practice guidelines as topic

Guidance regarding how to triage adults with symptoms of urinary tract infection. I'm not sure it applies well to older women who may have UTI-like symptoms related to atrophic changes in the urethra. James W. Mold, MD, MPH

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Importance: Urinary tract infection (UTI) is common in ambulatory care settings and the primary reason for antibiotic prescribing. Despite several guidelines focused on the type and duration of antibiotics prescribed for treating UTI, there is limited outpatient guidance on how to best triage patients with presumed UTI.

Objective: To assess the appropriateness of different triage and management recommendations involving empiric antibiotics, urine testing strategies, and visit types and how these recommendations vary by patient sex, age, presenting symptoms, and clinical history.

Evidence review: Using the RAND/UCLA Appropriateness Method, a 13-member multidisciplinary panel (physicians, advanced practice providers, and nurses) performed a scoping review of the literature publications from 2009 to June 2024 and rated the appropriateness of 136 clinical scenarios (48 for women, 49 for men, and 39 scenarios not specific to sex) with up to 9 management strategies per scenario for a total of 1094 scenarios. For each scenario, experts rated the appropriateness of empiric treatment, types of urine testing, and triage to visit type (in-person, virtual, or none) as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. Appropriateness ratings were summarized into 2 groups: nonpregnant adult women and adult men.

Findings: Major recommendations based on symptoms included (1) same-day in-person evaluation if symptoms were concerning for pyelonephritis, complicated cystitis, or urinary obstruction; (2) a visit if additional nonurinary symptoms were present (ie, diarrhea, genital discharge, or cough); (3) neither urine testing nor empiric treatment solely due to a change in urine color or appearance without other bladder (cystitis) symptoms; (4) empiric treatment without testing or a visit, for women, if there were new classic cystitis symptoms of dysuria, urinary frequency, urgency, or suprapubic pain without risks for antibiotic resistance; (5) urinalysis with culture (ideally reflexed to culture) before taking first antibiotic dose for women at risk of antibiotic resistance (eg, recent antibiotic treatment for UTI or recurrent UTIs) and all men; and (6) empiric treatment considered for patients with barriers to obtaining timely urine testing or visits.

Conclusions and relevance: The appropriateness of empiric antibiotics, urine testing, and different clinical evaluation options were defined for adults presenting with concerns for UTI in common ambulatory triage settings, including telehealth. These criteria for ambulatory triage of suspected UTI symptoms in adults are anticipated to help standardize and improve the appropriateness of empiric antibiotic prescribing, urine testing, and visit type triage.

Author/s:

Jennifer Meddings, Kristin Chrouser, Karen E. Fowler

Lung Cancer in Nonsmoking Individuals: A Review

Megan George — Tue, 02 Dec 2025 15:53:35 +0000

Date Added:

December 2, 2025

Journal/Publication:

JAMA

Publication Date:

October 20, 2025

URL:

Lung Cancer in Nonsmoking Individuals: A Review

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.1001/jama.2025.17695

Keywords

Early Detection of Cancer

PMID (1):

