Pulmonary Nodules: Common Questions and Answers.

Pulmonary nodules are often incidentally discovered on chest imaging or from dedicated lung cancer screening. Screening adults 50 to 80 years of age who have a 20-pack-year smoking history and currently smoke or have quit smoking within the past 15 years with low-dose computed tomography is associated with a decrease in cancer-associated mortality. Once a nodule is detected, specific radiographic and clinical features can be used in validated risk stratification models to assess the probability of malignancy and guide management. Solid pulmonary nodules less than 6 mm warrant surveillance imaging in patients at high risk, and nodules between 6 and 8 mm should be reassessed within 12 months, with the recommended interval varying by the risk of malignancy and an allowance for patient-physician decision-making. A functional assessment with positron emission tomography/computed tomography, nonsurgical biopsy, and resection should be considered for solid nodules 8 mm or greater and a high risk of malignancy. Subsolid nodules have a higher risk of cancer and should be followed with surveillance imaging for longer. Direct physician-patient communication, clinical decision support within electronic health records, and guideline-based management algorithms included in radiology reports are associated with increased compliance with existing guidelines.

Chronic Kidney Disease: Prevention, Diagnosis, and Treatment.

Chronic kidney disease (CKD) affects approximately 15% of the U.S. population, and many people are unaware of their diagnosis. Screening may be considered for patients with cardiovascular disease, diabetes mellitus, hypertension, age 60 years and older, family history of kidney disease, previous acute kidney injury, or preeclampsia. Diagnosis and staging of CKD are based on estimated glomerular filtration rate (eGFR), excessive urinary albumin excretion, or evidence of kidney parenchymal damage lasting more than three months. eGFR should be determined using the CKD-EPI creatinine equation without the race variable. Risk calculators are available to estimate the risk of progression to end-stage renal disease. When possible, serum cystatin C should be measured to confirm eGFR in patients with CKD. Blood pressure should be maintained at less than 140/90 mm Hg, with a systolic blood pressure target of 120 mm Hg or less for patients tolerant of therapy, using an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Sodium-glucose cotransporter-2 inhibitors and metformin should be considered in patients with CKD and type 2 diabetes who have not reached their glycemic goal. Intravenous iodinated contrast media temporarily reduces eGFR and should be avoided in patients with advanced CKD. Interdisciplinary management of patients with CKD is important for reducing morbidity and mortality, and patients at high risk of progression to end-stage renal disease should be referred to a nephrologist.

Scrotal Masses.

Scrotal and testicular masses can be broadly categorized into painful conditions, which include testicular torsion, torsion of the testicular appendage, and epididymitis, and painless conditions, which include hydrocele, varicocele, and testicular cancer. Testicular torsion is a urologic emergency requiring prompt surgical intervention to save the testicle, ideally within six hours of presentation when the salvage rate is about 90%. The Testicular Workup for Ischemia and Suspected Torsion score can be used to help physicians identify patients at high risk of torsion and those at lower risk who would benefit from imaging first. Torsion of the testicular appendage presents with gradual onset of superior unilateral pain, is diagnosed using ultrasonography, and is treated supportively with analgesics. Epididymitis is usually caused by infection with Chlamydia trachomatis, Neisseria gonorrhoeae, or enteric bacteria and is treated with antibiotics, analgesics, and scrotal support. Hydroceles are generally asymptomatic and are managed supportively. Varicoceles are also generally asymptomatic but may be associated with reduced fertility. It is uncertain if surgical or radiologic treatment of varicoceles in subfertile men improves the rate of live births. Testicular cancer often presents as a unilateral, painless mass discovered incidentally. Ultrasonography is used to evaluate any suspicious masses, and surgical treatment is recommended for suspected cancerous masses.

Adult Eye Conditions: Ophthalmic Emergencies.

