Latest Clinical Guidelines

IN THIS ARTICLE
• ACP: Telemedicine in Primary Care Settings
• AAP: Binge Drinking Among Adolescents
• Management of Primary Immunodeficiency
• Atopic Dermatitis in Children
• Obesity Treatment in Primary Care
• Management of Chronic Kidney Disease

ACP: TELEMEDICINE IN PRIMARY CARE SETTINGS
Daniel H, Sulmasy, LS. Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians position paper. Ann Intern Med. [Epub ahead of print September 8, 2015]. doi:10.7326/M15-0498.

The American College of Physicians (ACP) has issued policy recommendations to guide the use of telemedicine in primary care settings, along with clinician considerations for those who use telemedicine and policy recommendations on the practice and reimbursement of telemedicine. ACP’s position is that telemedicine can potentially be a beneficial and important part of the future of health care delivery; however, it also stresses the importance of balancing the benefits of telemedicine against the potential risks for patients. Among the ACP position statements and recommendations are:
• ACP believes that a valid patient-provider relationship must be established for a professionally responsible telemedicine service to take place.
• ACP recommends the telehealth activities address the needs of all patients without disenfranchising financially disadvantaged populations or those with low literacy or low technologic literacy.

ACP believes that clinicians should use their professional judgment about whether the use of telemedicine is appropriate for a patient.

COMMENTARY
The issue of professional judgment about when it is sufficient to see a patient using a digital interface will ultimately determine the safety and effectiveness of telemedicine. It is a mode of health care delivery that was nonexistent just a few years ago and now has an estimated annual growth rate of 20% per year, with an expected 7 million visits per year by 2018. The potential advantages include health savings, convenience, and the potential to deliver specialized services to people who might otherwise not have access to them. In addition, the use of telemedicine as a part of case-management and patient follow-up has shown promise. In this era of ever-changing technologies, we need to embrace new modes of care with skeptical open arms and be honest about the potential benefits as well as the risks.

Continue for AAP: Binge drinking among adolescents >>

AAP: BINGE DRINKING AMONG ADOLESCENTS
Siqueira L, Smith VC; Committee on Substance Abuse. Binge drinking (clinical report). Pediatrics. 2015;136(3):e718-e726. doi: 10.1542/peds.2015-2337.

A clinical report released by the American Academy of Pediatrics (AAP) details alcohol abuse by children and adolescents in the United States and offers guidance and recommendations to combat this high-risk behavior. The report states that among youth who drink, the proportion that drinks heavily is higher than among adult drinkers.

Among those who drink, binge drinking increases from approximately 50% in those ages 12 to 14 to 72% among those ages 18 to 20. Alcohol use is also associated with the leading causes of death and serious injury in this age-group, including motor vehicle accidents, homicides, and suicides. Recommendations offered in the report include
• In the office setting, provide programs designed to deliver messages about binge-drinking prevention to parents.
• Ask adolescents about alcohol use during office visits.
• Encourage schools to adopt preventive measures, including school-based health education programs.

COMMENTARY 
Binge drinking in adults is defined as consumption of five or more alcoholic drinks in a two-hour period for men and four or more drinks for women. The number of drinks that qualifies as binge drinking in teenagers is slightly less and varies by age.

Using a 30-day time period, 14% of adolescents (1 out of 7) reported binge drinking. When teenagers drink alcohol, they tend to binge drink. Of students who consume alcohol, two-thirds report binge drinking, and 10% report having drunk 10 or more drinks in a row.

It is important to address this problem with parents and youth beginning at about age 9, as the change in attitudes toward drinking appears to begin between ages 9 and 12. It is also important to remind parents, supported by good evidence, that the message they send to their children about alcohol is the most important influence on teenage and young adult decisions about drinking.¹

1. Turrisi R, Mallett KA, Cleveland MJ, et al. Evaluation of timing and dosage of a parent-based intervention to minimize college students’ alcohol consumption. J Stud Alcohol Drugs. 2013;74(1):30-40.

