Pacemakers are implantable cardiac devices used in the treatment of bradycardia and heart failure. They monitor electrical signals in the heart and deliver electrical stimuli to cause contraction in the targeted heart chamber. Permanent pacemaker therapy is recommended in patients with symptomatic bradycardia or asymptomatic infranodal atrioventricular block to improve symptoms and quality of life. Biventricular pacemakers can also be used in cardiac resynchronization therapy, which corrects dyssynchrony between the ventricles. In patients who have symptomatic heart failure with reduced ejection fraction, left bundle branch block, and prolonged QRS duration, cardiac resynchronization therapy improves outcomes, including mortality. Medical procedures such as electrocautery or magnetic resonance imaging may interfere with a patient's pacemaker; family physicians should coordinate with cardiologists to ensure appropriate care for patients in whom these procedures are indicated.
Recurrent urinary tract infection (UTI) is defined as two or more UTIs within 6 months or three or more within 1 year. The annual recurrence rate of UTI in women is approximately 14% to 25%. Risk factors for recurrent UTI include antimicrobial exposures, more frequent sexual activity, use of spermicidal agents or diaphragms, peri-or postmenopausal status, personal hygiene practices, urinary stasis from incomplete bladder emptying, pelvic organ prolapse, and voiding dysfunction. When women present with recurrent UTI symptoms, urinalysis and urine culture should be obtained. Management guidelines recommend empiric treatment with a first-line antibiotic based on prior culture results, then changing the antibiotic if the new culture shows resistance, or waiting for culture results before selecting an antibiotic. Longer duration of therapy does not reduce the risk of recurrent UTI. Asymptomatic bacteriuria should not be treated, except in patients who are pregnant or undergoing invasive urologic procedures. Prevention of recurrent UTI begins with behavioral modification and hygienic practices. The next step is prescription of antibiotic prophylaxis with shared decision-making. Nonantibiotic methods are also used to prevent recurrent UTI, and evidence of their effectiveness varies. These methods include use of cranberry products, Lactobacillus probiotics, vaginal estrogen, methenamine supplements.
Pathologic gambling, also known as gambling disorder, is a behavioral addiction. The prevalence of gambling disorder has increased in recent years as gambling has become more accessible. Gambling disorder is often underdiagnosed and may have disabling effects on patients. Although men are more often affected, the rate of gambling disorder has been increasing in women. Risk factors include comorbid substance use disorder, mental health diagnoses, lower socioeconomic status, and participation in other risky behaviors. The US Preventive Services Task Force has not addressed screening for gambling disorders. In the United Kingdom, the National Institute for Health and Care Excellence has developed a guideline for case-finding based on expert opinion; the guideline suggests asking a direct question, such as "Do you gamble?," to assess patients for gambling disorder. The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision criteria should be used to confirm the diagnosis and classify severity. Pharmacologic interventions such as naltrexone or olanzapine may reduce symptom severity in the short-term, although more study is needed. Psychotherapy, including cognitive behavior therapy and motivational interviewing, offers short-term benefits; however, its long-term effectiveness is uncertain. Self-help and family support groups have limited evidence but provide safe places for affected individuals and loved ones to alleviate the stress associated with the financial and emotional consequences of gambling.
Nausea and vomiting are some of the most common symptoms during pregnancy. Severity should be assessed with a tool such as the Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) score. In severe cases, additional medical history should be obtained to rule out possible secondary causes. Treatment depends on the severity of symptoms, beginningwith behavioral modification such astrigger avoidance and dietary changesfor mild cases. Modification includes mealsthat are small, frequent, bland, dry, and high in protein. First-line pharmacologic management for mild or moderate cases is vitamin B-6 with or without doxylamine. When conservative measures are ineffective or not tolerated, additional pharmacologic options include other antihistamines or dopamine antagonists. Metoclopramide and ondansetron are considered second-line treatments for persistent symptoms. Dehydration and electrolyte abnormalities should be corrected and may necessitate hospitalization if oral intake is not possible. Treatment of refractory or severe symptoms include the consideration of corticosteroids and, in rare cases, supplemental enteral or parenteral nutrition.
More than 29 million adults in the United States are diagnosed with type 2 diabetes, and insulin therapy is estimated to be needed in up to 15% of cases. Insulin should be considered first-line treatment in patients with severe hyperglycemia (eg, A1C greater than 10%, blood glucose 300 mg/dL or higher), symptoms of hyperglycemia, or catabolism. To optimize insulin use in an outpatient setting, family physicians must consider strategies for initiation, titration, and adherence. The preferred starting regimen is basal insulin with stepwise intensification to prandial or premixed insulin. Insulin regimens can be titrated as frequently as every 2 to 3 days until blood glucose targets are reached. Long-acting insulin analogues offer improved duration of action and reduced risk of hypoglycemia compared with intermediate-acting insulin. Continuous glucose monitoring may improve diabetes control and can be considered in patients who need insulin. Weight gain, hypoglycemia, and insulin regimen complexity are key challenges in diabetes management. Family physicians should use individualized targets that consider life expectancy, age, medical comorbidities, and hypoglycemia risk. Insulin treatment remains a significant but complex aspect of managing type 2 diabetes.
Metabolic dysfunction-associated steatotic liver disease (MASLD; formerly nonalcoholic fatty liver disease) is an increasingly common cause of chronic liver disease. It is fatty infiltration of the liver with at least one cardiometabolic risk factor, without a secondary cause and no or low alcohol use. People with MASLD and other risk factors (eg, diabetes, obesity) are at higher risk for long-term adverse outcomes, including cirrhosis and hepatocellular carcinoma. Screening for advanced fibrosis involves two-step sequential noninvasive testing. Clinicians should risk stratify using the Fibrosis-4 index. Secondary risk assessment with vibration-controlled transient elastography or ultrasound-based methods is needed in people with indeterminate or high-risk Fibrosis-4 scores. Monitoring and management of earlier stages of the MASLD spectrum in primary care may reduce the risk of adverse outcomes and maximize care before specialist referral. Patients should be counseled on lifestyle interventions (eg, at least 5% weight loss for people with overweight or obesity, healthy diet, at least 150 minutes of moderate aerobic physical activity per week) to improve steatosis and lower cardiovascular risk. Additional lifestyle recommendations include smoking cessation, limited alcohol intake in people with no or mild fibrosis, and no alcohol for those with more significant fibrosis. Semaglutide and resmetirom are approved by the US Food and Drug Administration for treatment of metabolic dysfunction-associated steatohepatitis in patients with moderate or severe fibrosis.
