Humans

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.

A 43-year-old woman with a history of obesity (body-mass index [the weight in kilograms divided by the square of the height in meters] of 32.0) reports urinary leakage with coughing, sneezing, and exercise. She first noticed these symptoms after delivering her third child 6 years ago. Since then, her symptoms have worsened, and she now soaks through pads when she runs. She is frustrated by her situation because she would like to exercise to lose weight, but exercise exacerbates her urinary leakage. How should this case be evaluated and managed?

Background: The presence of blood in the urine, or hematuria, is a common finding in clinical practice and can sometimes be a sign of occult cancer. This article describes the clinical epidemiology of hematuria and the current state of practice and science in this context and provides suggestions for clinicians evaluating patients with hematuria.

Methods: A narrative review of available clinical guidelines and other relevant studies on the evaluation of hematuria was conducted, with particular emphasis on considerations for urologic referral.

High-value care advice 1: Clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria.

High-value care advice 2: Clinicians should not use screening urinalysis for cancer detection in asymptomatic adults.

High-value care advice 3: Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults.

High-value care advice 4: Clinicians should refer for further urologic evaluation in all adults with gross hematuria, even if self-limited.

High-value care advice 5: Clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause.

High-value care advice 6: Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy.

High-value care advice 7: Clinicians should not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.

High-quality primary care is the foundation of a high-functioning health care system. When it is high-quality, primary care provides continuous, personcentered, relationship-based care that considers the needs and preferences of individuals, families, and communities. Without access to high-quality primary care, minor health problems can spiral into chronic disease, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, preventive care lags, and health care spending soars to unsustainable levels.

Unequal access to primary care remains a concern, and the COVID-19 pandemic amplified pervasive economic, mental health, and social health disparities that ubiquitous, high-quality primary care might have reduced. Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes. For this reason, primary care is a common good, which makes the strength and quality of the country’s primary care services a public concern.

The National Academies of Sciences, Engineering, and Medicine formed the Committee on Implementing High-Quality Primary Care in 2019. Building on the recommendations of the 1996 Institute of Medicine report Primary Care: America’s Health in a New Era, the committee was tasked to develop an implementation plan for high-quality primary care in the United States.

The committee’s definition of high-quality primary care (see Box 1) describes what it should be, not what most people in the United States experience today. To rebuild a strong foundation for the U.S. health care system, the committee’s implementation plan includes objectives and actions targeting primary care stakeholders and balancing national needs for scalable solutions while allowing for adaptations to meet local needs.

The committee set five implementation objectives to make high-quality primary care available to all people living in the United States:

1. Pay for primary care teams to care for people, not doctors to deliver services.

2.Ensure that high-quality primary care is available to every individual and family in every community.

3.Train primary care teams where people live and work.

4.Design information technology that serves the patient, family, and the interprofessional care team.

5.Ensure that high-quality primary care is implemented in the United States.

Background: Obesity is a chronic disease with limited treatment options in pediatric patients. Liraglutide may be useful for weight management in adolescents with obesity.

Methods: In this randomized, double-blind trial, which consisted of a 56-week treatment period and a 26-week follow-up period, we enrolled adolescents (12 to <18 years of age) with obesity and a poor response to lifestyle therapy alone. Participants were randomly assigned (1:1) to receive either liraglutide (3.0 mg) or placebo subcutaneously once daily, in addition to lifestyle therapy. The primary end point was the change from baseline in the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) standard-deviation score at week 56.

Results: A total of 125 participants were assigned to the liraglutide group and 126 to the placebo group. Liraglutide was superior to placebo with regard to the change from baseline in the BMI standard-deviation score at week 56 (estimated difference, -0.22; 95% confidence interval [CI], -0.37 to -0.08; P = 0.002). A reduction in BMI of at least 5% was observed in 51 of 113 participants in the liraglutide group and in 20 of 105 participants in the placebo group (estimated percentage, 43.3% vs. 18.7%), and a reduction in BMI of at least 10% was observed in 33 and 9, respectively (estimated percentage, 26.1% vs. 8.1%). A greater reduction was observed with liraglutide than with placebo for BMI (estimated difference, -4.64 percentage points) and for body weight (estimated difference, -4.50 kg [for absolute change] and -5.01 percentage points [for relative change]). After discontinuation, a greater increase in the BMI standard-deviation score was observed with liraglutide than with placebo (estimated difference, 0.15; 95% CI, 0.07 to 0.23). More participants in the liraglutide group than in the placebo group had gastrointestinal adverse events (81 of 125 [64.8%] vs. 46 of 126 [36.5%]) and adverse events that led to discontinuation of the trial treatment (13 [10.4%] vs. 0). Few participants in either group had serious adverse events (3 [2.4%] vs. 5 [4.0%]). One suicide, which occurred in the liraglutide group, was assessed by the investigator as unlikely to be related to the trial treatment.

Conclusions: In adolescents with obesity, the use of liraglutide (3.0 mg) plus lifestyle therapy led to a significantly greater reduction in the BMI standard-deviation score than placebo plus lifestyle therapy. (Funded by Novo Nordisk; NN8022-4180 ClinicalTrials.gov number, NCT02918279.).