While much medical literature has been devoted to the evaluation of chest pain in emergency room and acute care settings, relatively few tools have been published for evaluating chest pain in primary care offices. AFP's Deputy Editor for Evidence-Based Medicine, Mark Ebell, MD, MS, addresses this need in the March 1st issue of the journal with a Point-of-Care Guide that includes a five-item clinical decision rule to identify patients with chest pain caused by coronary artery disease. Dr. Ebell then provides a suggested algorithm for integrating decision rule results with ECG findings. Moderate- and high-risk patients should be evaluated further for coronary artery disease, while low-risk patients should generally be evaluated for noncardiac causes of chest pain.
You can find additional information about diagnosis, treatment, and prevention of coronary artery disease in the AFP By Topic collection, and more Point-of-Care Guides on a variety of clinical topics in the Department collection.
Minggu, 06 Maret 2011
Selasa, 01 Maret 2011
Lead screening recommendations: not "one size fits all"
In a Letter to the Editor in the March 1st issue of AFP, Dr. Matt Viel challenges a previous review article's "one size fits all" recommendation to test all Medicaid-enrolled or eligible children for elevated lead levels at one and two years of age. (This recommendation is based on a 2007 practice guideline from the Centers for Disease Control and Prevention.) Pointing out that his county has a known lead poisoning prevalence of less than 0.1 percent, making it unlikely that screening will yield appreciable health benefits, Dr. Veil reports that "our practice loses revenue because Medicaid often denies most or all of our claim for the well-child visit if we do not order lead screening tests."
In her response, Dr. Crista Warniment endorses a more targeted approach to lead screening:
The CDC has released revised guidelines urging local and state health officials to update screening recommendations for lead poisoning in Medicaid-enrolled or -eligible children based on state and local data rather than on insurance status alone. Recent data suggest that the incidence of elevated blood lead levels is decreasing among the Medicaid population in certain areas, approaching the lower risk seen in children not enrolled in or eligible for Medicaid. For example, Minnesota and Wisconsin are among the first states to report less of a disparity in elevated blood lead levels between children who are Medicaid-enrolled or -eligible and those who are not.
It is also worth mentioning that the U.S. Preventive Services Task Force and the AAFP consider the evidence to be "insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children one to five years of age who are at increased risk," and recommend against screening children at average risk. AFP's Putting Prevention Into Practice case study provides further information.
Financial considerations, evidence limitations, and conflicting recommendations make it tempting to simply take a "one size fits all" approach to lead screening, even if this approach is not necessarily in the best interest of our patients. What strategy does your practice use to manage lead screening and similar clinical issues?
In her response, Dr. Crista Warniment endorses a more targeted approach to lead screening:
The CDC has released revised guidelines urging local and state health officials to update screening recommendations for lead poisoning in Medicaid-enrolled or -eligible children based on state and local data rather than on insurance status alone. Recent data suggest that the incidence of elevated blood lead levels is decreasing among the Medicaid population in certain areas, approaching the lower risk seen in children not enrolled in or eligible for Medicaid. For example, Minnesota and Wisconsin are among the first states to report less of a disparity in elevated blood lead levels between children who are Medicaid-enrolled or -eligible and those who are not.
It is also worth mentioning that the U.S. Preventive Services Task Force and the AAFP consider the evidence to be "insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children one to five years of age who are at increased risk," and recommend against screening children at average risk. AFP's Putting Prevention Into Practice case study provides further information.
Financial considerations, evidence limitations, and conflicting recommendations make it tempting to simply take a "one size fits all" approach to lead screening, even if this approach is not necessarily in the best interest of our patients. What strategy does your practice use to manage lead screening and similar clinical issues?
Selasa, 22 Februari 2011
Practical guidance on caring for refugees
According to an article on primary care for refugees that appears in AFP's February 15th issue, more than 600,000 refugees from more than 60 countries have resettled in the United States during the past decade. Although all refugees must pass an overseas medical screening examination to be admitted to the U.S., they often present to family physicians with musculoskeletal and pain issues, mental and social health problems, infectious diseases, and undiagnosed chronic conditions. Additional challenges to providing high-quality primary care for refugees include language barriers, cultural medical beliefs, and low health literacy levels.
It is important to be aware that persons who have immigrated into the U.S. illegally, while having much in common with legal immigrants, will be less likely to have received examinations, immunizations, and infectious disease screenings recommended in domestic refugee health guidelines from the Centers for Disease Control and Prevention.
You can find additional information about caring for ethnic minorities in the AFP By Topic collection on Care of Special Populations.
It is important to be aware that persons who have immigrated into the U.S. illegally, while having much in common with legal immigrants, will be less likely to have received examinations, immunizations, and infectious disease screenings recommended in domestic refugee health guidelines from the Centers for Disease Control and Prevention.
You can find additional information about caring for ethnic minorities in the AFP By Topic collection on Care of Special Populations.