Prompt recognition and referral of patients with ophthalmic emergencies is crucial to preserving vision. Acute angle-closure glaucoma is the result of blockage of the outflow of aqueous humor, which increases intraocular pressure (IOP) and damages the retina. Patients typically report abrupt onset of a unilateral painful red eye with blurry vision and constitutional symptoms. The diagnosis is confirmed by measurement of elevated IOP. Urgent evaluation by an ophthalmologist is required to reduce the IOP before medical and surgical treatment. Retinal detachment occurs when fluid passes through a tear in the retina, lifting the retina away from its blood supply. This can occur spontaneously as a result of trauma or after cataract surgery. Patients may present with sudden onset of floaters or flashes of light followed by a curtainlike shadow in the visual field. Indirect ophthalmoscopy is the preferred modality to evaluate for retinal detachment. Prompt surgical repair is recommended. Mechanical trauma to the eye may cause globe rupture or full-thickness laceration. Antiemetics, pain management, systemic antibiotics, and use of an eye shield are recommended until the patient can be evaluated urgently by an ophthalmologist. Any protruding foreign bodies should not be removed. Ongoing follow-up with an ophthalmologist is recommended for patients with ophthalmic emergencies to assess for later complications.

Hepatitis A.

Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. The incidence of infection in the United States decreased by more than 90% after an effective vaccine was introduced, but the number of cases has been increasing because of large community outbreaks in unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice and are more common in older children and adults. People are most infectious 14 days before and seven days after the development of jaundice. Diagnosis of acute infection requires the use of serologic testing for immunoglobulin M anti-hepatitis A antibodies. The disease is usually self-limited, supportive care is often sufficient for treatment, and chronic infection or chronic liver disease does not occur. Routine hepatitis A immunization is recommended in children 12 to 23 months of age. Immunization is also recommended for individuals at high risk of contracting the infection, such as persons who use illegal drugs, those who travel to areas endemic for hepatitis A, incarcerated populations, and persons at high risk of complications from hepatitis A, such as those with chronic liver disease or HIV infection. The vaccine is usually recommended for pre- and postexposure prophylaxis, but immune globulin can be used in patients who are too young to be vaccinated or if the vaccine is contraindicated.

Men's Health: Benign Prostatic Hyperplasia.

Benign prostatic hyperplasia (BPH) commonly causes lower urinary tract symptoms (LUTS) through narrowing of the urethra and disruption of innervation of the gland. BPH is common in older men. Risk factors include Black race, Hispanic ethnicity, obesity, type 2 diabetes, high levels of alcohol consumption, physical inactivity, and a family history of BPH. The degree of LUTS can be assessed using the American Urological Association Symptom Index (AUASI). Watchful waiting is recommended for men with mild symptoms. Alpha1-adrenergic blockers or 5-alpha reductase inhibitors can be used to manage more severe symptoms. (This is an off-label use of some alpha1-adrenergic blockers.) Alpha1-adrenergic blockers typically are the initial choice. Combination therapy is more effective than monotherapy. Anticholinergics and beta3-adrenergic agonists can be used to manage irritative LUTS if the postvoiding residual urine volume is low. (This is an off-label use of anticholinergics and beta3-adrenergic agonists.) The phosphodiesterase type 5 inhibitor tadalafil is a second-line pharmacotherapy. There is insufficient evidence to support use of integrative medicine therapies. Physicians should consult with a urology subspecialist when patients do not benefit from medical therapy or have refractory LUTS, recurrent urinary tract infections, gross hematuria, bladder stones, or renal insufficiency.

Men's Health: Scrotal and Testicular Conditions.

