Potential delayed and/or missed STI diagnoses among outpatients presenting with lower genitourinary tract symptoms: a real-world database study.

OBJECTIVES: Sexually transmitted infection (STI) diagnosis is complicated as these infections can present with lower genitourinary tract symptoms (LGUTS) that overlap with other disorders, i.e. urinary tract infections (UTIs). The study's objective was to determine potential missed STI diagnoses from patients presenting with LGUTS in the US between January 2010 and December 2019. METHODS: The de-identified insurance claims data from the IBM® MarketScan® Research Databases were collected from patients (14-64 years old) who presented with LGUTS, which could be caused by an STI. A 'GAP' cohort was created, consisting of episodes with potentially delayed STI (Chlamydia trachomatis [CT]/Neisseria gonorrhoeae [NG]) treatment. The intention was to capture episodes where an STI was not initially suspected. Four subgroups were defined depending on the treatment received (fluoroquinolone; azithromycin and/or doxycycline; cephalosporins; gentamicin and azithromycin). RESULTS: The GAP cohort consisted of 833,574 LGUTS episodes from the original cohort (23,537,812 episodes). Post-index CT/NG testing was carried out for 4.6% and 5.4% of the episodes from men and women, respectively. There were ≥2 return visits for 16.1% and 15.8% of the episodes from men and women, respectively. A substantial percentage of episodes from men (52.1%) and women (68.3%) were diagnosed with a UTI and/or acute cystitis at the index prior to receiving post-index STI treatment. Other top conditions diagnosed at index for men were dysuria (25.8% of the episodes), orchitis/epididymitis (14.3% of the episodes), and acute prostatitis (10.1% of the episodes), and for women were dysuria (24.2% of the episodes), vaginitis/vulvitis/vulvovaginitis (11.7% of the episodes), and cervicitis (3.3% of the episodes). CONCLUSION: These findings highlight delayed STI antibiotic treatment and low rates of CT/NG testing, suggesting late STI consideration and suboptimal diagnosis. Additionally, our study illustrates the importance of accurately diagnosing and treating STIs in patients with LGUTS and associated conditions, to avoid antibiotic misuse and complications from delayed administration of appropriate treatment.

Safety and efficacy of dulaglutide, a once weekly GLP-1 receptor agonist, for the management of type 2 diabetes.

BACKGROUND: Type 2 diabetes (T2D) is an increasingly common endocrine disorder that is characterized by chronic hyperglycemia and tissue compartment abnormalities, including macrovascular and microvascular complications. More than 90% of patients with T2D will be diagnosed and treated in the primary care setting. One of the relatively recent additions to the increasing array of approved antidiabetic medications is the glucagon-like peptide-1 receptor agonist class. Mechanisms of action for glucagon-like peptide-1 receptor agonists include: 1) stimulation of insulin secretion through ß-cells, though only when glucose levels are elevated (hence, minimizing risk for hypoglycemia); 2) blunting of glucagon secretion; 3) increased satiety; and 4) decreased rate of release of gastric contents into the small intestine, thereby reducing glycemic load. Recent T2D treatment guidelines encourage individualization of therapy. Many patients still do not achieve optimal glycemic control. Therefore, other treatment options are important. METHODS: A literature search was performed using PubMed and MEDSCAPE to retrieve abstracts and articles pertinent to topics discussed in this review. Original research articles, reviews, and clinical trial manuscripts were identified based on relevance. Only English language articles were considered. Results In 3 phase 3 registration trials in patients with T2D, once-weekly dulaglutide demonstrated superior efficacy at the primary endpoint to metformin as monotherapy, to sitagliptin as add-on to metformin, and to exenatide twice daily as add-on to metformin and pioglitazone. The safety profile of dulaglutide in these trials is similar to currently available glucagon-like peptide-1 receptor agonists, characterized predominantly by gastrointestinal symptoms (ie, nausea, vomiting, and diarrhea). Based on these results, once-weekly dulaglutide should be a relevant additional treatment option for the management of T2D.

Identification and management of albuminuria in the primary care setting.

Albuminuria is an important risk marker for adverse cardiovascular (CV) and renal outcomes and mortality. The relationship between albuminuria and risk is continuous and linear, like that of blood pressure and cardiovascular risk. Evidence now supports increased risk even at levels traditionally considered within normal limits. In high-risk patients, routine annual screening can detect changes in urine albumin excretion and improve the timely identification of albuminuria, and therefore should be considered in patients with diabetes, hypertension, and chronic kidney disease. Preferred simple screening methods appropriate for use in the primary care setting include microalbumin-specific dipsticks and urinary albumin:creatinine ratio determination (from a spot urine sample). Cornerstones of albuminuria treatment include risk factor management, ongoing monitoring, and, in patients with hypertension, chronic kidney disease, or diabetes, the use of renin-angiotensin-aldosterone system (RAAS)-blocking agents. Both angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have demonstrated utility in this regard; data from studies of direct renin inhibition are promising. The combined use of an ACE inhibitor and ARB was once considered a viable option for the treatment of albuminuria; however, results of the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) raised important questions regarding the benefits and limitations of dual RAAS blockade. Ongoing studies should provide important insight into the effects of this approach on renal outcomes.

Managing type 2 diabetes in the primary care setting: beyond glucocentricity.

