American family physician最新文献

Keloid and hypertrophic scars are a result of aberrant wound healing responses within the reticular dermis. They are thought to be secondary to the formation of a disorganized extracellular matrix due to excessive fibroproliferative collagen response. Prevention of these scars focuses on avoiding elective or cosmetic procedures such as piercings in patients at high risk, reducing tension across the lesion, and decreasing the inflammatory response. Topical treatments, including tension reduction with gel sheets, inflammatory reduction with corticosteroid ointments, and combined treatment with corticosteroid-infused tapes and plasters, can reduce scarring. Liquid nitrogen is beneficial, especially when injected into the scar through intralesional cryotherapy. Corticosteroid injection is effective for prevention and treatment. OnabotulinumtoxinA appears to be superior to both fluorouracil and corticosteroid injections for treating keloids and hypertrophic scars. Advanced treatment includes laser therapies (direct ablation, postsurgical, or laser-assisted drug delivery). Surgical revisions can be successful when tension-reducing techniques are used and when combined with other treatments such as postoperative steroid injection, laser ablation, and radiation therapy. For keloid prevention, corticosteroid injections administered 10 to 14 days postsurgery is superior to injections administered before or during surgery. Radiation therapy is considered safe with low cancer risk and can be used alone or in combination with other therapies.

Approximately 10% to 20% of the general population has elevated liver chemistry levels, including aspartate and alanine transaminases. Elevated transaminase levels may be associated with significant underlying liver disease and increased risk of liver-related and all-cause mortality. The most common causes of mildly elevated transaminase levels (two to five times the upper limit of normal) are metabolic dysfunction-associated steatotic liver disease (MASLD) and alcoholic liver disease. Uncommon causes include drug-induced liver injury, chronic hepatitis B and C, and hereditary hemochromatosis. Rare causes are alpha1-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. Extrahepatic causes are celiac disease, hyperthyroidism, rhabdomyolysis, and pregnancy-associated liver disease. Initial laboratory testing assesses complete blood cell count with platelets, blood glucose, lipid profile, hepatitis B surface antigen, hepatitis C antibody, serum albumin, iron, total iron-binding capacity, and ferritin. If MASLD is suspected, the FIB-4 Index Score or NAFLD Fibrosis Score can be used to predict which patients are at risk for fibrosis and may benefit from further testing or referral to a hepatologist. All patients with elevated transaminases should be counseled about moderation or cessation of alcohol use, weight loss, and avoidance of hepatotoxic drugs.

Anemia affects more than 269 million children globally, including 1.2 million children in the United States. Although anemia can present with numerous symptoms, children are most often asymptomatic at the time of diagnosis. Anemia in infants and children most often arises from nutritional iron deficiency but can also be a result of genetic hemoglobin disorders, blood loss, infections, and other diseases. In the United States, newborn screening programs assess for various genetic causes of anemia at birth. The US Preventive Services Task Force notes insufficient evidence to recommend universal screening of asymptomatic children in the first year of life; however, the American Academy of Pediatrics recommends screening all children before 1 year of age. Initial laboratory evaluation consists of a complete blood cell count, with further testing dependent on mean corpuscular volume. Microcytic anemia is the most common hematologic disorder in children, with iron deficiency as the most common cause. A recommended dosage of 2 to 6 mg/kg per day of ferrous sulfate is the most effective oral iron supplementation for patients with iron deficiency anemia. Delayed cord clamping at birth might prevent early iron deficiency, but no clinically relevant outcomes are certain. Normocytic anemia is classified by reticulocyte count and can reflect hemolysis (high reticulocyte count) or bone marrow suppression (low reticulocyte count). Macrocytic anemia is less common in children and is typically a result of nutritional deficiencies or poor absorption of cobalamin (vitamin B12) or folate. Pediatric hematology referral might be beneficial for patients who do not respond to treatment, and referrals are critical for any bone marrow suppression that is diagnosed.

For patients with chest discomfort, noninvasive cardiac testing can be used for the diagnosis of acute coronary syndrome and for the evaluation of the risk of future cardiovascular events and disease severity in patients with known coronary artery disease. Clinical prediction rules can guide risk assessment for patients with acute or stable chest discomfort. For acute chest discomfort, patients with low risk do not need urgent testing, and those at high risk should have invasive coronary angiography. For acute chest discomfort in patients at intermediate risk, exercise stress testing can provide useful prognostic information on the likelihood of future mortality and survival despite modest sensitivity and specificity for coronary artery disease. Exercise or pharmacologic stress testing with imaging allows dynamic assessment of ventricular function and perfusion. For stable chest discomfort in patients with low risk, coronary artery calcium scoring can be used to exclude calcified plaque or exercise stress testing can be used for the evaluation of future cardiac risk and prognosis. For stable chest discomfort in patients with intermediate or high risk, exercise stress testing or stress testing with imaging (ie, echocardiography, myocardial perfusion imaging, or cardiac magnetic resonance imaging) may be used for the evaluation for myocardial ischemia.