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Automated Requests for Thyroid-Stimulating Hormone and Ferretin Tests in Young Primary Care Patients with Anorexia as an Intervention to Improve Detection of Underlying Conditions.
Salinas, M, López-Garrigós, M, Flores, E, Leiva-Salinas, C
Laboratory medicine. 2019;(3):268-272
Abstract
OBJECTIVE To improve clinical laboratory contribution to the treatment of primary care patients with anorexia through automated computerized strategies. METHODS We recorded the number of laboratory requests due to anorexia; the demographic data, laboratory values, and presence of pathological values for the applicable patients. In a prospective study, the laboratory information management system (LIMS) automatically added thyroid-stimulating hormone (TSH) and/or ferritin testing when it was not requested by general practitioners for all primary care patients with anorexia who were younger than 16 years. RESULTS A total of 3562 patients underwent laboratory testing due to anorexia, of whom 47% were younger than 16 years. The tests in which the results most frequently were abnormal were hemoglobin, ferritin, and TSH. TSH results were abnormal in 20% of patients younger than 16 years. Through the intervention, we detected 3 low ferritin values and 7 cases of pathological TSH levels. CONCLUSIONS The LIMS required TSH and ferritin testing in young patients even when not requested, potentially avoiding the adverse effects of iron deficiency and thyroid disorders on neurological development and cognition in those patients.
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A randomized control trial of primary care-based management of type 2 diabetes by a pharmacist in Pakistan.
Javaid, Z, Imtiaz, U, Khalid, I, Saeed, H, Khan, RQ, Islam, M, Saleem, Z, Sohail, MF, Danish, Z, Batool, F, et al
BMC health services research. 2019;(1):409
Abstract
BACKGROUND The role of a pharmacist in primary health care settings of Pakistan is still obscure. Thus, we aimed to demonstrate the pharmacist-led improvements in glycemic, blood pressure and lipid controls in type 2 diabetes mellitus (T2DM) patients of Lahore, Pakistan. METHODS The first open label, randomized control trial conducted at a primary health care facility of Lahore, Pakistan by enrolling 244 uncontrolled type 2 diabetes (hemoglobin A1 c, (HbA1c); 10.85 ± 1.74) patients. The pharmacological intervention included identification of drug related problems, drug interactions, change in dose, frequency and therapy switches in collaboration with physician, while non-pharmacological intervention consisted of diet, lifestyle and behavior counseling. Outcome measures were glycemic (HbA1c), blood pressure and lipid controls. RESULTS In intra-group comparison, compared to control arm (C, n = 52), subjects in the intervention arm (I, n = 83) demonstrated significant differences in process outcome measures; baseline vs final, such as HbA1c (C; 10.3 ± 1.3 vs 9.7 ± 1.3, p < 0.001, I; 10.9 ± 1.7 vs 7.7 ± 0.9, p < 0.0001), systolic blood pressure (SBP) (C; 129.9 ± 13.9 vs 136 ± 7.1, p = 0.0001, I; 145 ± 20.4 vs 123.9 ± 9.9 mmHg, p < 0.0001), diastolic blood pressure (DBP) (C; + 4, p = 0.03, I; - 7 mmHg, p < 0.0001), cholesterol (C; 235.8 ± 57.7 vs 220.9 ± 53.2, p = 0.15, I; 224 ± 55.2 vs 153 ± 25.9 mg/dL, p < 0.0001), triglycerides (C; 213.2 ± 86.6 vs 172.4 ± 48.7, p = 0.001, I; 273 ± 119.4 vs 143 ± 31.6 mg/dL, p < 0.0001) and estimated glomerular filtration rate (eGFR) (C; 77.5 ± 18.6 vs 76 ± 14.2, p = 0.5, I; 69.4 ± 21.3 vs 93.8 ± 15.2 ml/min/1.73m2, p < 0.0001). Likewise, inter-group improvements were more significant in the subjects of intervention group at final follow up in comparison to control for various process outcome measures; HbA1c (p < 0.001), SBP (p < 0.0001), DBP (p = 0.02), cholesterol (p < 0.0001), triglycerides (p < 0.0001), SCr (p < 0.001), eGFR (p < 0.001). Moreover, both male and female subjects exhibited similar responses towards intervention with similar improvements in outcome measures. CONCLUSION These data suggested that pharmacist intervention in collaboration with physician in primary health care settings may result in significant improvements in glycemic, blood pressure and lipid controls in Pakistani population. TRIAL REGISTRATION The trial was registered retrospectively with International Standard Registered Clinical/soCial sTudy Number (ISRCTN) registry on July 26, 2017 under nutritional, metabolic, endocrine category with assigned registration # ISRCTN22657497 and can be assessed at https://doi.org/10.1186/ISRCTN22657497.
