Syncope: Evaluation and Differential Diagnosis.

Syncope is an abrupt, transient, and complete loss of consciousness associated with an inability to maintain postural tone; recovery is rapid and spontaneous. The condition is common, resulting in about 1.7 million emergency department visits in 2019. The immediate cause of syncope is cerebral hypoperfusion, which may occur due to systemic vasodilation, decreased cardiac output, or both. The primary classifications of syncope are cardiac, reflex (neurogenic), and orthostatic. Evaluation focuses on history, physical examination (including orthostatic blood pressure measurements), and electrocardiographic results. If the findings are inconclusive and indicate possible adverse outcomes, additional testing may be considered. However, testing has limited utility, except in patients with cardiac syncope. Prolonged electrocardiographic monitoring, stress testing, and echocardiography may be beneficial in patients at higher risk of adverse outcomes from cardiac syncope. Neuroimaging should be ordered only when findings suggest a neurologic event or a head injury is suspected. Laboratory tests may be ordered based on history and physical examination findings (e.g., hemoglobin measurement if gastrointestinal bleeding is suspected). Patients are designated as having lower or higher risk of adverse outcomes according to history, physical examination, and electrocardiographic results, which can inform decisions regarding hospital admission. Risk stratification tools, such as the Canadian Syncope Risk Score, may be beneficial in this decision; some tools include cardiac biomarkers as a component. The prognosis of patients with reflex and orthostatic syncope is good; cardiac syncope is more likely to be associated with adverse outcomes.

Over-the-Counter Medications in Pregnancy.

High-quality research on the safety and effectiveness of over-the-counter medications in pregnancy is limited. Physicians should explore nonpharmacologic treatments before recommending medication. For nausea and vomiting in pregnancy, vitamin B6 (pyridoxine), H1 antihistamines, and ginger are safe and effective. Physicians can recommend calcium carbonate, H2 antihistamines, and proton pump inhibitors for gastroesophageal reflux disease. Osmotic laxatives, fiber preparations, and probiotics are safe and effective treatments for constipation. Many over-the-counter topical medications are safe in pregnancy due to low systemic absorption, but topical retinoids, such as adapalene, should be avoided. Hypertonic saline nasal rinse and antihistamines are safe, beneficial options for treating pregnancy-induced rhinitis, and intranasal corticosteroids have demonstrated benefit for chronic allergic rhinitis. The safety of acetaminophen for the treatment of headaches and low back pain during pregnancy has come into question with recent studies; therefore, judicious use is advised. Physicians should screen all pregnant patients for their risk of developing preeclampsia and initiate low-dose aspirin from 12 weeks' gestation until delivery for those at increased risk. Data are limited on the safety and effectiveness of herbal supplements during pregnancy.

An interactive approach to teaching practice management to family practice residents.

Three years ago, our residency program began a new approach to teaching practice management to our second- and third-year residents. The underlying principles for the new curriculum involved a realization that our residents lacked basic business understanding and that they would likely learn more effectively through a hands-on approach. The new curriculum, which we describe in this article, is in large part built around the establishment of a mock practice during the second year of residency. Although the curriculum is still evolving, initial response and evaluation have been encouraging.

Bupropion and restless legs syndrome: a randomized controlled trial.

INTRODUCTION: Restless legs syndrome (RLS) is a common neurological disorder affecting 10% of the population. Most antidepressants exacerbate symptoms; however, correlational studies have noted symptom improvement with bupropion. The purpose of the current study was to examine whether, in a controlled study, bupropion would improve the symptoms of RLS, or at least not exacerbate them. METHODS: This was a double-blinded, randomized controlled trial. Twenty-nine participants with moderate to severe RLS received 150 mg sustained-release bupropion once daily, and 31 control participants received a placebo. Participants were followed for 6 weeks and completed standardized tools, including the International Restless Legs Syndrome Study Group (IRLSSG) severity scale. RESULTS: The primary outcome was change from baseline in IRLSSG severity score; lower scores were associated with improved symptoms. At 3 weeks, IRLSSG scores were 10.8 points lower in the bupropion group and 6.0 points lower in the placebo group (P=.016). At 6 weeks, IRLSSG scores were 10.4 points lower in the bupropion group and 7.6 points lower in the placebo group (P=.108). Bupropion was more effective than placebo in the treatment of RLS at 3 weeks; however, this difference was not statistically significant at 6 weeks. CONCLUSIONS: The data from our study suggest that bupropion does not exacerbate the symptoms of RLS and may be a reasonable choice if an antidepressant is needed in individuals with RLS. Larger studies that include titration of bupropion should be considered to determine if bupropion is appropriate for primary treatment of RLS, particularly considering the lower cost and favorable side effect profile compared with currently recommended first-line dopamine agonists.

