FP essentials最新文献

Macrocytic anemia is divided into megaloblastic and nonmegaloblastic causes, with the former being more common. Megaloblastic anemia results from impaired DNA synthesis, leading to release of megaloblasts, which are large nucleated red blood cell precursors with chromatin that is not condensed. Vitamin B12 deficiency is the most common cause for megaloblastic anemia, although folate deficiency also can contribute. Nonmegaloblastic anemia entails normal DNA synthesis and typically is caused by chronic liver dysfunction, hypothyroidism, alcohol use disorder, or myelodysplastic disorders. Macrocytosis also can result from release of reticulocytes in the normal physiologic response to acute anemia. Management of macrocytic anemia is specific to the etiology identified through testing and patient evaluation.

Microcytic anemia is defined as anemia with a mean corpuscular volume (MCV) of less than 80 mcm3 in adults. Age-specific parameters should be used for patients younger than 17 years. The cause of microcytic anemia includes acquired and congenital causes, which should be considered separately according to the age of the patient, risk factors, and coexisting signs and symptoms. The most common cause of microcytic anemia is iron deficiency anemia; it can be managed with oral or intravenous iron, depending on the severity and comorbid conditions of the affected individual. Pregnant patients and patients with heart failure with iron deficiency anemia require special considerations to prevent significant morbidity and mortality. The wide spectrum of thalassemia blood disorders should be considered in patients with a particularly low MCV in the absence of systemic iron deficiency. Iron chelation may be required for some of these patients. Sickle cell anemia and sideroblastic anemia are important inherited causes of microcytic (as well as normocytic) anemia. Promising treatments are being developed for patients with transfusion-dependent thalassemia and sickle cell anemia.

Anemia is a common condition encountered in inpatient and outpatient primary care settings. When anemia is detected, it is essential to investigate the cause to provide appropriate treatment. Patients may present with symptomatic anemia (eg, fatigue, weakness, shortness of breath), or anemia may be an incidental finding on laboratory evaluation. Initial evaluation consists of a thorough history and physical examination and a complete blood cell count (CBC). Careful examination of the CBC and the mean corpuscular volume provides important clues to the classification and cause of anemia. Supplemental tests may include a peripheral blood smear; reticulocyte count; iron panel (ie, ferritin and iron levels, total iron-binding capacity, transferrin saturation); and levels of vitamin B12, folate, lactate dehydrogenase, haptoglobin, and bilirubin.

Normocytic anemia is anemia with a mean corpuscular volume of 80 to100 mcm3. Its causes include anemia of inflammation, hemolytic anemia, anemia of chronic kidney disease, acute blood loss anemia, and aplastic anemia. In most cases, correction of the anemia should focus on managing the underlying condition. Red blood cell transfusions should be limited to patients with severe symptomatic anemia. Hemolytic anemia can be diagnosed based on signs and symptoms of hemolysis, such as jaundice, hepatosplenomegaly, unconjugated hyperbilirubinemia, increased reticulocyte count, and decreased haptoglobin levels. Use of erythropoiesis-stimulating agents in patients with anemia due to chronic kidney disease should be individualized, but these agents should not be initiated in asymptomatic patients until the hemoglobin level is less than 10 g/dL. Cessation of bleeding is the focus of acute blood loss anemia, and management of the initial hypovolemia typically should be with crystalloid fluids. A mass transfusion protocol should be initiated if the blood loss is severe and ongoing with hemodynamic instability. Aplastic anemia management focuses on improving blood cell counts and limiting transfusions.

In 2022, it was estimated that 18.1 million US adults were cancer survivors. By 2032, this number is projected to increase to 22.5 million. All patients with cancer experience some degree of psychological distress associated with the diagnosis. This can include mental health conditions, most commonly anxiety and depression. Management of such conditions in cancer survivors begins with detection via screening. Commonly used screening tools include the National Comprehensive Cancer Network (NCCN) Distress Thermometer, the 7-item Generalized Anxiety Disorder (GAD-7) scale, and the Patient Health Questionnaire-9 (PHQ-9). Initial management involves patient education and psychotherapy. If needed, pharmacotherapy is similar to that for patients in the general population. Of note, several commonly prescribed antidepressants have been shown to decrease the effects of tamoxifen, which breast cancer survivors may be taking as adjuvant endocrine therapy. Integrative medicine therapies, such as music interventions, yoga, mindfulness meditation, and exercise, have shown benefit. Patients undergoing treatment should have outcomes assessed. Thoughts of self-harm or suicidal ideation are common among cancer survivors with mental health conditions. Clinicians should regularly ask patients about suicidal ideation. If present, this indicates the need for more intensive or altered treatment.

