American family physician
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Hip fractures are common causes of disability, with mortality rates reaching 30% at one year. Nonmodifiable risk factors include lower socioeconomic status, older age, female sex, prior fracture, metabolic bone disease, and bony malignancy. Modifiable risk factors include low body mass index, having osteoporosis, increased fall risk, medications that increase fall risk or decrease bone mineral density, and substance use. ⋯ Femoral neck stress fractures typically occur in dancers 20 to 30 years of age, endurance athletes, and military service members, often because of training overload. Insufficiency fractures due to compromised bone strength occur without trauma in postmenopausal women. If not recognized and treated, these fractures can progress to complete and displaced fractures with high rates of nonunion and avascular necrosis.
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Galactorrhea is the production of breast milk that is not the result of physiologic lactation. Milky nipple discharge within one year of pregnancy and the cessation of breastfeeding is usually physiologic. Galactorrhea is more often the result of hyperprolactinemia caused by medication use or pituitary microadenomas, and less often hypothyroidism, chronic renal failure, cirrhosis, pituitary macroadenomas, hypothalamic lesions, or unidentifiable causes. ⋯ Magnetic resonance imaging of the pituitary gland should be performed if the cause of hyperprolactinemia is unclear after a medication review and laboratory evaluation. Cabergoline is the preferred medication for treatment of hyperprolactinemia. Transsphenoidal surgery may be necessary if prolactin levels do not improve and symptoms persist despite high doses of cabergoline and in patients who cannot tolerate dopamine agonist therapy.
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Breastfeeding is universally recognized as the preferred method of infant nutrition, but is sometimes abbreviated because of fear of harm to the infant from maternal medication. The amount of medication that enters breast milk varies based on the maternal serum concentration and the pharmacologic properties of the medication. When prescribing medications for a breastfeeding patient, those with the lowest risk to the infant should be selected, and dosing should be before the infant's longest sleep interval. ⋯ Herbal supplements are concerning for risk of impurities and lack of study of effects on breastfed infants. Nonhormonal and progestin-only contraceptives are preferred over combination oral contraceptives. Contrast for computed tomography or magnetic resonance imaging is not concerning during lactation, but use of radiopharmaceuticals, such as iodine 131, can accumulate in the lactating breast and increase risk to the infant.
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Anxiety disorders are the most common psychiatric conditions in children and adolescents, affecting nearly 1 in 12 children and 1 in 4 adolescents. Anxiety disorders include specific phobias, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and generalized anxiety disorder. Risk factors include parental history of anxiety disorders, socioeconomic stressors, exposure to violence, and trauma. ⋯ Several validated screening measures are useful for initial assessment and ongoing monitoring. Cognitive behavior therapy and selective serotonin reuptake inhibitors are the mainstay of treatment and may be used as monotherapies or in combination. Prognosis is improved with early intervention, caretaker support, and professional collaboration.
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Homelessness affects more than 580,000 Americans on any given night. Risk factors for homelessness include extreme poverty, substance use, and mental illness. People experiencing homelessness are likely to have multiple chronic medical or mental health conditions. ⋯ Considerations for medical management include simplifying medication regimens, providing safe options for medication storage, and addressing environmental exposures. A multidisciplinary approach that includes pharmacists, case managers, and social workers improves chronic disease outcomes. Housing First initiatives decrease emergency department use and hospitalizations, and colocating primary care visits with shelters increases overall health care access.