RESUMO
DESCRIPTION: The Scientific Medical Policy Committee (SMPC) of the American College of Physicians (ACP) developed these living, rapid practice points to summarize the current best available evidence on the antibody response to SARS-CoV-2 infection and protection against reinfection with SARS-CoV-2. This is version 2 of the ACP practice points, which serves to update version 1, published on 16 March 2021. These practice points do not evaluate vaccine-acquired immunity or cellular immunity. METHODS: The SMPC developed this version of the living, rapid practice points based on an updated living, rapid, systematic review conducted by the Portland VA Research Foundation and funded by the Agency for Healthcare Research and Quality. PRACTICE POINT 1: Do not use SARS-CoV-2 antibody tests for the diagnosis of SARS-CoV-2 infection. PRACTICE POINT 2: Do not use SARS-CoV-2 antibody tests to predict the degree or duration of natural immunity conferred by antibodies against reinfection, including natural immunity against different variants. RETIREMENT FROM LIVING STATUS: Although natural immunity remains a topic of scientific interest, this topic is being retired from living status given the availability of effective vaccines for SARS-CoV-2 and widespread recommendations for and prevalence of their use. Currently, vaccination is the best clinical recommendation for preventing infection, reinfection, and serious illness from SARS-CoV-2 and its variants.
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COVID-19 , Médicos , Anticorpos Antivirais , Formação de Anticorpos , Vacinas contra COVID-19 , Humanos , Imunidade Inata , Reinfecção , SARS-CoV-2RESUMO
In response to the COVID-19 pandemic, the Scientific Medical Policy Committee (SMPC) of the American College of Physicians (ACP) began developing "practice points" to provide clinical advice based on the best available evidence for the public, patients, clinicians, and public health professionals. As one of the first organizations in the United States to develop evidence-based clinical guidelines, ACP continues to lead and advance the science of evidence-based medicine by implementing new methods to rapidly publish practice points and maintain them as living advice that regularly assesses and incorporates new evidence. The overarching aim of practice points is to answer targeted key questions for which there is a timely need to synthesize evidence for decision making. The SMPC believes these methods can potentially be adapted to address various clinical and public health topics beyond the COVID-19 pandemic. This article presents an overview of the SMPC's living, rapid practice points development process, which includes a rapid systematic review, use of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method, use of stringent policies on the disclosure of interests and management of conflicts of interest, incorporating a public (nonclinician) perspective, and maintenance of the documents as living through ongoing surveillance and synthesis of new evidence as it emerges.
Assuntos
COVID-19/diagnóstico , COVID-19/terapia , Medicina Baseada em Evidências/métodos , Guias de Prática Clínica como Assunto , Teste para COVID-19 , Tomada de Decisão Clínica , Conflito de Interesses , Humanos , Pandemias , Revisões Sistemáticas como Assunto/métodos , Estados UnidosRESUMO
DESCRIPTION: Antimicrobial overuse is a major health care issue that contributes to antibiotic resistance. Such overuse includes unnecessarily long durations of antibiotic therapy in patients with common bacterial infections, such as acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. This article describes best practices for prescribing appropriate and short-duration antibiotic therapy for patients presenting with these infections. METHODS: The authors conducted a narrative literature review of published clinical guidelines, systematic reviews, and individual studies that addressed bronchitis with COPD exacerbations, CAP, UTIs, and cellulitis. This article is based on the best available evidence but was not a formal systematic review. Guidance was prioritized to the highest available level of synthesized evidence. BEST PRACTICE ADVICE 1: Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume). BEST PRACTICE ADVICE 2: Clinicians should prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation. BEST PRACTICE ADVICE 3: In women with uncomplicated bacterial cystitis, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP-SMZ (14 days) based on antibiotic susceptibility. BEST PRACTICE ADVICE 4: In patients with nonpurulent cellulitis, clinicians should use a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.
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Antibacterianos/administração & dosagem , Infecções Bacterianas/tratamento farmacológico , Uso Excessivo de Medicamentos Prescritos/prevenção & controle , Bronquite/tratamento farmacológico , Celulite (Flegmão)/tratamento farmacológico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Cistite/tratamento farmacológico , Esquema de Medicação , Feminino , Humanos , Masculino , Pneumonia Bacteriana/tratamento farmacológico , Atenção Primária à Saúde , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Pielonefrite/tratamento farmacológicoRESUMO
DESCRIPTION: The widespread availability of SARS-CoV-2 antibody tests raises important questions for clinicians, patients, and public health professionals related to the appropriate use and interpretation of these tests. The Scientific Medical Policy Committee (SMPC) of the American College of Physicians developed these rapid, living practice points to summarize the current and best available evidence on the antibody response to SARS-CoV-2 infection, antibody durability after initial infection with SARS-CoV-2, and antibody protection against reinfection with SARS-CoV-2. METHODS: The SMPC developed these rapid, living practice points based on a rapid and living systematic evidence review done by the Portland VA Research Foundation and funded by the Agency for Healthcare Research and Quality. Ongoing literature surveillance is planned through December 2021. When new studies are identified and a full update of the evidence review is published, the SMPC will assess the new evidence and any effect on the practice points. PRACTICE POINT 1: Do not use SARS-CoV-2 antibody tests for the diagnosis of SARS-CoV-2 infection. PRACTICE POINT 2: Antibody tests can be useful for the purpose of estimating community prevalence of SARS-CoV-2 infection. PRACTICE POINT 3: Current evidence is uncertain to predict presence, level, or durability of natural immunity conferred by SARS-CoV-2 antibodies against reinfection (after SARS-CoV-2 infection).
