Fatigue in Adults: Evaluation and Management.

Fatigue is among the top 10 reasons patients visit primary care offices, and it significantly affects patients' well-being and occupational safety. A comprehensive history and cardiopulmonary, neurologic, and skin examinations help guide the workup and diagnosis. Fatigue can be classified as physiologic, secondary, or chronic. Physiologic fatigue can be addressed by proper sleep hygiene, a healthy diet, and balancing energy expenditure. Secondary fatigue is improved by treating the underlying condition. Cognitive behavior therapy, exercise therapy, and acupuncture may help with some of the fatigue associated with chronic conditions. Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic, severe, and potentially debilitating disorder with demonstrated inflammatory, neurologic, immunologic, and metabolic abnormalities. ME/CFS has a poor prognosis, with no proven treatment or cure. It may become more common after the COVID-19 pandemic because many patients with long COVID (post-COVID-19 condition) have symptoms similar to ME/CFS. The most important symptom of ME/CFS is postexertional malaise. The 2015 National Academy of Medicine diagnostic criteria diagnose ME/CFS. Exercise can be harmful to patients with ME/CFS because it can trigger postexertional malaise. Patients should be educated about pacing their activity not to exceed their limited energy capacity. Treatment should prioritize comorbidities and symptoms based on severity.

Rationalisation of meat consumption in New Zealand adolescents.

OBJECTIVE: This study aimed to describe meat consumption rationalisation and relationships with meat consumption patterns and food choice motivations in New Zealand adolescents. DESIGN: This was a cross-sectional study of adolescents from high schools across New Zealand. Demographics, dietary habits, and motivations and attitudes towards food were assessed by online questionnaire and anthropometric measurements taken by researchers. The 4Ns questionnaire assessed meat consumption rationalisation with four subscales: 'Nice', 'Normal', 'Necessary' and 'Natural'. SETTING: Nineteen secondary schools from eight regions in New Zealand, with some purposive sampling of adolescent vegetarians in Otago, New Zealand. PARTICIPANTS: Questionnaires were completed by 385 non-vegetarian and vegetarian (self-identified) adolescents. RESULTS: A majority of non-vegetarian adolescents agreed that consuming meat was 'nice' (65 %), but fewer agreed that meat consumption was 'necessary' (51 %). Males agreed more strongly than females with all 4N subscales. High meat consumers were more likely to agree than to disagree that meat consumption was nice, normal, necessary and natural, and vegetarians tended to disagree with all rationalisations. Adolescent non-vegetarians whose food choice was motivated more by convenience, sensory appeal, price and familiarity tended to agree more with all 4N subscales, whereas adolescents motivated by animal welfare and environmental concerns were less likely to agree. CONCLUSIONS: To promote a reduction in meat consumption in adolescents, approaches will need to overcome beliefs that meat consumption is nice, normal, necessary and natural.

Hemorrhoids: Diagnosis and Treatment Options.

Many Americans between 45 and 65 years of age experience hemorrhoids. Hemorrhoidal size, thrombosis, and location (i.e., proximal or distal to the dentate line) determine the extent of pain or discomfort. The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes. Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse. Other factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued. Medical management (e.g., stool softeners, topical over-the-counter preparations, topical nitroglycerine), dietary modifications (e.g., increased fiber and water intake), and behavioral therapies (sitz baths) are the mainstays of initial therapy. If these are unsuccessful, office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation. Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures; therefore, hemorrhoidectomy should be reserved for recurrent or higher-grade disease. Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain. Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue; however, this procedure has several potential postoperative complications. Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly. Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms.

Lung Cancer: Smoking Cessation.

Smoking cessation for patients who smoke should be a top priority for physicians. Nicotine dependence should be considered a chronic disease, with the expectation that relapse is normal. The US Preventive Services Task Force (USPSTF) recommends that physicians screen all adults for tobacco use, advise them to stop using tobacco, and provide behavioral interventions and Food and Drug Administration-approved pharmacotherapy for cessation to adults who use tobacco. It also recommends use of the 5 As (ie, Ask, Advise, Assess, Assist, Arrange) in discussing tobacco use with patients. All smokers should be offered behavioral and pharmacotherapy assistance in quitting. Pregnant women who smoke should be offered behavioral methods first. However, if these methods are unlikely to be effective, pharmacotherapy can be offered after a discussion about risks and benefits. The behavioral method with the most evidence of efficacy is group therapy. Nicotine replacement therapy (eg, gums, lozenges, transdermal patches, inhalers, nasal sprays), bupropion SR, and varenicline are approved by the Food and Drug Administration for management of nicotine withdrawal during smoking cessation.

Lung Cancer: Clinical Presentation and Diagnosis.

