa when compared with topical steroids. They also have more potential for systemic adverse effects. The only benefit oral decongestants provide when compared to topical is the decreased risk of tachyphylaxis.4 Mucolytics routinely prescribed alone or in combination with decongestants are thought to thin mucosal secretions and thus facilitate clearance. Although they have not been shown to cause harm, they have failed to show measurable benefit.4 Antihistamines only have benefit for those patients who have baseline allergic disorders. They also may dry the mucosa of non-allergic patients potentially worsening rhinosinusitis.

Therefore, they are not recommended for patients without allergies.1 Intranasal steroids, although not approved by the Food and Drug Administration in the United States for treatment

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of ABRS, have become more frequently recommended, particularly in recent consensus guidelines, but controversy does exist. Most of the research in this area has been done by the pharmaceutical industry.1 Nasal steroids are thought to reduce pro-inflammatory factors, decrease the allergic response, and improve sinus drainage.10 Some evidence has shown nasal steroids are equivalent to antibiotics in their results when treating sinusitis. Other studies have shown that adding nasal steroids to antibiotics improves efficacy. Short-term use has few side effects, although it may result in epistaxis. This is usually benign but very concerning to patients. Systemic corticosteroids are best reserved for severe disease, because their biggest role is in pain relief. They have not been shown to have other positive effects in the average patient.5 Nasal saline spray and irrigation have both been proposed for symptomatic relief of rhinosinusitis. Although the majority of research has been focused on chronic rhinosinusitis, some evidence has shown benefit in acute rhinosinusitis. The mechanism of action is uncertain, but it is thought to include direct cleansing, removal of inflammatory mediators, and improved mucocilliary function.11 Saline irrigation can be performed by using a neti pot or other low pressure spray bottle. Saline is instilled in one nostril and it returns through the other side. The most common adverse effect of this treatment is a sense of anxiety or discomfort the first time it is used.12 Table 1. Rhinosinusitis treatment highlights from an acute care perspective.

• Antibiotics should be considered when symptoms are severe.

• Patients with less than five days duration are most likely viral.

• Symptoms worsening after five days or initial improvement may be bacterial.

• Symptoms after 10 days are more likely bacterial in origin.

• Most patients’ symptoms will resolve spontaneously.

• Backup prescription may reduce antibiotic use.

• Amoxicillin and trimethoprim/sulfamethoxazole are first-line agents.

• Amoxicillin/clavulanate or fluoroquinolones for treatment failures.

• Intranasal steroids with or without antibiotics may be beneficial.

• In general imaging is not recommended.

• CT is superior to plain films when indicated.

Antibiotics have been the most commonly used treatment for all types of sinusitis. The decision to use antibiotics should be carefully considered. Studies have shown that 0.5 to 2% of acute sinusitis is likely to be bacterial in origin, and more than 60% of bacterial acute rhinosinusitis cases resolve on their own.7 If indicated, most authors and guidelines propose 10 days of amoxicillin or trimethoprim sulfamethoxazole for patients with penicillin allergy. Patients who fail after seven days or have indications for broader spectrum antibiotics would likely benefit from amoxicillin/clavulanic acid or a respiratory fluoroquinolone. There is some evidence that indicates less treatment failures in children using amoxicillin/clavulanate potassium; however, this was compared to placebo not amoxicillin.12 Other evidence points to five days of therapy being as good as ten, but most authors still recommend ten.

Challenges and Future Research Considering the current understanding of rhinosinusitis several factors make the care of these patients in an urgent care setting challenging. There is a low risk of bacterial infection (less than 2%) and no definitive bedside test. Unfortunately patients’ expectations for antibiotic treatment may be as high as 70%.13 Patient satisfaction has become even more important in recent years and will begin effecting reimbursement soon. These factors make the situation even more difficult for the provider without an ongoing relationship with the patient. Although national efforts to educate patients about the negatives of unnecessary antibiotics and the development of resistant bacteria are ongoing, patients still present with the expectation of an antibiotic prescription. Years of antibiotic prescriptions for most respiratory infection are not easily forgotten by patients. There are a few tools that providers can use to help meet patients’ expectations while following treatment guidelines. Backup antibiotics are one such tool, particularly in the situation where the provider’s assessment indicates a low risk of bacterial infection and the patient’s experience has included antibiotic prescriptions for similar symptoms. In this situation, the provider acknowledges the patient’s desire to get well and the successful history of antibiotic use in the past. The risks of antibiotics, such as allergic reaction, side effects, and resistance, are entertained. The likely viral nature of the current rhinosinusitis with the expectation of spontaneous resolution in a specified number of days is also presented. Finally, the compromise of an antibiotic prescription written today to be filled only in the event of failure of spontaneous resolution is offered. This approach does risk the patient leaving and just filling the antibiotic today but has been shown to reduce antibiotics use while maintaining patient satisfaction.14 Every time a patient actually waits and recovers, it reinforces the fact that an antibiotic is not always needed. Although not a perfect solution considering the state of current practice, every movement toward less unnecessary antibiotic prescriptions should be considered a victory. Recent studies using C-reactive protein to help decrease the use of antibiotics have shown some promise. Physicians provided with the results and the parameters of when to prescribe and when to

