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  • World Immunization Week 2022: Increasing Vaccine Adherence

    By: Rachel Koransky-Matson, DNP, APRN, FNP-C, A-CTTP

           World Immunization Week’s (April 24th–30th) theme of “Long life for all” aims to highlight and promote the use of vaccines to protect people of all ages against disease. Vaccination has long been a principal global public health activity, but recently the focus on the CoVID-19 pandemic has highlighted how vital vaccinations can be on a global level. However, there are still many that want to debate the efficacy of vaccination.

           Statistics show at least 3 out of every 4 adults are missing one or more of the routinely recommended vaccines1. A recent survey of families in 18 European countries polled for their confidence in childhood immunizations showed 4% of parents were “very hesitant” and 24% were “somewhat hesitant” to vaccinate their children.2 This is nearly a quarter of all patients.

           As nurse practitioners, we are responsible for having difficult, emotional conversations with patients and listening thoroughly to their objections, concerns, and acknowledging their research findings. When you hear an objection, don’t respond immediately but clarify their objections. Make sure these patients feel heard. By being responsible listeners and educators, we can have more meaningful and deep conversations with people and the world around us.3

           Years ago, I had a family come into the clinic with their newborn and they were “vaccine-hesitant”. There were some valid reasons for them to feel this way based on family history, personal vaccine history, and their research. Contrary to popular belief, they had used and researched valid articles and discourses on vaccination. The idea that everyone is a “Google Doctor” did not apply. After listening and discussing the concerns, we were able to formulate a vaccine schedule that made them comfortable while still fully vaccinating the child. It may not have been the CDC’s recommended schedule or even WHO’s schedule, but it worked. The goal was to get them vaccinated by the time they started school.

           Every patient should be offered vaccinations. Find common ground and acknowledge the fears of those that have objections. Be respectful no matter your opinion and provide educational resources. The patient is ultimately in control of the decision. We are here to help educate, support and guide those outcomes.

    Learn more

           Learn more and earn CE with our online course, Immunization Update: Vaccine Recommendations Across the Lifespan, or 2021 Infectious Disease bundle, available at our Learning Center.

     

    References

    1 Centers for Disease Control and Prevention (CDC). (2021) Strategies for Increasing Adult Vaccination Rates. Retrieved from https://www.cdc.gov/vaccines/hcp/adults/for-practice/increasing-vacc-rates.html

    2 Hadjipanayis, A., van Esso, D., Del Torso, S., et al. (2020). Vaccine confidence among parents: large scale study in eighteen European countries. Vaccine. 38(6): 1505-1512. https://doi.org/10.1016/j.vaccine.2019.11.068

    3 Reynolds L et al (2020) Nurses as educators: creating teachable moments in practice. Nursing Times [online]; 116: 2, 25-28.

  • Colorectal Cancer Screening Guidelines

    Sue Freeman, MSN, GNP-CS

    March is Colorectal Cancer Awareness month and recently updated guidelines for screening are reviewed here. In May 2021 the U.S. Preventative Services Task Force (USPSTF) expanded recommended screening to 45-75 from 50-75 for average risk adults. The American Cancer Society (ACS) makes the same recommendation.

    The recommended age was lowered from 50 to 45 because colorectal cancer cases are on the rise among young and middle-aged people. Deaths of people under age 55 increased 1% per year from 2008 to 2017, even though overall colorectal cancer rates have dropped.¹

    The overall goal is early identification and treatment to reduce the incidence and mortality of colorectal cancer. Early detection of pre-cancerous polyps by visual-based screening allows for their removal during colonoscopy, thus eliminating the disease. Stool based screenings detect blood in the stool, which prompts further diagnostic investigation. 

    Current guidelines are as follows for adults age 45-75. 

    • Flexible sigmoidoscopy every 5 years
    • Flexible sigmoidoscopy every 10 years with a FIT or FOBT annually
    • Colonoscopy every 10 years
    • CT Colonography every 5 years
    • sDNA-FIT every 1-3 years
    • High sensitivity gFOBT or FIT every year²

    Those at higher risk may be screened earlier and more frequently.

    • A personal history of colorectal cancer or adenomatous polyps.
    • A strong family history of colorectal cancer or polyps such as cancer or polyps in a first-degree relative younger than 60 or in 2 first-degree relatives of any age. A first-degree relative is defined as a parent, sibling, or child.
    • A personal history of chronic IBD

    A family history of any hereditary colorectal cancer syndrome, such as FAPLynch syndrome, or other syndromes (see Risk Factors and Prevention).³

    Nurse Practitioners are in an optimal role to both educate and support patients as they make decisions about which type of screening is best for them. Ongoing engagement allows for longitudinal surveillance, increasing the ability to detect early signs of colorectal cancer as well as prevent the progression of pre-cancerous lesions to colorectal cancer.

