Quantifying diagnosis and treatment practices of opioid use disorder in primary care practices using chart review data.

BACKGROUND: Opioid misuse is a significant public health crisis. The aim sought to identify potential gaps in opioid care in primary care practices. METHODS: American Academy of Family Physicians (AAFP) offered a monthly online educational series to seven U.S. practices. Practices were asked to complete up to 50 chart reviews for visits during two periods: February-April, 2019, and February-April, 2022. Each chart had to have an ICD-10 diagnosis of opioid misuse, opioid dependence, or opioid use. Chart reviews consisted of 14 questions derived from an American Academy of Addiction Psychiatry (AAAP) Performance in Practice activity, and then, scored based on practices' responses. Descriptive statistics and binary logistic and multinomial regressions were used. RESULTS: Both periods had 173 chart reviews (total: 346) from the six practices. Most chart reviews were for patients with a diagnosis of opioid dependence (2019: 90.2%; 2022: 83.2%). Three questions for assessing OUD treatment behaviors had high levels of documentation across both time periods (>85%): other drug use, treatment readiness, and treatment discussion. DISCUSSION: Results show a gap in the treatment of patients with OUD in primary care across several clinical practice recommendations. CONCLUSIONS: Expanding OUD treatment integration to primary care remains the most promising effort to combat the opioid crisis.

Integrated Behavioral Health Adaptations During the COVID-19 Pandemic.

INTRODUCTION: COVID-19 pandemic lockdowns threatened standard components of integrated behavioral health (IBH) such as in-person communication across care teams, screening, and assessment. Restrictions also exacerbated pre-existing challenges to behavioral health (BH) access. METHODS: Semistructured interviews were completed with clinicians from family medicine residency programs on the impact of the pandemic on IBH care delivery along with adaptations employed by care teams to ameliorate disruption. RESULTS: Participants (n = 41) from 14 family medicine residency programs described the rapid shift to virtual care, creating challenges for IBH delivery and increased demand for BH services. With patients and care team members at home, virtual warm handoffs and increased attention to communication were necessary. Screening and measurement were more difficult, and referrals to appropriate services were challenging due to higher demand. Tele-BH facilitated continued access to BH services but was associated with logistic challenges. Participants described adaptations to stay connected with patients and care teams and discussed the need to increase capacity for both in-person and virtual care. DISCUSSION: Most practices modified their workflows to use tele-BH as COVID-19 cases increased. Participants shared key learnings for successful implementation of tele-BH that could be applied in future health care crises. CONCLUSION: Practices adapted readily to challenges posed by pandemic restrictions and their ability to sustain key elements of IBH during the COVID-19 pandemic demonstrates innovation in maintaining access when in-person care is not possible, informing strategies applicable to other scenarios.

Integrated Behavioral Health Implementation and Training in Primary Care: A Practice-Based Research Network Study.

INTRODUCTION: Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders. METHODS: FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar. RESULTS: Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability. CONCLUSIONS: Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.

Implementation and Evaluation of Primary Care Team Participation in Opioid Use Disorder Learning Sessions.

INTRODUCTION: Previous studies show that some primary care clinicians do not feel equipped to treat patients with opioid use disorder (OUD). This study addressed the gaps in confidence and knowledge of primary care physicians and other participants (i.e., participants who were not physicians) in diagnosing, treating, prescribing, and educating patients with OUD through interactive learning sessions. METHODS: The American Academy of Family Physicians National Research Network held monthly OUD learning sessions from September 2021 to March 2022 with physicians and other participants (n = 31) from 7 practices. Participants took baseline (n = 31), post-session (n = 11-20), and post-intervention (n = 21) surveys. Questions focused on confidence, knowledge, among others. We used non-parametric tests to compare individual responses pre-versus-post participation as well as to compare responses between groups. RESULTS: All participants experienced significant changes in confidence and knowledge for most topics covered in the series. When comparing physicians to other participants, physicians had greater increases in confidence in dosing and monitoring for diversion (P = .047), but other participants had greater increases in confidence in the majority of topic areas. Physicians also had greater increases in knowledge than other participants in dosing and monitoring for safety (P = .033) and dosing and monitoring for diversion (P = .024), whereas other participants had greater increases in knowledge in most remaining topics. Participants agreed that sessions provided practical knowledge, except for relevancy of the case study portion of the session to current practice (P = .023) and the session improved participant ability to care for patients (P = .044). CONCLUSION: Through participating in interactive OUD learning sessions, knowledge and confidence increased among physicians and other participants. These changes may impact participants' decisions to diagnose, treat, prescribe, and educate patients with OUD.