Scrotal and testicular conditions include benign masses, infections, testicular torsion, and testicular cancer. Common palpable benign scrotal masses include spermatocele, varicocele, and hydrocele. Most patients with these masses require no treatment. Some varicoceles are associated with impaired fertility, probably due to an increase in scrotal temperature that leads to testicular hyperthermia, oxidative stress, and reduced spermatogenesis. Patients with documented infertility or scrotal pain should be referred to a urology subspecialist for consideration of surgical management. Epididymitis and epididymo-orchitis are caused by infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or enteric bacteria. Antibiotics and supportive measures (eg, scrotal elevation, bed rest) are recommended for management of acute epididymitis. Testicular torsion is a urologic emergency that requires rapid surgical exploration and orchidopexy to reduce the risk of testicular loss due to ischemia. Salvage rates exceed 90% when surgical exploration is performed within 6 hours of symptom onset. Testicular cancer commonly manifests as a painless, incidentally discovered mass in a single testis. Ultrasonography is recommended to confirm the diagnosis. The recommended primary intervention for a suspected malignant testicular tumor is radical inguinal orchiectomy.

Autoimmune Conditions: Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is the most common autoimmune inflammatory arthritis, and is seen more commonly in women, smokers, and individuals with a family history of RA. It should be considered if unexplained pain and swelling in the metacarpophalangeal and/or metatarsophalangeal joints and morning stiffness of fingers lasting for longer than 30 minutes are present. RA may be present in the lungs, skin, and eyes. It is associated with an increased risk of cardiovascular death independent of other risk factors. Disease activity should be monitored using a validated scale, such as the Disease Activity Score 28 (DAS28), among others. Earlier management to achieve remission or decrease disease activity is associated with less joint damage, better quality of life, and improved survival rates. Methotrexate with consideration of low-dose glucocorticoids is considered first-line therapy for RA. Other disease-modifying antirheumatic drugs, including immunobiologics, may be used for patients who do not benefit from methotrexate. Before undergoing treatment, patients should be screened for tuberculosis and hepatitis B and C infection. Drug dosages may be tapered in patients with remission or decreased disease activity, but drugs should not be discontinued.

Office Spirometry: Indications and Interpretation.

High-quality, office-based spirometry provides diagnostic information as useful and reliable as testing performed in a pulmonary function laboratory. Spirometry may be used to monitor progression of lung disease and response to therapy. A stepwise approach to spirometry allows for ease and reliability of interpretation. Airway obstruction is suspected when there is a decreased forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio, but there is no strong evidence to clearly define what constitutes a significant decrease in this ratio. A low FVC is defined as a value below the 5th percentile in adults or less than 80% of predicted in children and adolescents five to 18 years of age. The FEV1/FVC ratio and FVC are used together to identify obstructive defects and restrictive or mixed patterns. Obstructive defects should be assessed for reversibility, as indicated by an improvement of the FEV1 or FVC by at least 12% and 0.2 L in adults, or by more than 12% in children and adolescents five to 18 years of age after the administration of a short-acting bronchodilator. FEV1 is used to determine the severity of obstructive and restrictive disease, although the values were arbitrarily determined and are not based on evidence from patient outcomes. Bronchoprovocation testing may be used if spirometry results are normal and allergen- or exercise-induced asthma is suspected. For patients with an FEV1 less than 70% of predicted, a therapeutic trial of a short-acting bronchodilator may be tried instead of bronchoprovocation testing.

Benign Prostatic Hyperplasia.

Benign prostatic hyperplasia (BPH) is a common condition in aging men that is frequently associated with troublesome lower urinary tract symptoms (LUTS). The American Urologic Association Symptom Index is a validated, self-administered tool that is used to diagnose LUTS, guide initial treatment, and assess treatment response. Watchful waiting is an option for men with mild symptoms. Pharmacologic treatment includes alpha-adrenergic blockers and 5-alpha reductase inhibitors. There is no evidence to support the use of herbal supplements in the treatment of LUTS. Surgical therapy is effective and indicated for men with complications from BPH or who fail medical therapy.

Vitamin B12 Deficiency: Recognition and Management.