    Additional information on screening for colorectal cancer can be found here: https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html

     

    References:

    1. Bartosch, Jamie; New Guidelines Lower Colorectal Cancer Screening Age from 50 to 45, May 26, 2021.  UChicagoMedicine, https://www.uchicagomedicine.org/forefront/cancer-articles/new-guidelines-lower-colorectal-screening-age-from-50-to-45 , referenced 2.5.22
    2. Screening for Colorectal Cancer: US Preventative Services Taskforce Recommendation Statement, U.S. Preventative Services Taskforce.   2021;325(19):1965-1977. doi:10.1001/jama.2021.6238  Available at https://jamanetwork.com/journals/jama/fullarticle/2779985, referenced 2.5.22
    1. American Society of Clinical Oncology, Cancer.Net, approved by the Cancer.Net editorial board, 01/2021. Available at https://www.cancer.net/cancer-types/colorectal-cancer/screening, reference 2.5.2

     

  • Herbal Supplements Used in the Treatment of Hypertension

    by Indira Maurer, DNP, FNP-C

    In today’s age, individuals are turning to home and traditional remedies to control their illnesses. With the increased number of patients turning to alternative medication such as herbal remedies for their ailments or conditions, it is necessary for health care providers to be aware of the use and adverse effects associated with herbal supplements. Herbs are utilized by the population as a form of self-care for many ailments, including hypertension. Many supplements have claims to support cardiac health and improve blood pressure readings. The three herbs addressed include Hawthorn, Garlic, and Hibiscus.  

    Hawthorn (Crataegus laevigata).  Hawthorn, Crataegus laevigata, has been used traditionally as a diuretic, an appetite suppressant, to ease stomach aches, and to improve circulation (University of South Florida [USF], 2010). Hawthorn has a long history of use in the treatment of heart failure and currently remains as one of the top herbs utilized in the self-treatment of hypertension.

    Safety and side effects.  Hawthorn is considered safe for use when ingested for short periods of time (National Center for Complementary and Integrative Health [NCCAM], 2020).  Side effects reported include abdominal discomfort, headache, and dizziness although these are rare findings (NCCAM). Other rare side effects include arrhythmias, fatigue, or insomnia (Banyan Botanicals, 2021). 

    Forms and dose.  The German Commission E recommends a daily dosage of 160-900 milligrams to be divided in 2 to 3 equal doses daily (USF, 2010). The herb should be in the form of an extract made of the leaves and flowers (USF). The hypotensive actions develop with chronic use, and one should expect to see the desired effect after 4 to 6 weeks of use (USF).

     

    Garlic (Allium sativum).  Garlic, Allium sativum, is one of the most-used herbal supplements (NCCAM, 2020). 

    Safety and side effects.  Garlic has not been associated with many adverse effects.  Side effects reported include halitosis, body odor, heartburn, and abdominal discomfort. However, most of these adverse effects are associated with the ingestion of raw garlic (NCCAM, 2020). 

    Forms and dose.  It is recommended that a dose of 600-900 milligrams per day be taken for desired results (Matsutomo, 2019). This dose should be divided in three doses per day (USF, 2010). Dried garlic should be taken in an enteric-coated tablet to bypass the acidic environment of our gastric fluid and allow the enzyme conversion to take place in the intestine (USF).

                 

    Hibiscus (Hibiscus sabdariffa).  Hibiscus, Hibiscus sabdariffa, is a plant that has been used traditionally in the treatment of hypertension, head lice, and to speed up the childbirth process. Additionally, it is believed to contain anti-fungal, antimicrobial, antipyretic, contraceptive, and anti-tumor properties (Banyan Botanicals, 2021). 

    Forms and dose.  For the treatment of hypertension, a typical adult dosage is 10 grams of the calyx used to make a tea. The calyx is steeped in 1 cup of boiling water for approximately ten minutes and administered once daily (Banyan Botanicals, 2021). 

     

    These herbs may require more research and clinical trials to confirm efficacy. However, maintaining an open mind for herbal supplement use may lead to alternate treatment regimens to consider with the inclusion of herbal supplements either in combination with lifestyle changes, or as an adjunct in therapy with the more contemporary, synthetic medications. 

     

    References

    Banyan Botanicals (2021). The Benefits of Hibiscus. Retrieved from https://www.banyanbotanicals.com/info/plants/ayurvedic-herbs/the-benefits-of-hibiscus/     

    Chang, Q., Zuo, Z., Harrison, F., & Chow, M. S. S. (2002). Hawthorn. The Journal of Clinical Pharmacology, 42(6), 605-612.

    Matsutomo, T. (2020). Potential benefits of garlic and other dietary supplements for the management of hypertension. Experimental and therapeutic medicine19(2), 1479-1484.

    National Center for Complementary and Alternative Medicine (2020).  Herbs at a glance: Hawthorn. Retrieved from http://nccam.nih.gov/health/hawthorn?lang=es

    University of South Florida (2010).  Shimberg health sciences library: Hawthorn. Retrieved from http://www.clinicalpharmacology-ip.com.ezproxy.hsc.usf.edu/Forms/Monograph/monograph.aspx?cpnum=2223&sec=moncontr&t=0

  • Cervical Cancer Screening Updates

    by Terri Schmitt, PhD, APRN, FNP-BC, FAANP

    January is cervical cancer awareness month and in the past year, amidst all the pandemic information and updates, cervical cancer screening guidelines established by the USPSTF were endorsed by both ACOG and the ASCP.  After just over 15 years of FDA approval of HPV vaccines and data trending, this effective screening method remains the tool of choice for early detection. As with prior guidelines screening is not recommended prior to age 21 or after age 65. Below is a summary of the guidelines.