Priorities for improvement across cancer and non-cancer related preventive services among rural and non-rural clinicians.

INTRODUCTION: It is not realistic for most clinicians to perform the multitude of recommended preventive primary care services. This is especially true in low resource and rural settings, creating challenges to delivering high-quality care. This study collected stakeholder input from clinicians on which services they most need to improve. METHODS: The authors conducted a survey of primary care physicians 9-12/2021, with an emphasis on rural practices, to assess areas in which clinicians felt the greatest needs for improvement. The survey focused on primary prevention (behavior change counseling) and cancer screening, and contrasted needs for improvement for these services vs. other types of screening, and between clinicians in rural vs. non-rural practices. RESULTS: There were 326 respondents from 4 different practice-based research networks, a wide range of practice types, 49 states and included 177 clinicians in rural settings. Respondents rated the need to improve delivery of primary prevention counseling services highest, with needs for nutrition and dietary assessment and counseling rated highest followed by physical activity and with almost no differences between rural and nonrural. Needs for improvement in cancer screenings were rated higher than non-cancer screenings, except for blood pressure screening. CONCLUSIONS: Both rural and nonrural primary care clinicians feel a need for improvement, especially with primary prevention activities. Although future research is needed to replicate these findings with different populations and other types of preventive service activities, greater priority should be given to development of practical, stakeholder informed assistance and resources for primary care to conduct primary prevention.

Alpha-1 Acid Glycoprotein Reduction Differentiated Recovery from Remission in a Small Cohort of Cats Treated for Feline Infectious Peritonitis.

Feline infectious peritonitis (FIP) is a systemic immune-mediated inflammatory perivasculitis that occurs in a minority of cats infected with feline coronavirus (FCoV). Various therapies have been employed to treat this condition, which was previously usually fatal, though no parameters for differentiating FIP recovery from remission have been defined to enable clinicians to decide when it is safe to discontinue treatment. This retrospective observational study shows that a consistent reduction of the acute phase protein alpha-1 acid glycoprotein (AGP) to within normal limits (WNL, i.e., 500 µg/mL or below), as opposed to duration of survival, distinguishes recovery from remission. Forty-two cats were diagnosed with FIP: 75% (12/16) of effusive and 54% (14/26) of non-effusive FIP cases recovered. Presenting with the effusive or non-effusive form did not affect whether or not a cat fully recovered (p = 0.2). AGP consistently reduced to WNL in 26 recovered cats but remained elevated in 16 cats in remission, dipping to normal once in two of the latter. Anaemia was present in 77% (23/30) of the cats and resolved more quickly than AGP in six recovered cats. The presence of anaemia did not affect the cat's chances of recovery (p = 0.1). Lymphopenia was observed in 43% (16/37) of the cats and reversed in nine recovered cats but did not reverse in seven lymphopenic cats in the remission group. Fewer recovered cats (9/24: 37%) than remission cats (7/13: 54%) were lymphopenic, but the difference was not statistically different (p = 0.5). Hyperglobulinaemia was slower than AGP to return to WNL in the recovered cats. FCoV antibody titre was high in all 42 cats at the outset. It decreased significantly in 7 recovered cats but too slowly to be a useful parameter to determine discontinuation of antiviral treatments. Conclusion: a sustained return to normal levels of AGP was the most rapid and consistent indicator for differentiating recovery from remission following treatment for FIP. This study provides a useful model for differentiating recovery from chronic coronavirus disease using acute phase protein monitoring.

Evaluating a Web-Based Adult ADHD Toolkit for Primary Care Clinicians.

