This editorial illustration was created for a July 2014 cover of American Family Physician. The image summarizes Constipation in Children.
Childhood constipation is common and almost always functional without an organic etiology. Stool retention can lead to fecal incontinence in some patients. Often, a medical history and physical examination are sufficient to diagnose functional constipation. Further evaluation for Hirschsprung disease, a spinal cord abnormality, or a metabolic disorder may be warranted in a child with red flags, such as onset before one month of age, delayed passage of meconium after birth, failure to thrive, explosive stools, and severe abdominal distension. Successful therapy requires prevention and treatment of fecal impaction, with oral laxatives or rectal therapies. Polyethylene glycol–based solutions have become the mainstay of therapy, although other options, such as other osmotic or stimulant laxatives, are available. An increase in dietary fiber may improve the likelihood that laxatives can be discontinued in the future. Education is equally important as medical therapy and should include counseling families to recognize withholding behaviors; to use behavior interventions, such as regular toileting and reward systems; and to expect a chronic course with prolonged therapy, frequent relapses, and a need for close follow-up. Referral to a subspecialist is recommended only when there is concern for organic disease or when the constipation persists despite adequate therapy. (Am Fam Physician. 2014;00(0):000-000. Copyright © 2014 American Academy of Family Physicians.)
SAMUEL NURKO, MD, and LORI A. ZIMMERMAN, MD, Boston Children’s Hospital, Boston, Massachusetts, Evaluation and Treatment of Constipation in Children and Adolescents, Am Fam Physician.
This editorial illustration was created for a May 2014 cover of American Family Physician. The image summarizes Unintentional Weight Loss in Elderly.
Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. The leading causes of involuntary weight loss are depression (especially in residents of long-term care facilities), cancer (lung and gastrointestinal malignancies), cardiac disorders and benign gastrointestinal diseases. Medications that may cause nausea and vomiting, dysphagia, dysgeusia and anorexia have been implicated. Polypharmacy can cause unintended weight loss, as can psychotropic medication reduction (i.e., by unmasking problems such as anxiety). A specific cause is not identified in approximately one quarter of elderly patients with unintentional weight loss. A reasonable work-up includes tests dictated by the history and physical examination, a fecal occult blood test, a complete blood count, a chemistry panel, an ultrasensitive thyroid-stimulating hormone test and a urinalysis. Upper gastrointestinal studies have a reasonably high yield in selected patients. Management is directed at treating underlying causes and providing nutritional support. Consideration should be given to the patient’s environment and interest in and ability to eat food, the amelioration of symptoms and the provision of adequate nutrition. The U.S. Food and Drug Administration has labeled no appetite stimulants for the treatment of weight loss in the elderly.
Unintentional weight loss in the elderly patient can be difficult to evaluate. Accurate evaluation is essential, however, because this problem is associated with increased morbidity and mortality. When a patient has multiple medical problems and is taking several medications, the differential diagnosis of unintentional weight loss can be extensive. If the patient also has cognitive impairment, the evaluation is further complicated. To successfully address this problem, the family physician needs to understand the normal physiologic changes in body composition that occur with aging, as well as the consequences of weight loss in the elderly patient.
GRACE BROOKE HUFFMAN, M.D., Brooke Grove Foundation, Sandy Spring, Maryland Am Fam Physician. 2002 Feb 15;65(4):640-651.
Diagnosis and Initial Management of Dysmenorrhea
AMIMI S. OSAYANDE, MD, and SUARNA MEHULIC, MD, University of Texas Southwestern Medical Center, Dallas, Texas Am Fam Physician. 2014 Mar 1;89(5):341-346.
Dysmenorrhea is one of the most common causes of pelvic pain. It negatively affects patients’ quality of life and sometimes results in activity restriction. A history and physical examination, including a pelvic examination in patients who have had vaginal intercourse, may reveal the cause. Primary dysmenorrhea is menstrual pain in the absence of pelvic pathology. Abnormal uterine bleeding, dyspareunia, noncyclic pain, changes in intensity and duration of pain, and abnormal pelvic examination findings suggest underlying pathology (secondary dysmenorrhea) and require further investigation. Transvaginal ultrasonography should be performed if secondary dysmenorrhea is suspected. Endometriosis is the most common cause of secondary dysmenorrhea. Symptoms and signs of adenomyosis include dysmenorrhea, menorrhagia, and a uniformly enlarged uterus. Management options for primary dysmenorrhea include nonsteroidal anti-inflammatory drugs and hormonal contraceptives. Hormonal contraceptives are the first-line treatment for dysmenorrhea caused by endometriosis. Topical heat, exercise, and nutritional supplementation may be beneficial in patients who have dysmenorrhea; however, there is not enough evidence to support the use of yoga, acupuncture, or massage.
Written by Gerald W. Hart, Lauren E. Ball & Rajendrani Mukhopadhyay
A special issue of the journal Molecular & Cellular Proteomics in December focused on post-translational modifications. To convey the complexity of the molecular biology and biochemistry involved in these modifications, Jennifer Fairman was recruited to help with the illustrations and schematics as well as to design the cover art of the special issue.