    Screening

    • Anyone with a cervix age 21 to 65 should be screened.
    • Ages 21 to 29 – cytology screening alone every three years.
    • Ages 30 to 65 can be screened by any one of the following methods:
      • Only cytology every three years
      • Primary High Risk Human Papillomavirus (hrHPV) testing alone every 5 years, if an FDA approved test
      • Using both cytology and hrHPV testing together every 5 years
    • Older than age 65 – no screening if ‘negative prior screening’.
    • For those with hysterectomy and cervix removal, no screening needed if no history of previous high grade pre-cancerous findings or cervical lesions.
    • Guidelines are the same for anyone with a cervix regardless of HPV vaccination history and who do not have any symptoms of cervical cancer.
    • Adequate ‘negative prior screening’ is defined as three negative cytology results, 2 negative co-testing cytology and hrHPV testing, or 2 negative hrHPB testing results within the 10 years prior.¹

    Of note is that in 2020 the American Cancer Society recommended primary hrHPV testing as their preferred screening option for patients age 25 to 65, but access to FDA approved tests, strains on infrastructure of production and labs and access to this type of testing in rural and under-served areas has proved challenging, leaving some at a continued disadvantage to optimal screening.² The efficacy of hrHPV testing is promising, with a 2 to 2.7 fold higher detection ability for grade 2 and higher cervical intraepithelial neoplasia.³

    Adherence to the above screening schedule and type of screening is recommended for all patients and will serve to improve patient outcomes and early detection. For more on cervical cancer screening guidelines visit the USPSTF at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening.

     

    References

    1. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force. JAMA 2018;320:674-86. Available at: https://jamanetwork.com/journals/jama/fullarticle/2697704. Retrieved Jan 10, 2022.
    2. American College of Obstetrics and Gynecology. Practice Advisory: Updated cervical cancer screening guidelines. April, 2021. Available at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/04/updated-cervical-cancer-screening-guidelines. Retrieved Jan 10, 2022
    3. Zhang J, Zhao Y, Dai Y, et al. Effectiveness of High-risk Human Papillomavirus Testing for Cervical Cancer Screening in China: A Multicenter, Open-label, Randomized Clinical Trial. JAMA Oncol.2021;7(2):263–270. doi:10.1001/jamaoncol.2020.6575. Available at: https://jamanetwork.com/journals/jamaoncology/fullarticle/2774442. Retrieved Jan 10, 2022
  • NPACE 2021 Needs Assessment Survey Results

    This fall, NPACE conducted a survey of approximately 116,000 nurse practitioners (NPs) and advanced practice registered nurses (APRNs) to identify gaps of knowledge, skill, and practice. A total of 1,666 NPs responded on their learning needs and preferred modalities. This critical information will guide NPACE as we target educational programming that meets defined practice gaps.

    Despite the barriers resulting from COVID, 615 respondents attended an NPACE virtual CE activity this past year:

    • 82% reported receiving a positive return secondary to their increased knowledge, skills, or patient outcomes,
    • 77% reported that they changed their practice due to an increase of knowledge gained from the activity,
    • 63% reported an increase in their quality outcome measures because of the activity.

     

    Learning Environment

    • NPACE has been heralded for peer gatherings that bring NPs from diverse clinical settings together with the nation’s top primary care and pharmacology speakers in relaxed, beautiful resort locations. Restricted from gathering since 2019, we were not surprised to learn that 75% of respondents reported that in-person education was their first choice followed by online/on-demand second and live virtual conferences trailing third. Webinars and podcasts were ranked the lowest of the choices.

     

    Continuing Education Budget

    • The availability of CE reimbursement from employers was across the board with 34% reporting allowed budgets of over $1,500 while 26% reported no budget at all.

     

    Continuing Education Topics of Interest

    • Pharmaceutical therapies was the standout topic of interest, followed closely by practice guidelines, and specific disease management. Diagnostic Approaches along with Therapeutic and Management Approaches followed underlining gaps in clinical practice. Legislation or regulatory practice updates was ranked lowest of the topic choices. About 20% of respondents agreed that hands-on workshops and those focused on wellness would be of interest.

     

    Professional Education Topics

    • When asked to choose five professional education topics that would meet needs, pharmacology topped the charts and was chosen by 62% of respondents. Cardiovascular medicine and endocrinology followed with dermatology, mental health, women’s health, pain management and others ranked behind. Men’s health was the topic that survey participants felt would least enhance their knowledge.

     

    Workshops

    • Suturing workshops were the most desired, though workshops were generally only selected by 20% of respondents as a milieu. Imaging and EKG interpretation were also identified by a large percentage.
  • Antibiotic Stewardship: Implementing Strategies Into Daily Practice

    Devin Pinaroc, FNP-C

     

    The CDC’s Antibiotic Resistance Threats in the United States, 2019 Report, identified 18 different multi-drug resistant bacteria and fungi that have a widespread prevalence and pose significant threat to the public. More than 2.8 million people in the US develop an antibiotic resistance infection annually and over 35,000 die as a result (2019). Additionally, the annual national cost to treat just 6 of these multi-drug resistant infections was over $4.6 billion dollars (Nelson et al., 2021). The US government’s efforts to reduce inappropriate antibiotic use and implement transmission prevention techniques have effectively decreased the amount of deaths since 2013, but the costs are still too high (CDC, 2019).

