American family physician
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American family physician · Sep 2023
Comment Practice GuidelineManagement of Heart Failure: Updated Guidelines From the AHA/ACC.
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In the United States, more than 30 million adults have reported taking a benzodiazepine within the past year. Misuse-use of a drug in a way that a doctor did not direct-accounts for 17.2% of all benzodiazepine use. Family physicians face challenges when balancing the patient's perceived benefits of benzodiazepines with known risks and lack of evidence supporting their use. ⋯ Adjunctive treatment with antiepileptics, antidepressants, and pregabalin has been shown to lessen withdrawal symptoms. Deprescribing benzodiazepines for patients who use them chronically should be individualized with slow tapering over weeks to months, or longer, to minimize the intensity of withdrawal symptoms. Incorporating behavioral interventions, such as cognitive behavior therapy, improves deprescribing outcomes.
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Primary aldosteronism is the underlying cause of hypertension in primary care settings in approximately 6% of cases, and it is even more common in patients with resistant hypertension. However, it is estimated that only about 2% of patients who have risk factors for primary aldosteronism have been formally tested or diagnosed. The first step in the diagnosis of primary aldosteronism is case detection and involves testing patients who are at risk, including individuals with resistant hypertension, as well as those with well-controlled hypertension and a first-degree relative with primary aldosteronism, hypokalemia, an adrenal nodule, atrial fibrillation, obstructive sleep apnea, or a family history of an early stroke (i.e., younger than 40 years). ⋯ Results are positive if aldosterone levels remain high after interventions that suppress or interrupt physiologic production of aldosterone. If the confirmatory test is positive, adrenal computed tomography and adrenal vein sampling should be performed to differentiate unilateral from bilateral adrenal production of aldosterone. Patients with unilateral primary aldosteronism should undergo adrenalectomy, whereas those with bilateral production should be treated with mineralocorticoid receptor antagonists, such as spironolactone or eplerenone.
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Disorders of smell and taste are reported by approximately one-fifth of people 40 years and older, and one-third of people 80 years and older. These disorders affect quality of life and the ability to identify smoke and toxins. Smell and taste disorders can be early signs of dementia or Parkinson disease and are associated with increased mortality. ⋯ Smell and taste disorders may resolve when reversible causes are treated, but improvement is less likely when they are due to trauma, age, or neurodegenerative disease. Olfactory training is a self-administered mindful exposure therapy that may improve olfactory function. Physicians should encourage patients to ensure that smoke and other alarms are operational and to adhere to food expiration dates.
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American family physician · Sep 2023
Gestational Diabetes Mellitus: Update on Screening, Diagnosis, and Management.
Gestational diabetes mellitus (GDM) is a common condition of pregnancy with increasing prevalence in the United States. GDM increases risks of complications, including operative delivery, hypertensive disorders, shoulder dystocia, fetal macrosomia, large-for-gestational-age infants, neonatal hypoglycemia, and neonatal respiratory distress. In patients who are overweight or obese, prepregnancy weight loss and lifestyle modifications during pregnancy may prevent GDM. ⋯ Practice patterns vary, but evidence suggests that glucose management during labor can safely include decreased glucose testing and sliding-scale dosing of insulin as an alternative to a continuous intravenous drip. Insulin resistance typically resolves after delivery; however, patients with GDM have an increased risk of developing overt diabetes. Continued lifestyle modifications, breastfeeding, and use of metformin can reduce this risk.