Continue for management of primary immunodeficiency >>

MANAGEMENT OF PRIMARY IMMUNODEFICIENCY
Bonilla FA, Khan DA, Ballas ZK, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. J Allergy Clin Immunol. [Epub ahead of print September 11, 2015]. doi: 10.1016/j.jaci.2015.04.049.

This practice parameter is intended to provide practical guidance on the clinical recognition and diagnosis of primary immunodeficiency (PIDD), along with general principles on management of these disorders. Highlights include
• PIDD has a prevalence of 1:2,000 children.
• PIDD is subdivided into humoral or antibody deficiencies and combined immunodeficiency.
• Initial evaluation is guided by the clinical presentation, and screening tests are applied and followed by advanced tests, ensuring efficient and thorough evaluation of mechanisms of immune dysfunction that underlie the clinical presentation.
• Diagnosis and therapy should be guided overall or performed in consultation with persons and centers with knowledge and experience diagnosing and treating a broad range of immunodeficiencies.

COMMENTARY
Clinicians should be aware of PIDD in order to refer appropriate patients on to an allergist/immunologist for further evaluation. While many different types of PIDD exist, they generally present with recurrent or severe infections or infections by unusual organisms. For example, approximately a quarter of patients older than 2 with invasive pneumococcal disease have an identifiable PIDD. This is a group of disorders that, while rare, is helpful to be aware of and to refer on for further evaluation when indicated.

Continue for atopic dermatitis in children >>

ATOPIC DERMATITIS IN CHILDREN
Eichenfield LF, Boguniewicz M, Simpson EL, et al. Translating atopic dermatitis management guidelines into practice for primary care providers. Pediatrics. [Epub ahead of print August 3, 2015]. doi: 10.1542/peds.2014-3678.

Treatment guidelines for atopic dermatitis (AD) in children, designed specifically for use by pediatricians and other primary care providers, include basic management such as skin care, antiseptic measures, and trigger avoidance, to be used regardless of AD severity, according to a roundtable discussion to address challenges in AD management. Recommendations for the primary care provider include
• The diagnosis of eczema is a clinical one, based on a chronic or relapsing course of a pruritic dermatitis consisting of erythematous papules or patches of scaling and/or excoriated skin.
• Basic management is important and should include skin hydration with an appropriate moisturizer, use of diluted bleach baths, trigger avoidance, and acute treatment for flares.
• Treatment of acute flares is managed with topical corticosteroids, using a more potent topical steroid initially and then deescalating therapy to a less potent agent after a few days to weeks.

For patients with moderate-to-severe eczema, maintenance therapy for flare-prone areas should be applied regularly or at first sign of a flare-up. Recommended agents include tacrolimus or pimecrolimus (topical calcineurin inhibitors) or medium- or low-potency topical corticosteroids (avoiding medium-potency topical steroids on the face), depending on the severity of eczema.

COMMENTARY
Eczema affects about 12% of US children (ages 0 to 17 years), most of whom have mild disease and are well taken care of by primary care providers. This article provides clear guidance for treatment of a disease that we see quite frequently. Use of diluted bleach baths or washes is an underappreciated approach, and I suspect the clear recommendation for it, based on very good evidence, will lead to a helpful addition to many clinicians’ standard approach.

Continue for obesity treatment in primary care >>

OBESITY TREATMENT IN PRIMARY CARE
Fitzpatrick SL, Wischenka D, Appelhans BM, et al. An evidence-based guide for obesity treatment in primary care. Am J Med. [Epub ahead of print July 31, 2015]. doi: 10.1016/j.amjmed.2015.07.015.

A new evidence-based guideline from the Society of Behavioral Medicine for obesity management and treatment in primary care is based on the “5As” counseling framework (assess, advise, agree, assist, and arrange). The guide recommends building a multidisciplinary team that helps patients lose weight and maintain their weight loss by
• Addressing patients’ psychosocial issues and medical and psychiatric comorbidities associated with obesity treatment failure
• Delivering intensive counseling consisting of goal setting, self-monitoring, and problem solving
• Connecting patients with community resources to assist them in making healthy lifestyle changes.