    Inappropriate antibiotic use is seen across all of health care, but the majority of prescriptions result from outpatient settings comprising about 60% of the US’s antibiotic use (Sanchez, 2016). Barriers that lead to inappropriate prescribing include knowledge deficits of clinician and patient, patient expectations and desires, time constraints of a daily clinic, and a misperception of resistance being a future problem. The CDC released a report to guide antibiotic stewardship in outpatient settings, advising clinicians how to overcome barriers and provide optimal care (Sanchez, 2016). Ultimately, improving the way antibiotics are used will maximize the effectiveness of antibiotic treatment and prevent avoidable adverse effects from antibiotic use to individuals and the community.

     

    Core Elements of Antibiotic Stewardship 

    The CDC’s Four Core Elements of Outpatient Antibiotic Stewardship report provides a framework on how to practice antibiotic stewardship for clinicians in the outpatient setting. These interventions apply to individual visits during daily clinical practice as well as organizational policy and reports, helping overcome barriers to antibiotic stewardship and reduce inappropriate prescribing throughout all levels of healthcare (Sanchez, 2016).

    Commitment.  Each individual of the healthcare team needs to commit to antibiotic stewardship and promote  appropriate antibiotic prescribing daily. Communication by all clinic members that an evaluation might or might not result in antibiotics creates a consistent message from start to finish that helps reduce the expectation that antibiotics are needed for every acute illness. In the exam room, publicly displaying a letter of the clinician’s commitment to antibiotic stewardship was shown to reduce inappropriate antibiotic prescriptions for acute respiratory infections. Ultimately, clinicians must choose to be an antibiotic steward with every patient encounter, utilizing antibiotics only when appropriate as well as the correct drug, dose, and duration, and opposing patient’s desires when necessary (Sanchez, 2016).

    Action for Policy and Practice. Clinicians should practice evidence-based diagnostic criteria and treatment recommendations from clinical practice guidelines informed by local pathogen susceptibilities. Developing simplified explanations of the research studies behind these treatment guidelines can reassure patients that antibiotics are not always necessary for acute illness. A “watch and wait” or delayed antibiotic prescription are both evidence-based ways to safely decrease antibiotic use while also sustaining satisfaction. This can involve post-dating prescriptions, instructing patients to fill prescriptions after a predetermined date, or providing symptomatic relief with a clear plan to follow up if symptoms worsen or persist (Sanchez, 2016).

    Clinic leaders can promote antibiotic stewardship by implementing policies to encourage adherence to clinical practice guidelines, like clinic decision support notifications that provide prescribing information during a typical work flow or requiring explicit justification in the EMR when prescribing a non-recommended antibiotic. This keeps accountability and is proven to reduce inappropriate prescribing. A triage or nurse line, especially during the winter months, can provide patients with information about over the counter therapies and supportive care, reducing unnecessary visits for “common colds” (Sanchez, 2016).

    Tracking and Reporting. Audit and feedback can inform about antibiotic prescribing data for both individual prescribers and the entire organization. This data can be utilized in effective feedback interventions across all levels of the organization. Antibiotic prescribing reports comparison of clinical performance with their peers or against clinical guidelines. This data can help clinicians self-evaluate and determine if they need to seek more information about prescribing guidelines (Sanchez, 2016).  

    Education and Expertise. Clinical education should not only review evidence-based guidelines for clinical knowledge but also address other influences like the concern for patient satisfaction and time constraints of a busy clinic. Misinformation and misunderstanding create incorrect expectations that cause patients to pressure clinicians to provide antibiotics and feel wrongly treated without a prescription. Counseling with an explanation that addresses when antibiotics are not needed, specific symptom management recommendations, and when to seek follow-up care has been shown to increase visit satisfaction. Education about the potential side effects of antibiotics may help patients understand the benefits of avoiding antibiotic use. In a busy clinic day, utilizing patient education materials may be useful for a more complete patient education (Sanchez, 2016).

     

    Learn More and Earn CE

    Earn CE on Antibiotic Stewardship. View our recorded webinar at our Learning Center

     

    Other Resources

    Adult Outpatient Treatment Recommendations | Antibiotic Use

    Healthcare Professional Information | Antibiotic Use

    Antibiotic stewardship targets in the outpatient setting

    Outpatient antibiotic stewardship: Interventions and opportunities

    Outpatient Antibiotic Prescribing for Acute Respiratory Infections During Influenza Seasons | Infectious Diseases | JAMA Network Open

     

    References

    CDC. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019.

    CDC. Antibiotic Use in the United States, 2021 Update: Progress and Opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. 

    Nelson, Richard E, et al. “National Estimates of Healthcare Costs Associated with Multidrug-Resistant Bacterial Infections among Hospitalized Patients in the United States.” OUP Academic, Oxford University Press, 29 Jan. 2021, https://doi.org/10.1093/cid/ciaa1581

    Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65 (No. RR-6):1–12., https://doi.org/10.15585/mmwr.rr6506a1.