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consider a backup antibiotic were less likely to prescribe antibiotics. This was accomplished without compromising patient care and actually increasing patient satisfaction.15 Research in this area is still in the early stages, and specific values for CRP as well as an inexpensive bedside test are not available to the average urgent care provider. Studies are also ongoing to consider the use of bedside ultrasound to make prescribing decisions as well. For now acute care providers will have to settle for understanding the facts as far as we know them and using duration, severity, and symptom course to make antibiotic prescribing decisions.

6.

Batra P. Radiologic Imaging in Rhinosinusitis. Cleve Clin J Med. 2004;71(11):886-888.

7.

Derosiers M, Evans G, Keith P. Canadian Clinical Practice Guidelines for Acute and Chronic Rhinosinusitis. Allergy, Asthma and Clinical Immunology. 2011;7:2-40.

8.

Lim M, Lew-Gor S, Darby Y, et al. The Relationship Between Subjective Assessment instruments in Chronic Rhinosinusitis. Rhinology.

2007;45(2):144-7.

9.

McQuillan L, Crane L, Kempe A. Diagnosis and Management of Acute Sinusitis by Pediatricians. Pediatrics. 2009;123:e193-e198.

10. Lund V. Therapeutic Targets in Rhinosinusitis: Infection or Inflammation. Medscape J Med. 2008;10(4):105-120.

Conclusion Rhinosinusitis is a frequent complaint in the acute care setting.

Providing evidence based care while meeting patient expectations is often a difficult task. Careful choice of tools such as backup antibiotics and medications for symptomatic relief may help. Unfortunately, significant potential for side effects limits the use of these tools in many patients. Identifying which patients might improve with antibiotics is still a challenge. The patient’s history particularly duration, symptom pattern and severity are the most important in making this decision. For the majority of patients imaging is not helpful. Antibiotic choice is also controversial. Most guidelines recommend amoxicillin or trimethoprim with sulfamethoxazole for patients with penicillin allergy. Duration of treatment is usually 10-14 days. Hopefully as we teach our patients the difference between viral and bacterial infections treating sinus symptoms will become less of a challenge from a customer service perspective.

Sean M. McNeeley, MD, is a board-certified family physician who has been practicing urgent care medicine since 1997.

He is a founding board member of the Urgent Care College of Physicians and the Board of Certification in Urgent Care Medicine. Dr. McNeeley has lectured nationally over the last several years and teaches students, residents, and fellows in his position as Medical Director of University Hospitals Urgent Care Network in Cleveland.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References 1.

Management of Rhinosinusitis and Nasal Polyps 2007 – a summary.

Primary Care Respiratory Journal. 2008;17(2):79-89.

Aring A, Chan M. Acute Rhinosinusitis in Adults. Am Fam Physician.2011;83(9)1057-1063.

2. Meltzer E, Hamilos D. Rhinosinusitis Diagnosis and Management for the Clinician: A Synopsis of Recent Consensus Guidelines. Mayo Clin Proc. 2011;86(5):427-443.

3.

Worrall G. Acute Sinusitis. Can Fam Physician. 2011;57:565-567.

4.

Masood A, Moumoulidis L, Panesar J. Acute Rhinosinusitis in Adults: An Update on Current Management. Postgrad Med J. 2007;83:402-408.

5.

Thomas M, Yawn B, Price D, et al. EPOS Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and

11. Rabago D, Zgierska A. Saline Nasal Irrigation for Upper Respiratory Conditions. Am Fam Physician. 2009;80(10):1117-1119.

12. Wald E, Nash D, Eickhoff J. Effectiveness of Amoxicillin/Clavulanate Potassium in the Treatment of Acute Bacterial Sinusitis in Children.

Pediatrics. 2009;124: 9-15.

13. Rabago D, Barrett B, Marchand L, Maberry R, Mundt M. Qualitative aspects of nasal saline irrigation use by patients with chronic sinus disease in a multimethod study. Ann Fam Med. 2006;4(4):295-301.

