Screening, Brief Intervention, and Referral to Treatment in Oklahoma (SBIRT-OK)
is an evidence-based, integrated approach to identify and intervene with patients whose
patterns of tobacco, alcohol, and/or drug use, or depression, put their health at risk.
This cohort study of children younger than 6 years uses electronic health records to investigate whether a child’s age is associated with the probability of spontaneous umbilical hernia closure and to refine guidelines for surgical repair.
»Neutropenia is seen in 5%–10% of healthy people
Based on absolute neutrophil count, neutropenia is commonly defined as
mild (1.0–1.5 × 109
/L), moderate (0.5–0.9 × 109
/L) or severe (< 0.5 × 109
/L).1
However, the reference interval is specific to the population. Mild asymptomatic neutropenia per the above definition is common in people of subSaharan African, Arab or West Indian ancestry,2
and is strongly associated
with the Duffy-null phenotype of red blood cells that protects against
Plasmodium vivax malaria.
2 Common causes include medications, infection, nutritional
deficiency, malignant disease and autoimmune disease
Causes include underproduction (e.g., myelodysplastic syndrome),
immune-mediated destruction or redistribution of neutrophils to the
endothelium and reticuloendothelial system. Antithyroid, anti-infective
and psychotropic drugs, as well as chemotherapy, are causes of druginduced neutropenia.3,4 Transient neutropenia may occur after acute
viral infection and typically resolves within 2 weeks. Joint swelling, rash,
bony pain, splenomegaly or lymphadenopathy may suggest malignant or
autoimmune disease.
3Investigation should begin with a repeat complete blood count
and peripheral blood film
Neutropenia is often identified incidentally. Persistent and unexplained
neutropenia requires further work-up for a range of causes, including
chronic viral infection (e.g., hepatitis, HIV) and nutritional deficiency (e.g.,
vitamin B12) (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/
cmaj.220499/tab-related-content).
4 Treatment of mild neutropenia should be directed at the
underlying cause
Patients with mild neutropenia are not at substantially increased risk of
infection.5
The neutrophil count should be checked every 3–6 months for
at least 1 year to rule out progression to more severe neutropenia.
5 Patients with moderate-to-severe neutropenia for more than
6 months should be referred to a specialist
Patients with recurrent or severe bacterial infections (e.g., requiring hospital admission or intravenous antibiotics), abnormalities on peripheral blood
films (e.g., circulating blasts, hairy cells, large granular lymphocytes, dysplastic granulocytes) or pancytopenia also warrant referral to a specialist
(e.g., hematologist, internist, pediatrician).1
Febrile neutropenia (absolute
neutrophil count < 0.5 × 109
/L and an oral temperature > 38.0°C sustained
over 1 h) requires immediate treatment with broad-spectrum antibiotics.
Importance
Allergic reactions among some individuals who received the Pfizer-BioNTech (BNT162b2) COVID-19 vaccine discourage patients with allergic conditions from receiving this vaccine and physicians from recommending the vaccine.
Objective
To describe the assessment and immunization of highly allergic individuals with the BNT162b2 vaccine.
Design, Setting, and Participants
In a prospective cohort study from December 27, 2020, to February 22, 2021, 8102 patients with allergies who applied to the COVID 19 vaccine referral center at the Sheba Medical Center underwent risk assessment using an algorithm that included a detailed questionnaire. High-risk patients (n = 429) were considered “highly allergic” and were immunized under medical supervision.
Exposures
Pfizer-BioNTech (BNT162b2) COVID-19 vaccine.
Main Outcomes and Measures
Allergic and anaphylactic reactions after the first and second doses of BNT162b2 vaccine among highly allergic patients.
Results
Of the 429 individuals who applied to the COVID-19 referral center and were defined as highly allergic, 304 (70.9%) were women and the mean (SD) age was 52 (16) years. This highly allergic group was referred to receive immunization under medical supervision. After the first dose of the BNT162b2 vaccine, 420 patients (97.9%) had no immediate allergic event, 6 (1.4%) developed minor allergic responses, and 3 (0.7%) had anaphylactic reactions. During the study period, 218 highly allergic patients (50.8%) received the second BNT162b2 vaccine dose, of which 214 (98.2%) had no allergic reactions and 4 patients (1.8%) had minor allergic reactions. Other immediate and late reactions were comparable with those seen in the general population, except for delayed itch and skin eruption, which were more common among allergic patients.
Conclusions and Relevance
The rate of allergic reactions to BNT162b2 vaccine, is higher among patients with allergies, particularly among a subgroup with a history of high-risk allergies. This study suggests that most patients with a history of allergic diseases and, particularly, highly allergic patients can be safely immunized by using an algorithm that can be implemented in different medical facilities and includes a referral center, a risk assessment questionnaire, and a setting for immunization under medical supervision of highly allergic patients. Further studies are required to define more specific risk factors for allergic reactions to the BNT162b2 vaccine.
Background: Bellin Health in Wisconsin has pioneered the colocation and integration of physical therapists into primary care pods.
Methods: This is an observational study based on one in-person visit and several interviews.