In the absence of screening, most patients with lung cancer are not diagnosed until later stages, when the prognosis is poor. The most common symptoms are cough and dyspnea, but the most specific symptom is hemoptysis. Digital clubbing, though rare, is highly predictive of lung cancer. Symptoms can be caused by the local tumor, intrathoracic spread, distant metastases, or paraneoplastic syndromes. Clinicians should suspect lung cancer in symptomatic patients with risk factors. The initial study should be chest x-ray, but if results are negative and suspicion remains, the clinician should obtain a computed tomography scan with contrast. The diagnostic evaluation for suspected lung cancer includes tissue diagnosis, staging, and determination of functional capacity, which are completed simultaneously. Tissue samples should be obtained using the least invasive method possible. Management is based on the individual tumor histology, molecular testing results, staging, and performance status. The management plan is determined by a multidisciplinary team consisting of a pulmonology subspecialist, medical oncology subspecialist, radiation oncology subspecialist, and thoracic surgeon. The family physician should remain involved with the patient to ensure that patient priorities are supported and, if necessary, to arrange for end-of-life care.

Prevention and Treatment of Drowning.

Nearly 4,000 drowning deaths occur annually in the United States, with drowning representing the most common injury-related cause of death in children one to four years of age. Drowning is a process that runs the spectrum from brief entry of liquid into the airways with subsequent clearance and only minor temporary injury, to the prolonged presence of fluid in the lungs leading to lung dysfunction, hypoxia, neurologic and cardiac abnormalities, and death. The World Health Organization has defined drowning as "the process of experiencing respiratory impairment from submersion/immersion in liquid." Terms such as near, wet, dry, passive, active, secondary, and silent drowning should no longer be used because they are confusing and hinder proper categorization and management. The American Heart Association's Revised Utstein Drowning Form and treatment guidelines are important in guiding care, disposition, and prognosis. Prompt resuscitation at the scene after a shorter duration of submersion is associated with better outcomes. Because cardiac arrhythmias due to drowning are almost exclusively caused by hypoxia, the resuscitation order prioritizes airway and breathing before compressions. Prevention remains the best treatment. Education, swimming and water safety lessons, and proper pool fencing are the interventions with the highest level of current evidence, especially in children two to four years of age. Alcohol use during water activities dramatically increases the risk of drowning; therefore, abstinence is recommended for all participants and supervisors.

Lung cancer: diagnosis, treatment principles, and screening.

Lung cancer is classified histologically into small cell and non-small cell lung cancers. The most common symptoms of lung cancer are cough, dyspnea, hemoptysis, and systemic symptoms such as weight loss and anorexia. High-risk patients who present with symptoms should undergo chest radiography. If a likely alternative diagnosis is not identified, computed tomography and possibly positron emission tomography should be performed. If suspicion for lung cancer is high, a diagnostic evaluation is warranted. The diagnostic evaluation has three simultaneous steps (tissue diagnosis, staging, and functional evaluation), all of which affect treatment planning and determination of prognosis. The least invasive method possible should be used. The diagnostic evaluation and treatment of a patient with lung cancer require a team of specialists, including a pulmonologist, medical oncologist, radiation oncologist, pathologist, radiologist, and thoracic surgeon. Non-small cell lung cancer specimens are tested for various mutations, which, if present, can be treated with new targeted molecular therapies. The family physician should remain involved in the patient's care to ensure that the values and wishes of the patient and family are considered and, if necessary, to coordinate end-of-life care. Early palliative care improves quality of life and may prolong survival. Family physicians should concentrate on early recognition of lung cancer, as well as prevention by encouraging tobacco cessation at every visit. The U.S. Preventive Services Task Force recommends lung cancer screening using low-dose computed tomography in high-risk patients. However, the American Academy of Family Physicians concludes that the evidence is insufficient to recommend for or against screening. Whether to screen high-risk patients should be a shared decision between the physician and patient.

Chronic headache: stop the pain before it starts.

Familiarity with the risks associated with medication overuse and the importance of headache prophylaxis is key to easing your patient's pain.

Evaluation and management of common anorectal conditions.

The prevalence of benign anorectal conditions in the primary care setting is high, although evidence of effective therapy is often lacking. In addition to recognizing common benign anorectal disorders, physicians must maintain a high index of suspicion for inflammatory and malignant disorders. Patients with red flags such as increased age, family history, persistent anorectal bleeding despite treatment, weight loss, or iron deficiency anemia should undergo colonoscopy. Pruritus ani, or perianal itching, is managed by treating the underlying cause, ensuring proper hygiene, and providing symptomatic relief with oral antihistamines, topical steroids, or topical capsaicin. Effective treatments for anal fissures include onabotulinumtoxinA, topical nitroglycerin, and topical calcium channel blockers. Symptomatic external hemorrhoids are managed with dietary modifications, topical steroids, and analgesics. Thrombosed hemorrhoids are best treated with hemorrhoidectomy if symptoms are present for less than 72 hours. Grades I through III internal hemorrhoids can be managed with rubber band ligation. For the treatment of grade III internal hemorrhoids, surgical hemorrhoidectomy has higher remission rates but increased pain and complication rates compared with rubber band ligation. Anorectal condylomas, or anogenital warts, are treated based on size and location, with office treatment consisting of topical trichloroacetic acid or podophyllin, cryotherapy, or laser treatment. Simple anorectal fistulas can be treated conservatively with sitz baths and analgesics, whereas complex or nonhealing fistulas may require surgery. Fecal impaction may be treated with polyethylene glycol, enemas, or manual disimpaction. Fecal incontinence is generally treated with loperamide and biofeedback. Surgical intervention is reserved for anal sphincter injury.