ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Effective pain management in the terminally ill patient requires an understanding of pain control strategies. Ongoing assessment of pain is crucial and can be accomplished using various forms and scales. It is also important to determine if the pain is nociceptive (somatic or visceral pain) or neuropathic (continuous dysesthesias or chronic lancinating or paroxysmal pain). Nociceptive pain can usually be controlled with nonsteroidal antiinflammatory drugs or corticosteroids, whereas neuropathic pain responds to tricyclic antidepressants or anticonvulsants. Relief of breakthrough pain requires the administration of an immediate-release analgesic medication. If a significant amount of medication for breakthrough pain is already being given, the baseline dose of sustained-release analgesic medication should be increased. If pain does not respond to one analgesic medication, physicians should use an equianalgesic dose chart when changing the medication or route of administration. Opioid rotation can be used if pain can no longer be controlled on a specific regimen. The impact of unresolved psychosocial or spiritual issues on pain management may need to be addressed.
ABSTRACT: Ten percent of the population abuses drugs or alcohol, and 20 percent of patients seen by family physicians have substance-abuse problems, excluding tobacco use. These patients can be identified by relying on regular screening or a high index of suspicion based on "red flags" that can be noted in various clinical situations. The modified CAGE questionnaire is an excellent screening instrument, but several alternatives are available. The best screening test is one that the physician will routinely use well. Laboratory indicators such as gamma-glutamyl transpeptidase, mean corpuscular volume, and carbohydrate-deficient transferrin are nonspecific but can add to the evidence of alcohol abuse. If problem alcohol use is diagnosed, even brief physician advice can be helpful. If the problem has progressed to addiction, referral to an addiction specialist or treatment center is recommended. Special issues arise in dealing with substance abuse in adolescents, elderly patients, and patients with mental illness, but the family physician can play an important role in recognizing this common problem.
ABSTRACT: Family physicians must decide how to screen for depression or dementia and which patients to screen. Mental health questionnaires can be helpful. In practice-based screening, questionnaires are administered to all patients, regardless of risk status. In case-finding screening, questionnaires are administered only when depression or dementia is suspected. The 2002 U.S. Preventive Services Task Force report recommends screening adults for depression to improve detection and patient outcomes but does not suggest the use of any particular screening instrument. Serial or sequential testing with the Patient Health Questionnaire-2 and the Patient Health Questionnaire-9 is a good strategy for detecting major depressive episodes in primary care settings. The Patient Health Questionnaire-2 consists of two questions that assess the presence of anhedonia and dysphoria. If a patient answers "yes" to either question, the more specific Patient Health Questionnaire-9 is administered to assess the severity of depressive symptoms and to ascertain the presence of major depressive episode. The Patient Health Questionnaire-9 also can be used to monitor symptom severity and treatment response. The 2003 U.S. Preventive Services Task Force report does not recommend for or against routine screening for dementia in older adults. However, the report does assert that cognitive function should be assessed when impairment is suspected. The Folstein Mini-Mental State Examination and the Functional Activities Questionnaire are suggested tools. The Clock Drawing Test also has been shown to be useful in primary care settings.
ABSTRACT: Physicians face several barriers to counseling their patients about nutrition, including conflicting evidence of the benefit of counseling, limited training and understanding of the topic, and imperfect and varied guidelines to follow. Because cardiovascular disease remains the leading cause of death in industrialized nations, family physicians should provide more than pharmacologic interventions. They must identify the patient's dietary habits and attitudes and provide appropriate counseling. Tools are available to help, and a seven-step approach to nutritional therapy for the dyslipidemic patient may be useful. These steps include recommending increased intake of plant proteins; increased intake of omega-3 fatty acids; modification of the types of oils used in food preparation; decreased intake of saturated and trans-fatty acids; increased intake of whole grains and dietary fiber (especially soluble fiber) and decreased intake of refined grains; modification of alcohol intake, if needed; and regular exercise. Recommendations should be accompanied by patient information handouts presenting acceptable substitutions for currently identified detrimental food choices.
