American family physician最新文献

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.

Prescription opioids continue to be commonly used for chronic non-cancer pain, despite inherent risks. Primary care physicians and advanced practice clinicians have been integral to driving change in opioid prescribing, preventing overuse, and reducing risk. The authors of this article assessed the current extent of opioid prescribing using publicly available data to identify which specialties are most likely to prescribe opioids and to what extent.