Este es un blog medico que nunca podrá sustituir el buen juicio médico en la toma de decisiones.Intentamos compartir con los profesionales nuestras experiencias, conocimientos,lecturas,etc con la finalidad de mejorar la practica clinica.No es un blog para pacientes aunque no rechazamos sus comentarios
Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults
The US Preventive Services Task Force (USPSTF) has recently published recommendations on screening for intimate partner violence, elder abuse, and abuse of vulnerable adults.
The Problem of Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults
Intimate partner violence, also called domestic or dating violence, can be physical, sexual, or psychological (for example, stalking). It is a major problem in the United States, with potentially serious health effects including injury, mental illness, substance abuse, unintended pregnancy, and death.
Elder abuse refers to harm caused to an adult older than 60 years by a trusted person such as a family member or caregiver. Abuse of vulnerable adults refers to harm caused to someone who cannot care for himself or herself because of old age, disability, or both. Abuse in these situations can be physical, sexual, psychological, neglectful, or financial.
What Tests Are Used to Screen for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults?
There are several questionnaires that are used for screening for intimate partner violence. Examples include the Humiliation, Afraid, Rape, Kick (HARK); Hurt/Insult/Threaten/Scream (HITS); Extended Hurt/Insult/Threaten/Scream (E-HITS); Partner Violence Screen (PVS); and Woman Abuse Screening Tool (WAST). The USPSTF did not find any reliable screening tools for elder abuse or abuse of other vulnerable adults.
What Is the Patient Population Under Consideration for Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults?
This USPSTF recommendation applies to women of reproductive age as well as older or vulnerable adults without recognized signs and symptoms of abuse.
What Are the Potential Benefits and Harms of Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults?
The potential benefit of screening for intimate partner violence is finding and helping women of reproductive age who are at risk. There is evidence that available screening questionnaires can detect cases of intimate partner violence, and there is also evidence that providing interventions (ongoing support services) for women of reproductive age who screen positive reduces violence, abuse, and physical or mental harm. There is currently not enough evidence on potential harms of screening for intimate partner violence, but they are most likely small. There is also currently not enough evidence on potential benefits vs harms of screening for abuse of older or vulnerable adults.
How Strong Is the Recommendation to Screen for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults?
The USPSTF concludes with moderate certainty that screening for intimate partner violence in women of reproductive age and providing women who screen positive with ongoing support services has a moderate net benefit. The USPSTF concludes that there is not enough evidence to assess the balance of benefits vs harms of screening for elder abuse or abuse of vulnerable adults.
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Article Information
Source: US Preventive Services Task Force. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force final recommendation statement [published October 23, 2018]. JAMA. doi:10.1001/jama.2018.14741
The impact of e-visits on patient access to primary care
To improve patient access to primary care, many healthcare organizations have introduced electronic visits (e-visits) to provide patient-physician communication through secure messages. However, it remains unclear how e-visit affects physicians' operations on a daily basis and whether it would increase physicians' panel size. In this study, we consider a primary care physician who has a steady patient panel and manages patients' office and e-visits, as well as other indirect care tasks. We use queueing-based performance outcomes to evaluate the performance of care delivery. The results suggest that improved operational efficiency is achieved only when the service time of e-visits is smaller enough to compensate the effectiveness loss due to online communications. A simple approximation formula of the relationship between e-visit service time and e-visit to office visit referral ratio is provided serving as a guideline for evaluating the performance of e-visit implementation. Furthermore, based on the analysis of the impact of e-visits on physician's capacity, we conclude that it is not the more e-visits the better, and the condition for maximal panel size is investigated. Finally, the expected outcomes of implementing e-visits at Dean East Clinic are discussed.
La nueva vacuna de la gripe en Asturias: más efectiva y más cara
La campaña de vacunación antigripal comenzará el lunes y durará hasta final de año
LAURA MAYORDOMOOviedo.
