Physician Beliefs, Attitudes, and Approaches
|
|
- Marilyn Pitts
- 7 years ago
- Views:
Transcription
1 Physician Beliefs, Attitudes, and Approaches Toward Lyme Disease in an Endemic Area Stephen C. Eppes, M.D.1 Joel D. Klein, M.D.1 Gregory M. Caputo, M.D. 2 Carlos D. Rose, M.D. 1 Summary: To assess the beliefs and practice habits regarding Lyme disease among practitioners, questionnaires were sent to physicians in a seven-county Lyme-endemic region. One hundred twenty-four evaluable responses were returned from 53 family physicians, 39 pediatricians, 27 internists, and five subspecialists who diagnosed three to four cases of Lyme disease per year, on average. The majority presented with erythema migrans (EM) or other early symptoms, although arthritis was the presenting sign in 16%. The enzyme-linked immunosorbent assay (ELISA) was the most frequently ordered diagnostic test, but 45% of respondents did not specify which test when ordering Lyme serology. The majority would use amoxicillin or doxycycline to treat EM in children or adults, respectively. Nearly all would use ceftriaxone for meningitis, and half would use it to treat Lyme arthritis or Bell s palsy. Physicians differed markedly in the duration of therapy they would prescribe. Eighty-three percent would treat a patient for possible Lyme disease with antibiotics (many intravenously), even in the absence of EM or positive serology. Thirty-five percent of practitioners prescribed antibiotics for deer-tick bites. Our survey documents significant variation in approaches to Lyme disease among primary-care physicians and suggests the need for well-designed clinical trials, continuing basic research, and physician education. Introduction 1 ymptomatic infection with Borrelia burgdorferi, commonly known as Lyme disease, has become endemic in many areas of the United States. The clinical manifestations of Lyme disease have been the subject of numerous papers Address correspondence to: Stephen C. Eppes, M.D., Alfred I. dupont Institute, P.O. Box 269, Wilmington, DE in the medical 1 Division of Pediatric Infectious Diseases, Alfred I. dupont Institute, Wilmington, Delaware 2 Division of Infectious Diseases, Department of Internal Medicine, Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania literature and of frequent reports by the lay media. Physicians who practice in endemic areas are likely to be familiar with the classic findings in this illness. However, many symptoms and signs are nonspecific, and Lyme disease is known to have varied presentations. Consequently, it can be a difficult diagnosis to make on clinical grounds. 1-3 Moreover, some serologic tests for B. burgdorferi lack optimal standardization and may lack sensitivity and/or specificity. 4-8 While guidelines for treatment have been published, 1,9, 0-&dquo; appropriate therapy may depend on patient-associated variables and the perceived 130
2 even severity of the disease. In receiving referrals to our Lyme disease clinic, it has been our observation that practitioners differed widely in their approaches to the diagnosis and treatment of Lyme disease, perhaps as a result of the above uncertainties. In order to assess the beliefs, attitudes, and practice habits of physicians, we performed a survey in an area endemic for Lyme disease. Materials and Methods A questionnaire was designed to evaluate physicians practices with regard to the number and nature of the patients they diagnosed with Lyme disease, the tests they were likely to order, the consultations they would obtain, and the treatment they would administer in several hypothetical situations. This questionnaire was mailed to 500 physicians in the three counties of Delaware; Salem County, New Jersey; Cecil County, Maryland ; and Chester and Delaware counties, Pennsylvania. This area is endemic for Lyme disease. 