14. Martin C, Njike V, Katz D. Back-up Antibiotic Prescriptions could reduce unnecessary antibiotic use in rhinosinusitis. J Clin Epidemiol.

2004;57(4):429-434.

15. Cals J, Schot M, Jong S, et al. Point-of-Care C-Reactive Protein Testing and Antibiotic Prescribing for Respiratory Tract Infections: A Randomized Controlled Trial. Ann Fam Med. 2010;8(2):124-132.

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Case Report Wellens’ Syndrome: A Case Report Joseph Toscano, MD

Introduction Patients uncommonly present to urgent care clinics with ischemic cardiac symptoms, but these situations do occur and represent a high risk to both clinician and patient. All clinicians should be aware of any ECG findings which may predict potential cardiac risk. Wellens’ sign is one ECG pattern which, when present, is highly specific for significant coronary heart disease, even in patients whose symptoms have resolved by the time the ECG is performed. This article will present a specific patient case and review the pertinent ECG findings of Wellens’ syndrome.

Case Scenario

family history is significant for a myocardial infarction in his father when he was 60. SS has felt well lately, and his review of systems is unrevealing except for the chest discomfort.

Physical examination shows following: Vital signs are as follows: •

T: 98.9oF

•

P: 72

•

R: 18

•

BP: 148/88

General: Mildly overweight, alert, lucid, and in no distress.

SS is a fifty-two-year-old white male who had had intermittent chest discomfort for two days. The discomfort occurs only with walking and resolved with rest. At his wife’s urging, he began to take an aspirin daily, but, when the symptoms persisted, he came to the urgent care clinic. He describes the discomfort as “pressure” located in the mid-chest without radiation. It has been mild to moderate in intensity. There is mild associated dyspnea, but no diaphoresis, nausea, or vomiting. He is currently asymptomatic.

HEENT: Normocephalic, no abnormalities.

SS’s past medical history is significant for 40 pack-years of cigarette smoking, but he has had no medical problems and has no diagnosed hypertension, diabetes, or hyperlipidemia. His

Extremities: Warm, nontender, no peripheral edema.

Neck: Supple, no masses, no JVD or carotid bruits.

Chest: Nontender, lungs are clear with good air movement bilaterally.

Cardiovascular: Equal, normal pulses at the wrists, cardiac rhythm is regular.

Abdomen: Nondistended and nontender.

Neurological: No deficits in mental status, motor function, co-

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Figure 1: ECG from patient showing symmetric inverted T waves in anterior leads. The biphasic shape of the T wave inversions is also a characteristic of one variant of Wellens’ syndrome.

ordination or gait. An ECG was performed in clinic (Figure 1) and shows biphasic changes. The patient reports that the only other ECG he can recall ever having was done for an insurance physical, and this is unavailable for comparison. He was given aspirin by mouth in clinic and transferred by ambulance to the emergency department, where ECG was repeated and unchanged. Initial cardiac markers were normal, and he was admitted to the telemetry unit and observed. Due to the ECG changes, the treating cardiologist opted for cardiac catheterization rather than stress testing, and the patient was found to have a 99% stenosis of his proximal left anterior descending coronary artery, which was successfully stented.

Discussion First described in 1982, Wellens’ sign consists of deep, symmetric T wave inversion in the anterior ECG leads, with a less common variant being biphasic T wave inversion in these leads,2 as is the case with the patient presented here. Approximately 90% of patients with these changes have high-grade stenosis of the proximal left anterior descending coronary artery.3 The abnormalities are often present even when a patient is asymptomatic, and they normalize with correction of the stenosis.2,3 Because of the large area of myocardium at risk with the causative lesion, these patients have a worse prognosis when treated medically and are often treated more aggressively by cardiologists. Frequently, stress testing is avoided out of concern for precipitating a myocardial infarction.2,3 1

SS presented with symptoms which were worrisome for coronary artery disease regardless of his ECG finding. The clinician’s detection of Wellens’ sign in this case led to more specific suspicion and expeditious referral, even though the patient had no rest symptoms.

Conclusion Wellens’ sign is an important ECG pattern for clinicians to recognize and may occur even in asymptomatic patients. Because of substantially increased risk of significant coronary disease and poor outcomes for these patients, immediate consultation with cardiologist is recommended.

Joseph Toscano, MD, has been practicing urgent care and emergency medicine in the San Francisco Bay area for more than 15 years. He develops and reviews continuing medical education material in urgent care and emergency medicine for a variety of publications and presents regularly at urgent care conferences. Dr. Toscano is a founding board member of both the Urgent Care College of Physicians and the Board of Certification in Urgent Care Medicine.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References 1.

De Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 pt 2):730-736.

2.

