Hemoptysis: Evaluation and Management.

Hemoptysis is the expectoration of blood from the lower respiratory tract, usually from bronchial arteries. The most common causes are acute respiratory infections, cancer, bronchiectasis, and chronic obstructive pulmonary disease. No cause is identified in 20% to 50% of cases. Hemoptysis must be differentiated from pseudohemoptysis, which is blood that originates from nasopharyngeal or gastrointestinal sources. The initial evaluation includes determining the severity of bleeding and stability of the patient and may require bronchoscopy for airway protection. Mild hemoptysis comprises more than 90% of cases and has a good prognosis, whereas massive hemoptysis has a high mortality rate. A history and physical examination can assist in identifying an etiology, but diagnostic testing is often required. Chest radiography is a good initial test, but it has limited sensitivity for determining the site and etiology of the bleeding. Computed tomography and computed tomography angiography of the chest with intravenous contrast are the preferred modalities to determine the etiology of bleeding; however, bronchoscopy may also be needed. In addition to supportive medical treatment, management should include treatment of the underlying etiology because recurrence often takes place in the absence of treatment of the identified cause. Bronchial arterial embolization is used to treat massive hemoptysis, particularly when an involved artery is noted on computed tomography angiography. Surgery is reserved for patients whose medical treatment and embolization are not effective.

Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians.

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).

Sexual Health History: Techniques and Tips.

Family physicians should use a proactive, integrated, patient-centered approach to sexual health that includes, but is not limited to, disease identification and treatment. Successfully delivering positive, affirming, nonjudgmental sexual health care requires intentionally creating safe spaces for all patients. Physician and staff training could include identifying individual implicit bias around sexuality and sexual topics, adverse childhood experiences, and trauma-informed care. Models such as the five Ps (partners, practices, protection from sexually transmitted diseases, past history of sexually transmitted diseases, and pregnancy plans) and ExPLISSIT (extended permission giving, limited information, specific suggestions, and intensive therapy) can help physicians organize their approach to sexual health histories. Preventive health strategies include screening for sexually transmitted diseases and sexually transmitted infections, screening for and offering preexposure prophylaxis for HIV, behavioral counseling to reduce the risk of sexually transmitted infections, and preconception care for all patients, including gender-diverse patients. Because sexual health concerns are quite common, family physicians should be prepared to discuss topics such as erectile dysfunction, dyspareunia, and arousal disorders.

Guidelines and Policies: Implications for Individual and Population Health.

Rising rates of prescription opioids for chronic pain from the 1990s along with a concomitant worsening overdose crisis led to rapid evaluation and public health strategies to curb problems with prescription opioids. Guideline development, grounded in solid theory but based on limited evidence that translated into rigid and discordant policies, has contributed to controversies in pain management, worsening the treatment experience for people experiencing chronic pain and highlighting existing inequities from a system clouded with systemic racism. Newer public health approaches need to evaluate root causes and be more holistic addressing inequities as well as using trauma-informed principles.

Designing and Evaluating COVID-19 Protocols for an Office-Based Opioid Treatment Program in an Urban Underserved Setting.

BACKGROUND: Despite changing federal regulations for providing telehealth services and provision of controlled substances during the COVID-19 pandemic, there is little guidance available for office-based opioid treatment (OBOT) programs integrated into primary care settings. PURPOSE: (1) Develop disaster-preparedness protocols specific to the COVID-19 pandemic for an urban OBOT program, and (2) evaluate the impacts of the protocol and telehealth on care. METHODS: Disaster-preparedness protocols specific to the COVID-19 pandemic were developed for an urban OBOT program, implemented on March 16, 2020. Retrospective chart review compared patients from January 1, 2020 to March 13, 2020, to patients from March 16, 2020 to April 30, 2020, abstracting patient demographics and comparing show and no-show rates between studied groups. RESULTS: The disaster-preparedness protocol was developed under a deliberative process to address social issues of the urban underserved population. Of 852 visits conducted between Jan 1, 2020, and April 30, 2020, a 91.7% show rate (n = 166/181) was documented for telemedicine visits after protocol implementation compared with a 74.1% show rate (n = 497/671) for routine in-person care (P = .06) without significant differences between the study populations. The no-show rate was significantly lower after protocol implementation (8.3% vs 25.9%; P <0.05). CONCLUSIONS: OBOTs require organized workflows to continue to provide services during the COVID-19 pandemic. Telemedicine, in the face of relaxed federal regulations, has the opportunity to enhance addiction care, creating a more convenient as well as an equally effective mechanism for OBOTs to deliver care that should inform future policy.

Expanding buprenorphine treatment to people experiencing homelessness through a mobile, multidisciplinary program in an urban, underserved setting.

BACKGROUND AND OBJECTIVES: Inequities in access to buprenorphine treatment remain despite measures to increase access to treatment. "Begin the Turn," a low-barrier, multidisciplinary mobile care unit with access to outreach services, counseling, case management, and buprenorphine treatment addresses these disparities in an urban setting. METHODS: Retrospective medical record review of patients during the initial 6 months of operation abstracted patient demographics and clinical data, including 10 categories of adverse childhood experiences (ACEs) using a total number of ACEs (ACE score) and measuring scores greater than or equal to 4 given higher risk of chronic disease states at this level. The study collected data in electronic data capture tools. The study assessed retention rates at 1, 3, and 5 months. RESULTS: Among the 147 individuals who received care, the mean age was 39.6 years and median onset of opioid use was 21 years of age. Among study participants, 67.3% (n = 99) reported IV use, 91.9% (n = 135) reported previous experiences with addiction treatment, and 49.7% (n = 73) had previously suffered an overdose. Adverse Childhood Experiences surveys demonstrated a mean score of 4.6 (n = 141), with 63.1% (n = 89) having a score of 4 or greater. The percentages of patients retained in care at 1, 3, and 5 months were 61.2%, 36.6%, and 27.6%, respectively. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: The program serves a population with high rates of trauma and overdose. The program can serve as a model for treatment for this population.