ABSTRACT: Substance abuse in adolescents is undertreated in the United States. Family physicians are well positioned to recognize substance use in their patients and to take steps to address the issue before use escalates. Comorbid mental disorders among adolescents with substance abuse include depression, anxiety, conduct disorder, and attention-deficit/ hyperactivity disorder. Office-, home-, and school-based drug testing is not routinely recommended. Screening tools for adolescent substance abuse include the CRAFFT questionnaire. Family therapy is crucial in the management of adolescent substance use disorders. Although family physicians may be able to treat adolescents with substance use disorders in the office setting, it is often necessary and prudent to refer patients to one or more appropriate consultants who specialize specifically in substance use disorders, psychology, or psychiatry. Treatment options include anticipatory guidance, brief therapeutic counseling, school-based drug-counseling programs, outpatient substance abuse clinics, day treatment programs, and inpatient and residential programs. Working within community and family contexts, family physicians can activate and oversee the system of professionals and treatment components necessary for optimal management of substance misuse in adolescents.
ABSTRACT: Early identification of alcohol-related problems is important because these problems are prevalent, pose serious health risks to patients and their families, and are amenable to intervention. Physicians may be able to help patients change their drinking behaviors. The most effective tool for screening is a thorough history of the patient's drinking behavior, designed to identify patterns of alcohol-related difficulties with physical and mental health, family life, legal authorities and employment. Alcohol drinkers can be categorized as at-risk, problem or alcohol dependent, according to a protocol developed by the National Institute on Alcohol Abuse and Alcoholism. The severity of the alcohol problem and the patient's readiness to change should determine the intervention selected by the family physician.
ABSTRACT: Outpatient detoxification of patients with alcohol or other drug addiction is being increasingly undertaken. This type of management is appropriate for patients in stage I or stage II of withdrawal who have no significant comorbid conditions and have a support person willing to monitor their progress. Adequate dosages of appropriate substitute medications are important for successful detoxification. In addition, comorbid psychiatric, personality and medical disorders must be managed, and social and environmental concerns need to be addressed. By providing supportive, nonjudgmental, yet assertive care, the family physician can facilitate the best possible chance for a patient's successful recovery.
Alcoholism in the Elderly - Article
ABSTRACT: Alcohol abuse and alcoholism are common but underrecognized problems among older adults. One third of older alcoholic persons develop a problem with alcohol in later life, while the other two thirds grow older with the medical and psychosocial sequelae of early-onset alcoholism. The common definitions of alcohol abuse and dependence may not apply as readily to older persons who have retired or have few social contacts. Screening instruments can be used by family physicians to identify older patients who have problems related to alcohol. The effects of alcohol may be increased in elderly patients because of pharmacologic changes associated with aging. Interactions between alcohol and drugs, prescription and over-the-counter, may also be more serious in elderly persons. Physiologic changes related to aging can alter the presentation of medical complications of alcoholism. Management of alcohol withdrawal in elderly persons should be closely supervised by a health care professional. Alcohol treatment programs with an elder-specific focus may improve outcomes in some patients.
Case Studies in Partner Violence - Article
ABSTRACT: Interpersonal violence and abuse, especially between relatives and domestic partners, are leading causes of morbidity and mortality. Family physicians and other professionals who provide primary care health services must deal with acute presentations and chronic sequelae of this epidemic. Many victims of abuse hesitate to seek help, while those who batter are often difficult to identify. Medical management of patients in abusive relationships can be frustrating. Evaluating injury patterns, understanding factors that increase the risk for violence and making use of specific interview questions and techniques will aid family physicians in the difficult task of assessing and managing patients living in abusive partnerships.
ABSTRACT: The number of persons 65 years of age and older continues to increase dramatically in the United States. Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients include sensory perception and injury prevention. Geriatric patients are at higher risk of falling for a number of reasons, including postural hypotension, balance or gait impairment, polypharmacy (more than three prescription medications) and use of sedative-hypnotic medications. Interventional areas that are common to other age groups but have special implications for older patients include immunizations, diet and exercise, and sexuality. Cognitive ability and mental health issues should also be evaluated within the context of the individual patient's social situation-not by screening all patients but by being alert to the occurrence of any change in mental function. Using an organized approach to the varied aspects of geriatric health, primary care physicians can improve the care that they provide for their older patients.