41114991

MeSH

Adenocarcinoma* / diagnosis

Adenocarcinoma* / epidemiology

Adenocarcinoma* / genetics

Adenocarcinoma* / therapy

Anaplastic Lymphoma Kinase / genetics

Carcinoma

Adenosquamous* / diagnosis

Adenosquamous* / epidemiology

Adenosquamous* / genetics

Adenosquamous* / therapy

Squamous Cell* / diagnosis

Squamous Cell* / epidemiology

Squamous Cell* / genetics

Squamous Cell* / therapy

Chemoradiotherapy

Adjuvant / methods

Early Detection of Cancer / standards

ErbB Receptors / genetics

Lung Neoplasms* / diagnosis

Lung Neoplasms* / epidemiology

Lung Neoplasms* / genetics

Lung Neoplasms* / therapy

male

Mass Screening / standards

Mutation

Neoplasm Staging

Non-Smokers* / statistics & numerical data

Pneumonectomy

practice guidelines as topic

Receptor Protein-Tyrosine Kinases / antagonists & inhibitors

Receptor Protein-Tyrosine Kinases / genetics

risk factors

Sex Factors

Small Cell Lung Carcinoma* / diagnosis

Small Cell Lung Carcinoma* / epidemiology

Small Cell Lung Carcinoma* / genetics

Small Cell Lung Carcinoma* / therapy

Smoking / adverse effects

tomography

X-Ray Computed / standards

Tyrosine Kinase Inhibitors / therapeutic use

A review of current knowledge regarding lung cancer in non-smokers. James W. Mold, MD, MPH

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Importance: Lung cancer in nonsmoking individuals (defined as people who have smoked fewer than 100 cigarettes in their lifetime) accounts for 15% to 20% of all lung cancer cases worldwide. In the US, the annual incidence of lung cancer in nonsmoking individuals is 14.4 to 20.8 per 100 000 person-years in females and 4.8 to 12.7 per 100 000 person-years in males.

Observations: Most lung cancers in nonsmoking individuals are histologically adenocarcinomas (60%-80%) with the remainder being squamous or adenosquamous (10%-20%) and rarely small cell lung cancer (<10%). Risk factors include exposure to passive smoking, radon exposure, air pollution, asbestos, and history of lung cancer in a first-degree family member. Therapeutically targetable genomic variants, such as EGFR mutations or ALK gene rearrangements, are more common in tumors from nonsmoking individuals compared with those with a smoking history (defined as people who currently or formerly smoked) (43% vs 11% for EGFR and 12% vs 2% for ALK). In contrast, tumor mutation burden, the number of somatic mutations in a tumor cell, is lower in lung cancer among nonsmoking individuals (0-3 mutations/megabase [Mb] vs 0-30 mutations/Mb). Similar to individuals with a history of smoking, nonsmoking individuals with lung cancer may present with wheeze, chest pain, dyspnea, hemoptysis, or symptoms attributable to metastatic disease (eg, bone pain and headache) or be diagnosed with incidentally detected disease. The US Preventive Services Task Force does not currently recommend lung cancer screening with low-dose computed tomographic scans for nonsmoking individuals, although screening guidelines vary globally. Treatment typically involves a combination of surgery, radiotherapy, and systemic therapies depending on stage, performance status, and molecular features of the tumor. Comprehensive next-generation sequencing should be performed on stage Ib to IIIa lung cancer tumor tissue from nonsmoking individuals because actionable genomic alterations, such as EGFR mutations or ALK gene rearrangements, are treated with targeted therapy such as the tyrosine kinase inhibitors osimertinib or lorlatinib, respectively. Median survival among nonsmoking individuals with advanced non-small cell lung cancer (stage IIIb or higher) and actionable genomic alterations can exceed 3 to 5 years, while survival without these genomic alterations is similar to lung cancer in people with a history of smoking (1-2 years).

Conclusions: Lung cancer in nonsmoking individuals accounts for 15% to 20% of lung cancer cases worldwide. Among patients with lung cancer, nonsmoking individuals are more likely to have genomic alterations such as EGFR mutations or ALK gene rearrangements, and these patients have improved survival when treated with tyrosine kinase inhibitors compared with chemotherapy.

Author/s:

Cian Murphy, Tej Pandya, Charles Swanton

Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians

Bethie Seay — Tue, 25 May 2021 05:00:00 +0000

Date Added:

May 25, 2021

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.7326/M15-1496

PMID (1):

26810935

MeSH

Adult

asymptomatic diseases

physicians, primary care

Platelet Aggregation Inhibitors

practice guidelines as topic

practice patterns, physicians'

referral and consultation

risk factors

urinalysis

urologic neoplasms

A quick summary of ACP guidance regarding evaluation of hematuria in adults.

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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.

Author/s:

Nielsen, Matthew, Qaseem, Amir, High Value Care Task Force of the American College of Physicians