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Which patients benefit from physical activity on prescription (PAP)? A prospective observational analysis of factors that predict increased physical activity.
Lundqvist, S, Börjesson, M, Larsson, MEH, Cider, Å, Hagberg, L
BMC public health. 2019;(1):482
Abstract
BACKGROUND There is robust evidence that regular physical activity (PA) has positive health effects. However, the best PA methods and the most important correlates for promoting PA remain unclear. Physical activity on prescription (PAP) aims to increase the patient's motivation for and level of PA. This study investigated possible predictive baseline correlates associated with changes in the PA level over a 6-month period of PAP treatment in order to identify the primary care patients most likely to benefit from a PAP intervention. METHODS The study included 444 patients with metabolic risk factors who were aged 27 to 85 years and physically inactive. The patients received PAP treatment that included individual counseling plus an individually-tailored PA recommendation with a written prescription and individualised structured follow-up for 6 months. Eight baseline correlates of PA were analysed against the PA level at the 6-month follow-up in a predictor analysis. RESULTS Five baseline correlates predicted the PA level at the 6-month follow-up: self-efficacy expectations for changing PA; the patient's preparedness and confidence regarding readiness to change PA; a BMI < 30; and a positive valued physical health. The proportion of patients increasing the PA level and achieving a PA level that was in accordance with public health recommendations was higher with a positive valued baseline correlate. The odds of achieving the recommended PA level increased substantially when 2 to 4 predictive correlates were present. PA levels increased to a greater extent among patients with low PA at baseline than patients with high PA at baseline, especially in combination with 2 to 4 positively-valued correlates (87-95% vs. 62-75%). CONCLUSIONS This study identified potential predictive correlates of an increased PA level after a 6-month PAP intervention. This contributes to our understanding of PAP and could help individualise PAP support. The proportion of patients with the lowest PA level at baseline increased their PA level in a higher extent (84%) and thus may benefit the most from PAP. These results have clinical implications for behavioural change in those patients having the greatest health gains by increasing their PA level. TRIAL REGISTRATION ClinicalTrials.gov ; NCT03586011 . Retrospectively registered on July 17, 2018.
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Addressing adverse childhood experiences and health risk behaviors among low-income, Black primary care patients: Testing feasibility of a motivation-based intervention.
Goldstein, E, Topitzes, J, Birstler, J, Brown, RL
General hospital psychiatry. 2019;:1-8
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Abstract
OBJECTIVE This pilot study tests the feasibility of implementing a two-session intervention that addresses adverse childhood experiences (ACEs), post-traumatic stress symptoms, and health risk behaviors (HRBs) among Black primary care patients. African Americans are disproportionately exposed to stressful and traumatic events and are at greater risk for PTSD than the general population. METHOD A prospective cohort, experimental (pre-post) design with 2 post-intervention assessments were used to evaluate the feasibility of a motivation-based intervention for Black primary care patients with one or more ACEs. Indicators of feasibility implementation outcomes were assessed by participant adherence to treatment; suitability, satisfaction, and acceptability of the intervention; in addition to clinical outcomes of stress, HRBs, and behavioral health referral acceptance. RESULTS Out of 40 intervention participants, 36 completed the intervention. Of the patients with one or more ACEs who participated in the intervention, 65% reported 4 or more ACEs and 58% had positive PTSD screens, and nearly two-thirds of those had at least one HRB. Satisfaction with the program was high, with 94% of participants endorsing "moderately" or "extremely" satisfied. The sample showed significant post-intervention improvements in stress, alcohol use, risky sex, and nutrition habits. Although stress reduction continued through 2-month follow-up, unhealthy behaviors rebounded. Almost one-third of participants were connected to behavioral health services. CONCLUSIONS Brief motivational treatment for ACEs is feasible in underserved primary care patients and could help individuals develop healthier ways of coping with stress and improve health.
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The Balance protocol: a pragmatic weight gain prevention randomized controlled trial for medically vulnerable patients within primary care.