COMMENTARY
Combating obesity is the critical health issue of the next decade. Currently, two-thirds of the adult population is either overweight or obese, and if the current trend continues, diabetes, one of the most important consequences of obesity, will develop in one out of three Americans born today. Clinicians are generally good at accomplishing the first and second of the three “As”: assessing and advising.¹ The challenge for most of us in busy office practices is in assisting patients with the development of specific, concrete goals using specific, concrete behaviors, and then, when appropriate, arranging for referral to nutritionists, personal trainers, and multicomponent programs to help patients accomplish the agreed-upon goals.

1. Spring B, Ockene JK, Gidding SS, et al. Better population health through behavior change in adults. Circulation. 2013;128:2169-2176.

Continue for management of CKD >>

MANAGEMENT OF CKD
Vassalotti JA, Centor R, Turner BJ, et al; US Kidney Disease Outcomes Quality Initiative. A practical approach to detection and management of chronic kidney disease for the primary care clinician. Am J Med. [Epub ahead of print September 25, 2015]. doi: 10.1016/j.amjmed.2015.08.025.

This guideline was developed for the primary care provider to guide assessment and care of chronic kidney disease (CKD). Recommendations include
• Assessment of estimated glomerular filtration rate (GFR) and albuminuria should be performed for persons with diabetes and/or hypertension but is not recommended for the general population.
• Prevention of CKD progression requires blood pressure < 140/90 mm Hg, use of ACE inhibitors or angiotensin receptor blockers (ARB) for patients with albuminuria and hypertension, A1C < 7% for patients with diabetes, and correction of CKD-­associated metabolic acidosis.
• Nephrotoxic drugs (eg, NSAIDs) should be avoided, and providers should be aware to use reduced doses of medications that are renally excreted, such as insulin, many antibiotics, and some statins.

The ultimate goal of CKD management is to prevent disease progression, minimize complications, and promote quality of life.

COMMENTARY 
More than 10% of the US population has CKD, defined as a GFR < 60 mL/min/1.73 m² and/or albumin-creatinine ratio > 30 mg/g. Both GFR and albuminuria independently predict progression of CKD. Control of blood pressure and A1C and use of an ACE inhibitor or an ARB are well-appreciated methods of slowing CKD progression. What is not as well appreciated is that treatment with ACE inhibitors or ARBs remains renal protective even with GFR < 30. Also important is the use of oral alkali therapy to maintain normal serum bicarbonate levels, which may slow CKD progression. When bicarbonate levels decrease to < 22 mmol/L, sodium bicarbonate (650 mg tid) should be added to raise the bicarbonate level above 22 mmol/L. For patients with severe CKD, referral to a nephrologist is appropriate.

IN THIS ARTICLE
• ACP: Telemedicine in Primary Care Settings
• AAP: Binge Drinking Among Adolescents
• Management of Primary Immunodeficiency
• Atopic Dermatitis in Children
• Obesity Treatment in Primary Care
• Management of Chronic Kidney Disease

ACP: TELEMEDICINE IN PRIMARY CARE SETTINGS
Daniel H, Sulmasy, LS. Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians position paper. Ann Intern Med. [Epub ahead of print September 8, 2015]. doi:10.7326/M15-0498.

The American College of Physicians (ACP) has issued policy recommendations to guide the use of telemedicine in primary care settings, along with clinician considerations for those who use telemedicine and policy recommendations on the practice and reimbursement of telemedicine. ACP’s position is that telemedicine can potentially be a beneficial and important part of the future of health care delivery; however, it also stresses the importance of balancing the benefits of telemedicine against the potential risks for patients. Among the ACP position statements and recommendations are:
• ACP believes that a valid patient-provider relationship must be established for a professionally responsible telemedicine service to take place.
• ACP recommends the telehealth activities address the needs of all patients without disenfranchising financially disadvantaged populations or those with low literacy or low technologic literacy.

ACP believes that clinicians should use their professional judgment about whether the use of telemedicine is appropriate for a patient.