13 Our hospital database of area pediatricians, internists, family practitioners, and generalists was used to generate the mailing list. One hundred thirty physicians returned the questionnaire during fall, 1991; six forms were incomplete and were not included in the analysis. Responses for the 124 completed questionnaires were analyzed according to medical specialty and as a group (Figure 1). Results Of the 124 completed questionnaires, 53 were from family or general practitioners, 39 were from pediatricians, 27 were from internists, and five were from hospitalbased subspecialists (Figure 2). Most physicians diagnosed between one and eight cases of Lyme disease per year; 10% diagnosed none; and 6% diagnosed more than eight cases per year. The numbers of patients diagnosed with Lyme disease were similar for each subgroup of practitioners. Seventy-three percent of patients had EM or other symptoms of early disease (e.g., flu-like illness). Internists were more likely to see patients with acute neurologic signs ( 14% ) and chronic central nervous system (CNS) complaints or fatigue (25%) attributed to Lyme disease than were other practitioners. Arthritis was the presenting sign in 16% of patients, similar for all groups of practitioners. Cardiac involvement was rarely reported as the presenting feature of Lyme disease. Eighty-five percent of practitioners believed that the presence of EM was diagnostic of Lyme disease ; many also considered Bell s palsy, recurring arthritis, and heart block to be diagnostic. Six percent felt that no physical findings could be considered pathognomonic of Lyme disease. To facilitate diagnosis, the majority of physicians (55%) obtained serum ELISA tests. Pediatricians were likely to also order serum Western blot assays for antibodies to tests and B. burgdorferi. Urine antigen antibody tests on cerebrospinal fluid were not commonly ordered. Fortyfive percent of physicians did not specify which testwhen they ordered Lyme serology. Most physicians managed presumptive cases of Lyme disease without consultation. Twenty-one to infec- percent referred patients tious disease specialists; 10% to rheumatologists; and 7% to neurologists, orthopedic surgeons, or other specialists. Referral patterns did not differ among the groups of practitioners. There was distinct variability in the choice of antibiotic and duration of therapy for several hypothetical patients with various mani- disease. Some festations of Lyme internists did not respond to questions involving children, and some pediatricians did not answer questions about adults. Eightyone percent of respondents would treat EM in adults with oral doxycycline and, in children, with amoxicillin (with or without probenecid) or oral penicillin. Erythema migrans in pregnancy was most often treated with penicillin or amoxicillin by the physicians who responded to this question. Most would treat a patient with multiple EM the same as for solitary lesions. Ninety-six percent would treat Lyme meningitis with intravenous (IV) ceftriaxone. Roughly half of respondents would treat Lyme-associated Bell s palsy with IV ceftriaxone, as opposed to oral antibiotics; 28% of pediatricians would treat this manifestation in a child with IV ceftriaxone, while 74% of internists would use IV ceftriaxone for a similarly affected adult. For treating Lyme arthritis, respondents were equally divided between oral doxycycline and IV ceftriaxone for adults and between amoxicillin and IV ceftriaxone for children. Few practitioners would treat Lyme disease in any stage for less than 2 weeks. Durations of 2, 3, and 4 weeks were chosen with almost with ar- equal frequency, except thritis, for which the longer courses were favored. Eighty-three percent responded that they would treat a patient for suspected Lyme disease - in the absence of EM or positive serology. Of these physicians, a quarter said they would also consider treating such a patient intravenously, some for as long as a month. Almost half of family and general practitioners would prescribe an antibiotic for a known 131
3 132 Figure 1. Lyme disease questionnaire with responses of physicians (expressed as a percentage of those responding to questions).