Vitamin B12 deficiency is a common cause of megaloblastic anemia, various neuropsychiatric symptoms, and other clinical manifestations. Screening average-risk adults for vitamin B12 deficiency is not recommended. Screening may be warranted in patients with one or more risk factors, such as gastric or small intestine resections, inflammatory bowel disease, use of metformin for more than four months, use of proton pump inhibitors or histamine H2 blockers for more than 12 months, vegans or strict vegetarians, and adults older than 75 years. Initial laboratory assessment should include a complete blood count and serum vitamin B12 level. Measurement of serum methylmalonic acid should be used to confirm deficiency in asymptomatic high-risk patients with low-normal levels of vitamin B12. Oral administration of high-dose vitamin B12 (1 to 2 mg daily) is as effective as intramuscular administration for correcting anemia and neurologic symptoms. Intramuscular therapy leads to more rapid improvement and should be considered in patients with severe deficiency or severe neurologic symptoms. Absorption rates improve with supplementation; therefore, patients older than 50 years and vegans or strict vegetarians should consume foods fortified with vitamin B12 or take vitamin B12 supplements. Patients who have had bariatric surgery should receive 1 mg of oral vitamin B12 per day indefinitely. Use of vitamin B12 in patients with elevated serum homocysteine levels and cardiovascular disease does not reduce the risk of myocardial infarction or stroke, or alter cognitive decline.

Update on vitamin B12 deficiency.

Vitamin B(12) (cobalamin) deficiency is a common cause of megaloblastic anemia, a variety of neuropsychiatric symptoms, and elevated serum homocysteine levels, especially in older persons. There are a number of risk factors for vitamin B(12) deficiency, including prolonged use of metformin and proton pump inhibitors. No major medical organizations, including the U.S. Preventive Services Task Force, have published guidelines on screening asymptomatic or low-risk adults for vitamin B(12) deficiency, but high-risk patients, such as those with malabsorptive disorders, may warrant screening. The initial laboratory assessment of a patient with suspected vitamin B(12) deficiency should include a complete blood count and a serum vitamin B(12) level. Measurements of serum vitamin B(12) may not reliably detect deficiency, and measurement of serum homocysteine and/or methylmalonic acid should be used to confirm deficiency in asymptomatic high-risk patients with low normal levels of vitamin B(12). Oral administration of high-dose vitamin B(12) (1 to 2 mg daily) is as effective as intramuscular administration in correcting the deficiency, regardless of etiology. Because crystalline formulations are better absorbed than naturally occurring vitamin B(12), patients older than 50 years and strict vegetarians should consume foods fortified with vitamin B(12) and vitamin B(12) supplements, rather than attempting to get vitamin B(12) strictly from dietary sources. Administration of vitamin B(12) to patients with elevated serum homocysteine levels has not been shown to reduce cardiovascular outcomes in high-risk patients or alter the cognitive decline of patients with mild to moderate Alzheimer disease.

Caring for pregnant women and newborns with hepatitis B or C.

Family physicians encounter diagnostic and treatment issues when caring for pregnant women with hepatitis B or C and their newborns. When hepatitis B virus is perinatally acquired, an infant has approximately a 90 percent chance of becoming a chronic carrier and, when chronically infected, has a 15 to 25 percent risk of dying in adulthood from cirrhosis or liver cancer. However, early identification and prophylaxis is 85 to 95 percent effective in reducing the acquisition of perinatal infection. Communication among members of the health care team is important to ensure proper preventive techniques are implemented, and standing hospital orders for hepatitis B testing and prophylaxis can reduce missed opportunities for prevention. All pregnant women should be screened for hepatitis B as part of their routine prenatal evaluation; those with ongoing risk factors should be evaluated again when in labor. Infants of mothers who are positive for hepatitis B surface antigen should receive hepatitis B immune globulin and hepatitis B vaccination within 12 hours of birth, and other infants should receive hepatitis B vaccination before hospital dis- charge. There are no effective measures for preventing perinatal hepatitis C transmission, but transmission rates are less than 10 percent. Perinatally acquired hepatitis C can be diagnosed by detecting hepatitis C virus RNA on two separate occasions between two and six months of age, or by detecting hepatitis C virus antibodies after 15 months of age.