Restless legs syndrome.

Restless legs syndrome is a common neurologic movement disorder that affects approximately 10 percent of adults. Of those affected with this condition, approximately one third have symptoms severe enough to require medical therapy. Restless legs syndrome may be a primary condition, or it may be secondary to iron deficiency, renal failure, pregnancy, or the use of certain medications. The diagnosis is clinical, requiring an urge to move the legs usually accompanied by an uncomfortable sensation, occurrence at rest, improvement with activity, and worsening of symptoms in the evening or at night. Restless legs syndrome causes sleep disturbances, is associated with anxiety and depression, and has a negative effect on quality of life. Treatment of secondary causes of restless legs syndrome may result in improvement or resolution of symptoms. Currently, there is little information regarding the effects of lifestyle changes on the symptoms of restless legs syndrome. If medications are needed, dopamine agonists are the primary medications for moderate to severe restless legs syndrome. Other medications that may be effective include gabapentin, carbidopa/levodopa, opioids, and benzodiazepines.

Valproate-associated hyperammonemic encephalopathy.

The use of valproic acid (VPA) (also known as Depakote, Depakene, and others) frequently results in elevated plasma ammonia. In some people, hyperammonemia may be clinically significant, resulting in hyperammonemic encephalopathy, which may be severe. Valproic acid-induced hyperammonemic encephalopathy may occur in people with normal liver function, despite normal doses and serum levels of VPA. We describe 2 cases of valproic acid-induced hyperammonemic encephalopathy in patients with supratherapeutic VPA levels, although the condition has been described in people with normal VPA levels. With the increasing indications and off-label uses of VPA, family physicians should be aware of this potential complication of VPA and check ammonia levels in patients taking VPA who present with alterations in mental status. Treatment with L-carnitine may be beneficial in reducing ammonia levels.

Nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease is a common condition associated with metabolic syndrome. It is the most common cause of elevated liver enzymes in U.S. adults, and is diagnosed after ruling out other causes of steatosis (fatty infiltration of liver), particularly infectious hepatitis and alcohol abuse. Liver biopsy may be considered if greater diagnostic and prognostic certainty is desired, particularly in patients with diabetes, patients who are morbidly obese, and in patients with an aspartate transaminase to alanine transaminase ratio greater than one, because these patients are at risk of having more advanced disease. Weight loss is the primary treatment for obese patients with nonalcoholic fatty liver disease. Medications used to treat insulin resistance, hyperlipidemia, and obesity have been shown to improve transaminase levels, steatosis, and histologic findings. However, no treatments have been shown to affect patient-oriented outcomes.

Exercise and restless legs syndrome: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Restless legs syndrome (RLS) is a common, underdiagnosed neurological movement disorder of undetermined etiology. The primary treatments for restless legs syndrome are pharmacological. To date, no randomized controlled trials have examined the effectiveness of an exercise program on the symptoms of RLS. METHODS: Study participants (N = 41) were randomized to either exercise or control groups. 28 participants (average age 53.7; 39% males) were available and willing to begin the 12-week trial. The exercise group was prescribed a conditioning program of aerobic and lower-body resistance training 3 days per week. Restless legs symptoms were assessed by the International RLS Study Group (IRLSSG) severity scale and an ordinal scale of RLS severity at the beginning of the trial, and at 3, 6, 9, and 12 weeks. RESULTS: Twenty-three participants completed the trial. At the end of the 12 weeks, the exercise group (N = 11) had a significant improvement in symptoms compared with the control group (N = 12) (P = .001 for the IRLSSG severity scale and P < .001 for the ordinal scale). CONCLUSIONS: The prescribed exercise program was effective in improving the symptoms of RLS.

Alcohol withdrawal syndrome.

The spectrum of alcohol withdrawal symptoms ranges from such minor symptoms as insomnia and tremulousness to severe complications such as withdrawal seizures and delirium tremens. Although the history and physical examination usually are sufficient to diagnose alcohol withdrawal syndrome, other conditions may present with similar symptoms. Most patients undergoing alcohol withdrawal can be treated safely and effectively as outpatients. Pharmacologic treatment involves the use of medications that are cross-tolerant with alcohol. Benzodiazepines, the agents of choice, may be administered on a fixed or symptom-triggered schedule. Carbamazepine is an appropriate alternative to a benzodiazepine in the outpatient treatment of patients with mild to moderate alcohol withdrawal symptoms. Medications such as haloperidol, beta blockers, clonidine, and phenytoin may be used as adjuncts to a benzodiazepine in the treatment of complications of withdrawal. Treatment of alcohol withdrawal should be followed by treatment for alcohol dependence.