4 Figure 2. Breakdouvn of practitioners responding to Lyme disease survey. deer-tick attachment; 21 % of pediatricians and 30% of internists would provide an antibiotic in that situation. Discussion The results of this study confirm our suspicion that practitioners approaches to Lyme disease vary substantially. Physicians responding to the questionnaire cared for an average of three to four patients with a diagnosis of Lyme disease in the 1 year prior to the survey. This result may not have been representative of all physicians in this area, inasmuch as response to the questionnaire may have selected for physicians who were more likely to have an interest in the disease. As might be expected in primary-care settings, most patients were seen with early disease symptoms and were diagnosed and treated by their primarycare physicians. It is of interest that internists were more likely to see both acute and chronic neurologic complaints, as well as chronic fatigue ascribed to Lyme disease. This may reflect a relatively greater frequency of these symptoms in adult patients. Conversely, adults with other neurologic diseases may receive the diagnosis of Lyme disease based on nonspecific epidemiologic evidence or falsely positive or irrelevant serum tests. 14 The vast majority of respondents correctly identified EM as a diagnostic feature of Lyme disease. It is noteworthy, however, that a substantial number of each group of physicians felt that Bell s palsy, recurring arthritis, or heart block were also diagnostic. While each of these conditions in the appropriate epidemiologic setting may suggest the diagnosis, none is pathognomonic. A smaller number apparently believed that no clinical finding could be considered diagnostic of Lyme disease. This is curious because, while EM may take several forms, the classic expanding lesion with central clearing is considered by most authorities to be pathognomonic. 3,15-18 Respondents varied in their choice of serologic tests, but almost half did not specify a particular assay when ordering Lyme serology. More pediatricians ordered the Western blot assay, a useful confirmatory test, perhaps owing to its at our children s ready availability hospital. Few physicians indicated that they used antibody tests on cerebrospinal fluid (CSF) as an adjunct to the diagnosis of neuroborreliosis, despite the substantial number of patients with neurologic symptoms. It is possible that the variability in utilization of certain tests reflects a lack of familiarity with the technologies or with the relative sensitivities and specificities of the tests. On the other be aware of hand, physicians may shortcomings of certain serologic methodologies available for Lyme disease diagnosis, as well as interand intralaboratory variability. 17 We were impressed with the generally sound approach to treatment of hypothetical cases of Lyme disease. Most physicians treated early Lyme disease manifestations in accordance with accepted recommendations.1,10-12 The vast ma- used IV ceftriaxone in jority patients with meningitis, as is considered appropriate. While published recommendations consider sufficient for treat- an oral regimen ing isolated Bell s palsy, many respondents, especially internists, chose ceftriaxone in that situation. Recent evidence from both and the United States indi- Europe cates that many such patients will often have concomitant CNS involvement, 19,20 which would suggest that a parenteral regimen might be warranted. Respondents the selection of antibiotic treatment for reflect the were divided regarding Lyme arthritis. This may individual styles of practitioners, but may also indicate a lack of confidence in oral therapy for arthritis. For arthritis that persists on oral IV antibiotics have been therapy, recommended, but well-designed trials comparing oral and IV therapy are lacking. There was considerable variability in the duration of therapy chosen by practitioners for all conditions described in the survey ; this may be due to the range of durations given in recommended treatment regimens. One of the most striking findings of the survey was the fact that the vast majority of physicians would treat a patient for Lyme disease, even in the absence of a firm diagnosis (i.e., EM or later clinical finding with positive serology), and that 25% would consider using IV antibiotics in that situation. This may reflect the respondents recognition that EM is not detected or remembered in half of cases of proven Lyme disease and that cur- tests are sometimes rent serologic not reliable. Delayed production 133