INTRODUCTION: Approximately 5% of the US adult population has Attention Deficient Hyperactivity Disorder (ADHD) that can negatively impact quality of life. Health care professionals report a need to increase their knowledge of and confidence in treating adult ADHD. The American Academy of Family Physicians National Research Network (AAFP NRN) collaborated with a panel of experts to create a web-based AAFP Adult ADHD Toolkit composed of resources to aid in the diagnosis, management, and treatment of adults with ADHD. OBJECTIVES: Assess the impact of using an AAFP Adult ADHD Toolkit in a practice setting. METHODS: Ninety-seven primary and behavioral health care professionals from AAFP NRN practices (n=6) used the Toolkit for 17 weeks. Data on Toolkit use, usefulness, implementation, impact, and changes in knowledge and confidence were collected via pre-post and weekly surveys. Mixed methods, regression analyses, t-tests, and mixed ANOVA were used to assess change over time. RESULTS: Use of the Toolkit improved health care providers' knowledge by midpoint relative to baseline in areas related to treatment effects, side effects, and outcomes (3.6 vs 3.0; P = .004); existing ADHD resources (3.3 vs 2.9; P = .03); and management of ADHD in patients with comorbid conditions (3.2 vs 2.7; P = .01). By the end of the study, Toolkit use was associated with increased confidence in mental health and life history interview techniques (3.5 vs 3.0; P = .03); treatment options for ADHD with comorbid mental health disorders (3.2 vs 2.3; P ≤ .001); and treatment options for ADHD with coexisting substance use disorders (3.0 vs 2.3; P = .003). By the end of the study, most participants (n=47, 87%) reported the Toolkit addressed most of their needs related to diagnosis, treatment, and management of adult ADHD. CONCLUSION: Availability and adoption of the Toolkit into the routine care of adults with ADHD measurably increased health care professionals' knowledge especially in those providers who regularly see adult patients with ADHD.

Diagnosis of non-effusive feline infectious peritonitis by reverse transcriptase quantitative PCR from mesenteric lymph node fine-needle aspirates.

OBJECTIVES: The aim of this study was to evaluate a feline coronavirus (FCoV) reverse transcriptase quantitative PCR (RT-qPCR) on fine-needle aspirates (FNAs) from mesenteric lymph nodes (MLNs) collected in sterile saline for the purpose of diagnosing non-effusive feline infectious peritonitis (FIP) in cats. METHODS: First, the ability of the assay to detect viral RNA in MLN FNA preparations compared with MLN biopsy preparations was assessed in matched samples from eight cats. Second, a panel of MLN FNA samples was collected from a series of cats representing non-effusive FIP cases (n = 20), FCoV-seropositive individuals (n = 8) and FCoV-seronegative individuals (n = 18). Disease status of the animals was determined using a combination of gross pathology, histopathology and/or 'FIP profile', consisting of serology, clinical pathology and clinical signs. RESULTS: Viral RNA was detected in 18/20 non-effusive FIP cases; it was not detected in two cases that presented with neurological FIP. Samples from 18 seronegative non-FIP control cats and 7/8 samples from seropositive non-FIP control cats contained no detectable viral RNA. Thus, as a method for diagnosing non-effusive FIP, MLN FNA RT-qPCR had an overall sensitivity of 90.0% and specificity of 96.1%. CONCLUSIONS AND RELEVANCE: In cases with a high index of suspicion of disease, RT-qPCR targeting FCoV in MLN FNA can provide important information to support the ante-mortem diagnosis of non-effusive FIP. Importantly, viral RNA can be reliably detected in MLN FNA samples in saline submitted via the national mail service. When applied in combination with biochemistry, haematology and serological tests in cases with a high index of suspicion of disease, the results of this assay may be used to support a diagnosis of non-effusive FIP.

Successful treatment of tracheal lymphoma in a Siamese cat.

CASE SUMMARY: An 8-year-old female spayed Siamese indoor cat presented with a 3 week history of inspiratory dyspnoea, stridor and open-mouth breathing after exercise. Laryngoscopy, tracheoscopy, bronchoscopy and retroflexed nasopharyngoscopy were performed, and identified a multilobulated intraluminal mass within the trachea. Brush cytology was performed on the mass but was inconclusive in providing a definitive diagnosis. A CT scan of the neck failed to identify an obvious intraluminal mass and was negative to contrast uptake. Surgery was performed and seven rings of the trachea were removed to enable the complete excision of the mass. Histopathology of the excised mass was consistent with B cell lymphoma. After surgery, chemotherapy treatment was started. At the time of writing, 20 months since diagnosis, the cat remained clinically well, with no clinical signs or recurrence of macroscopic disease on endoscopic evaluation. RELEVANCE AND NOVEL INFORMATION: Upper airway endoscopy was considered to be an essential diagnostic tool in this case presenting with signs of upper respiratory dyspnoea. Moreover, combined surgery and chemotherapy were considered effective treatments and positively affected the long-term prognosis of this patient.

