Unicorn Sighting

Happy guideline season!

I’ve been hearing about JNC 8 for so long, that I thought it didn’t really exist.  Thanks to some persistent hypertension experts, it is here at long last.  Here’s a quick review of the major points. I’m sure that we will see some commentary in the days and weeks to come, I’ll try to keep you updated on that as well.   I’d love to hear what you think- start the conversation in the comments below.

Higher BP targets

We are used to aiming for 140/90 for most people, and 130/80 for those with CKD, diabetes, CAD, and other comorbidities.  But new evidence  has emerged that these may not be so great, particularly for elderly patients.  So JNC 8 says- Adults 18-60 (even with DM or CKD) should aim for BP <140/90.  We can be a little more relaxed with patients over 60, and aim at 150/90 for them, so long as they don’t have CKD or DM.  Most of this change comes because there really was no outcome data for our prior target, and it seems that getting people to the 140s systolic provides just as much benefit as the 130s range.

Relaxed first line medicine choices

We’ve known that this was coming for a while.  JNC 7 recommended thiazides as first line for all, but there was never any real data to back that up.  So JNC 8 says that we can use thiazides, ACE-I/ARBs, or calcium channel blockers as a first choice for most patients.  They do acknowledge the racial difference in response to ACE inhibition, and recommend that we DON’T use ACE/ARB as first line for our black patients. EXCEPT (there’s always an exception) that for patients with chronic kidney disease (but not necessarily diabetes without ckd), use ACE-I first, no matter the race.

Second, and third, and fourth line medicines

Really not much different here, except there are not really recommendations about when to start two medicines at first visit.  JNC 8 says we can pick a variety of treatment strategies– maximize one medicine at a time, add a second agent before maximizing the first, or start two medicines at once.  When you add agents; pick from that first line list (thiazides, ACE/ARB, CCB) until you’ve used them all, then use aldosterone antagonists, beta blockers, central agents, or other vasodilators.  They do recommend avoiding ACE-I and ARB combos for most patients.

What’s Missing

JNC 7 discussed prehypertension, secondary hypertension, resistant hypertension, adherence, how to measure blood pressure, and lots of other related issues. The JNC 8 group just picked 3 questions that they felt were most important: does starting treatment at a particular threshold improve outcomes, does a particular treatment goal improve outcomes, do various drugs have important differences in risk/benefit calculation and outcomes.  Very evidence based and outcome oriented, which is kind of refreshing.

What about my patients now?

For all of us who have been trying to follow JNC 7 (and the subsequent performance measures created from that guideline), should we go adjusting therapy on our patients to meet new targets?  No, say these experts.  If your patient has a blood pressure of <150/90 on their current therapy, and is doing well, no need to change. Stay tuned to see if any of our performance targets change.

A great big picture algorithm from the JNC 8 group is here, and the link to the guidelines themselves is here (on the JAMA website subscription may be needed).

Here’s a great, plain language summary from the NYT Well blog.

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What’s in a Wet Prep?

We have been doing wet preps a plenty in resident clinic lately, and I find myself reviewing the same info.  That’s sounds like a good reason for a blog post!  I’ve organized by diagnosis below, with history, PE, and wet prep clinical pearls.

Bacterial Vaginosis (40-45% of vagnitis)

  • HX: profuse discharge, thin, watery. Worse after menses or after intercourse.  May be foul-smelling. Usually not painful, pruritic.
  • PE: Cup of milk

BV

  • Wet Prep: Clue cells.  Which is one of those things that is easy to say, but hard to describe.  Here’s a picture of normal squamous epithelial cells, followed by clue cells.

Cell borders are smooth, cytoplasm is clear, except for the nucleus.

Clue Cells

Cells look “dirty”- cytoplasm is not so clear and the borders are irregular. In reality, the cytoplasm is the same, but bacteria are all around the outside of the cell. 

Candidiasis (20-25%)

  • HX: Thick, white, clumpy, “cottage cheese” discharge, but may be thin and watery. Pruritus, irritation, vaginal soreness
  • PE: White adherent discharge. Really don’t need the wet prep to diagnose this. candidiasis
  • Wet Prep: This is where the KOH prep is helpful.  KOH breaks down the normal squamous cell walls, so hyphae are left.hyphae

Trichomonas (15-20%)