5 - Lyme of antibody in early Lyme disease and interruption of the humoral response by antibiotic administration are two often-cited reasons for disease.21,22 Of seronegative Lyme greater concern is the possibility that inherent imprecision in the diagnosis of Lyme disease may lead to unnecessary treatment of some seronegative patients who do not have Lyme disease.23 Patient, parent, and community pressure to diagnose Lyme disease in an endemic area may drive some physicians toward this diagnosis and its treatment, even in the absence of objective clinical and serologic evidence of infection with B. burgdorferi.24,25 Unfortunately, significant adverse effects have occurred in a treated with number of patients intravenous antibiotics for unproven Lyme disease The wisdom of prophylactic treatment of tick bites with an antibiotic has been controversial. A re- found a low rate of cent study infection (1.2%) following confirmed deer-tick attachments and suggests that this practice is not routinely necessary.29 In our survey, less than half of physicians prescribed an antibiotic in this situation ; some who did cited a favorable cost-benefit ratio as the rationale. However, a model analyzing cost effectiveness of this approach concluded that empiric treatment of deer-tick bites was warranted only when the probability of infection in a given endemic area exceeds 3.5%.30 A recent survey concerning Lyme disease assessed the knowledge, attitudes, and behaviors of 200 heads of households in Connecticut.31 Responses were quite varied, and the results of the study supported the importance of educating the community about Lyme disease. Ours is the only such survey of physicians of which we are aware, and also suggests the need for physicians to remain current about this important public-health problem. Moreover, uncertainties about the diagnosis and management of Lyme disease, at the level of the practitioner, underscore the need for continued basic research and clinical trials. REFERENGES 1. Steere AC. Lyme disease. N Engl J Med. 1989;321: Ostrov BE, Arhreya BH. Lyme disease: Difficulties in diagnosis and management Pediatr Clin North Am 1991; 38: Gerber MA, Shapiro ED. Diagnosis of Lyme disease in children. J Pediatr. 1992;121: Corpuz M, Hilton E, Lardis MP, et al. Problems in the use of serologic tests for the diagnosis of Lyme disease. Arch Intern Med. 1991;151: Luger SW, Kraus E. Serologic tests for Lyme disease: Interlaboratory variability. Arch Intern Med. 1990;150: Schwartz BS, Goldstein MD, Ribeiro JM, et al. Antibody testing in Lyme disease: A comparison of results in four laboratories. JAMA. 1989; 262: Bakken LL, Case KL, Callister SM, et al. Performance of 45 laboratories participating in a proficiency testing program for Lyme disease serology. JAMA. 1992;268: Dattwyler RJ, Luft BJ. Immunodiagnosis of Lyme borreliosis. Rheum Dis Clin North Am. 1989;15: Luft BJ, Dattwyler RJ. Treatment of Lyme borreliosis. Rheum Dis Clin North Am. 1989;15: Treatment of Lyme disease. The Medical Letter. 1992;34: Committee on Infectious Diseases. borreliosis. Pediat- Treatment of Lyme rics. 1991;88: Rahn DW, Malawista SE. Lyme disease: Recommendations for diagnosis and treatment. Ann Intern Med. 1991;114: Lyme disease United States, MMWR. 1993;42: Reik L Jr. Lyme Disease and the Nervous System. New York, NY Thieme Medical Publishers; 1991: Lyme disease surveillance: United States MMWR. 1991;40: Berger BW. Cutaneous manifestations of Lyme borreliosis. Rheum Dis Clin North Am. 1989;15: Eichenfield AH, Athreya BH. Lyme disease : of ticks and titers. JPediatr. 1989; 114: Consensus conference on Lyme disease. Can Med. Assoc J 1991;144: Christen HJ, Bartlau N, Hanefeld F, et al. Peripheral facial palsy in childhood borreliosis to be suspected unless proven otherwise. Acta Paediatr Scand. 