Novel characteristics identified in two cases of feline cowpox virus infection.

CASE SERIES SUMMARY: This case series discusses novel characteristics identified in two cases of cowpox. One presented with upper airway signs, and was identified to have a focal laryngeal lesion. The other had central neurological signs at the terminal stages, with intracytoplasmic inclusion bodies identified within the cerebral hemispheres on histopathology. RELEVANCE AND NOVEL INFORMATION: Currently, cowpox would be an unlikely consideration in patients with neurological signs or upper respiratory noise. These cases both document novel presentations of cowpox infection, which clinicians should be aware of and consider as differential diagnoses in patients with these atypical presentations.

Sinonasal aspergillosis in a British Shorthair cat in the UK.

Case summary A 13-year-old, castrated male, British Shorthair cat presented for investigation of chronic, intermittent, bilateral epistaxis and stertor. CT revealed severe asymmetric bilateral intranasal involvement with extensive turbinate lysis, increased soft tissue attenuation and lysis of the sphenopalatine bone and cribriform plate. On retroflexed pharyngoscopy, a plaque-like mass occluded the choanae. Rostral rhinoscopic examination revealed extensive loss of nasal turbinates, necrotic tissue and mucosal fungal plaques in the left nasal cavity. The right nasal cavity was less severely affected. The nasal cavities were debrided extensively of plaques and necrotic tissue. Aspergillus fumigatus was isolated on fungal culture, and species identity was confirmed using comparative sequence analysis of the partial ß-tubulin gene. On histopathology of nasal biopsies, there was ulcerative lymphoplasmacytic and neutrophilic rhinitis, and fungal hyphae were identified on nasal mucosa, consistent with a non-invasive mycosis. The cat was treated with oral itraconazole after endoscopic debridement, but signs relapsed 4.5 months from diagnosis. Residual left nasal fungal plaques were again debrided endoscopically and oral posaconazole was administered for 6 months. Fourteen months from diagnosis, the cat remains clinically well with mild intermittent left nasal discharge secondary to atrophic rhinitis. Relevance and novel information This is the first case of rhinoscopically confirmed sinonasal aspergillosis to be diagnosed in a cat in the UK. Endoscopic confirmation of resolution of infection is useful in cases where mild nasal discharge persists after treatment.

Diagnostic laparoscopy in the cat: 1. Rationale and equipment.

PRACTICAL RELEVANCE: The integration of minimally invasive techniques into feline practice seems to be an intuitive step forward, especially for those cases where the owner may be reluctant to subject their cat to major surgery 'just for a biopsy'. Although ultrasound is frequently employed as a diagnostic tool in similar cases, this modality can only provide information on gross abnormalities in organ size and shape, echogenicity and internal architecture; even with ultrasound-guided fine-needle aspiration a definitive diagnosis is rarely achieved. So the clinician and owner are left with unanswered questions that are central to the diagnosis, the most appropriate treatment to pursue and the prognosis for the cat. Laparoscopy does require anesthesia and is more expensive than ultrasound; however, when performed correctly, it is only marginally more invasive and vastly more informative, with a proven track record of minimal morbidity. AUDIENCE: This article is aimed at all feline practitioners, from first opinion through to the referral setting. It is intended to encourage practitioners untrained in minimally invasive procedures to seek formalized training, especially those who want to expand their diagnostic capabilities. For those already performing minimally invasive surgery, it describes how laparoscopic techniques can be applied to many feline gastrointestinal cases. EVIDENCE BASE: Information provided in this article is based on published literature, comprising original studies, case review series and textbook chapters, and the authors' own clinical experience.

Diagnostic laparoscopy in the cat: 2. Common procedures.