Viernes, 12 octubre 2018, 08:26
'La gripe no es un resfriado, es una enfermedad infecciosa muy contagiosa. Puede causar dolor de garganta, de cabeza, tos, cansancio, fiebres altas o, incluso, la muerte'. Con este mensaje, visible en dípticos y carteles, pretende la Consejería de Salud convencer al 65% de la población mayor de 65 años -el grupo de riesgo más numeroso- de la conveniencia de vacunarse. El año pasado apenas lo hicieron el 55%. Una tasa que «es necesario mejorar», reconoció el director general de Salud Pública, Antonio Molejón. En la pasada campaña hubo cerca de un centenar de casos graves y 19 personas fallecidas. De ellas, la mitad no se había vacunado.
Las 220.000 dosis que se han adquirido este año (8.000 más que el año pasado) ya se encuentran en los 500 puntos de vacunación en los que, a partir del lunes y hasta el 31 de diciembre (o febrero, mientras siga habiendo existencias) se podrán dispensar a la población que integra los grupos de riesgo. Es decir, a los mayores de 65 años, los enfermos crónicos de cualquier edad, las embarazadas, las personas con obesidad importante y los residentes en centros de atención a enfermos crónicos o residencias. Un año más, la campaña de vacunación también va dirigida a quienes cuidan o conviven con estos grupos de riesgo y al propio personal sanitario.
La Consejería de Sanidad ha desembolsado 1.059.000 euros en la adquisición de 158.000 vacunas reforzadas con adyuvante -una sustancia química que mejora la respuesta inmune- y 62.000 dosis de la tetravalente -«con una protección directa mayor tanto para los dos tipos de virus A como para los dos linajes del virus B», explicó Ismael Huerta, responsable del Servicio de Vigilancia Epidemiológica del Principado.
Cada dosis de esta vacuna, la tetravalente, cuesta 5,95 euros. Prácticamente el doble que la trivalente (2,7 euros), que es la que estaba disponible en anteriores campañas. La vacuna con adyuvante sale a 4,5 euros. «Pero no consideramos que sea un gasto, sino una inversión en salud», remarcó Molejón.
La novedad de este año es que habrá una profilaxis específica para cada persona en función de su edad. Así, la tetravalente queda reservada a los menores de 65 años incluidos en los grupos de riesgo mientras que la vacuna con adyuvante irá destinada a los mayores de 65. «Son las mejores vacunas disponibles para asegurar la mayor protección», apuntó el director general de Salud Pública.
Se pretende así reducir el impacto de una gripe que en las últimas campañas se ha cebado con la población infantil y, sobremanera, con la de los mayores de 65 años. Se ha visto que en este grupo de población las vacunas clásicas no han funcionado bien. También, que existe una relación directa «clara» entre la tasa de cuadros graves y de mortalidad y la de vacunación. El crecimiento de los casos de gravedad y los fallecimientos crece «de manera exponencial» cuanto menor es la inmunización.
«Es impredecible»
¿Cómo viene la gripe de este año? Para responder a esta pregunta se suele observar lo ocurrido previamente en el hemisferio sur, pero la variedad de virus ha sido tal que la conclusión es que «nos podemos encontrar con cualquier cosa. La gripe es muy impredecible», reconoció Ismael Huerta. Así, en las dos últimas campañas, la fase epidémica se adelantó respecto a lo acontecido otros años y los picos de mayor incidencia se registraron ya en noviembre.
La vacunación es la herramienta más eficaz para evitar complicaciones graves en una enfermedad infecciosa que puede llegar incluso a causar la muerte. «La vacuna salva vidas», insistió Molejón. Además, es gratuita. Para recibirla solo hay que pedir cita previa en el centro de salud.
Frequency and Associations of Prescription Nonsteroidal Anti-inflammatory Drug Use Among Patients With a Musculoskeletal Disorder and Hypertension, Heart Failure, or Chronic Kidney Disease | Cardiology | JAMA Internal Medicine | JAMA Network
Frequency and Associations of Prescription Nonsteroidal Anti-inflammatory Drug Use Among Patients With a Musculoskeletal Disorder and Hypertension, Heart Failure, or Chronic Kidney Disease
Key Points
QuestionWhat are the frequency and associations of nonsteroidal anti-inflammatory drug (NSAID) use among patients with hypertension, heart failure, or chronic kidney disease?