  • Type 2 Diabetes Mellitus Management: Keeping Up with the Standards of Care

    Devin Pinaroc, FNP-C

     

    On a typical day, primary care physicians run from exam room to exam room, completing various tasks and to-do’s for each patient as well as fielding questions from support staff and helping run the operations of the clinic. To add a layer of complexity, visit times are limited, and chief complaints require knowledge on the management of any number of chronic illnesses and acute symptoms. These difficulties can make chronic disease management overwhelming given that comprehensive care requires evaluation of the current status of disease as well as preventing any further complications or progression. For Type 2 Diabetes Mellitus (T2DM), specifically, this is quite the list. 

    There are many specific care requirements that must be confirmed and monitored when managing patients with T2DM. Organization of T2DM follow-up visits ensure completion of unique steps that prevent the disease progression and reduce risk of complications and comorbidities. By creating a checklist, charting templates, and/or standardizing visits as much as possible, clinicians can deliver complete, holistic management and fulfill all routine screenings and methods to reduce progression and risk for associated comorbidities (Wexler, 2021).

     

    Special Screenings 

    Yearly Eye Exam. Patients with T2DM have increased risk for vision loss, cataracts, glaucoma, and retinopathy. Asking about visual acuity or any visual impairment during routine visits can help detect these issues and promote further evaluation. Regardless, an annual referral for a dilated eye exam is necessary for all diabetes to aid in early detection (Wexler, 2021).

    Routine Foot Examination. Visualize the feet at every routine visit to assess for evidence of neglect or loss of sensation, like toenail infections or non-healing wounds. The medical assistant (MA) can ask the patient to remove their shoes and socks during intake and vital signs measurement. A more comprehensive foot exam can occur yearly in the primary care setting and should include pedal pulses and testing for loss of sensation with monofilament and one of the following: vibration using 128 Hz tuning fork, pinprick sensation, ankle reflex, and VPT (vibratory perception threshold) testing. An abnormal foot examination warrants a podiatrist or expert in diabetic foot care referral (Wexler, 2021).

    Urinary albumin. Urinary albumin and eGFR should be screened annually to detect elevation and possible chronic kidney disease (American Diabetes Association [ADA], 2021).  

     

    Glycemic Control Assessment

    Glucose log and Hemoglobin A1C. An A1C value of ≤7.0 percent shows adequately controlled glucose levels.  This means target blood glucose levels should be between 80 to 130mg/dL, fasting status, and a postprandial glucose less than 180mg/dL (Wexler, 2021).The patient may have a glucose log book or a glucometer that displays daily blood glucose readings, usually in relation to time of day or meals. Asking the patient to present the average of their glucose log or directing the MA to calculate the average may be most helpful for quick assessment. The glucose log is usually necessary and more helpful with medication adjustment for insulin dependent diabetics. 

     

    Reducing Cardiovascular Risk 

    The American Diabetes Association recommends different statin dose therapies depending on CVSD risk stratification (2021). In general all patients with T2DM should be placed on AT LEAST a moderate intensity statin. A lipid panel should be taken at time of diagnosis, with every medication change, and at least yearly when stable. If the patient is under 40 yrs old, screening can occur every 5 years (ADA, 2021). 

    Blood pressure should be assessed at every visit, and elevated blood pressure (≥140/90 mmHg) readings re-assessed. If hypertension is discovered, ACE inhibitors or angiotensin receptor blockers (ARBs) are recommended as first-line therapy. (ADA, 2021).  

    Patients should also be on aspirin therapy (75-162md/day) to prevent secondary ASCVD (ADA, 2021).

     

    Important Health Maintenance Topics

    As with all chronic conditions, discussing healthy diet and physical activity completes a comprehensive visit. For patients with T2DM and hypertension, specifically recommend a DASH style diet (reducing sodium and potassium, moderating alcohol, and increasing physical activity) (ADA, 2021). Given these topics can be time intensive, pre-prepared handouts on how to incorporate physical activity throughout daily life and diabetic friendly meals help effectively provide information.

    Address smoking cessation and highly encourage patients to quit smoking all forms of nicotine and tobacco. Studies have shown that smoking cessation has a much greater effect on overall survival than most other interventions (Wexler, 2021).

    Routine vaccinations should be kept up-to-date and assessed yearly, at least. T2DM puts patients more at risk for complications from otherwise simple respiratory illness. These especially include the COVID 19 vaccine, yearly flu vaccine, and pneumonia series as per the CDC vaccine schedule. 

     

    Learn More & Earn CE

    Visit our Learning Center for courses related to Diabetes.

     

    Other helpful links…

    ​​Disease Management: Diabetes — FPM Toolbox

    Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

     

    References

    American Diabetes Association (2021). Standards of Medical Care in Diabetes-2021 Abridged for Primary Care Providers. Clinical diabetes : a publication of the American Diabetes Association, 39(1), 14–43. https://doi.org/10.2337/cd21-as01

    Wexler, D. (2021, January 13). Overview of general medical care in nonpregnant adults with diabetes mellitus. UpToDate. Retrieved October 22, 2021, from https://www.uptodate.com/contents/overview-of-general-medical-care-in-nonpregnant-adults-with-diabetes-mellitus?source=autocomplete&index=2~3&search=Diabetes+mellitus+management

  • The Effects of the COVID 19 Pandemic on Pediatric Obesity

    Devin Pinaroc, FNP-C

     

    In March 2020, cities shut down, schools closed, and economies stalled, completely disrupting the routine of daily life. Public spaces no longer served the public, instead, posing as breeding grounds for an unfamiliar life-threatening virus. The coronavirus disease 2019 made the world hold its breath, and social distancing became the norm. 

