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Exposures to pollutants and contaminants can occur through water or soil, which can be contaminated naturally or through human activities. The toxicity and adverse health effects of these substances depend on exposure route, quantity, and duration. Mechanisms of water contamination include runoff, flooding, infrastructure failures, and contamination from air and surface water pollution. Pesticides and organophosphates commonly are used in agricultural and residential applications, frequently cause water contamination, and commonly cause poisoning in agricultural workers and gardeners. Soil contamination disproportionately affects minority and low-income populations because they are more likely to live in proximity to a pollution source. Fetuses, children, and individuals with preexisting medical conditions are more vulnerable to adverse health effects of soil contamination compared with healthy adults. Some of the most common soil pollutants are heavy metals, pesticides, and polychlorinated biphenyls. Preventing exposure to contaminated soil involves avoidance of historically contaminated sites and ingestion of soil. Approaches to cleanup depend on the extent of contamination, location, and planned future use of the land. Remediation strategies include containment, bioremediation, chemical oxidation, soil washing, and thermal treatment.

Heavy metals are naturally occurring, high-density elements such as arsenic, cadmium, chromium, lead, and mercury. These five metals are the most common causes of heavy metal poisonings. Zinc is also of concern. Heavy metals are widely distributed in the environment and can be toxic even at low concentrations. Exposure commonly occurs via ingestion, inhalation, or skin absorption. Occupational exposures are common and can occur in mining, refining, and smelting operations. Lead exposure disproportionately affects lower-income, inner-city communities due to older housing stock and historical industrial contamination. Adverse health effects of exposure to heavy metals vary by type and form of metal, exposure factors (eg, route, dose, duration), and individual patient characteristics (eg, age, sex). Toxicity management includes supportive treatments, decontamination, chelation, and/or surgery depending on the clinical situation and metal involved. For some types of heavy metal toxicity, there are no definitive treatments. Acute poisoning with arsenic and chromium can be fatal. Pregnant and breastfeeding patients and young children are particularly vulnerable to heavy metal exposure due to its effects on fetal and child development. In cases of suspected exposure, patients should be evaluated with a thorough history, including detailed occupational and social histories, and a physical examination, with laboratory tests and imaging as needed.

Endocrine-disrupting chemicals (EDCs) increasingly have been a subject of concern and study in the past few decades. These chemicals can interfere directly or indirectly with normal physiology of endocrine system organs or organs under the influence of hormones. EDCs have been shown to cause a range of adverse effects, such as developmental abnormalities, abnormal growth patterns in children, reproductive abnormalities, hormone-sensitive cancers, and alterations in immune function. Some have been shown to contribute to obesity. Most EDCs are synthetically developed compounds that are ubiquitous in food packaging, consumer products, and the environment. They are found in pesticides, herbicides, plastics, solvents, flame retardants, and in the environment as industrial byproducts and waste. These substances are poorly regulated and exposures are not tracked. It is virtually impossible to avoid contact with EDCs in everyday life. Populations at greatest risk of adverse health effects include fetuses, newborns, and pregnant individuals. Comprehensive preconception and prenatal care can help family members and caregivers identify sources of and minimize EDC exposure in newborns and infants. For individuals, the clinical significance of these exposures is unknown and there is no current role for testing. For patients with possible exposure, a pertinent history should be taken and counseling provided to help minimize exposure.

Poisoning is the leading cause of death due to unintentional injury in the United States. Each year, between 2,000,000 and 4,000,000 US poison exposures occur. Poison control centers (PCCs), health departments, and family physicians work at different levels of the health care system to identify, manage, and prevent poisoning. PCCs provide assistance to the public and to clinicians and health care facilities, with expert consultation in identification, diagnosis, and treatment of poison exposures. They also provide education for clinicians and support primary prevention activities. State, tribal, and local health departments have been established by law to address public health in their jurisdictions. For patients exposed to a poison, family physicians are often the first point of contact with the health care system. Patients who present with undifferentiated symptoms, such as headache, rash, or respiratory symptoms, may have had an unknown exposure. A comprehensive history, including detailed occupational and social histories, and physical examination are often the first steps in identifying an exposure. Family physicians performing an initial assessment of symptoms can call the PCC if they suspect a toxic exposure or are unable to identify a cause.

Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis in children older than 10 years in the United States. AIS is defined as a lateral spine curvature of 10° or more in the coronal plane, without congenital or neuromuscular comorbidities. The U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians (AAFP) do not recommend for or against AIS screening in asymptomatic patients. Physical examination includes the forward bend test with or without scoliometer, wherein scoliometer rotation between 5° and 7° warrants further evaluation with x-rays. Definitive diagnosis with x-rays allows for measurement of the Cobb angle. For Cobb angles less than 20°, watchful waiting and/or referral for physical therapy are indicated. Referral to a spine specialist for bracing is reasonable for curves between 20° and 26° and is recommended for curves between 26° and 45°. Surgical intervention is considered for initial Cobb angles greater than 40° and recommended for Cobb angles greater than 50°.

Active children and adolescents have unique risk factors for musculoskeletal injuries compared with adults. Physes and developing bones are at higher risk of injury than tendons and ligaments. Children's bone remodeling is robust, allowing most clavicle fractures and torus fractures of the forearm to be managed conservatively. Radial head subluxation is managed with reduction. Apophyseal injuries are traction or overuse injuries that typically can be managed nonoperatively. Osteochondritis dissecans and other osteochondroses require frequent monitoring and occasionally surgical intervention.

Duchenne muscular dystrophy (DMD) is an X-linked recessive genetic disorder with progressive proximal weakness as the principal sign. Glucocorticoids and physical therapy are the mainstay of treatment. Exercise intolerance is the hallmark of metabolic myopathies, which require a combination of laboratory testing, electrodiagnostic testing, and muscle biopsy for diagnosis. Joint hypermobility may be an isolated finding or be associated with hypermobility Ehlers-Danlos syndrome (EDS), other variants of EDS, or marfanoid syndromes. The latter conditions are associated with aortic and cardiac valvular abnormalities. Osteogenesis imperfecta encompasses a group of disorders characterized by bone fragility presenting with a low-impact fracture as a result of minimal trauma. Management includes multidiscipline specialists. Down syndrome (DS), or trisomy 21, is the most common chromosome abnormality identified in live births. Routine evaluation of atlantoaxial instability with x-ray is no longer recommended for children with DS without symptoms of atlantoaxial instability; however, clinical evaluation of symptoms is required for sports preparticipation. Achondroplasia is the most common skeletal dysplasia. Clinical signs are macrocephaly, short limb, short stature with disproportionately shorter humerus and femur, along with characteristic findings in pelvis and lumbar spine x-rays. Caregivers should be educated on proper positioning and handling to avoid complications, including car seat-related deaths.

Prenatal and delivery history guides a thorough musculoskeletal examination of the newborn. Amniotic bands from amniotic sequence/syndrome typically are apparent on visual inspection but may present as limb amputation. Management is guided by the degree of tissue compromise. Risk factors for birth trauma are maternal obesity, pelvic anomalies, macrosomia, and operative delivery. Fractures of the clavicle, humerus, and femur heal well with few sequelae. Splinting recommendations differ for each. Polydactyly, syndactyly, and clinodactyly are associated with syndromic conditions. In general, most are managed by orthopedists or plastic surgeons. Talipes equinovarus (clubfoot) can be diagnosed on prenatal ultrasonography, and 20% of cases are part of a syndromic condition. Treatment is via the Ponseti method and is followed by bracing, typically until age 5 years. Developmental dysplasia of the hip is a spectrum where the natural course is not clearly defined. Most instability initially discovered spontaneously resolves by age 2 months, and 90% resolves by age 12 months. Abduction splinting results in sustained hip reduction in 90% of infants requiring treatment.