Recognition and management of vitamin D deficiency.

Vitamin D deficiency affects persons of all ages. Common manifestations of vitamin D deficiency are symmetric low back pain, proximal muscle weakness, muscle aches, and throbbing bone pain elicited with pressure over the sternum or tibia. A 25-hydroxyvitamin D level should be obtained in patients with suspected vitamin D deficiency. Deficiency is defined as a serum 25-hydroxyvitamin D level of less than 20 ng per mL (50 nmol per L), and insufficiency is defined as a serum 25-hydroxyvitamin D level of 20 to 30 ng per mL (50 to 75 nmol per L). The goal of treatment is to normalize vitamin D levels to relieve symptoms and decrease the risk of fractures, falls, and other adverse health outcomes. To prevent vitamin D deficiency, the American Academy of Pediatrics recommends that infants and children receive at least 400 IU per day from diet and supplements. Evidence shows that vitamin D supplementation of at least 700 to 800 IU per day reduces fracture and fall rates in adults. In persons with vitamin D deficiency, treatment may include oral ergocalciferol (vitamin D2) at 50,000 IU per week for eight weeks. After vitamin D levels normalize, experts recommend maintenance dosages of cholecalciferol (vitamin D3) at 800 to 1,000 IU per day from dietary and supplemental sources.

Eye on the elderly. Hypertension care: striking the proper balance.

Treat systolic hypertension in the elderly to reduce their risk of cardiovascular events and mortality. Don't shy away from treating the very old. Hypertension treatment is beneficial even in patients who are 80 years of age or older. Don't prescribe an angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker for elderly patients without heart failure; the combination increases the risk of adverse effects without reducing cardiovascular events.

Ulcerative colitis: diagnosis and treatment.

Ulcerative colitis is a chronic disease with recurrent symptoms and significant morbidity. The precise etiology is still unknown. As many as 25 percent of patients with ulcerative colitis have extraintestinal manifestations. The diagnosis is made endoscopically. Tests such as perinuclear antineutrophilic cytoplasmic antibodies and anti-Saccharomyces cerevisiae antibodies are promising, but not yet recommended for routine use. Treatment is based on the extent and severity of the disease. Rectal therapy with 5-aminosalicylic acid compounds is used for proctitis. More extensive disease requires treatment with oral 5-aminosalicylic acid compounds and oral corticosteroids. The side effects of steroids limit their usefulness for chronic therapy. Patients who do not respond to treatment with oral corticosteroids require hospitalization and intravenous steroids. Refractory symptoms may be treated with azathioprine or infliximab. Surgical treatment of ulcerative colitis is reserved for patients who fail medical therapy or who develop severe hemorrhage, perforation, or cancer. Longstanding ulcerative colitis is associated with an increased risk of colon cancer. Patients should receive an initial screening colonoscopy eight years after the onset of pancolitis and 12 to 15 years after the onset of left-sided disease; follow-up colonoscopy should be repeated every two to three years.

Discharge procedures for healthy newborns.

Physicians should use a checklist to facilitate discussions with new parents before discharging their healthy newborn from the hospital. The checklist should include information on breastfeeding, warning signs of illness, and ways to keep the child healthy and safe. Physicians can encourage breastfeeding by giving parents written information on hunger and feeding indicators, stool and urine patterns, and proper breastfeeding techniques. Physicians also should emphasize that infants should never be given honey or bottles of water before they are one year of age. Parents should be advised of treatments for common infant complaints such as constipation, be aware of signs and symptoms of more serious illnesses such as jaundice and lethargy, and know how to properly care for the umbilical cord and genital areas. Physicians should provide guidance on how to keep the baby safe in the crib (e.g., placing the baby on his or her back) and in the car (e.g., using a car seat that faces the rear of the car). It is also important to schedule a follow-up appointment for the infant.