    Unfortunately, while isolation measures were meant to help decrease transmission of COVID 19, they caused unintentional suffering that may negatively impact people well into the future. Perhaps the most concerning, given the associated long-term health effects, is the exacerbation of pediatric obesity.

     

    Increased Risk Factors for Weight Gain 

    The pandemic created new burdens and strengthened existing barriers to maintaining a healthy lifestyle for families. Social distancing caused limited physical activity, economic hardships, food insecurities, and a lack of social support that put children’s weight at risk (Jenson et al., 2021). Kids were unable to participate in organized sports, rely on appropriately portioned school breakfasts/lunches, or simply hang out with friends. As physical activity was severely limited, screen time inversely increased (American Academy of Pediatrics [APP], 2020a). Disrupted family routines from school closures and job losses caused sleep dysregulation (APP, 2020a). Both food insecurity and food scarcity issues, disproprotionately exacerbated by the financial implications of the pandemic, negatively impacted pediatric nutrition as families shifted to high-calorie snacks and processed, nonperishable foods (APP, 2020b).

     

    Pediatric Obesity Rates Pre and Post 

    Combined with persistent financial and emotional stress, there is little surprise the data shows an increase in obesity in children and adolescents from pre-pandemic levels (AAP, 2021). Recently, the CDC reported that during the pandemc the body mass index (BMI) of persons 2-19 years approximately doubled as compared to the pre-pandemic period with the largest increases seen in younger school-aged children and children already moderately or severely obese. Between March and November 2020, moderately and severely obese children gained 1.0 and 1.2 pounds per month, resulting in a 6.1 and 7.3 pound gain over 6 months, respectively (Lange et al, 2021).

    As childhood obesity rates rise, there is also increased risk for other chronic diseases like hypertension, type 2 diabetes, and cardiovascular disease (APP, 2021b). The lifetime implications of chronic disease suggest the effects of the COVID 19 pandemic will span generations.

     

    Health Disparities Highlighted in the COVID 19 Pandemic

    The disruption from the COVID 19 pandemic did not affect all families equally. Families already negatively affected by the social determinants of health were particularly vulnerable to the new environment created by the COVID 19 pandemic (APP, 2021). Existing inequities in accessing healthy food or physical activity worsened, increasing some children’s risk for pediatric obesity more than others. The pandemic magnified health inequalities and widened pre-existing disparities with Black and Hispanic children, children with special needs, low income families, and children living in rural areas experiencing a higher risk for unmet health care needs (APP, 2020b).

     

    Guidance for Clinicians 

    In response, the American Academy of Pediatrics released interim recommendations to help clinicians address pediatric obesity and help families sustain a healthy lifestyle during the pandemic. The guidance recommends detailed screenings for obesity (onset and worsening), continued assessment of physical activity and nutrition at well visits, and obesity treatment/management considerations as related to the COVID 19 pandemic (APP, 2020a). Clinicians are recommended to support families with their individual barriers that prevent adequate physical activity, food access, and sleep, tailoring the counseling to a family’s unique challenges and considering their cultural, socioeconomic, and psychological characteristics (APP, 2020b). The guidance also emphasizes the need for continued management and treatment for pre-existing pediatric obesity, avoiding any gaps or delay in treatment (APP, 2020a).

    Clinicians should consider new approaches that help maintain social distancing, but still promote physical activity and healthy lifestyle choices. Virtual workout classes and walking/running in the park can be great ways to get moving, and connecting families to local community resources that provide nutritious meals can improve dietary choices as well as relieve financial burdens. Exploring telehealth options can promote accessibility and reduce the burdens of coming to the clinic. Virtual obesity related visits allow clinicians to provide weight tracking and lifestyle counseling, successfully conducted over the phone or video. 

     

    The American Academy of Pediatrics interim guidance can be found in the following documents:

    Supporting Healthy Nutrition and Physical Activity during the COVID-19 Pandemic”

    “Obesity Management and Treatment During COVID-19” 

    Want to know more… 

    When Pandemics Collide: The Impact of COVID-19 on Childhood Obesity

    Projecting the impact of the coronavirus disease-2019 pandemic on childhood obesity in the United States: A microsimulation model 

    References

    American Academy of Pediatrics. (2020a, December 09). American Academy of Pediatric raises concern about children’s nutrition and physical activity during the pandemic. Retrieved October 09,2020, from https://www.aap.org/en/news-room/news-releases/aap/2020/american-academy-of-pediatrics-raises-concern-about-childrens-nutrition-and-physical-activity-during-pandemic/

    American Academy of Pediatrics. (2020b, December 9). Supporting healthy nutrition and physical activity during the COVID-19 pandemic. Retrieved October 9, 2021, from https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/supporting-healthy-nutrition-and-physical-activity-during-the-covid-19-pandemic/

    American Academy of Pediatrics. (2021, September 1). Obesity management and treatment during COVID-19. Retrieved October 9, 2021, from https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/obesity-management-and-treatment-during-covid-19/

    Jenssen, B. P., Kelly, M. K., Powell, M., Bouchelle, Z., Mayne, S. L., & Fiks, A. G. (2021). Covid-19 and changes in child obesity. Pediatrics, 147(5). https://doi.org/10.1542/peds.2021-050123 

    Lange SJ, Kompaniyets L, Freedman DS, et al. Longitudinal Trends in Body Mass Index Before and During the COVID-19 Pandemic Among Persons Aged 2–19 Years — United States, 2018–2020. MMWR Morb Mortal Wkly Rep 2021;70:1278–1283. DOI: http://dx.doi.org/10.15585/mmwr.mm7037a3.