COMMENTARY
The issue of professional judgment about when it is sufficient to see a patient using a digital interface will ultimately determine the safety and effectiveness of telemedicine. It is a mode of health care delivery that was nonexistent just a few years ago and now has an estimated annual growth rate of 20% per year, with an expected 7 million visits per year by 2018. The potential advantages include health savings, convenience, and the potential to deliver specialized services to people who might otherwise not have access to them. In addition, the use of telemedicine as a part of case-management and patient follow-up has shown promise. In this era of ever-changing technologies, we need to embrace new modes of care with skeptical open arms and be honest about the potential benefits as well as the risks.

Continue for AAP: Binge drinking among adolescents >>

AAP: BINGE DRINKING AMONG ADOLESCENTS
Siqueira L, Smith VC; Committee on Substance Abuse. Binge drinking (clinical report). Pediatrics. 2015;136(3):e718-e726. doi: 10.1542/peds.2015-2337.

A clinical report released by the American Academy of Pediatrics (AAP) details alcohol abuse by children and adolescents in the United States and offers guidance and recommendations to combat this high-risk behavior. The report states that among youth who drink, the proportion that drinks heavily is higher than among adult drinkers.

Among those who drink, binge drinking increases from approximately 50% in those ages 12 to 14 to 72% among those ages 18 to 20. Alcohol use is also associated with the leading causes of death and serious injury in this age-group, including motor vehicle accidents, homicides, and suicides. Recommendations offered in the report include
• In the office setting, provide programs designed to deliver messages about binge-drinking prevention to parents.
• Ask adolescents about alcohol use during office visits.
• Encourage schools to adopt preventive measures, including school-based health education programs.

COMMENTARY 
Binge drinking in adults is defined as consumption of five or more alcoholic drinks in a two-hour period for men and four or more drinks for women. The number of drinks that qualifies as binge drinking in teenagers is slightly less and varies by age.

Using a 30-day time period, 14% of adolescents (1 out of 7) reported binge drinking. When teenagers drink alcohol, they tend to binge drink. Of students who consume alcohol, two-thirds report binge drinking, and 10% report having drunk 10 or more drinks in a row.

It is important to address this problem with parents and youth beginning at about age 9, as the change in attitudes toward drinking appears to begin between ages 9 and 12. It is also important to remind parents, supported by good evidence, that the message they send to their children about alcohol is the most important influence on teenage and young adult decisions about drinking.¹

1. Turrisi R, Mallett KA, Cleveland MJ, et al. Evaluation of timing and dosage of a parent-based intervention to minimize college students’ alcohol consumption. J Stud Alcohol Drugs. 2013;74(1):30-40.

Continue for management of primary immunodeficiency >>

MANAGEMENT OF PRIMARY IMMUNODEFICIENCY
Bonilla FA, Khan DA, Ballas ZK, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. J Allergy Clin Immunol. [Epub ahead of print September 11, 2015]. doi: 10.1016/j.jaci.2015.04.049.

This practice parameter is intended to provide practical guidance on the clinical recognition and diagnosis of primary immunodeficiency (PIDD), along with general principles on management of these disorders. Highlights include
• PIDD has a prevalence of 1:2,000 children.
• PIDD is subdivided into humoral or antibody deficiencies and combined immunodeficiency.
• Initial evaluation is guided by the clinical presentation, and screening tests are applied and followed by advanced tests, ensuring efficient and thorough evaluation of mechanisms of immune dysfunction that underlie the clinical presentation.
• Diagnosis and therapy should be guided overall or performed in consultation with persons and centers with knowledge and experience diagnosing and treating a broad range of immunodeficiencies.

COMMENTARY
Clinicians should be aware of PIDD in order to refer appropriate patients on to an allergist/immunologist for further evaluation. While many different types of PIDD exist, they generally present with recurrent or severe infections or infections by unusual organisms. For example, approximately a quarter of patients older than 2 with invasive pneumococcal disease have an identifiable PIDD. This is a group of disorders that, while rare, is helpful to be aware of and to refer on for further evaluation when indicated.