FindingsAmong a retrospective cohort of more than 2.4 million musculoskeletal-related primary care visits by 814 049 older adult patients with hypertension, heart failure, or chronic kidney disease, 9.3% of visits resulted in prescription NSAID use within the following 7 days. Prescription NSAID use was not associated with increased risk of safety-related outcomes at 37 days.
MeaningPrescription NSAID use was common among high-risk patients, with widespread physician-level variation; however, use had no association with acute safety-related outcomes.
Abstract
ImportanceInternational nephrology societies advise against nonsteroidal anti-inflammatory drug (NSAID) use in patients with hypertension, heart failure, or chronic kidney disease (CKD); however, recent studies have not investigated the frequency or associations of use in these patients.
ObjectivesTo estimate the frequency of and variation in prescription NSAID use among high-risk patients, to identify characteristics associated with prescription NSAID use, and to investigate whether use is associated with short-term, safety-related outcomes.
Design, Setting, and ParticipantsIn this retrospective cohort study, administrative claims databases were linked to create a cohort of primary care visits for a musculoskeletal disorder involving patients 65 years and older with a history of hypertension, heart failure, or CKD between April 1, 2012, and March 31, 2016, in Ontario, Canada.
ExposurePrescription NSAID use was defined as at least 1 patient-level Ontario Drug Benefit claim for a prescription NSAID dispensing within 7 days after a visit.
Main Outcomes and MeasuresMultiple cardiovascular and renal safety-related outcomes were observed between 8 and 37 days after each visit, including cardiac complications (any emergency department visit or hospitalization for cardiovascular disease), renal complications (any hospitalization for hyperkalemia, acute kidney injury, or dialysis), and death.
ResultsThe study identified 2 415 291 musculoskeletal-related primary care visits by 814 049 older adults (mean [SD] age, 75.3 [4.0] years; 61.1% female) with hypertension, heart failure, or CKD, of which 224 825 (9.3%) were followed by prescription NSAID use. The median physician-level prescribing rate was 11.0% (interquartile range, 6.7%-16.7%) among 7365 primary care physicians. Within a sample of 35 552 matched patient pairs, each consisting of an exposed and nonexposed patient matched on the logit of their propensity score for prescription NSAID use (exposure), the study found similar rates of cardiac complications (288 [0.8%] vs 279 [0.8%]), renal complications (34 [0.1%] vs 33 [0.1%]), and death (27 [0.1%] vs 30 [0.1%]). For cardiovascular and renal-safety related outcomes, there was no difference between exposed patients (308 [0.9%]) and nonexposed patients (300 [0.8%]) (absolute risk reduction, 0.0003; 95% CI, −0.001 to 0.002; P = .74).
Conclusions and RelevanceWhile prescription NSAID use in primary care was frequent among high-risk patients, with widespread physician-level variation, use was not associated with increased risk of short-term, safety-related outcomes.
It was July 1, my first day of residency, and a queasy feeling lodged in my stomach as I donned my new white coat. It was different from the previous ones I'd worn — not just longer, but heavier. I was carrying in my pockets everything I thought I needed as a freshly minted doctor: my three favorite pens, a glossy Littmann Cardiology III stethoscope, copies of studies related to my patient with cirrhosis, and of course my trusty purple Sabatine's Pocket Medicine.
Before the day was over, my bodily-fluid–covered white coat would have made a fitting prop for a CSI episode, my attending physician wasn't nearly as impressed as I'd hoped with the studies I waved in front of her, and worst of all, I had lost all three of my pens. But with the aid of my pockets, I'd gotten through. I'd played my part reasonably well most of the day, but the moment when my attending had brought me up short with a question kept replaying in my mind. During morning rounds, I had presented a patient who was admitted for chest pain after walking his dog. My attending had asked, "What was the name of his dog?"