In the United States, prostate cancer is the most common nonskin cancer in men. Approximately 12.6% of US men will be diagnosed with this cancer in their lifetimes. Although the overall 5-year relative survival rate is high (96.8%), ethnic and racial disparities have been shown to affect survival. There also are genetic risks. If the family history of the patient includes familial cancers, the patient and family members should be referred for genetic counseling and testing for cancer-associated sequence variants. Prostate cancer treatments have significant long-term effects. After radical prostatectomy, 27% to 29% of patients experience urinary incontinence and 66% to 70% have erectile dysfunction. These effects also can occur after radiation therapy, though at lower rates. Mild urinary incontinence can be managed with incontinence pads. The most effective treatments are artificial urinary sphincter implantation and urethral sling procedure. Urinary incontinence after radiation therapy tends to decrease over time. Symptoms of urinary urgency or nocturia can be managed with anticholinergic drugs. Erectile dysfunction typically is managed with oral phosphodiesterase type 5 inhibitors and/or vacuum pump erectile devices. Androgen deprivation therapy increases cardiovascular risk by increasing insulin resistance and blood pressure. This therapy also is associated with osteoporosis, so patients with nonmetastatic cancer and one or more risk factors for fracture should be offered fracture risk assessment and bone mineral density testing.

Colorectal cancer (CRC) survival is influenced by numerous factors, including age, sex, race and ethnicity, familial cancer syndromes, stage and location of tumor, and comorbid conditions. The 5-year survival rate for patients with stage I CRC is 91%, but it is only 15% for patients with stage IV CRC. These survivors may experience multiple health issues. Gastrointestinal dysfunction is common, even years after treatment. This can include chronic diarrhea, occurring in approximately half of patients, and fecal incontinence, which is common after radiation therapy. Bladder dysfunction can occur due to surgical injury or radiation therapy. Many patients also experience sexual dysfunction. Standard therapies can be used to manage many of these symptoms and conditions. Patients with colostomy typically experience decreased quality of life. Referral to an ostomy therapist or wound, ostomy, and continence nurse may be beneficial. Pelvic radiation therapy can reduce bone mineral density (BMD) and increase fracture risk, so patients with rectal cancer who have received such therapy should undergo BMD monitoring. CRC survivors should undergo surveillance for recurrent CRC with interval colonoscopy, measurement of carcinoembryonic antigen levels, and computed tomography scan of the chest, abdomen, and/or pelvis. The intervals for and duration of surveillance depend on the cancer stage. Family physicians can help support CRC survivors through survivorship programs, shared care models, multidisciplinary interventions, and community partnerships.

A minority of cancer survivors meet guideline recommendations for nutrition and physical activity. There is a high prevalence of obesity in adult cancer survivors. It has been shown to increase cancer recurrence risk and be associated with poorer survival. There also is a high prevalence of malnutrition in patients with cancer. Those at highest risk include older patients, patients with advanced cancer, and patients with cancers that affect organs and body systems involved in eating and digestion. All patients with cancer should be screened regularly for the risk or presence of malnutrition. The Malnutrition Screening Tool (MST) has been validated for such screening. Individualized counseling by a dietitian can help patients achieve optimal intake. Patients should achieve adequate caloric (25-30 kcal/kg body weight) and protein (more than 1 g/kg) intake, have vitamin and/or mineral deficiencies corrected, and consider taking fish oil or long-chain N-3 fatty acid supplements. Enteral nutrition is recommended if food intake is inadequate, and parenteral nutrition can be considered if enteral nutrition is not possible or adequate. Physical activity is recommended. Standard recommendations are for at least 150 min/week of physical activity, with 300 minutes/week considered ideal. In general, supervised exercise programs have been shown to be more effective for cancer survivors than home-based exercise programs. Behavioral interventions that provide methods or materials to support behavior change (eg, fitness tracking devices, fitness classes) tend to be most effective.