Impact of Student-Run Clinics on Students' Attitudes Toward People Experiencing Homelessness.

INTRODUCTION: Student-run clinics can supplement medical education by exposing students to diverse clinical scenarios and collaborating with underresourced populations. We examined the impact of volunteering at THRIVE, a student-run bridge clinic located within sheltered housing for individuals with substance use disorder, on students' attitudes toward people experiencing homelessness (PEH). METHODS: This cohort study analyzed pre- and postsurvey matched responses from nonvolunteer and volunteer first-year medical students utilizing the Health Professional Attitudes Towards the Homeless (HPATHI) tool, totaled into three subcategories: Cynicism, Social Advocacy, and Personal Advocacy. We evaluated the association between change in scores and volunteering utilizing Student t tests and adjusting for participant characteristics using multivariable regression analysis. RESULTS: We received 106 responses (53% response rate); 58 students (55%) volunteered at the clinic and were mostly female (62%), White (52%), and had previous experience working with PEH (71%). The mean change in Personal Advocacy scores was higher for volunteers compared to nonvolunteers, even when adjusting for respondent characteristics (P=.02). Additionally, students who held a prior advanced degree and/or current enrollment in the master of bioethics program (Higher Education Students) had a positive association with change in Personal Advocacy scores (P=.02). CONCLUSION: Volunteering at the THRIVE Clinic appears to impact the Personal Advocacy scores of medical students. This suggests that interacting with PEH early in students' career may be associated with a commitment to working with this population. However, our study has multiple limitations, including self-selection bias, limited sample size, and unclear permanence of students' attitudes over time. Further studies of this cohort could help clarify the significance and permanence of volunteering in student-run clinics.

Vaccinating in Pregnancy: Opportunities and Challenges.

The continuum of preconception, antenatal period, fourth trimester, and interconception period are a critical time for comprehensive care to advance maternal-child health and deliver family-centered care. Immunizations are a key component of this care delivery; however, there are intricacies around indications of vaccinations during this key period. Both active immunity to the individual receiving the vaccine as well as passive immunity passed to the fetus during pregnancy highlight the benefits of this care. Understanding the indications and benefits of vaccine administration during this continuum is critical for providers caring for individuals of reproductive age.

Primary Care Practice Redesign: Challenges in Improving Behavioral Health Care for a Vulnerable Patient Population.

This study examined a program focused on integrating mental health in a family medicine practice in an economically challenged urban setting. The program included using a behavioral health technology platform, a behavioral health collaborative composed of community mental health agencies, and a community health worker (CHW). Of the 202 patients screened, 196 were used for analysis; 56% were positive for anxiety, 38% had scores consistent with moderate to severe depression, and 34% were positive for post-traumatic stress disorder. There was a statistically significant difference in the diagnosis of depression when comparing the screened group to a control group. Only 27% of patients followed through with behavioral health referrals despite navigational assistance provided by a CHW and assured access to care through a community agency engaged with the Behavioral Health Alliance. Further qualitative analysis revealed that there were complex patient factors that affected patient decision making regarding follow-up with behavioral health care.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder.

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

Increased emergency department computed tomography use for common chest symptoms without clear patient benefits.

OBJECTIVE: The aim of this study was to examine changes in the utilization of computed tomography (CT) in the evaluation of common chest symptoms and the rate of clinically significant diagnoses in emergency departments after 2004. METHODS: This study analyzed the National Hospital Ambulatory Medical Care Survey, comparing 1997 to 1999 and 2005 to 2007. Set in US emergency departments, individuals older than 14 years old were eligible. The main outcome was proportion of common chest symptom-related visits (n = 17,098) associated with a CT order before 2000 and after 2004. Secondary outcomes were the proportion of these visits associated with a clinically significant diagnosis (pulmonary embolism, acute myocardial infarction, acute coronary syndrome, heart failure, pneumonia, and pleural effusion); an incidental diagnosis such as lung mass; and a clinically nonsignificant diagnosis such as nonspecific chest pain. RESULTS: The proportion of common chest symptom-related visits associated with a CT order increased from 2.1% in 1997 to 1999 to 11.5% in 2005 to 2007 (P < .001), whereas the overall proportion of these visits associated with a clinically significant diagnosis decreased from 23.6% in 1997 to 1999 to 19.1% in 2005 to 2007 (P < .001).The rate of acute myocardial infarction diagnosis decreased from 6.6% to 3.3% (P < .001), whereas the rate of pulmonary embolism diagnosis did not change (0.33% vs. 0.47%; P = .24) from 1997 to 1999 to 2005 to 2007. The rate of incidental diagnoses did not change (0.13% vs. 0.17%; P = .69), whereas the rate of clinically nonsignificant diagnoses increased from 35.6% to 45.8% (P < .001) from 1997 to 1999 to 2005 to 2007. CONCLUSIONS: CT ordering in emergency departments for the evaluation of common chest symptoms has increased dramatically without improving the rate of pulmonary embolism or other clinically significant diagnoses. Overuse of CT exposes patients to radiation and increases health care costs without any apparent diagnostic benefit.