     

  • Helping Families Choose Long-Term Care Facilities

    Devin Pinaroc, FNP-C

     

    The decision to place a loved one in a long term care facility is not easy. Every situation is unique, but preparation and planning is key. Clinicians should encourage patients and their families to initiate the conversation well before the decision becomes unavoidable. Unfortunately, there may be times when this is not an option. 

    Before researching facilities, clinicians should suggest that the family prioritize needs and define what is most important. Suggest making a list of the top 5 important factors for a long term care facility and some “non negotiables”. These may be convenient visiting hours, a low ratio of staff to patients, or financial requirements. 

    Practical factors, like location and monetary restrictions, will reduce the list to realistic places and can be helpful to narrow down options. For instance, some facilities have waiting lists that may not be feasible to the situation. A case worker is a good resource to utilize during the transition from hospital to long term care facility. If one is unavailable, calling the insurance company directly can provide details regarding long term care facility benefits and the copay requirements. If the patient’s insurance company does not give the family specific answers, each specific facility can be helpful in understanding benefits. 

    Common top priorities include the safety of the residents and the quality of the facility. Medicaid and Medicare certify nursing homes that pass government quality inspections and usually only pay for these certified facilities. Inform families that nursing homes are required to make the most recent state/federal facility survey available to families/residents, which will display how well the nursing home meets federal health/safety regulations. Families should also inquire about lawsuits/accusations of elder abuse for each facility. The Medicare.gov website displays if facilities have been cited in the last 2 years for elder abuse and show the star ratings for individual nursing homes, but observing the interactions between the residents and staff can be telling as well. Furthermore, understanding the safety of your loved one’s possession is necessary. Where will their possessions be safe? What type of privacy measures are taken for the residences? (Your Guide to Choosing a Nursing Home or Other Long‑Term Services & Supports, 2019)

    The next step may be to consider the medical requirements of the patient’s condition and the reason long term care is needed. These questions might include: What type of medical care is required? How long will the patient need to stay in this facility- months versus years versus lifetime? What medical services are required and what are the qualifications of the staff? Patients who struggle with activities of daily living and need daily, constant supervision will require a different atmosphere than those who require simple medication management and have only minimal mobility issues. 

    If there is time, suggest families visit the sites. During these site visits, families and patients speak directly with staff, meet current residents, and observe a typical day. Families should ask about the staff-to-resident ratio as a small staff-to- resident ratio may be beneficial if their loved one requires constant supervision or intricate medical care. This is a good time to ask about the available services, like meal plans, extracurricular activities, clubs, etc. Ensure families ask about the facility’s visitor policy, and consider if the visiting times are convenient to promote frequent visits and sustained family connection. Some long care facilities allow patients a certain degree of independence, and families should consider if this will make the loved one happy or place undue stress.

    Lastly, remind the family that this is (or will be) a very difficult time, and there is no “wrong” choice. Support families through the entire process, even after choosing the facility.  Prepare the family for an adjustment period while their loved one settles into their new place of dwelling. This transition may last months and can be just as difficult as choosing a facility. 

     

    Want to know more?

    The Center for Medicaid and Medicare have developed a booklet to help with all parts of the process: 

    https://www.medicare.gov/sites/default/files/2019-10/02174-nursing-home-other-long-term-services.pdf

     

    References

    Department of Health & Human Services: Centers for Medicare & Medicaid Services. (Oct 2019). Your Guide to Choosing a Nursing Home or Other Long‑Term Services & Supports. https://www.medicare.gov/sites/default/files/2019-10/02174-nursing-home-other-long-term-services.pdf

    Jenkins, S. (2021, January 7). Choosing the right long-term-care facility for your loved one. NAFC. Retrieved September 17, 2021, from https://www.nafc.org/bhealth-blog/choosing-the-right-long-term-care-facility-for-your-loved-one. 

     

  • Major Depressive Disorder in the Primary Care Setting

    Devin Pinaroc, FNP-C

     

    The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria defines major depressive disorder as a combination of certain, specific symptoms, like depressed mood or loss of interest/pleasure, that present during the same 2-week period, not caused by a substance or another medical condition, and create clinically significant distress or impairment in social, occupational, or other important functioning (Maurer et al., 2018).

    The lack of access to specialty providers, stigmatization regarding mental health disorders, and associated costs utilizing some mental health resources drives patients to seek initial treatment from their primary care provider. Overall, an estimated 60% of mental health care delivery occurs in the primary care setting, and most patients seek (Park, L. T., & Zarate, 2019). 