Continue for atopic dermatitis in children >>

ATOPIC DERMATITIS IN CHILDREN
Eichenfield LF, Boguniewicz M, Simpson EL, et al. Translating atopic dermatitis management guidelines into practice for primary care providers. Pediatrics. [Epub ahead of print August 3, 2015]. doi: 10.1542/peds.2014-3678.

Treatment guidelines for atopic dermatitis (AD) in children, designed specifically for use by pediatricians and other primary care providers, include basic management such as skin care, antiseptic measures, and trigger avoidance, to be used regardless of AD severity, according to a roundtable discussion to address challenges in AD management. Recommendations for the primary care provider include
• The diagnosis of eczema is a clinical one, based on a chronic or relapsing course of a pruritic dermatitis consisting of erythematous papules or patches of scaling and/or excoriated skin.
• Basic management is important and should include skin hydration with an appropriate moisturizer, use of diluted bleach baths, trigger avoidance, and acute treatment for flares.
• Treatment of acute flares is managed with topical corticosteroids, using a more potent topical steroid initially and then deescalating therapy to a less potent agent after a few days to weeks.

For patients with moderate-to-severe eczema, maintenance therapy for flare-prone areas should be applied regularly or at first sign of a flare-up. Recommended agents include tacrolimus or pimecrolimus (topical calcineurin inhibitors) or medium- or low-potency topical corticosteroids (avoiding medium-potency topical steroids on the face), depending on the severity of eczema.

COMMENTARY
Eczema affects about 12% of US children (ages 0 to 17 years), most of whom have mild disease and are well taken care of by primary care providers. This article provides clear guidance for treatment of a disease that we see quite frequently. Use of diluted bleach baths or washes is an underappreciated approach, and I suspect the clear recommendation for it, based on very good evidence, will lead to a helpful addition to many clinicians’ standard approach.

Continue for obesity treatment in primary care >>

OBESITY TREATMENT IN PRIMARY CARE
Fitzpatrick SL, Wischenka D, Appelhans BM, et al. An evidence-based guide for obesity treatment in primary care. Am J Med. [Epub ahead of print July 31, 2015]. doi: 10.1016/j.amjmed.2015.07.015.

A new evidence-based guideline from the Society of Behavioral Medicine for obesity management and treatment in primary care is based on the “5As” counseling framework (assess, advise, agree, assist, and arrange). The guide recommends building a multidisciplinary team that helps patients lose weight and maintain their weight loss by
• Addressing patients’ psychosocial issues and medical and psychiatric comorbidities associated with obesity treatment failure
• Delivering intensive counseling consisting of goal setting, self-monitoring, and problem solving
• Connecting patients with community resources to assist them in making healthy lifestyle changes.

COMMENTARY
Combating obesity is the critical health issue of the next decade. Currently, two-thirds of the adult population is either overweight or obese, and if the current trend continues, diabetes, one of the most important consequences of obesity, will develop in one out of three Americans born today. Clinicians are generally good at accomplishing the first and second of the three “As”: assessing and advising.¹ The challenge for most of us in busy office practices is in assisting patients with the development of specific, concrete goals using specific, concrete behaviors, and then, when appropriate, arranging for referral to nutritionists, personal trainers, and multicomponent programs to help patients accomplish the agreed-upon goals.

1. Spring B, Ockene JK, Gidding SS, et al. Better population health through behavior change in adults. Circulation. 2013;128:2169-2176.

Continue for management of CKD >>

MANAGEMENT OF CKD
Vassalotti JA, Centor R, Turner BJ, et al; US Kidney Disease Outcomes Quality Initiative. A practical approach to detection and management of chronic kidney disease for the primary care clinician. Am J Med. [Epub ahead of print September 25, 2015]. doi: 10.1016/j.amjmed.2015.08.025.