Results: For patients with musculoskeletal complaints, providers make warm handoffs to the physical therapist, who is a few steps away. The physical therapist performs most of the visit, providing diagnosis, treatment, and patient education. Research studies show that-compared with physician management-appropriate patients managed by physical therapists have better outcomes, lower costs, and higher patient satisfaction. In a fee-for-service environment, the business case for this innovation requires an increased number of follow-up referrals to the physical therapy department. In the Coronavirus disease 2019 (COVID-19) era, physical therapists can provide video visits with equal quality compared with in-person visits.
Conclusion: The Bellin Health program is a blueprint for other primary care practices to integrate physical therapists into primary care teams.
Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of blood pressure (BP) in patients with chronic kidney disease (CKD) not receiving dialysis is an update of the KDIGO 2012 guideline on the same topic and reflects new evidence on the risks and benefits of BP-lowering therapy among patients with CKD. It is intended to support shared decision making by health care professionals working with patients with CKD worldwide. This article is a synopsis of the full guideline.
Methods: The KDIGO leadership commissioned 2 co-chairs to convene an international Work Group of researchers and clinicians. After a Controversies Conference in September 2017, the Work Group defined the scope of the evidence review, which was undertaken by an evidence review team between October 2017 and April 2020. Evidence reviews were done according to the Cochrane Handbook. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to guide the development of the recommendations and rate the strength and quality of the evidence. Practice points were included to provide guidance when evidence was insufficient to make a graded recommendation. The guideline was revised after public consultation between January and March 2020.
Recommendations: The updated guideline comprises 11 recommendations and 20 practice points. This synopsis summarizes key recommendations pertinent to the diagnosis and management of high BP in adults with CKD, excluding those receiving kidney replacement therapy. In particular, the synopsis focuses on recommendations for standardized BP measurement and a target systolic BP of less than 120 mm Hg, because these recommendations differ from some other guidelines.
Background: Obtaining timely access to addiction medicine treatment for patients with substance use disorders is challenging and patients often have to navigate complex referral pathways. This randomized controlled trial examines the effect of providing an expedited pathway to addiction medicine treatment on initial treatment engagement and health care utilization.
Methods: Individuals with possible alcohol or opioid use disorder were recruited from three residential withdrawal management services (WMS). Subjects randomized to the Delayed Intervention (DI) group were given contact information for a nearby addiction medicine clinic; those randomized to the Rapid Intervention (RI) group were given an appointment at the clinic within 2 days and were accompanied to their first appointment.
Results: Of the 174 individuals who were screened, 106 were randomized to either the DI or RI group. The two groups were similar in demographics, housing status, and substance use in the last 30 days. In the 6-month period following randomization, 85% of the RI group attended at least one clinic appointment, compared to only 29% in the DI group (p < 0.0001). The RI group had a mean of 6.39 ED visits per subject in the 12 months after randomization, while the DI group had a mean of 13.02 ED visits per subject in the same 12-month period (p = 0.0469). Other health utilization measures did not differ between the two groups.
Conclusion: Providing immediate facilitated access to an addiction medicine service resulted in greater initial engagement and reduced emergency department visits at 6 months. Trial registration This trial is registered at the National Institutes of Health (ClinicalTrials.gov) under identifier #NCT01934751.
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.
Chronic obstructive pulmonary disease (COPD) is common and has significant morbidity and mortality as the fourth leading cause of death in the United States. In many patients, particularly those with emphysema, COPD is characterized by markedly increased residual volume contributing to exertional dyspnea. Current therapies have limited efficacy. Surgical resection of diseased areas of the lung to reduce residual volume was effective in identified subgroups but also had significant mortality in and suboptimal cost effectiveness. Lung-volume reduction, using bronchoscopic techniques, has shown substantial benefits in a broader patient population with less morbidity and mortality. This review is meant to spread the awareness about bronchoscopic lung-volume reduction and to promote its consideration and early referral for patients with advanced COPD and emphysema frequently encountered by both primary care physicians and specialists. A search was conducted on PubMed (MEDLINE), EMbase, and Cochrane library for original studies, using the following keywords: "lung-volume reduction." "endobronchial valves," "intrabronchial valves," "bronchoscopic lung-volume reduction," and "endoscopic lung-volume reduction." We included reports from systematic reviews, narrative reviews, clinical trials, and observational studies. Two reviewers evaluated potential references. A total of 27 references were included in our review. Included studies report experience in the diagnosis and bronchoscopic treatment for emphysema; case reports and non-English or non-Spanish studies were excluded.
Copyright © 2020. Published by Elsevier Inc.
As usual, the new year brings changes in how doctors bill and get paid for the services they provide to Medicare patients. The reforms that will most affect family physicians’ pay aren’t coming until 2021, when several changes in evaluation and management (E/M) coding and payment are projected to result in a 12% increase for family medicine.1 But there are still a host of things family physicians should know for 2020, including new codes to help you get paid for interacting with patients via the internet and new codes that should help make chronic care management (CCM) more financially rewarding. The Centers for Medicare & Medicaid Services (CMS) is also continuing its quest to streamline documentation requirements and develop new payment models intended to reward quality instead of volume. This article summarizes the 2020 changes most relevant to family medicine. As always, private payers’ policies may differ, so consult with your billing staff to understand any important differences.
