Stone Cold Facts on Renal Stones

Over at www.familypracticenews.com, a fairly decent family medicine periodical, in the April 1, 2015 edition resides a nice summary of current recommendations for renal colic prevention. We all, especially in the more dehydration prone summers, see many painful renal colic patients. I admit I often get confused as to what to suggest, as like diet therapy to prevent diverticulitis, the evidence for/against various suggestions seems to sway form year to year. One year peanuts are good, the next year and study later they are bad! Usually, once the toradol has taken hold and the writhing/pacing have lessened, the patient often asks what he/she can do to prevent a recurrence. I will summarize the tips below, most of which are based from the American College of Physicians, or ACP.

• Tactfully tell the patient that once you have ONE stone, the odds are high (30-50%) that within 5 years a recurrence will occur. For people with one recurrence already, the repeat odds are even higher.
• There is no current evidence to support the use of stone analysis in tailoring any type of prevention therapy.
• Major prevention pearl #1 is: All patients should be told to increase fluids to attain 2 liters of urine per day. A good comparison is the old maxim, "except for the first am void, all other voids should be crystal clear."
• Major prevention pearl #2 is: To decrease soft drink/cola consumption. In people with renal stones who stopped colas, the recurrence rate went from 40.6% down to 33.7%. DO NOTE the studies were mainly done with colas that were acidified by phosphoric acid, as opposed to many fruity colas that use citric acid.
• Major prevention pearl #3 is: Although unlikely to be initiated in urgent care as it is a long term medicine, in order of efficacy one can consider potassium citrate and other citrate supplements (most efficacious with 75% reductions), high dose thiazide diuretics, and lastly allopurinol coming in last with 35% reductions. Surprisingly combination therapy was not more effective than monotherapy for any of these.

And so, to fully seize the painful teaching moment of the first episode of renal colic, advise the patient to stop the soda, crank up the water, and see his/her primary for a preventive agent if they are willing to adhere to a daily regimen.  

Don't Let Your Mono Knowledge Fatigue!

Welcome back y'all. After a reprieve from Ebola and such, I recently saw in the 3/15/15 American Family Physician journal a superb summary with actionable points on one of our most common urgent care conditions- mononucleosis. If you are an AAFP member, you can get the article online, but for the ER people, mid-levels, and others, here are the salient points:

• The article cites a 2008 Clinical Journal of Sports Medicine EBM literature review stating that all athletic participation should be curtailed in mononucleosis for the FIRST 3 WEEKS OF ILLNESS. Yes, that is news to me also, but that is why you keep reading in life. Note that is the first 3 weeks of the actual illness, not when the patient presents to you on day 7. I know that this will make many ultra competitive high school athletes happy that the "old school" 4- 6 weeks regime of rest has been countered, in a rigorous, medico-legally safe sort of way.
• As I often harp about to other providers, the article cites that the rapid "monospot" heterophile antibody test has a 25% false negative rate in the first week of illness. This fact matches the physiology, since it takes several days to get the antibody counts cranked out from the immune system. As such, for the child presenting on day 3 with the parent insisting for a mono test, you may want to write in your discharge instructions to return in a few days if symptoms (usually fatigue) continue for a recheck. In this CSI world it breaks patients' hearts that the medical religion of lab testing has limits, but this is a case where some patient education is needed. 
• For that false negative monospot, early presenting case though, you may want to co-order a CBC, since you may luck up and get a lymphocyte count LESS than 4,000. The article states, a lymphocyte count of less than 4,000 has a negative predictive value of 99%. Not too shabby. 
• Steroids only help the sore throat within the first 12 hours of illness. Beyond that, there is absolutely no benefit to steroids or antivirals either. For the patient needing the "magic of a prescription", it may be the safer alternative to alleviate the sore throat with Magic Mouthwash, as opposed to steroids. 
• While splenic rupture only occurs in 0.1%-0.5% of mono patients, the most common cause of hospitalization for mono is actually airway obstruction, more commonly in children than teens. I am sure you all have seen in the clinic firsthand that usually the "nastiest mouths" are indeed exudates from mono.

Hope this helps, but certainly the points are pertinent to our real world practices.