ITEMS IN AFP WITH MESH TERM:
Practical Considerations for Determining Patient Capacity and Consent - Curbside Consultation
Facial Hyperpigmentation - Photo Quiz
ABSTRACT: More than 72 million Americans have hypertension, and the majority of these persons have essential hypertension. However, a significant subset has a secondary cause. The most common cause of secondary hypertension is renal vascular hypertension, of which renal artery stenosis is the leading pathology. Up to 5 percent of all occurrences of hypertension are caused by renal artery stenosis, equating to as many as 3.5 to 4 million occurrences in the United States. Detecting renal artery stenosis is particularly important for ensuring that this potentially curable form of hypertension is identified and treated properly. Duplex Doppler ultrasonography is a good screening test in many patients, but it has limitations in larger persons and can overlook small accessory arteries. For patients with normal renal function but a high clinical index of suspicion for renovascular disease, contrast-enhanced magnetic resonance angiography and computed tomographic angiography are the most accurate imaging tests. For patients with diminished renal function, gadolinium-enhanced contrast magnetic resonance angiography is the best imaging test. However, caution is warranted because exposure to gadolinium contrast agents is associated with nephrogenic systemic fibrosis in patients with renal failure. The American College of Radiology has developed appropriateness criteria for imaging tests related to the diagnosis of renal artery stenosis. This article is a summary of the recommendations, with the advantages and limitations of each test.
ABSTRACT: The Expert Panel Report 3 of the National Asthma Education and Prevention Program represents a major advance in the approach to asthma care by emphasizing the monitoring of clinically relevant aspects of care and the importance of planned primary care, and by providing patients practical tools for self-management. Treatment of asthma should be guided by a new system of classification that assesses severity at initial evaluation and control at all subsequent visits. Asthma severity is determined by current impairment (as evidenced by impact on day-to-day activities) and risk of future exacerbations (as evidenced by frequency of oral systemic corticosteroid use), and allows categorization of disease as intermittent, persistent-mild, persistent-moderate, and persistent-severe. Initial treatment is guided by the disease-severity category. The degree of control is also determined by the analysis of current impairment and future risk. Validated questionnaires can be used for following the impairment domain of control with patients whose asthma is categorized as "well controlled," "not well controlled," and "very poorly controlled." Decisions about medication adjustment and planned follow-up are based on the category of disease control. Whereas a stepwise approach for asthma management continues to be recommended, the number of possible steps has increased.
Vision Loss in Older Persons - Article
ABSTRACT: Family physicians have an essential role in assessing, identifying, treating, and preventing or delaying vision loss in the aging population. Approximately one in 28 U.S. adults older than 40 years is visually impaired. Vision loss is associated with depression, social isolation, falls, and medication errors, and it can cause disturbing hallucinations. Adults older than 65 years should be screened for vision problems every one to two years, with attention to specific disorders, such as diabetic retinopathy, refractive error, cataracts, glaucoma, and age-related macular degeneration. Vision-related adverse effects of commonly used medications, such as amiodarone or phosphodiesterase inhibitors, should be considered when evaluating vision problems. Prompt recognition and management of sudden vision loss can be vision saving, as can treatment of diabetic retinopathy, refractive error, cataracts, glaucoma, and age-related macular degeneration. Aggressive medical management of diabetes, hypertension, and hyperlipidemia; encouraging smoking cessation; reducing ultraviolet light exposure; and appropriate response to medication adverse effects can preserve and protect vision in many older persons. Antioxidant and mineral supplements do not prevent age-related macular degeneration, but may play a role in slowing progression in those with advanced disease.
Diagnosing Lumbar Spinal Stenosis - Point-of-Care Guides
NSAID Prescribing Precautions - Article
ABSTRACT: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used, but have risks associated with their use, including significant upper gastrointestinal tract bleeding. Older persons, persons taking anticoagulants, and persons with a history of upper gastrointestinal tract bleeding associated with NSAIDs are at especially high risk. Although aspirin is cardioprotective, other NSAIDs can worsen congestive heart failure, can increase blood pressure, and are related to adverse cardiovascular events, such as myocardial infarction and ischemia. Cyclooxygenase-2 inhibitors have been associated with increased risk of myocardial infarction; however, the only cyclooxygenase-2 inhibitor still available in the United States, celecoxib, seems to be safer in this regard. Hepatic damage from NSAIDs is rare, but these medications should not be used in persons with cirrhotic liver diseases because bleeding problems and renal failure are more likely. Care should be used when prescribing NSAIDs in persons taking anticoagulants and in those with platelet dysfunction, as well as immediately before surgery. Potential central nervous system effects include aseptic meningitis, psychosis, and tinnitus. Asthma may be induced or exacerbated by NSAIDs. Although most NSAIDs are likely safe in pregnancy, they should be avoided in the last six to eight weeks of pregnancy to prevent prolonged gestation from inhibition of prostaglandin synthesis, premature closure of the ductus arteriosus, and maternal and fetal complications from antiplatelet activity. Ibuprofen, indomethacin, and naproxen are safe in breastfeeding women. Care should be taken to prevent accidental NSAID overdose in children by educating parents about correct dosing and storage in childproof containers.
Estimating the Risk of Ovarian Cancer - Point-of-Care Guides