     

    Screening Recommendations

    The United States Preventive Services Task Force recommends regular screening for depression in the general population when there are adequate systems in place for treatment and follow-up (2). While there is not a single screening instrument proven to be most efficacious, the two- and nine-item Patient Health Questionnaires (PHQs) are the most widely used (2). Primary care providers should consider incorporating these questionnaires or some other screening tools with each new patient visit, yearly preventive exams, and during mental health follow-up assessments. Not only are they helpful in identifying depressive disorders, they can help with assessing treatment response and condition status. 

     

    Treatment Options

    The initial treatment for unipolar major depressive disorder should be a combination of pharmacology and psychotherapy or a trial of each one independently, depending on severity (Rush,2020). Randomized controlled trials (RCTs) have displayed efficacy with combination pharmacology and psychology over one alone, but pharmacology alone and psychotherapy alone still prove effective in treating depression (Rush, 2020). Primary care clinicians should also consider that many RCTs showing the efficacy of pharmaceuticals only used patients with moderate to severe depression  (Park, L. T., & Zarate, 2019). 

    Psychotherapy.  Initiating psychotherapy alone and monitoring symptoms for mild to moderate depression treatment may be appropriate, particularly given the potential for unpleasant medication side effects (Park, L. T., & Zarate, 2019). There are many types of psychotherapy proven successful in the treatment of depression, but one has not emerged as superior (Rush, 2020). Consider the exacerbating factors, comorbidities, and patient situation when recommending the appropriate type of psychotherapy (Park, L. T., & Zarate, 2019). For example, interpersonal psychotherapy may help with relationship problems, behavioral activation can increase motivation, and cognitive behavior therapy may help with distorted thoughts that exacerbate depression (Park, L. T., & Zarate, 2019).  

    Regardless of type, adherence to psychotherapy is often a limiting factor, so regular follow up visits are key (Rush, 2020). 

    Pharmaceuticals. Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), atypical antidepressants (bupropion), and serotonin modulators are generally the first line pharmaceuticals for major depressive disorder (Rush, 2020). Multiple RCTs prove that antidepressants are highly effective in reducing and remitting depressive symptoms, and, given that they are often characterized by their low cost and ease to tolerate, patients with mild-to-moderate depression may find relatively quick benefits (Rush, 2020). A singularly superior SSRI or SNRI has not been identified for treating depression as each medication has its advantages (Park, L. T., & Zarate, 2019). Escitalopram and sertraline are reasonable SSRIs for primary care providers to suggest as initial treatment given their tolerability and low potential for side effects (Rush, 2020).  SNRIs can be advantageous for those with anxiety and chronic pain, but can be costly and difficult to tolerate (Park, L. T., & Zarate, 2019). Bupropion is useful for tobacco users and those worried about sexual side effects (Rush, 2020). 

    Encouraging a healthy lifestyle – regular exercise, adequate sleep, nutritious diet, and stress management – and ensuring other comorbidities are controlled may optimize interventions. Mindfulness and meditation has recently been popular in mental health treatment plans and may be beneficial to some patients.

     

    Telemedicine Delivery in Mental Health 

    Recently, light has been shed on the lack of education regarding the prevalence of depression and limited mental health resources available to all patient populations regardless of their socioeconomic status or location. Psychotherapy is often not covered by insurance, inconvenient, and stigmatized. The vast amount of pharmaceuticals can create uncertainty and hesitancy for primary care providers. However, fueled by the need to social distance, the development of mental health telemedicine platforms seems to help bridge this gap in mental health resources. Websites and phone apps, like TalkSpace™ or BetterHelp™, bring access to anyone with internet access. These platforms provide completely remote tele-therapy, access to support groups, and mental health seminars. While still new, remote delivery of psychotherapy is proving just as effective as face-to-face delivery with the advantage of being convenient and cost effective (Simon et al, 2014).  

    Learn More and Earn CE

    We have many courses on our Learning Center on the topic of depression and depression treatments. Click here for a list of courses.

     

    Want to know more…

    Major Depressive Disorder in Primary Care: Strategies for Identification

    Psychological Treatment of Depression in Primary Care: Recent Developments

    The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Trial: A Review

    Cognitive behaviour therapy for depression in primary care: systematic review and meta-analysis | Psychological Medicine | Cambridge Core

    Effect of Treatments for Depression on Quality of Life: A Meta-Analysis

    PHQScreeners.com

    A growing wave of online therapy

     

    References

    Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and Diagnosis. American family physician, 98(8), 508–515.

    Park, L. T., & Zarate, C. A., Jr (2019). Depression in the Primary Care Setting. The New England journal of medicine, 380(6), 559–568. https://doi.org/10.1056/NEJMcp1712493

    Rush, A. J. (2020, November). Unipolar major depression in adults: Choosing initial treatment. UpToDate. https://www.uptodate.com/contents/unipolar-major-depression-in-adults-choosing-initial-treatment?search=depression+treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H432086717. 

    Simon GE, Ludman EJ, Tutty S, Operskalski B, Korff MV. Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment: A Randomized Controlled Trial. JAMA. 2004;292(8):935–942. doi:10.1001/jama.292.8.935

     

No thanks, just take me to the Exhibit Hall.