This guideline was developed for the primary care provider to guide assessment and care of chronic kidney disease (CKD). Recommendations include
• Assessment of estimated glomerular filtration rate (GFR) and albuminuria should be performed for persons with diabetes and/or hypertension but is not recommended for the general population.
• Prevention of CKD progression requires blood pressure < 140/90 mm Hg, use of ACE inhibitors or angiotensin receptor blockers (ARB) for patients with albuminuria and hypertension, A1C < 7% for patients with diabetes, and correction of CKD-­associated metabolic acidosis.
• Nephrotoxic drugs (eg, NSAIDs) should be avoided, and providers should be aware to use reduced doses of medications that are renally excreted, such as insulin, many antibiotics, and some statins.

The ultimate goal of CKD management is to prevent disease progression, minimize complications, and promote quality of life.

COMMENTARY 
More than 10% of the US population has CKD, defined as a GFR < 60 mL/min/1.73 m² and/or albumin-creatinine ratio > 30 mg/g. Both GFR and albuminuria independently predict progression of CKD. Control of blood pressure and A1C and use of an ACE inhibitor or an ARB are well-appreciated methods of slowing CKD progression. What is not as well appreciated is that treatment with ACE inhibitors or ARBs remains renal protective even with GFR < 30. Also important is the use of oral alkali therapy to maintain normal serum bicarbonate levels, which may slow CKD progression. When bicarbonate levels decrease to < 22 mmol/L, sodium bicarbonate (650 mg tid) should be added to raise the bicarbonate level above 22 mmol/L. For patients with severe CKD, referral to a nephrologist is appropriate.

IN THIS ARTICLE
• ACP: Telemedicine in Primary Care Settings
• AAP: Binge Drinking Among Adolescents
• Management of Primary Immunodeficiency
• Atopic Dermatitis in Children
• Obesity Treatment in Primary Care
• Management of Chronic Kidney Disease

ACP: TELEMEDICINE IN PRIMARY CARE SETTINGS
Daniel H, Sulmasy, LS. Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians position paper. Ann Intern Med. [Epub ahead of print September 8, 2015]. doi:10.7326/M15-0498.

The American College of Physicians (ACP) has issued policy recommendations to guide the use of telemedicine in primary care settings, along with clinician considerations for those who use telemedicine and policy recommendations on the practice and reimbursement of telemedicine. ACP’s position is that telemedicine can potentially be a beneficial and important part of the future of health care delivery; however, it also stresses the importance of balancing the benefits of telemedicine against the potential risks for patients. Among the ACP position statements and recommendations are:
• ACP believes that a valid patient-provider relationship must be established for a professionally responsible telemedicine service to take place.
• ACP recommends the telehealth activities address the needs of all patients without disenfranchising financially disadvantaged populations or those with low literacy or low technologic literacy.

ACP believes that clinicians should use their professional judgment about whether the use of telemedicine is appropriate for a patient.

COMMENTARY
The issue of professional judgment about when it is sufficient to see a patient using a digital interface will ultimately determine the safety and effectiveness of telemedicine. It is a mode of health care delivery that was nonexistent just a few years ago and now has an estimated annual growth rate of 20% per year, with an expected 7 million visits per year by 2018. The potential advantages include health savings, convenience, and the potential to deliver specialized services to people who might otherwise not have access to them. In addition, the use of telemedicine as a part of case-management and patient follow-up has shown promise. In this era of ever-changing technologies, we need to embrace new modes of care with skeptical open arms and be honest about the potential benefits as well as the risks.

Continue for AAP: Binge drinking among adolescents >>

AAP: BINGE DRINKING AMONG ADOLESCENTS
Siqueira L, Smith VC; Committee on Substance Abuse. Binge drinking (clinical report). Pediatrics. 2015;136(3):e718-e726. doi: 10.1542/peds.2015-2337.

A clinical report released by the American Academy of Pediatrics (AAP) details alcohol abuse by children and adolescents in the United States and offers guidance and recommendations to combat this high-risk behavior. The report states that among youth who drink, the proportion that drinks heavily is higher than among adult drinkers.

