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.

Subacute to chronic mild traumatic brain injury.

Although a universally accepted definition is lacking, mild traumatic brain injury and concussion are classified by transient loss of consciousness, amnesia, altered mental status, a Glasgow Coma Score of 13 to 15, and focal neurologic deficits following an acute closed head injury. Most patients recover quickly, with a predictable clinical course of recovery within the first one to two weeks following traumatic brain injury. Persistent physical, cognitive, or behavioral postconcussive symptoms may be noted in 5 to 20 percent of persons who have mild traumatic brain injury. Physical symptoms include headaches, dizziness, and nausea, and changes in coordination, balance, appetite, sleep, vision, and hearing. Cognitive and behavioral symptoms include fatigue, anxiety, depression, and irritability, and problems with memory, concentration and decision making. Women, older adults, less educated persons, and those with a previous mental health diagnosis are more likely to have persistent symptoms. The diagnostic workup for subacute to chronic mild traumatic brain injury focuses on the history and physical examination, with continuing observation for the development of red flags such as the progression of physical, cognitive, and behavioral symptoms, seizure, progressive vomiting, and altered mental status. Early patient and family education should include information on diagnosis and prognosis, symptoms, and further injury prevention. Symptom-specific treatment, gradual return to activity, and multidisciplinary coordination of care lead to the best outcomes. Psychiatric and medical comorbidities, psychosocial issues, and legal or compensatory incentives should be explored in patients resistant to treatment.

Lung Cancer: Screening and Evaluation of Patients With Solitary Pulmonary Nodules.

Low-dose computed tomography (CT) scan is the only modality currently considered acceptable for lung cancer screening in high-risk populations. Screening recommendations vary. The US Preventive Services Task Force recommends annual low-dose CT scan to screen high-risk patients (ie, asymptomatic patients ages 55 to 80 years with a 30 pack-year smoking history and who currently smoke or have quit within the previous 15 years). The American Academy of Family Physicians recommends a shared decision-making discussion between the clinician and patient regarding the benefits and potential harms of screening. Medicare covers lung cancer screening to age 77 years as part of a shared decision-making visit and when offered in conjunction with smoking cessation. Approximately 320 high-risk patients who smoke need to be screened annually over 3 years to prevent 1 death from lung cancer. The false-positive rate is 96%. Solitary pulmonary nodules or masses identified on screening or incidentally on other imaging should be managed based on appearance and size and the clinical risk factors of the patient, in accordance with guidelines.

Lung Cancer: Management.

Lung cancer management that is individualized for age, comorbidities, cancer type, cancer stage, and patient preference has long been a cornerstone of management. New to this realm of individualized management are the emerging biologic therapies, immunotherapies, and targeted therapies for non-small-cell lung cancer provided by advances in genetics and molecular medicine. These techniques have led to a new field of precision medicine based on the unique molecular characteristics of a specific patient and the specific cancer. However, standard management including surgery, chemotherapy, and radiation therapy remains the most common management options for stage I through III lung cancers. Advancements in precision medicine are most relevant to patients with stage IV (ie, metastatic) lung cancers. Functional patient assessment and pulmonary function testing are keys to preoperative assessment. Early palliative care and a minimally invasive approach to surgery should be considered in patients who can tolerate surgery.