PRACTICAL RELEVANCE: Minimally invasive techniques are becoming increasingly available in both first opinion and referral veterinary surgeries. Clients may be reluctant to pursue open surgery for the collection of biopsy samples in a sick cat but may be more open to a laparoscopic approach. Furthermore, a laparoscopic approach provides excellent visualization of the abdominal organs and enables high quality biopsies to be taken that are invariably more diagnostic than percutaneous needle biopsies. Although the feline patient is small in size, its distensible abdomen allows more room for surgical manipulation than afforded by a similar sized canine patient. CLINICAL CHALLENGES: Clinical challenges for the most part relate to mastering laparoscopic technique. Familiarity with the use of long instrumentation viewed on a two-dimensional screen is essential. Hemostasis is an important consideration and suitable instrumentation for achieving hemostasis should be available at all times. Insufflation of the abdomen carries its own challenges with regard to anesthesia and this is covered in an accompanying article in this Special Issue series. AIM: This article introduces the feline practitioner to basic techniques required to effectively utilize diagnostic laparoscopy within feline medical investigations. It focuses on the common procedures of liver biopsy, cholecystocentesis, pancreatic biopsy, kidney biopsy and laparoscopic-assisted intestinal biopsy. EVIDENCE BASE: Information provided in this article is drawn from the published literature and the authors' own clinical experience.

Introduction to endoscopy in the cat: where to start? What to buy?

PRACTICAL RELEVANCE: For many years, endoscopy and minimally invasive surgery have been considered 'standard' in human healthcare. With the expansion of the used medical equipment market, and the falling cost of new equipment, veterinary practitioners are now starting to appreciate first-hand the benefits of performing endoscopic procedures: for example, vastly improved visualisation of the surgical site, reduced tissue trauma, minimal postoperative pain and faster recovery times, especially in feline patients. In addition, clients almost always choose a less invasive procedure if the capabilities are present, and will often consent to these procedures sooner than they would to conventional surgery. AIM: This article aims to guide the general feline practitioner towards a basic understanding of endoscopic and ancillary equipment, and in the direction of appropriate training required to perform routine endoscopic procedures. EVIDENCE BASE: The authors draw on information provided in a combination of published texts, articles, reviews and their own clinical experience to provide a practical information guide for the clinician interested in feline endoscopy.

Gastrointestinal endoscopy in the cat: equipment, techniques and normal findings.

PRACTICAL RELEVANCE: Feline gastrointestinal (GI) endoscopy is in high demand, particularly by cat owners already aware of the clinical benefits and availability of this procedure within the human healthcare system. This article will provide a basic introduction to GI flexible endoscopy, covering important aspects of endoscope selection, clinical indications, and basic techniques required to perform a thorough and diagnostically meaningful examination in the cat. CLINICAL CHALLENGES: Challenges associated with implementing endoscopy in GI tract investigations can include lack of appropriate/suitable-sized equipment to perform a thorough examination in the cat, insufficient operator training/understanding in how to 'drive the scope' through the GI tract, and/or lack of confidence in differentiating normal from abnormal. AUDIENCE: This article is intended to familiarize and motivate the feline practitioner to develop basic endoscopic skills. Clinical proficiency can only be obtained through use of appropriate equipment, formal training and hours of practice indistinguishing normal from abnormal. EVIDENCE BASE: The guidance contained in this article is based on a combination of the published literature, the authors' personal experience and the experience of colleagues.

Gastrointestinal endoscopy in the cat: diagnostics and therapeutics.

PRACTICAL RELEVANCE: Endoscopic examination of the feline gastrointestinal (GI) tract is a minimally invasive method for obtaining biopsy samples of the GI mucosa, which is often necessary for a diagnosis of chronic GI diseases. In addition endoscopy has several therapeutic indications including foreign body retrieval, oesophageal stricture dilation and placement of a percutaneous gastrostomy tube. CLINICAL CHALLENGES: Initially, practitioners must learn the subtle manipulations necessary to efficiently guide the endoscope through the GI tract to obtain biopsy samples of high diagnostic quality, and develop skills for implementing interventional procedures (eg, foreign body removal). Another challenge in mastering GI endoscopy is the ability to recognise normal from abnormal, which requires many years of practice and experience. Endoscopy is a diagnostic and interventional procedure that should be performed only in conjunction with a thorough history, physical examination, appropriate laboratory evaluation, and radiographic and/or ultrasonographic imaging. AUDIENCE: This review is intended to familiarize both the general and referral practitioner with GI endoscopy as a minimally invasive diagnostic and therapeutic intervention for the feline patient. EVIDENCE BASE: The guidance contained within this article is based on a combination of the published literature, the authors' personal experience and the experience of colleagues.