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Anticorpos Antivirais/imunologia , Formação de Anticorpos , Teste para COVID-19/normas , COVID-19/imunologia , Imunidade Inata/imunologia , SARS-CoV-2/imunologia , HumanosRESUMO
DESCRIPTION: The American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) developed this guideline to provide clinical recommendations on nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults in the outpatient setting. The guidance is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences. This guideline does not address noninvasive treatment of low back pain, which is covered by a separate ACP guideline that has also been endorsed by AAFP. METHODS: This guideline is based on a systematic evidence review on the comparative efficacy and safety of nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults in the outpatient setting and a systematic review on the predictors of prolonged opioid use. We evaluated the following clinical outcomes using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system: pain (at ≤2 hours and at 1 to 7 days), physical function, symptom relief, treatment satisfaction, and adverse events. TARGET AUDIENCE AND PATIENT POPULATION: The target audience is all clinicians, and the target patient population is adults with acute pain from non-low back, musculoskeletal injuries. RECOMMENDATION 1: ACP and AAFP recommend that clinicians treat patients with acute pain from non-low back, musculoskeletal injuries with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient's treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence). RECOMMENDATION 2A: ACP and AAFP suggest that clinicians treat patients with acute pain from non-low back, musculoskeletal injuries with oral NSAIDs to reduce or relieve symptoms, including pain, and to improve physical function, or with oral acetaminophen to reduce pain (Grade: conditional recommendation; moderate-certainty evidence). RECOMMENDATION 2B: ACP and AAFP suggest that clinicians treat patients with acute pain from non-low back, musculoskeletal injuries with specific acupressure to reduce pain and improve physical function, or with transcutaneous electrical nerve stimulation to reduce pain (Grade: conditional recommendation; low-certainty evidence). RECOMMENDATION 3: ACP and AAFP suggest against clinicians treating patients with acute pain from non-low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).
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Dor Aguda/terapia , Sistema Musculoesquelético/lesões , Acupressão , Dor Aguda/tratamento farmacológico , Dor Aguda/etiologia , Adulto , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Anti-Inflamatórios não Esteroides/efeitos adversos , Anti-Inflamatórios não Esteroides/uso terapêutico , Humanos , Estimulação Elétrica Nervosa Transcutânea , Estados UnidosAssuntos
Dor Aguda , Dor Crônica , Dor Lombar , Dor Aguda/tratamento farmacológico , Adulto , HumanosAssuntos
Monofosfato de Adenosina/análogos & derivados , Alanina/análogos & derivados , Antivirais/uso terapêutico , Tratamento Farmacológico da COVID-19 , Monofosfato de Adenosina/administração & dosagem , Monofosfato de Adenosina/efeitos adversos , Monofosfato de Adenosina/uso terapêutico , Alanina/administração & dosagem , Alanina/efeitos adversos , Alanina/uso terapêutico , Antivirais/administração & dosagem , Antivirais/efeitos adversos , Esquema de Medicação , Medicina Baseada em Evidências , Humanos , SARS-CoV-2 , Índice de Gravidade de DoençaAssuntos
Azitromicina/uso terapêutico , Cloroquina/uso terapêutico , Hidroxicloroquina/uso terapêutico , Azitromicina/efeitos adversos , Betacoronavirus , Cloroquina/efeitos adversos , Infecções por Coronavirus/tratamento farmacológico , Humanos , Hidroxicloroquina/efeitos adversos , SARS-CoV-2 , Estados Unidos , Tratamento Farmacológico da COVID-19Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Transmissão de Doença Infecciosa/prevenção & controle , Guias como Assunto , Máscaras/estatística & dados numéricos , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , COVID-19 , Infecções por Coronavirus/transmissão , Humanos , Pneumonia Viral/transmissão , SARS-CoV-2 , Estados Unidos/epidemiologiaRESUMO
With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care "receivers" and tailoring home care to meet patient needs, (3) building "recovery plans" into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.
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Assistência ao Convalescente , Continuidade da Assistência ao Paciente/organização & administração , Serviços de Saúde para Idosos/organização & administração , Alta do Paciente/normas , Serviços Preventivos de Saúde , Assistência ao Convalescente/métodos , Assistência ao Convalescente/organização & administração , Idoso , Cuidadores/educação , Doença Crônica/terapia , Participação da Comunidade , Comorbidade , Feminino , Política de Saúde , Humanos , Vida Independente/educação , Masculino , Avaliação de Resultados em Cuidados de Saúde , Planejamento de Assistência ao Paciente , Assistência Centrada no Paciente/organização & administração , Serviços Preventivos de Saúde/métodos , Serviços Preventivos de Saúde/organização & administração , Melhoria de Qualidade , Estados UnidosRESUMO
OBJECTIVE: To present the first reported fatality from invasive aspergillosis related to factitious Cushing's syndrome. METHODS: We summarize the history, clinical findings, and outcome in a patient ultimately found to have factitious Cushing's syndrome. In addition, the dangers of fulminant infections in untreated Cushing's syndrome are analyzed relative to molecular and immunologic aspects, and the pertinent literature is reviewed. RESULTS: A 33-year-old female medical transcriptionist was admitted with rapidly fatal septic shock and diffuse pulmonary infiltrates. Autopsy revealed invasive pulmonary aspergillosis and atrophied adrenal cortices. On subsequent investigation, hidden bottles of prednisone were found throughout the patient's home. Factitious Cushing's syndrome has rarely been described and can be a difficult diagnosis to establish, but it is important to recognize this condition because of its potentially drastic consequences. Our understanding of the mechanism of immunosuppression from glucocorticoids related to the increased risk of invasive fungal infections is evolving. Factitious illness can manifest in numerous ways; therefore, health-care providers in all specialties should be familiar with epidemiologic, diagnostic, and treatment considerations for this illness. CONCLUSION: Endocrinologists should be aware of the possibility of factitious Cushing's syndrome because it can be an elusive and ultimately fatal condition.