I was stumped. Worse, I didn't know why we needed to know. Nowhere in the books or the studies I'd read had a dog's name contributed to the differential. But the attending took us back to the patient's bedside and asked. "Rocky," the patient said. And there followed a brief conversation that was more colorful than any other I'd had with a patient that day. It led to a transformation I did not fully appreciate at the time: there was an actual person behind that hospital-issued gown.
Four years later, I'm not sure anything I've carried from residency has been more useful than that question.
It's because of that question that I found myself discussing the plot of a Spanish soap opera with another patient, a show I found him watching every morning. We even had company sometimes, when the translator would join us and explain the murder of the stepson by his twin brother or some other complicated event. Later, the patient and I would have difficult discussions about his immigration status and what it meant for his treatment plan. But I like to think that because he and I were fellow witnesses to an evil twin's murder, he had faith in me when I asked him to trust our medical team as we did our best to get him the care he needed.
The question was my guidepost when I saw a "difficult" patient who nearly left against medical advice while being admitted by the night team. She was 62, with new-onset heart failure. She was refusing medications, since she trusted the herbal supplement in her purse and not the "toxic chemicals" we doled out. Every day she would hand me a new article on a miraculous plant found on the Ivory Coast or a mineral from Chilean mines that promised her a cure. I couldn't offer the same, but I would return at the end of the day and discuss the article with her. When she was discharged, she asked me to be her primary care doctor. Soon we signed a treaty under which I would read the "studies" she brought in about black cherry and milk thistle and she would start taking one new medication every 2 months. We started with an ACE inhibitor.
Sometimes, the lessons of the question helped when little else could. Ms. W. was 78 years old, although she looked no older than 68 when I admitted her. She had white and gray hair with some curls; she also had heart disease. She had been admitted for influenza, but most mornings we would discuss stuffing or pie recipes. Thanksgiving was only a few days away, her grandchildren were coming, and she was the brains behind the family feast operation. She insisted on going home to help her daughters.
Diagnosed with atrial fibrillation while in the hospital, she stayed an extra night because her heart rate dipped to the 30s. Maybe this year, I suggested, she should take it easy and let her daughters do more of the work. We stopped some of her medications that could be affecting her heart rate and, with the agreement of both the patient and her cardiologist, started blood thinners. But there were risks: I drew a diagram of the heart on a whiteboard in her room to show where a blood clot could form and discussed the risk of bleeding. She noted that she was glad I had gone to medical school and not art school.
She made it home before Thanksgiving after all. But on Thanksgiving Day, she was back in the emergency department because her family found her to be drowsy. A CT scan of her brain showed a severe bleed. She spent a few days in the ICU and then was moved to hospice.
Before Ms. W. died, I went to visit her. As a trainee, I had viewed hospice as medicine's kryptonite: our powers were no good there. I stood outside her room having a staring contest with the closed wooden door, unable to command my hand to grasp the doorknob. What would her family think of the decisions we'd made? What did I think of them myself, given how things had worked out? Once I opened the door, though, I found Ms. W.'s family entirely supportive and understanding of the care we'd provided. They asked about my training and my plans and we talked about their kids, while my patient, their mom, rested under a pink-and-white checkered blanket in the bed beside us.
I stepped out of that room and took a breath — something I realized I hadn't done since I first scrolled through Ms. W.'s CT images. Hospice provided some comfort to her family that I had not thought possible, and they provided me a comfort I could not find in the evidence-based medicine we practiced. I found that the question that I'd been carrying around since my first day of residency could work another type of transformation: it helped my patients see the person behind the white coat.
It is easy to lose sight of yourself during residency, as you endure the countless hours spent in windowless rooms entering data in electronic medical records or completing administrative tasks or juggling a dozen other competing priorities. But if I may offer one piece of advice to my new colleagues who don a long white coat for the first time each July: Make sure to get the name of the dog.