This special issue of Molecular and Cellular Proteomics grew out of the bi-annual Special Symposium “Post Translational Modifications: Detection and Physiological Roles” held at Lake Tahoe in October of 2012, which was supported by the American Society for Biochemistry and Molecular Biology (ASBMB) and Molecular and Cellular Proteomics. Papers in this issue illustrate ongoing work in the field of PTMs that builds upon the advances in proteomics made during the past decades.
To visually capture the complex intricacies of the molecular biology involved in post-translational modifications, certified medical illustrator Jennifer Fairman designed several of the figures as well as its cover art. Fairman is the Founder and Principal of Fairman Studios and is an Assistant Professor in the Department of Art as Applied to Medicine (AAM, medart) at the Johns Hopkins University School of Medicine where she previously received her Master of Arts in Medical and Biological Illustration.
Creating cover art and illustrations for MCP
The way Fairman worked on the art for the MCP special issue on post-translation modifications was typical for any project she does. She met with Gerald Hart of Johns Hopkins University, the MCP associate editor overseeing the issue, and ASBMB’s publications director, Nancy Rodnan, whose idea it was to hire a professional medical illustrator. Hart explained the science in the various articles. With input from Mary Chang, MCP’s managing editor, the group focused on the images that were either schematics or illustrations. They left alone the images that were captured by a camera or a computer.
“One of the things that I strived to do for this journal was to come up with a consistent style,” explains Fairman. For elements that came up repeatedly, such as ubiquitination, acetylation, proteins and organelles, Fairman established a style so that all of the figures throughout the special issue had the same look and feel. Fairman also says she stuck to scientific conventions as much as possible in terms of colors and symbols. “For example, thinking back to my time in organic chemistry in undergrad, in the little molecular model set, oxygen is usually red, carbon is black, and hydrogen is white,” she says. “Whenever we create any visual, we have to keep in mind who the audience is. Because MCP has a scientific audience, I’ve tried to come up with conventions that people are used to seeing.”
Fairman says it can be a challenge to figure out what should be kept in and left out of an illustration. She had a difficult case with one of the figures from the MCP special issue. “The illustration shows a really complicated mechanism, where these different proteins on the cell membrane, endoplasmic reticulum, nucleus, all the different organelles, are interacting with each other,” she says. “Instead of showing every single protein in its correct configuration, the best thing to do to drive home the message is to use color coding. Not worry so much about what those proteins actually look like but focus more on what they do.”
With the cover, Fairman took another tack, because the cover has a different role than figures in the scientific articles. The inspiration for the cover art came from figure 1 in the article by Corina Antal and Alexandra C. Newton at the University of California, San Diego, on the dynamics of lipid second messenger phosphorylation. “The cover isn’t necessarily meant to show the whole mechanism in a way that the readers will completely understand it,” says Fairman. “It is supposed to engage them and bring them into the journal, wanting to read that featured article.”
This editorial illustration was created for a September 2013 cover of American Family Physician. The image summarizes Otitis Media, infection of the middle ear. Although several subtypes of otitis media are distinguished, the term is often used synonymously with acute otitis media. It is very common in childhood. An integral symptom of acute otitis media is ear pain; other possible symptoms include fever, and irritability (in infants). Since an acute otitis media is usually precipitated by an upper respiratory tract infection, there often are accompanying symptoms like cough and nasal discharge.
The common cause of all forms of otitis media is blockage of the Eustachian tube. This is usually due to swelling of the mucous membranes in the nasopharynx, which in turn can be caused by a viral upper respiratory infection or by allergies. Because of the blockage of the Eustachian tube, the air volume in the middle ear is trapped and parts of it are slowly absorbed by the surrounding tissues, leading to a mild vacuum in the middle ear. Eventually the vacuum can reach a point where fluid from the surrounding tissues is sucked in to the middle ear’s cavity (also called tympanic cavity), causing middle ear effusion. This is seen as a progression from a Type A tympanogram to a Type C to a Type B tympanogram.
By reflux or suction of material from the nasopharynx into the normally sterile middle ear space, the fluid may then become infected – usually with bacteria. In rare cases, however, the virus that caused the initial upper respiratory tract infection can itself be identified as the pathogen causing the infection in the middle ear.
Acute otitis media (AOM) is usually developing on the basis of a (viral) upper respiratory infection with blockage of the Eustachian tube and effusion in the middle ear, when the fluid in the middle ear gets additionally infected with bacteria. The most common bacteria found in this case are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
As its typical symptoms overlap with other conditions, clinical history alone is not sufficient to predict whether acute otitis media is present; it has to be complemented by visualization of the tympanic membrane.
To confirm the diagnosis, middle ear effusion and inflammation of the eardrum have to be identified; signs of these are fullness, bulging, cloudiness and redness of the eardrum. Viral otitis may also result in blisters on the external side of the tympanic membrane, which is called bullous myringitis (myringa being Latin for “eardrum”). However, sometimes even examination of the eardrum may not be able to confirm the diagnosis, especially if the canal is small and there is wax in the ear that obscures a clear view of the eardrum. Also, an upset child’s crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media.