Tandy TK, Bottomy DP, Lewis JG. Wellens’ Syndrome. Ann Emerg Med. 1999 Mar;33:347-351.

3.

Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002 Nov;20(7):638-643.

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M e d i c a l E t h i c s

Without the Rhetoric Cases presented here involve real physicians and patients. Unlike the cases in medical ethics textbooks, these cases seldom involve human cloning, bizarre treatments, or stem cell research. We emphasize cases more common to the practice of medicine.

Most cases are circumstantially unique and require the viewpoints of the practitioners and patients involved. For this reason, I solicit your input on the cases discussed here at councile@aol.com. Reader perspectives along with my own viewpoint are published in the issue following each case presentation.

We are also interested in cases submitted by readers. The following case addresses a potential conflict between the physician’s role as caregiver and the requirements of law.

Mark Pastin, PhD Mark Pastin, PhD, is president and CEO of the Council of Ethical Organizations, Alexandria, VA. The Council, a non-profit, non-partisan organization, is dedicated to promoting ethical and legal conduct in business, government, and the professions.

case twelve

The Customer Is Always Right?

Your patient is recovering from colon cancer, and you are explaining the consequences going forward.

Most patients in her situation will have an external ostomy bag for the rest of their lives. There is a somewhat controversial procedure that allows creation of an internal ostomy bag (ilio-anal pouch) built from the patient’s tissue. You have had success with this procedure in the past. You explain this to the patient, who is somewhat vain, and the patient says, “I don’t care about risks, you have my confidence - and I won’t wear a smelly bag.” There is a video explaining the risks of the procedure, and you insist that the patient view the video. When the video ends, the patient asks questions suggesting that she did not pay close attention. She says, “I am the customer, and I accept the risks. But you are good at what you do, and this is what I want.” She is willing, even anxious, to sign a waiver indicating that you explained the risks to her. But you doubt that she has really understood the risks. Should you proceed according to her wishes?

This is an actual case. Of course, there are any number of complicating circumstances and additional details; but please address the case on the basis of the information provided.

There will be an analysis of this case and a new case in the next issue.

Your input is requested. Email your responses to: councile@aol.com. © Copyright Council of Ethical Organizations 2012

Medical Ethics Without the Rhetoric

American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

M e d i c a l E t h i c s

Without the Rhetoric CASE eleven ANALYSIS H a n d s O f f D o c !

Our case from the last issue involves a physician caring for a patient in a shared room who notices that a monitoring device for the patient in the other bed is beeping, indicating that the patient is in immediate danger. When the physician tries to assist the patient, the patient says he does not want “one of you” touching him. The physician is from the Middle East. Since touching a patient against their wishes is considered assault in some states, the physician wonders if he should intervene.

Our readers were nearly unanimous in agreement that the physician should intervene to save the patient at least if there is no other qualified person who can respond in time. I agree with the readers on this one. Many readers assumed that there were laws (such as “Good Samaritan” laws), or exceptions in laws, that would protect the physician. This is true in some but not all states. Consider the situation in which the physician intervenes against the patient’s wishes, and the patient does not survive. You can easily imagine the patient’s relatives blaming the physician. On the other hand, even if the physician saves the patient, there is no guarantee that the patient or the patient’s family will see things this way. Nonetheless, the physician has a moral obligation to intervene, and I would be willing to bet that there is not a judge or jury that would find otherwise.

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Manuscript Criteria and Information The American Journal of Clinical Medicine® (AJCM®), the official journal of the American Association of Physician Specialists, Inc. (AAPS), is a peer-reviewed journal dedicated to improving the clinical practice of medicine by publishing educational and informational articles. AJCM® is the official journal of the American Association of Physician Specialists, Inc. Send all manuscripts via email to editor@aapsus.org in Microsoft Word format. No other file formats will be accepted.

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JAMA. 2001;286:89-91).

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American Journal of Clinical Medicine® • Summer 2012 • Volume Nine Number Two

three, list first three and “et al.”), (2) title, (3) journal name (as abbreviated in PubMed), (4) year, (5) volume number, and (6) inclusive page numbers. References to books should include (1) author(s) (list all authors and/or editors up to six; if more than six, list first three and “et al.”), (2) chapter title (if any), (3) editor (if any), (4) title of book, (5) city of publication, (6) publisher, and (7) year. Volume and edition numbers, specific pages, and name of translator should be included when appropriate. The reference numbers in the reference list (if any) should be keystroked. Do not let the word processing program generate the reference numbers, using such features as automatic footnotes or endnotes. The author is responsible for the accuracy and completeness of the references and for their correct text citation. Please note how reference is set in text in example below.

Set yours to match.

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