A Strategy for Identifying and Disseminating Best Practice Innovations in the Care of Patients with Multiple Chronic Conditions or End-of-Life Care Needs
Abstract
Patients with multiple chronic conditions and those with end-of-life care needs experience high health care costs and needs for skilled coordination and well-trained staff. Focusing on these populations presents an opportunity to improve the patient experience toward the goal of more patient-centered care and reduced costs. Although innovative programs that provide better care to these patient populations have been developed, these innovations are often localized and not actively disseminated to other settings. This paper describes a quality-improvement project aimed at developing a process to identify best practices implemented in community-based clinical settings, develop a platform to share and disseminate these best practices, and facilitate the adoption of successful practices across other similar settings. The facilitation process involved structured coaching by clinicians and researchers experienced with practice change and quality improvement. The coaching component ensured that implementation teams receive guidance in the planning and adoption process, stay on track with implementation, and have access to timely support in addressing unanticipated barriers.
Carpal tunnel syndrome, the most common entrapment neuropathy of the upper extremity, is caused by compression of the median nerve as it travels through the carpal tunnel. Classically, patients with the condition experience pain and paresthesias in the distribution of the median nerve, which includes the palmar aspect of the thumb, index and middle fingers, and radial half of the ring finger. Additional clues include positive physical examination findings, such as the flick sign, Phalen maneuver, and median nerve compression test. Although patients with typical symptoms and signs of carpal tunnel syndrome do not need additional testing, ultrasonography and electrodiagnostic studies are useful to confirm the diagnosis in atypical cases and rule out other causes. If surgical decompression is planned, electrodiagnostic studies should be obtained to determine severity and surgical prognosis. Conservative treatment may be offered initially to patients with mild to moderate carpal tunnel syndrome. Options include splinting, corticosteroids, physical therapy, therapeutic ultrasound, and yoga. Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin B6 are not effective therapies. Local corticosteroid injection can provide relief for more than one month and delay the need for surgery at one year. Patients with severe carpal tunnel syndrome or whose symptoms have not improved after four to six months of conservative therapy should be offered surgical decompression. Endoscopic and open techniques are equally effective, but patients return to work an average of one week earlier with endoscopic repair.
Carpal tunnel syndrome (CTS) is often a debilitating disorder that is commonly encountered in primary care. It is the most common entrapment neuropathy of the upper extremity, affecting approximately 3% of the general adult population.1 Women are three times more likely to have CTS than men, and the prevalence and severity increase with age. Work-related activities that require a high degree of repetition and force or use of hand-operated vibratory tools significantly increase the risk of CTS.2 A large prospective cohort study found that forceful hand exertion was the most important factor in the development of CTS in workers.3 Additional risk factors include family history and a personal history of diabetes mellitus, obesity, hypothyroidism, pregnancy, and rheumatoid arthritis.
Antihypertensive drug therapy for mild to moderate hypertension during pregnancy
What is the issue?
The aim of this review was to determine the benefits and adverse effects of blood pressure-lowering drugs (antihypertensive drugs) for pregnant women with mild to moderate hypertension (high blood pressure). The other aim was to assess the benefits and adverse effects of these drugs for their babies.
Why is this important?
During pregnancy, up to one in 10 women have blood pressure readings that are above normal. For some women, their blood pressure remains slightly high (termed 'mild to moderate high blood pressure'), with no apparent complications. Some of these women go on to develop very high blood pressure. Very high blood pressure can result in a medical emergency if it affects the woman's organs (such as her liver, or brain in the form of a stroke). Also, it can seriously affect the growth and health of her baby.
Drugs that lower blood pressure are used to treat mild to moderate high blood pressure, in the belief that this treatment will prevent the blood pressure from continuing to rise. Over the years, information from good quality research studies has been contradictory, so we cannot be sure if this drug treatment is worthwhile.
What evidence did we find?
This Cochrane Review is an update of a review that was first published in 2001 and updated in 2007 and 2014. We searched for randomised controlled trials in September 2017, and this review now includes data from 58 trials involving more than 5900 women. A total of 31 trials with 3485 women compared a number of different blood pressure-lowering drugs to a placebo or no treatment. There were a further 29 trials involving 2774 women which compared one blood pressure-lowering drug with another one.