Minggu, 13 Februari 2011
Diphtheria as a cause of sore throat
I read with interest the editorial in AFP's January 1st issue, "Avoiding Sore Throat Morbidity and Mortality: When Is It Not 'Just A Sore Throat'?" It brought back memories. I was surprised that diphtheria was not mentioned as a cause of tonsillitis and sore throat.
I graduated from Minnesota Medical School in 1944 after a 9-month Ob-Gyn residency. I was then sent to Japan to be Chief of Obstetrics and Gynecology at the 118th Station Hospital, 24th Infantry Division, at Fukuoka Kyushu, Japan. On one occasion, as officer of the day, I admitted a newly arrived recruit to the hospital with tonsillitis. A viral culture was taken and a smear swab sent to our lab. He was given sulfanilamide (penicillin was just being tried as a new wonder drug). We had a wake-up call when he died shortly after being admitted. He was a new recruit from a ship docked at Yokohama that was manned mainly by soldiers from the rural South where childhood vaccinations were not always routinely administered. We quickly quarantined the ship's personnel, many of whom were experiencing similar symptoms.
Dr. Cy (Cyrus) Lifshultz, an internist from the northeast U.S., was our medical officer in charge of infectious disease. Dr. Lifshultz stayed up all night with these very sick men, spraying their throats with a hand syringe containing penicillin. He also painstakingly removed the scar tissue that lined the throat and upper lung areas. Dr. Lifschultz never got an award for what he did, but in my opinion, he deserved the Medal of Honor.
Fortunately, routine vaccination has made diphtheria a rare cause of sore throat in the U.S. today. However, when treating unvaccinated populations in other areas of the world, clinicians would be wise to not underestimate diphtheria – it is deadly.
Frederick M. Hass, MD
Minneapolis, Minnesota
I graduated from Minnesota Medical School in 1944 after a 9-month Ob-Gyn residency. I was then sent to Japan to be Chief of Obstetrics and Gynecology at the 118th Station Hospital, 24th Infantry Division, at Fukuoka Kyushu, Japan. On one occasion, as officer of the day, I admitted a newly arrived recruit to the hospital with tonsillitis. A viral culture was taken and a smear swab sent to our lab. He was given sulfanilamide (penicillin was just being tried as a new wonder drug). We had a wake-up call when he died shortly after being admitted. He was a new recruit from a ship docked at Yokohama that was manned mainly by soldiers from the rural South where childhood vaccinations were not always routinely administered. We quickly quarantined the ship's personnel, many of whom were experiencing similar symptoms.
Dr. Cy (Cyrus) Lifshultz, an internist from the northeast U.S., was our medical officer in charge of infectious disease. Dr. Lifshultz stayed up all night with these very sick men, spraying their throats with a hand syringe containing penicillin. He also painstakingly removed the scar tissue that lined the throat and upper lung areas. Dr. Lifschultz never got an award for what he did, but in my opinion, he deserved the Medal of Honor.
Fortunately, routine vaccination has made diphtheria a rare cause of sore throat in the U.S. today. However, when treating unvaccinated populations in other areas of the world, clinicians would be wise to not underestimate diphtheria – it is deadly.
Frederick M. Hass, MD
Minneapolis, Minnesota
Rabu, 09 Februari 2011
Osteochondrosis and joint pain in children
A review article in the February 1st issue of AFP summarizes a group of childhood skeletal disorders known collectively as osteochondrosis:
Osteochondrosis results from abnormal development, injury, or overuse of the growth plate and surrounding ossification centers. Overall, boys are more affected and symptoms generally appear between 10 and 14 years of age. It is thought that boys are more commonly affected because of their greater susceptibility to childhood trauma and overuse injuries. Patients usually present with pain and disability. Areas of the body most often affected include the hip, knee, foot, elbow, and back.
Although the majority of these disorders are self-limited and require only rest and pain control, all patients with possible diagnoses of Legg-Calve-Perthes disease (interruption of vascular supply to the femoral head) or Scheuermann disease (disturbance of the vertebral end plates causing kyphosis, or humpback deformity) should be referred for orthopedic evaluation. In addition, medial eipcondyle apophysitis (better known as "Little League elbow") can be prevented by limiting young athletes' numbers of pitches, curveballs, and sliders.
Osteochondrosis results from abnormal development, injury, or overuse of the growth plate and surrounding ossification centers. Overall, boys are more affected and symptoms generally appear between 10 and 14 years of age. It is thought that boys are more commonly affected because of their greater susceptibility to childhood trauma and overuse injuries. Patients usually present with pain and disability. Areas of the body most often affected include the hip, knee, foot, elbow, and back.
Although the majority of these disorders are self-limited and require only rest and pain control, all patients with possible diagnoses of Legg-Calve-Perthes disease (interruption of vascular supply to the femoral head) or Scheuermann disease (disturbance of the vertebral end plates causing kyphosis, or humpback deformity) should be referred for orthopedic evaluation. In addition, medial eipcondyle apophysitis (better known as "Little League elbow") can be prevented by limiting young athletes' numbers of pitches, curveballs, and sliders.