Among those who drink, binge drinking increases from approximately 50% in those ages 12 to 14 to 72% among those ages 18 to 20. Alcohol use is also associated with the leading causes of death and serious injury in this age-group, including motor vehicle accidents, homicides, and suicides. Recommendations offered in the report include
• In the office setting, provide programs designed to deliver messages about binge-drinking prevention to parents.
• Ask adolescents about alcohol use during office visits.
• Encourage schools to adopt preventive measures, including school-based health education programs.

COMMENTARY 
Binge drinking in adults is defined as consumption of five or more alcoholic drinks in a two-hour period for men and four or more drinks for women. The number of drinks that qualifies as binge drinking in teenagers is slightly less and varies by age.

Using a 30-day time period, 14% of adolescents (1 out of 7) reported binge drinking. When teenagers drink alcohol, they tend to binge drink. Of students who consume alcohol, two-thirds report binge drinking, and 10% report having drunk 10 or more drinks in a row.

It is important to address this problem with parents and youth beginning at about age 9, as the change in attitudes toward drinking appears to begin between ages 9 and 12. It is also important to remind parents, supported by good evidence, that the message they send to their children about alcohol is the most important influence on teenage and young adult decisions about drinking.¹

1. Turrisi R, Mallett KA, Cleveland MJ, et al. Evaluation of timing and dosage of a parent-based intervention to minimize college students’ alcohol consumption. J Stud Alcohol Drugs. 2013;74(1):30-40.

Continue for management of primary immunodeficiency >>

MANAGEMENT OF PRIMARY IMMUNODEFICIENCY
Bonilla FA, Khan DA, Ballas ZK, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. J Allergy Clin Immunol. [Epub ahead of print September 11, 2015]. doi: 10.1016/j.jaci.2015.04.049.

This practice parameter is intended to provide practical guidance on the clinical recognition and diagnosis of primary immunodeficiency (PIDD), along with general principles on management of these disorders. Highlights include
• PIDD has a prevalence of 1:2,000 children.
• PIDD is subdivided into humoral or antibody deficiencies and combined immunodeficiency.
• Initial evaluation is guided by the clinical presentation, and screening tests are applied and followed by advanced tests, ensuring efficient and thorough evaluation of mechanisms of immune dysfunction that underlie the clinical presentation.
• Diagnosis and therapy should be guided overall or performed in consultation with persons and centers with knowledge and experience diagnosing and treating a broad range of immunodeficiencies.

COMMENTARY
Clinicians should be aware of PIDD in order to refer appropriate patients on to an allergist/immunologist for further evaluation. While many different types of PIDD exist, they generally present with recurrent or severe infections or infections by unusual organisms. For example, approximately a quarter of patients older than 2 with invasive pneumococcal disease have an identifiable PIDD. This is a group of disorders that, while rare, is helpful to be aware of and to refer on for further evaluation when indicated.

Continue for atopic dermatitis in children >>

ATOPIC DERMATITIS IN CHILDREN
Eichenfield LF, Boguniewicz M, Simpson EL, et al. Translating atopic dermatitis management guidelines into practice for primary care providers. Pediatrics. [Epub ahead of print August 3, 2015]. doi: 10.1542/peds.2014-3678.

Treatment guidelines for atopic dermatitis (AD) in children, designed specifically for use by pediatricians and other primary care providers, include basic management such as skin care, antiseptic measures, and trigger avoidance, to be used regardless of AD severity, according to a roundtable discussion to address challenges in AD management. Recommendations for the primary care provider include
• The diagnosis of eczema is a clinical one, based on a chronic or relapsing course of a pruritic dermatitis consisting of erythematous papules or patches of scaling and/or excoriated skin.
• Basic management is important and should include skin hydration with an appropriate moisturizer, use of diluted bleach baths, trigger avoidance, and acute treatment for flares.
• Treatment of acute flares is managed with topical corticosteroids, using a more potent topical steroid initially and then deescalating therapy to a less potent agent after a few days to weeks.

For patients with moderate-to-severe eczema, maintenance therapy for flare-prone areas should be applied regularly or at first sign of a flare-up. Recommended agents include tacrolimus or pimecrolimus (topical calcineurin inhibitors) or medium- or low-potency topical corticosteroids (avoiding medium-potency topical steroids on the face), depending on the severity of eczema.