The evidence showed that treating pregnant women who had moderately raised blood pressure with blood pressure-lowering drugs probably halved the number of the women developing severe high blood pressure (20 trials, 2558 women). However, blood pressure-lowering drugs probably had little or no effect on the risk of the baby dying (29 trials, 3365 women), and there is insufficient data on maternal deaths to make a judgement on whether this risk is lowered (five trials, 525 women).
The use of blood pressure-lowering drugs may have little or no effect on the number of the women developing pre-eclampsia (23 trials, 2851 women), or the number of women who had to change drugs because of side-effects (16 trials, 1503 women).
We found no difference in the number of babies born preterm, that is before 37 weeks (15 trials, 2141 women). There was also no difference in the number of babies born small for their gestational age (21 trials, 2686 babies).
The quality of the evidence was mostly moderate (but for pre-eclampsia it was low). This was due to a number of small studies, and problems with the way the studies were undertaken.
The available evidence is still insufficient to demonstrate if there is any antihypertensive drug that is better than another. However, beta blockers and calcium channel blockers seem to be better than the alternative drugs for blood pressure control.
What does this mean?
More research is needed in order to confirm the true effect of antihypertensive drugs in mothers and in their babies, and to identify the drug which would be best.
Antihypertensive drug therapy for mild to moderate hypertension during pregnancy reduces the risk of severe hypertension. The effect on other clinically important outcomes remains unclear. If antihypertensive drugs are used, beta blockers and calcium channel blockers appear to be more effective than the alternatives for preventing severe hypertension. High-quality large sample-sized randomised controlled trials are required in order to provide reliable estimates of the benefits and adverse effects of antihypertensive treatment for mild to moderate hypertension for both mother and baby, as well as costs to the health services, women and their families.
An asymptomatic 66-year-old man had a 3.1-cm left adrenal mass detected on CT scan w normal vital signs, BMI of 37, normal physical examination, and an elevated cortisol level after an overnight 1-mg dexamethasone suppression test. What would you do next? ja.ma/2Iz8H0jpic.twitter.com/HzsxIAQ24b
Most Pertussis Cases in Infants Tied to Unvaccinated Mother
Overall, only 30% of pregnant women whose infants developed pertussis were appropriately vaccinated with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), according to a study published September 28 in the Morbidity and Mortality Weekly Report. Barriers to vaccination were attending a prenatal clinic that did not stock Tdap vaccine and having Medicaid rather than private insurance, regardless of whether the clinic stocked Tdap.
"[S]tocking vaccines on-site in prenatal clinics is the best way to ensure that all pregnant women are vaccinated and reduce the incidence of pertussis among infants too young to be vaccinated," write Sarah New, MPH, from the Immunization Branch, California Department of Public Health, and colleagues.
In the current study, California local health department personnel identified mothers of all 114 infants younger than 4 months known to have pertussis onset during 2016. Of these mothers, 66 (58%) were interviewed, and their prenatal care providers completed a supplemental questionnaire.
Among the 26 (39%) women who received Tdap during pregnancy, 24 (92%) were vaccinated at their provider's office, and most (80%) were vaccinated according to Advisory Committee on Immunization Practices recommendations, during 27 to 36 weeks' gestation (median, 32 weeks).
Vaccination appeared to reduce both the likelihood of disease and the severity of disease. Among the 40 interviewed mothers (61%) not vaccinated with Tdap during pregnancy, 20 (50%) of their infants were hospitalized, including eight admitted to an intensive care unit and one who died.
In contrast, among the 20 infants whose mothers were vaccinated between 27 and 36 weeks' gestation, four were hospitalized, but none needed intensive care unit admission. Among the five infants whose mothers received Tdap at other times, two were hospitalized, including one who was admitted to the intensive care unit admission and subsequently died.
Mothers whose providers stocked Tdap vaccine on-site were three times more likely to have been vaccinated (relative risk, 3.3; 95% confidence interval, 1.9 - 5.5), compared with women whose providers did not stock the vaccine.