Rabu, 02 Februari 2011
2011 Immunization Schedules are here
The February 1st issue of AFP contains copies of the new Child and Adolescent and Adult immunization schedules from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP). Dr. Doug Campos-Outcalt, the AAFP's liasion to the ACIP, summarizes the new and revised recommendations in a Practice Guidelines commentary. The paradox of vaccines, he notes, is that the better they work, the harder it is to persuade patients to accept them:
Many of today's physicians have never seen a patient with measles, rubella, polio, or other diseases that in the past were leading causes of morbidity and mortality. One could say that vaccines are a victim of their own success—the better they work, the less they are appreciated. With the absence of vaccine-preventable diseases, the benefit of vaccines goes unnoticed, while exaggerated and false claims of harm receive increasing attention and concern about safety becomes the most important issue to parents. Family physicians now need to spend more time reassuring patients and families of the safety and effectiveness of vaccines.
Speaking of "exaggerated and false claims," the British Medical Journal recently disclosed that Dr. Andrew Wakefield falsified the data for his subsequently retracted 1998 Lancet article that suggested a link between autism and the measles, mumps, and rubella vaccine. Hopefully, this new revelation, as well as a summary of the evidence in the September 15, 2010 AFP Journal Club, will help family physicians "debunk the myth" that childhood vaccines are more likely to harm than help.
Many of today's physicians have never seen a patient with measles, rubella, polio, or other diseases that in the past were leading causes of morbidity and mortality. One could say that vaccines are a victim of their own success—the better they work, the less they are appreciated. With the absence of vaccine-preventable diseases, the benefit of vaccines goes unnoticed, while exaggerated and false claims of harm receive increasing attention and concern about safety becomes the most important issue to parents. Family physicians now need to spend more time reassuring patients and families of the safety and effectiveness of vaccines.
Speaking of "exaggerated and false claims," the British Medical Journal recently disclosed that Dr. Andrew Wakefield falsified the data for his subsequently retracted 1998 Lancet article that suggested a link between autism and the measles, mumps, and rubella vaccine. Hopefully, this new revelation, as well as a summary of the evidence in the September 15, 2010 AFP Journal Club, will help family physicians "debunk the myth" that childhood vaccines are more likely to harm than help.
Minggu, 30 Januari 2011
Who should teach patients about nutrition?
A recent national survey published in the journal Academic Medicine found that on average, U.S. medical students receive less than 20 hours of education about nutrition in all four years of medical school, a figure that has decreased since 2004. Since improving patients' dietary habits plays a crucial role in the management of many common conditions, AFP is committed to providing our readers with practical nutritional information in articles such as "Diet and Exercise in the Treatment of Hyperlipidemia," in the May 1, 2010 issue.
In a Letter to the Editor in the January 15th issue, however, Dr. Sean Lucan points out that translating advice about food constituents into guidance that patients can easily understand is easier said than done:
[The article] mentions a food constituent, saturated fats, as a prime target for dietary reduction in patients with dyslipidemia. The problem is that people do not eat saturated fat; they eat foods. So what foods should patients avoid to limit their intake of saturated fat? Dr. Kelly describes one option, the Mediterranean Diet, as recommending “low consumption of saturated fats” and “limited consumption of red meat and dairy products.” In fact, with regard to lipids, red meat, dairy, and saturated fats are one and the same; the former two being the principal dietary sources of the latter. Unfortunately, few people know this because medical science tends to reduce foods to their constituent parts, and because the beef and dairy industries work hard to ensure that consumers do not make connections between undesired abstract nutritional constituents and food.
One might question whether family physicians are really the most qualified professionals to educate patients about basic and specialized nutrition issues, given the limited education that we receive. Wouldn't it be nice to have a nutritionist routinely available to counsel patients about what to eat? Unfortunately, most insurers will not pay practices for dietary education given by anyone except a physician, if they pay anything at all.
In a Letter to the Editor in the January 15th issue, however, Dr. Sean Lucan points out that translating advice about food constituents into guidance that patients can easily understand is easier said than done:
[The article] mentions a food constituent, saturated fats, as a prime target for dietary reduction in patients with dyslipidemia. The problem is that people do not eat saturated fat; they eat foods. So what foods should patients avoid to limit their intake of saturated fat? Dr. Kelly describes one option, the Mediterranean Diet, as recommending “low consumption of saturated fats” and “limited consumption of red meat and dairy products.” In fact, with regard to lipids, red meat, dairy, and saturated fats are one and the same; the former two being the principal dietary sources of the latter. Unfortunately, few people know this because medical science tends to reduce foods to their constituent parts, and because the beef and dairy industries work hard to ensure that consumers do not make connections between undesired abstract nutritional constituents and food.
One might question whether family physicians are really the most qualified professionals to educate patients about basic and specialized nutrition issues, given the limited education that we receive. Wouldn't it be nice to have a nutritionist routinely available to counsel patients about what to eat? Unfortunately, most insurers will not pay practices for dietary education given by anyone except a physician, if they pay anything at all.
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