Successful management of type 2 diabetes mellitus (T2DM) requires attention to additional conditions often associated with hyperglycemia including overweight or obesity, dyslipidemia and hypertension, as each has some relationship with microvascular or macrovascular complications. Because control of cardiovascular risk factors is as important as glucose control in T2DM, these risk factors need to be addressed, and it is critical that antidiabetes medications do not exacerbate these risk factors. A patient-centered approach to treatment in which clinicians maximize patient involvement in the selection of antidiabetes therapy may lead to increased adherence and improved clinical outcomes. The incretin hormones, which include glucagon-like peptide-1 (GLP-1), are involved in glucoregulation and have become an important focus of T2DM research and treatment. Incretin-based therapies, such as the glucagon-like peptide-1 receptor agonists and the dipeptidyl peptidase-IV inhibitors, have shown beneficial effects on hyperglycemia, weight, blood pressure and lipids with a low incidence of hypoglycemia.

Screening for urologic malignancies in primary care: pros, cons, and recommendations.

Interest in screening for urologic cancers has grown in recent years. This article considers the pros and cons of screening for four epidemiologically compelling urologic cancers: prostate, bladder, kidney, and testicular. Unfortunately, many of the urologic cancers do not meet the criteria for a successful cancer screening program-namely, high prevalence, availability of a sensitive and specific screening test, ability to detect clinically important cancers at an early stage, and cost-effectiveness. While age-based screening for prostate cancer should be offered to the general population after discussion of its benefits and risks, for the other three urologic malignancies the current consensus points more toward selective screening based on specific patient risk factors.

Noninvasive management of lower urinary tract symptoms and sexual dysfunction associated with benign prostatic hyperplasia in the primary care setting.

Most men who live to middle age and beyond will ultimately develop lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), and many will also experience sexual dysfunction. Clinical studies indicate that most patients will experience improvement in BPH-related LUTS with alpha-adrenergic blockade or 5alpha-reductase inhibition. Recent studies suggest that alpha-blockers and 5alpha-reductase inhibitors may help to slow the progression of LUTS; 5alpha-reductase inhibitors reduce the need for surgery and complications, such as acute urinary retention. Third-generation alpha-blockers (alfuzosin, tamsulosin) are infrequently associated with cardiovascular side effects, in contrast to their predecessors (doxazosin, terazosin, prazosin). This may provide an advantage for consideration as firstline therapy. alpha-Blocker therapy may also improve sexual functioning, with the exception of ejaculation disorders, predominantly associated with subtypeselective alpha-blockers. By contrast, 5alpha-reductase inhibition is not recommended for men without demonstrable prostatic enlargement, may be associated with a long delay between treatment initiation and LUTS improvement, and is clearly associated with sexual side effects, including decreased libido, ejaculatory dysfunction, and erectile dysfunction. When choosing appropriate pharmacotherapy, the clinician should consider not only the expeditious relief of the presenting symptoms but also the patient's quality of life, including sexual function and potential long-term outcomes, such as acute urinary retention and the need for surgical intervention.

Advances in rheumatology: coxibs and beyond.

Arthritis is a growing health concern in the US with approximately 70 million Americans currently affected. This figure will inevitably rise as the population ages. The pain and decreased mobility associated with arthritis have a significant impact on quality of life and because patients with arthritis are less active than the general population, they are at risk of additional conditions such as obesity, heart disease, diabetes, and hypertension. There are currently no disease modifying osteoarthritis (OA) drugs available; therefore anti-inflammatory, and/or analgesic medications such as acetaminophen and NSAIDs and simple analgesics form the mainstay of treatment. Coxibs may be preferred to traditional NSAIDs because of their improved gastrointestinal (GI ) safety and tolerability profile. The use of topical agents may also be beneficial in some patients. In rheumatoid arthritis (RA) where disease modifying drugs (DMARDs) are available, anti-inflammatory agents such as NSAIDs and coxibs are used as adjuncts to disease modifying therapy. However, patients with RA are at increased risk of NSAID-related GI injury, particularly if they are also on corticosteroid medication. Pharmacological treatment of both RA and OA should be combined with appropriate nonpharmacological modalities such as patient education, exercise programs, and joint motion and strengthening exercises. Such activities may delay joint degradation and help maintain physical function.

A Primary Care Physician's Perspective on Benign Prostatic Hyperplasia.

Primary care clinicians are generally the first point of contact for men who suffer troublesome symptoms of benign prostatic hyperplasia. Although a subset of these patients will ultimately require referral to a urologist for an invasive procedure to provide symptom control, the majority can be appropriately managed in the ambulatory setting. Most symptomatic men respond favorably to alpha-blockers, which provide prompt improvement in symptoms such as nocturia. Although alpha-blockers may control troublesome lower urinary tract symptoms, there is no suggestion that they forestall the need for surgery or reduce the likelihood of development of acute urinary retention. Therefore, clinicians need to become familiar with use of 5-alpha-reductase inhibitors, as this is the only class of pharmacotherapy that has been shown to have a diseasemodifying effect.

Polycystic ovary syndrome [PCOS]: comprehensive management in primary care.

Polycystic ovary syndrome is a common premenopausal endocrino-metabolic disorder. In addition to hyperandrogenism, menstrual abnormalities, ovulatory disturbances and infertility, insulin resistance, dyslipidemia, and obesity may eventuate in long-term cardiovascular consequences.