COMMENTARY
Eczema affects about 12% of US children (ages 0 to 17 years), most of whom have mild disease and are well taken care of by primary care providers. This article provides clear guidance for treatment of a disease that we see quite frequently. Use of diluted bleach baths or washes is an underappreciated approach, and I suspect the clear recommendation for it, based on very good evidence, will lead to a helpful addition to many clinicians’ standard approach.

Continue for obesity treatment in primary care >>

OBESITY TREATMENT IN PRIMARY CARE
Fitzpatrick SL, Wischenka D, Appelhans BM, et al. An evidence-based guide for obesity treatment in primary care. Am J Med. [Epub ahead of print July 31, 2015]. doi: 10.1016/j.amjmed.2015.07.015.

A new evidence-based guideline from the Society of Behavioral Medicine for obesity management and treatment in primary care is based on the “5As” counseling framework (assess, advise, agree, assist, and arrange). The guide recommends building a multidisciplinary team that helps patients lose weight and maintain their weight loss by
• Addressing patients’ psychosocial issues and medical and psychiatric comorbidities associated with obesity treatment failure
• Delivering intensive counseling consisting of goal setting, self-monitoring, and problem solving
• Connecting patients with community resources to assist them in making healthy lifestyle changes.

COMMENTARY
Combating obesity is the critical health issue of the next decade. Currently, two-thirds of the adult population is either overweight or obese, and if the current trend continues, diabetes, one of the most important consequences of obesity, will develop in one out of three Americans born today. Clinicians are generally good at accomplishing the first and second of the three “As”: assessing and advising.¹ The challenge for most of us in busy office practices is in assisting patients with the development of specific, concrete goals using specific, concrete behaviors, and then, when appropriate, arranging for referral to nutritionists, personal trainers, and multicomponent programs to help patients accomplish the agreed-upon goals.

1. Spring B, Ockene JK, Gidding SS, et al. Better population health through behavior change in adults. Circulation. 2013;128:2169-2176.

Continue for management of CKD >>

MANAGEMENT OF CKD
Vassalotti JA, Centor R, Turner BJ, et al; US Kidney Disease Outcomes Quality Initiative. A practical approach to detection and management of chronic kidney disease for the primary care clinician. Am J Med. [Epub ahead of print September 25, 2015]. doi: 10.1016/j.amjmed.2015.08.025.

This guideline was developed for the primary care provider to guide assessment and care of chronic kidney disease (CKD). Recommendations include
• Assessment of estimated glomerular filtration rate (GFR) and albuminuria should be performed for persons with diabetes and/or hypertension but is not recommended for the general population.
• Prevention of CKD progression requires blood pressure < 140/90 mm Hg, use of ACE inhibitors or angiotensin receptor blockers (ARB) for patients with albuminuria and hypertension, A1C < 7% for patients with diabetes, and correction of CKD-­associated metabolic acidosis.
• Nephrotoxic drugs (eg, NSAIDs) should be avoided, and providers should be aware to use reduced doses of medications that are renally excreted, such as insulin, many antibiotics, and some statins.

The ultimate goal of CKD management is to prevent disease progression, minimize complications, and promote quality of life.

COMMENTARY 
More than 10% of the US population has CKD, defined as a GFR < 60 mL/min/1.73 m² and/or albumin-creatinine ratio > 30 mg/g. Both GFR and albuminuria independently predict progression of CKD. Control of blood pressure and A1C and use of an ACE inhibitor or an ARB are well-appreciated methods of slowing CKD progression. What is not as well appreciated is that treatment with ACE inhibitors or ARBs remains renal protective even with GFR < 30. Also important is the use of oral alkali therapy to maintain normal serum bicarbonate levels, which may slow CKD progression. When bicarbonate levels decrease to < 22 mmol/L, sodium bicarbonate (650 mg tid) should be added to raise the bicarbonate level above 22 mmol/L. For patients with severe CKD, referral to a nephrologist is appropriate.