Items in AFP with MESH term: Risk Assessment
ABSTRACT: Adverse drug events are common in older patients, particularly in those taking at least five medications, but such events are predictable and often preventable. A rational approach to prescribing in older adults integrates physiologic changes of aging with knowledge of pharmacology. Focusing on specific outcomes, such as the prompt recognition of adverse drug events, allows the family physician to approach prescribing cautiously and confidently. Physicians need to find ways to streamline the medical regimen, such as periodically reviewing all medications in relation to the Beers criteria and avoiding new prescriptions to counteract adverse drug reactions. The incorporation of computerized alerts and a multidisciplinary approach can reduce adverse drug events.
ABSTRACT: Obesity continues to be a growing public health problem. According to the 2003-2004 National Health and Nutrition Examination Survey, 17 percent of persons two to 19 years of age are overweight. The number of obese children and adolescents has tripled in the past 20 years. Obesity in adults is associated with cardiovascular risk factors including hypertension, dyslipidemia, and diabetes. The growing prevalence of overweight in children and adolescents is paralleled by the growth of its associated complications in that population: hypertension, diabetes, hyperlipidemia, and metabolic syndrome. A modification of the metabolic syndrome criteria designed for children and adolescents shows that as many as 50 percent of those who are severely overweight have the syndrome. The U.S. Preventive Services Task Force has not found sufficient evidence to support screening children for obesity or other cardiovascular risk factors. The American Academy of Pediatrics and the American Heart Association have adopted a more aggressive stance, based largely on consensus opinion. Current suggestions include focusing on children whose body mass indexes exceed the 85th percentile; who are rapidly gaining weight; who have a family history of type 2 diabetes or hypercholesterolemia; or who have hypertension or signs of insulin resistance. Physician advocacy for healthy communities and institutions that foster physical activity, good eating habits, and healthy lifestyles is also encouraged.
ABSTRACT: Although it is often unrecognized, family physicians provide a significant amount of mental health care in the United States. Time is one of the major obstacles to providing counseling in primary care. Counseling approaches developed specifically for ambulatory patients and traditional psychotherapies modified for primary care are efficient first-line treatments. For some clinical conditions, providing individualized feedback alone leads to improvement. The five A's (ask, advise, assess, assist, arrange) and FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) techniques are stepwise protocols that are effective for smoking cessation and reducing excessive alcohol consumption. These models can be adapted to address other problems, such as treatment nonadherence. Although both approaches are helpful to patients who are ready to change, they are less likely to be successful in patients who are ambivalent or who have broader psychosocial problems. For patients who are less committed to changing health risk behavior or increasing healthy behavior, the stages-of-change approach and motivational interviewing address barriers. Patients with psychiatric conditions and acute psychosocial stressors will likely respond to problem-solving therapy or the BATHE (background, affect, troubles, handling, empathy) technique. Although brief primary care counseling has been effective, patients who do not fully respond to the initial intervention should receive multimodal therapy or be referred to a mental health professional.
Risks and Benefits of Pacifiers - Article
ABSTRACT: Physicians are often asked for guidance about pacifier use in children, especially regarding the benefits and risks, and when to appropriately wean a child. The benefits of pacifier use include analgesic effects, shorter hospital stays for preterm infants, and a reduction in the risk of sudden infant death syndrome. Pacifiers have been studied and recommended for pain relief in newborns and infants undergoing common, minor procedures in the emergency department (e.g., heel sticks, immunizations, venipuncture). The American Academy of Pediatrics recommends that parents consider offering pacifiers to infants one month and older at the onset of sleep to reduce the risk of sudden infant death syndrome. Potential complications of pacifier use, particularly with prolonged use, include a negative effect on breastfeeding, dental malocclusion, and otitis media. Adverse dental effects can be evident after two years of age, but mainly after four years. The American Academy of Family Physicians recommends that mothers be educated about pacifier use in the immediate postpartum period to avoid difficulties with breastfeeding. The American Academy of Pediatrics and the American Academy of Family Physicians recommend weaning children from pacifiers in the second six months of life to prevent otitis media. Pacifier use should not be actively discouraged and may be especially beneficial in the first six months of life.
Weighing the Risks and Benefits of Clinical Interventions - Improving Patient Care
Diagnosing Pulmonary Embolism - Improving Patient Care
Estimating the Risks of Coronary Angioplasty - Improving Patient Care
ABSTRACT: Recreational scuba diving has become a popular sport in the United States, with almost 9 million certified divers. When severe diving injury occurs, the nervous system is frequently involved. In dive-related barotrauma, compressed or expanding gas within the ears, sinuses and lungs causes various forms of neurologic injury. Otic barotrauma often induces pain, vertigo and hearing loss. In pulmonary barotrauma of ascent, lung damage can precipitate arterial gas embolism, causing blockage of cerebral blood vessels and alterations of consciousness, seizures and focal neurologic deficits. In patients with decompression sickness, the vestibular system, spinal cord and brain are affected by the formation of nitrogen bubbles. Common signs and symptoms include vertigo, thoracic myelopathy with leg weakness, confusion, headache and hemiparesis. Other diving-related neurologic complications include headache and oxygen toxicity.
ABSTRACT: Each year, more than 1 million patients are admitted to U.S. hospitals because of unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI). To help standardize the assessment and treatment of these patients, the American College of Cardiology and the American Heart Association convened a task force to formulate a management guideline. This guideline, which was published in 2000 and updated in 2002, highlights recent medical advances and is a practical tool to help physicians provide medical care for patients with UA/NSTEMI. Management of suspected UA/NSTEMI has four components: initial evaluation and management; hospital care; coronary revascularization; and hospital discharge and post-hospital care. Part I of this two-part article discusses the first two components of management. During the initial evaluation, the history, physical examination, electrocardiogram, and cardiac biomarkers are used to determine the likelihood that the patient has UA/NSTEMI and to aid in risk assessment when the diagnosis is established. Hospital care consists of appropriate initial triage and monitoring. Medical treatment includes anti-ischemic therapy (oxygen, nitroglycerin, beta blocker), antiplatelet therapy (aspirin, clopidogrel, platelet glycoprotein IIb/IIIa inhibitor), and antithrombotic therapy (heparin, low-molecular-weight heparin).