http://www.aafp.org/afp/2012/1001/p653.html
The American Family Physician magazine recently had a concise summary of bedbug diagnosis and treatment. A few caveats that I thought were worth mentioning:
1 The article has a nice picture depicting the full range of sizes and appearances of bedbugs across the bug's lifespan (nymphs, etc). While none of us are entomologists, knowing the general appearance is helpful. If you cannot access the AFP article, check out the life cycle pictures on the below linked Wikipedia article.
http://en.wikipedia.org/wiki/Bed_bug
2. People worry about eradication of bedbugs that have latched onto travel items, like backpacks and luggage. Note in the ending table it suggests either 2 hrs of heat over 120F, or 5 days of freezing. While bedbugs are hardy in a normal room environment, they are very temperature sensitive. For travel item decontamination, one easy tip in the North Carolina summers is to leave luggage, travel items, etc. in your car trunk for one afternoon, as temperatures are well over 120F. Alternatively, placing items in the freezer should help also-but note the time difference of 5 days.
3. Perhaps I did not read enough or was misled when I read about bedbugs as they re-emerged in the early 2000s, but I was under the clinical impression that most of the bites were papule or wheal like. However, as the article mentions, the appearance of bedbug bites can run the "maculopapular" gamut. A typical red flag, per the article, is the "breakfast, lunch, dinner" linear pattern of bites, but clinically I have also seen that with scabies clumping along an elastic waistband, or chiggers hitting a sockline.
4. Lastly, in true "academic" non real world fashion the article cites that no treatment has been shown effective, so give reassurance and tell the patient to wait a week or two. Good luck with that strategy. People who are told of a bedbug diagnosis would rather drink cyanide than do nothing. If you are leery of topical or po steroids, I have heard many dermatologists recommend topical, over the counter Sarna lotion for 20-30 minutes of relief from the itch.
What varied appearances have you seen of suspected bedbugs? Papules? Scabbed macules?
Any favorite medicines for the itch?
Any tips to calm the hysteria?
Wednesday, October 24, 2012
Tuesday, October 2, 2012
Your "Gut"- You know When to Hold 'Em, and When to Fold 'Em
http://www.bmj.com/content/345/bmj.e6144
Above is a free article that summarizes what many practicing clinicians have long (literally) felt: sometimes you just have to "go" with your intuition. The article essentially validates that these "gut" impressions, especially for pediatrics, are accurate.
A few quick points:
- Yes, the article is from Europe where the malpractice climate may be different, but it still has a solid number of patients.
- Newer/less experienced providers still "have" a gut feeling, it is just that the "newbies" often lack the ability to clinically correlate it into a diagnosis. This finding is important. Heed your "gut" regardless of your experience level, and take correct action/referral.
-While I am staunchly against "fever phobia" the article revalidates the finding that for every degree over 102 F, your chance of an occult "deep" infection (pneumonia, uti/pyelonephritis, sepsis) increases. Specifically, the article states that 1 out of every 20 children with a documented fever over 40C/104F end up with a documented "significant" bacterial issue.
-Once again, the article is a firm reminder of the importance in children to document their immunization status. The decrease-thanks to immunization- in invasive forms of Streptococcus pneumoniae has been impressive over the years. As such, as previous blog articles have outlined, the days of "rocephinizing febrile kids for 2-3 days until the labs are normal" are fading. Converesely, unvaccinated kids, from an urgent care perspective, with high fever may be more needing of ER evaluation.
-Lastly, note that the "gut" impression is majorly composed of a global, "stepping back" and looking at the patient and observing! Sometimes it is best to just unclothe the child, step back 3 or 4 feet, and watch for the "eternity" of 30 seconds to a minute. This tactic displays thoroughness to parents and often yields important clincal information.
GO WITH YOUR GUT- IT USUALLY IS RIGHT!
Above is a free article that summarizes what many practicing clinicians have long (literally) felt: sometimes you just have to "go" with your intuition. The article essentially validates that these "gut" impressions, especially for pediatrics, are accurate.
A few quick points:
- Yes, the article is from Europe where the malpractice climate may be different, but it still has a solid number of patients.
- Newer/less experienced providers still "have" a gut feeling, it is just that the "newbies" often lack the ability to clinically correlate it into a diagnosis. This finding is important. Heed your "gut" regardless of your experience level, and take correct action/referral.
-While I am staunchly against "fever phobia" the article revalidates the finding that for every degree over 102 F, your chance of an occult "deep" infection (pneumonia, uti/pyelonephritis, sepsis) increases. Specifically, the article states that 1 out of every 20 children with a documented fever over 40C/104F end up with a documented "significant" bacterial issue.
-Once again, the article is a firm reminder of the importance in children to document their immunization status. The decrease-thanks to immunization- in invasive forms of Streptococcus pneumoniae has been impressive over the years. As such, as previous blog articles have outlined, the days of "rocephinizing febrile kids for 2-3 days until the labs are normal" are fading. Converesely, unvaccinated kids, from an urgent care perspective, with high fever may be more needing of ER evaluation.
-Lastly, note that the "gut" impression is majorly composed of a global, "stepping back" and looking at the patient and observing! Sometimes it is best to just unclothe the child, step back 3 or 4 feet, and watch for the "eternity" of 30 seconds to a minute. This tactic displays thoroughness to parents and often yields important clincal information.
GO WITH YOUR GUT- IT USUALLY IS RIGHT!
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