Berger, MB, Steinberg, DM, Askew, S, Gallis, JA, Treadway, CC, Egger, JR, Kay, MC, Batch, BC, Finkelstein, EA, DeVries, A, et al
BMC public health. 2019;(1):596
Abstract
BACKGROUND For patients with obesity who are not ready for or experience barriers to weight loss, clinical practice guidelines recommend provider counseling on preventing further weight gain as a first-line treatment approach. Unfortunately, evidence-based weight gain prevention interventions are not routinely available within primary care. To address this gap, we will implement a pragmatic 12-month randomized controlled trial of a digital weight gain prevention intervention delivered to patients receiving primary care within a network of Federally Qualified Community Health Centers in central North Carolina. METHODS Balance (Equilibrio in Spanish) is a pragmatic effectiveness trial that will randomize adult patients who have overweight or obesity (BMI of 25-40 kg/m2) to either: 1) a weight gain prevention intervention with tailored behavior change goals and tracking, daily weighing on a network-connected electronic scale, and responsive weight and goal coaching delivered remotely by health center registered dietitians; or 2) a usual care program with automated healthy living text messages and print materials and routine primary care. The primary outcome will be weight gain prevention at 24-months, defined as ≤3% change in baseline weight. To align with its pragmatic design, trial outcome data will be pulled from the electronic health record of the community health center network. DISCUSSION For underserved, often rurally-located patients with obesity, digital approaches to promote a healthy lifestyle can curb further weight gain. Yet enrolling medically vulnerable patients into a weight gain prevention trial, many of whom are from racial/ethnic minorities, can be difficult. Despite these potential challenges, we plan to recruit a large, diverse sample from rural areas, and will implement a remotely-delivered weight gain prevention intervention to medically vulnerable patients. Upcoming trial results will demonstrate the effectiveness of this pragmatic approach to implement and evaluate a digital weight gain prevention intervention within primary care. TRIALS REGISTRATION NCT03003403 . Registered December 28, 2016.
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Health Promotion and Obesity in the Arab Gulf States: Challenges and Good Practices.
Samara, A, Andersen, PT, Aro, AR
Journal of obesity. 2019;:4756260
Abstract
This debate paper focuses on available strategies, policies, and challenges of health promotion for combating obesity in the Arab Gulf states (Saudi Arabia, Bahrain, Kuwait, Oman, and Qatar). The paper focuses on the abovementioned countries due to their similarity on many aspects and because of their alarming obesity rates that are on the rise and keep increasing. The paper argues that there are significant efforts to be made in sectors such as policies, intersectoral work, primary healthcare, health promotion strategies development, and qualified personnel for health promotion and health education. Among the six states, Qatar, United Arab Emirates, and to a degree Oman have shown some development with regard to the implementation and evaluation of obesity-related health promotion policies, and thus other Arab Gulf countries could be inspired by existing good practices and move from good intentions to using their available wealth to invest in the implementation and evaluation of published policies and strategies. All Arab Gulf countries are in need of more qualified personnel and the development of infrastructure that can help tackle the growing obesity challenge that such countries are experiencing.
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Clinically Relevant Drug-Drug Interactions in Primary Care.
Carpenter, M, Berry, H, Pelletier, AL
American family physician. 2019;(9):558-564
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Drug interactions are common in the primary care setting and are usually predictable. Identifying the most important and clinically relevant drug interactions in primary care is essential to patient safety. Strategies for reducing the risk of drug-drug interactions include minimizing the number of drugs prescribed, re-evaluating therapy on a regular basis, considering nonpharmacologic options, monitoring for signs and symptoms of toxicity or effectiveness, adjusting dosages of medications when indicated, and adjusting administration times. Inhibition or induction of cytochrome P450 drug metabolizing isoenzymes is the most common mechanism by which clinically important drug interactions occur. The antimicrobials most likely to affect the international normalized ratio significantly in patients receiving warfarin are trimethoprim/sulfamethoxazole, metronidazole, and fluconazole. An empiric warfarin dosage reduction of 30% to 50% upon initiation of amiodarone therapy is recommended. In patients receiving amiodarone, limit dosages of simvastatin to 20 mg per day and lovastatin to 40 mg per day. Beta blockers should be tapered and discontinued several days before clonidine withdrawal to reduce the risk of rebound hypertension. Spironolactone dosages should be limited to 25 mg daily when coadministered with potassium supplements. Avoid prescribing opioid cough medicines for patients receiving benzodiazepines or other central nervous system depressants, including alcohol. Physicians should consider consultation with a clinical pharmacist when clinical circumstances require the use of drugs with interaction potential.
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A multimodal and multidisciplinary program to prevent loss of mobility in patients aged over 70 years: study protocol of a multicenter cluster randomized study in primary care (the PRISME-3P study).