  • HX:  Kind of a mix between the above two. Lots of discharge, foul-smelling, thin (like BV), but pain, pruritus, dysuria (like Candida).
  • PE: Strawberry cervix is the board question, but it is rare. More often you see the discharge (it’s thin and yellowish), and the cervical mucosa is red, friable.
  • Wet Prep:  Trichomonads.  Best way to see these is to look at the edges of the sample, and just leave the slide in one place for a while.  Trich cells are more round/oval and smaller than the irregular shaped squamous cells.  If you are patient, you can often see something moving – might just be the flagella moving, or you might notice the whole cell slowly moving against the flow of the rest of the liquid on the slide.

trichomonads

Cervicitis (GC, Chlamydia)

  • HX: discharge is similar to Trichomonas, thin and watery but with associated symptoms of pain/pruritus/dysuria.  If systemic sx: nausea, fever, abdominal pain- think PID.
  • PE: friable, irritated cervix.  Cervical motion tenderness  or uterine tenderness on bimanual exam.
  • Wet Prep: Normal looking squamous cells, may see lots of white cells (smaller, less clear cytoplasm) in the background.

If you are more of a table person, here’s most of the info above in handy chart form.

Disease History Wet Prep Pearls
Bacterial Vaginosis Profuse Discharge, not painful/pruritic Clue Cells Women live with this for months before presenting.  Worse after menses, intercourse
Candidiasis Thick, white adherent discharge Normal cells, but use KOH to identify Hyphae If you see this, can skip the wet prep
Trichomonas Combo of above- thin watery discharge, also painful/pruritic Normal, but with white cells/trichomonads Foul smelling discharge (even without the KOH)
Cervicitis Similar to Trich, friable and painful cervix Lots of white cells May be GC, Chlamydia, Trich, HSV, others. (always  test for other STIs)

Did you know that we have a dropbox for pocket cards? This is so that you can keep them all in your pocket (on your phone). I’ll put the chart below there. If you want a link to the dropbox, send me an email or comment below and I’ll hook you up.  Another benefit to reading I Hate Rashes!

Guest Poster: Conjunctivitis

Thanks to Michael Harmon for developing this awesome review of conjunctivitis for AMR, AND agreeing to let me put it up for all to see. That is kind of the point of this blog- share some of the great ambulatory teaching that is going on throughout the residency program with everyone.
If you want to be a guest poster too, it’s easy. Just shoot me an email and we’ll make it happen.

Images from visual DX.

Conjunctivitis

By Michael Harmon

Bacterial

  • Bugs: Staph aureus is common in adults.  Strep pneumo, H. Influenza, and Moraxella catarrhalis are common in kids.  Think pseudomonas if a contact wearer
  • Hyperacute bacterial conjunctivitis is usually secondary to N. gonorrhoeae.  Often have concomitant urethritis.  Requires hospitalization
  •  Presentation: Usually unilateral conjunctival injection with thick discharge that reappears within minutes.  Eye matting is a non specific finding also seen in viral/allergic
  • Treatment:  Usually self limited but treatment can decrease course.
    •  1st line erythromycin ointment or polymyxin/trimethoprim gtts for 5-7 days
    • 2nd line fluoroquinolones (contacts) or azithromycin
  • Course: Should see improvement in 1-2 days  Send to optho if no improvement

Viral

conjunctivitis, viral

  • Bugs: adenovirus
  • Presentation: conjunctivitis +/- viral prodrome (fever, URI symptoms).
    • Conjunctivitis is often bilateral.  Discharge is watery although may see some mucous on close exam.   Often complain of burning/gritty sensation in eyes.
    • Rapid (10 minute) test now available for adenovirus
  • Treatment:  Self limited.  Treatment can help symptoms,  but won’t affect duration of symptoms.  Treat with OTC topical antihistamines/ decongestants
  • Course: similar to that of common cold:  Symptoms may worsen in first few days and take several weeks to recover.

Allergic

allergy-eyes1

  • Presentation: Patients usually have history of seasonal /topical allergy or atopy
    • Exam similar to viral, although main complaint is usually itching
  • Treatment:  May alleviate symptoms, doesn’t affect duration.  Treat with artificial tears and topical antihistamines.

Non-infectious, non-allergic

  • Transient mechanical or chemical exposure
  • Treatment:  Lubricant ointment/gtts
  • Course: Usually resolves spontaneously within 24 hours

Red flags (when to refer)

  • Decreased visual acuity
  • Photophobia
  • severe pain, severe HA/nausea
  • severe sensation of foreign object that precludes opening eye
  • corneal opacity
  •  fixed pupil

Don’t give topical steroids because could cause corneal scarring, melting, perforation.  

Not due to topical steroids, but the best “corneal melting” picture I could find. This is due to advanced RA>