Compared with mothers with private insurance, those with Medicaid were significantly less likely to receive prenatal Tdap (relative risk, 0.4; 95% confidence interval, 0.2 - 0.8), or to receive it during 27 to 36 weeks' gestation, even when it was stocked on-site (relative risk, 0.5; 95% confidence interval, 0.3 - 1.1).
The authors interviewed 61 prenatal care providers regarding their Tdap vaccine stocking policies. Of those, 34 (56%) stocked Tdap vaccine on-site. The most common reasons given for not stocking Tdap were cost (44%) and reimbursement (41%) issues.
The authors recommend incorporating Tdap vaccination into routine prenatal care visits as an effective means to increase coverage.
Advisory Committee on Immunization Practices Recommends Timely Tdap Administration
The Advisory Committee on Immunization Practices recommends vaccinating pregnant women with Tdap as early as possible between 27 and 36 weeks' gestation during every pregnancy as the best way to protect young infants against whooping cough. Most severe and fatal cases occur in infants who have not begun the primary pertussis vaccination series.
However, prenatal Tdap vaccine coverage in California remains low (52% overall; 40% among women with Medicaid).
"A recommendation by prenatal care providers for their pregnant patients to receive Tdap is important, particularly among providers who do not stock Tdap vaccine on-site," the study authors write. "[I]t is important to provide pregnant patients with specific information about where they can receive Tdap vaccination and to follow up at subsequent visits to ensure Tdap vaccine is received within the recommended time frame."
Referral for Tdap vaccination should be to an accessible site covered by the mother's insurance. Approximately 40% of the unvaccinated mothers in this analysis never received any recommendation or referral for Tdap vaccine, or were not vaccinated for reasons not cited by current Advisory Committee on Immunization Practices recommendations, and 20% refused prenatal Tdap. Postpartum vaccination with Tdap occurred in 40% of the mothers unvaccinated during pregnancy, which has not been recommended since 2011, highlighting the need for provider education about current recommendations.
"Promoting on-site prenatal vaccination, educating providers about Tdap recommendations, and strengthening off-site referral likely will improve Tdap vaccination coverage during pregnancy," the study authors note.
The authors have disclosed no relevant financial relationships.
Morb Mortal Wkly Rep. 2018;67(38);1068-1071. Full text
Artículo Especial Veinticinco mitos en enfermedades infecciosas en atención primaria que se asocian con sobrediagnóstico y sobretratamientoTwenty-five myths in infectious diseases in primary care associated with overdiagnosis and overtreatment
Resumen
El sobrediagnóstico y el sobretratamiento son comunes en la práctica clínica de las enfermedades infecciosas en atención primaria. A partir de estudios publicados en la literatura médica, identificamos mediante una revisión no sistemática un total de 25 mitos asociados al diagnóstico y tratamiento de las enfermedades infecciosas más frecuentemente manejadas en atención primaria y repasamos la literatura referente a cada mito. Estos mitos generan un uso inapropiado de pruebas diagnósticas (sobrediagnóstico) y prescripción innecesaria de antibióticos (sobretratamiento). La mayoría de estos mitos están arraigados entre los médicos de familia en nuestro país. Estos mitos no solo deben desacreditarse de nuestra práctica clínica, sino que tienen que ser revertidos y animamos a nuestros lectores a evaluar críticamente su práctica cuando se trata de los conceptos erróneos tratados en este artículo. Intentamos dar una guía a los profesionales clínicos que se enfrentan con estos cuadros clínicos frecuentes.
Abstract
Overdiagnosis and overprescribing is common in current clinical practice of infectious diseases in primary care. On the basis of studies published in the medical literature we identify by means of a non-systematic review a total of 25 myths associated with the diagnosis and treatment and present the literature pertaining to each myth. These myths result in extraneous testing (overdiagnosis) and excessive antimicrobial treatment (overtreatment). Most of these myths are ingrained among general practitioners in our country. Not only should these myths be debunked from our clinical practice, but they should also be reversed, and we encourage our readers to critically appraise their practice when it comes down to the misconceptions treated in this manuscript. We attempt to give guidance to clinicians facing these frequent clinical scenarios.