Perrotin, S, Gilbert, T, Dupuis, M, Villeneuve, L, Bin-Dorel, S, Klich, A, Letrilliart, L, Bonnefoy, M
BMC geriatrics. 2019;(1):48
Abstract
BACKGROUND Reduced mobility is the first sign of functional decline and can lead to dependency in elderly people. Screening for the risk of mobility limitation in this population is an important public health issue to prevent further disabilities. Despite the current lack of guidelines, primary care healthcare providers may have a central role to play in this type of screening. Multi-domain physical exercise interventions in older persons have shown some efficacy/effectiveness on frailty status, yet, to the best of our knowledge, no published study has focused on patients screened in primary care. METHOD The PRISME-3P study is a national, interventional, multicenter, cluster randomized trial. Patients over 70 years of age will be systematically screened by their general practitioner (GP) on the basis of clinical criteria of mobility limitation. To avoid contamination bias, the unit of randomization will be the GP practice. In the intervention group, patients will consult a geriatrician and a dietician, and will receive a physical training program from a personal trainer who will demonstrate the exercises and provide follow-up coaching. The control group will receive standard care. The primary outcome will be the change in Short Physical Performance Battery (SPPB) scores between inclusion and 6-months follow-up. DISCUSSION We expect an improvement of the SPPB between inclusion and 6 months of follow-up. TRIAL REGISTRATION This study is registered in ClinicalTrials.gov ( NCT02847871 , 27 July 2016).
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Effect of Electronic Health Record-Based Coaching on Weight Maintenance: A Randomized Trial.
Conroy, MB, McTigue, KM, Bryce, CL, Tudorascu, D, Gibbs, BB, Arnold, J, Comer, D, Hess, R, Huber, K, Simkin-Silverman, LR, et al
Annals of internal medicine. 2019;(11):777-784
Abstract
BACKGROUND Weight regain after intentional loss is common. Most evidence-based weight management programs focus on short-term loss rather than long-term maintenance. OBJECTIVE To evaluate the benefit of coaching in an electronic health record (EHR)-based weight maintenance intervention. DESIGN Randomized controlled trial. (ClinicalTrials.gov: NCT01946191). SETTING Practices affiliated with an academic medical center. PARTICIPANTS Adult outpatients with body mass index (BMI) of 25 kg/m2 or higher, intentional weight loss of at least 5% in the previous 2 years, and no bariatric procedures in the previous 5 years. INTERVENTION Participants were randomly assigned to EHR tools (tracking group) versus EHR tools plus coaching (coaching group). The EHR tools included weight, diet, and physical activity tracking flow sheets; standardized surveys; and reminders. The coaching group received 24 months of personalized coaching through the EHR patient portal, with 24 scheduled contacts. MEASUREMENTS The primary outcome was weight change at 24 months. Secondary outcomes included 5% weight loss maintenance and changes in BMI, waist circumference, number of steps per day, health-related quality of life, physical function, blood pressure, and satisfaction. RESULTS Among 194 randomly assigned participants (mean age, 53.4 years [SD, 12.2]; 143 [74%] women; 171 [88%] white), 157 (81%) completed the trial. Mean baseline weight and BMI were 85.8 kg (SD, 19.1) and 30.4 kg/m2 (SD, 5.9). At 24 months, mean weight regain (± SE) was 2.1 ± 0.62 kg and 4.9 ± 0.63 kg in the coaching and tracking groups, respectively. The between-group difference in weight change at 24 months was significant (-2.86 kg [95% CI, -4.60 to -1.11 kg]) in the linear mixed model. At 24 months, 65% of participants in the coaching group and 50% in the tracking group maintained weight loss of at least 5%. LIMITATION Single-site trial, which limits generalizability. CONCLUSION Among adults with intentional weight loss of at least 5%, use of EHR tools plus coaching resulted in less weight regain than EHR tools alone. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality and National Institutes of Health.
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Top studies relevant to primary care from 2018: From PEER.
Perry, D, Moe, S, Korownyk, C, Lindblad, AJ, Kolber, MR, Thomas, B, Ton, J, Garrison, S, Allan, GM
Canadian family physician Medecin de famille canadien. 2019;(4):260-263
Abstract
OBJECTIVE To summarize high-quality studies for 10 topics from 2018 that have strong relevance to primary care practice. QUALITY OF EVIDENCE Study selection involved routine literature surveillance by a group of primary care health professionals. This included screening abstracts of important journals and Evidence Alerts, as well as searching ACP Journal Club. MAIN MESSAGE Topics of the 2018 articles include whether low-dose acetylsalicylic acid improves health outcomes like cardiovascular disease (CVD); whether a low-carbohydrate diet is better than a low-fat diet for weight loss (and whether genetics matter); whether vaginal estradiol is superior to placebo for vulvovaginal symptoms of menopause; whether opioid management is better than nonopioid management for chronic back or osteoarthritis pain; whether additional water intake will decrease recurrent urinary tract infections; whether omega-3 fatty acids prevent CVD or reduce dry eyes; whether the new drug icosapent improves CVD; whether bath additives help eczema; whether acetaminophen can prevent recurrent febrile seizures; and recommendations for glycemic targets in diabetes based on reviews of evidence and other guidelines. Five "runner-up" studies are also briefly reviewed. CONCLUSION Research from 2018 produced several high-quality studies in CVD but also spanned the breadth of primary care including pediatrics, women's health, and pain management, among other areas.