referral and consultation

If you work with children, then you are seeing children who have been sexually abused. Many presentations in a health setting go unrecognised.

It is a field of paediatric practice that has changed rapidly over the last fifteen years. The evidence base is now set out by the RCPCH, giving a much clearer steer on the interpretation of physical signs. There has been a shift from examinations being provided within a child protection rota, to being carried out by specialists in a Sexual Assault Referral Centre (SARC). In many places, this has meant regionalisation of the service, and in some places, provision outside the NHS. There has been a seismic cultural change in recognition of, and response to, sexual abuse in society as a whole.

Alongside this, the internet has created new ways of grooming and exploitation, and linked together those who seek to normalise CSA offending. The challenge to paediatrics (and to safeguarding and criminal justice systems), is to meet the need that these developments have exposed.

Older drivers are putting more miles on the road during their “golden years” than generations prior. Many older adults have safe driving habits, but unique age-related changes increase the risk for crash-related morbidity and mortality. Generalists are poised to assess and guide older adults' driving fitness. Although there is no uniformly accepted tool for driving fitness, assessment of 5 key domains (cognition, vision, physical function, medical comorbidities, and medications) using valid tools can help clinicians stratify older drivers into low, intermediate, and high risk for unsafe driving. Clinicians can then make recommendations about fitness to drive and appropriate referrals for rehabilitation or alternative transportation resources to optimize mobility, independence, and quality of life for older adults.

Introduction to the guidelines The Center of Excellence for Transgender Health (CoE) at the University of California – San Francisco is proud to present these Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Transgender people have a gender identity that differs from the sex which they were assigned at birth, and are estimated to represent 0.5% of the U.S. population.[1] Numerous needs assessments have demonstrated that transgender people encounter a range of barriers to accessing primary health care. A 2006 survey of more than 600 transgender people in California found that 30% postponed seeking medical care due to prior disrespect or discrimination, and that 10% were primary care outright.[2] The 2011 National Transgender Discrimination Survey of more than 6000 transgender people in all 50 U.S. states found several noteworthy disparities, including 28% who delayed care due to past discrimination and 19% who were denied care outright. Most alarmingly, 50% of respondents reported having to teach their providers about their own healthcare.[3] These guidelines aim to address these disparities by equipping primary care providers and health systems with the tools and knowledge to meet the health care needs of their transgender and gender nonconforming patients. These guidelines expand on the original UCSF Primary Care Protocol for Transgender Care, which since its launch in 2011 has served thousands of providers and policymakers across the U.S. and around the world; the page on hormone administration alone received more than 5000 visitors in the month of November, 2015. These Guidelines complement the existing World Professional Association for Transgender Health Standards of Care and the Endocrine Society Guidelines in that they are specifically designed for implementation in every day evidence-based primary care, including settings with limited resources.[4,5] The overall structure and list of topics for inclusion were developed in consultation with the CoE’s Medical Advisory Board (MAB), a diverse group of expert clinicians from a variety of academic and community based settings. Also contributing to the overall design and structure was a review of the range of consultation requests received by the CoE since the 2011 launch of the original Protocol. The guidelines were then written using an authorship – peer review approach. Primary authors from both within and outside the MAB were invited for individual topics, after which a peer review and modified consensus process was used to arrive at the final guidelines presented here. The diverse authorship allows the development of a broadly applicable document, rather than one that solely reflects the practice at a single academic medical center, such as UCSF. These guidelines would not be possible without the contributions of our Medical Advisory Board and other authors and reviewers, as well as the support of my CoE colleagues JoAnne Keatley, MSW and E. Michael Reyes, MD, MPH, as well as Lissa Moran who assisted immensely with literature reviews, bibliography management, version control, copy editing, formatting, and compiling peer reviewer comments. Ben Zovod also assisted with literature reviews, bibliography management, and compiling peer reviewer comments. Their dedication and hours of hard work has resulted in a final product that is relevant, broadly applicable, evidence based, and scientifically sound. I hope you find these guidelines useful and welcome any feedback or questions, which are June 17, 2016 2 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People helpful in framing future revisions. Thank you for caring about the health of transgender and gender nonconforming people. Madeline B. Deutsch, MD, MPH Editor Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People Director of Clinical Services Center of Excellence for Transgender Health Associate Professor of Clinical Family and Community Medicine Department of Family and Community Medicine University of California, San Francisco Madeline.Deutsch@ucsf.edu

Why screen for heavy drinking?

• At-risk drinking and alcohol problems are common. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. Of these heavy drinkers, about 1 in 4 currently has alcohol abuse or dependence.All heavy drinkers have a greater risk of hypertension, gastro - intestinal bleeding, sleep disorders, major depression, hemorrhagic stroke, cirrhosis of the liver, and several cancers. 
• Heavy drinking often goes undetected. In a recent study of primary care practices, for example, patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10 percent of the time.
• Patients are likely to be more receptive, open, and ready to change than you expect. Most patients don’t object to being screened for alcohol use by clinicians and are open to hearing advice afterward. In addition, most primary care patients who screen positive for heavy drinking or alcohol use disorders show some motivational readiness to change, with those who have the most severe symptoms being the most ready.
• You’re in a prime position to make a difference. Clinical trials have demonstrated that brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who aren’t alcohol dependent.8 Some drinkers who are dependent will accept referral to addiction treatment programs. Even for patients who don’t accept a referral, repeated alcohol-focused visits with a health care provider can lead to significant improvement.
• If you’re not already doing so, we encourage you to incorporate alcohol screening and intervention into your practice. With this Guide, you have what you need to begin.