1990;79: Luft BJ, Steinman CR, Neimark HC, et al. Invasion of the central nervous system by Borrelia burgdorferi in acute disseminated infection. JAMA. 1992;267: Dattwyler RJ, Volkman DJ, Luft BJ, et al. Seronegative Lyme disease: Dissociation of specific T- and B-lymphocyte responses to Borrelia burgdorferi. N Engl J Med. 1988;319: Magnarelli LA. Laboratory diagnosis of Lyme disease. Rheum Dis Clin North Am. 1989;15: Steere AC, Taylor E, McHugh GL, et al. The overdiagnosis of Lyme disease. JAMA. 1993;269: Sigal LH. Summary of the first 100 patients seen at a Lyme disease referral center. Am J Med. 1990;88: Caputo GM. Lyme anxiety. JAMA. 1991; 266: Ceftriaxone-associated biliary complications of treatment of suspected disseminated Lyme disease. MMWR. 1993; 42: Nadelman RB, Zalmen A, Wormser GP. Life threatening complications of empiric ceftriaxone therapy for "seronegative Lyme disease." South Med J. 1991; 84: Feder HM, Rosenthal KE. Letter. JAMA. 264; Shapiro ED, Gerber MA, Holabird NB, et al. A controlled trial of antimicrobial pro- disease after deer-tick phylaxis for Lyme bites. N Engl J Med. 1992;327: Magid D, Schwartz B, Craft J, et al. Prevention of Lyme disease after tick bites. N Engl J Med. 1992;327: Lyme disease knowledge, attitudes, and behaviors-connecticut, MMWR. 1992;41:
Persistence of Immunoglobulin M or Immunoglobulin G Antibody Responses to Borrelia burgdorferi 10 20 Years after Active Lyme Disease
MAJOR ARTICLE Persistence of Immunoglobulin M or Immunoglobulin G Antibody Responses to Borrelia burgdorferi 10 20 Years after Active Lyme Disease Robert A. Kalish, 1 Gail McHugh, 1 John Granquist, 1 Barry
More informationALS and Lyme Disease Questions from Patient and Families Responses from Medical Experts
ALS and Lyme Disease Questions from Patient and Families Responses from Medical Experts Introduction: When anyone receives a diagnosis of ALS, it is normal and understandable to ask why you ve developed
More informationLyme Disease in 2013: Lessons Learned in Diagnosis
Lyme Disease in 2013: Lessons Learned in Diagnosis John N. Aucott, M.D. Assistant Professor, Department of Medicine Johns Hopkins University School of Medicine Lyme Disease Research Foundation Park Medical,
More informationA Concise Critical Analysis of Serologic Testing for the Diagnosis of Lyme Disease
Curr Infect Dis Rep (2014) 16:450 DOI 10.1007/s11908-014-0450-9 PEDIATRIC INFECTIOUS DISEASES (I BROOK, SECTION EDITOR) A Concise Critical Analysis of Serologic Testing for the Diagnosis of Lyme Disease
More informationUnderstanding the Western Blot
Understanding the Western Blot By Carl Brenner Revised: September, 1996 Inquiries about various issues relating to Western blot (WB) testing are frequently posted to the Lyme disease discussion groups
More informationNeuroborreliosis in Childhood - Facts and Fictions
Neuroborreliosis in Childhood - Facts and Fictions Hans-Jürgen Christen Kinderkrankenhaus auf der Bult/Hannover 6th Danish Pediatric Infectious Diseases Symposium Korsør, October 5-6th, 2012 Willy Burgdorfer,
More informationCorporate Medical Policy Intravenous Antibiotic Therapy for Lyme Disease
Corporate Medical Policy Intravenous Antibiotic Therapy for Lyme Disease File Name: intravenous_antibiotic_therapy_for_lyme_disease Origination: 3/2006 Last CAP Review: 2/2016 Next CAP Review: 2/2017 Last
More informationBorrelia burgdorferi IgG, IgM Fully automated chemiluminescence assays for quantitative determination of Borrelia antibodies in serum and CSF
Borrelia burgdorferi IgG, IgM Fully automated chemiluminescence assays for quantitative determination of Borrelia antibodies in serum and FOR OUTSIDE THE US AND CANADA ONLY Borrelia burgdorferi IgG, IgM
More informationLyme arthritis. Initially described as a distinct entity in 1975, after the identification of an epidemic of what appeared to be
Lyme arthritis Initially described as a distinct entity in 1975, after the identification of an epidemic of what appeared to be "juvenile rheumatoid arthritis" (pauciarthritis and monarthritis) in adults
More informationLyme (IgG and IgM) Antibody Confirmation
Pathology & Laboratory Medicine Lyme (IgG and IgM) Antibody Confirmation TEST UPDATE: New Test Notification Date: 1/9/2013 Effective Date: 1/7/2013 CONTACT INFO Call 802-847-5121 800-991-2799 email labmarketing@vtmednet.org
More informationAnimal Health Diagnostic Center. Lyme Disease Multiplex Testing for Dogs. Background on Lyme disease and Lyme diagnostics in dogs
Animal Health Diagnostic Center Lyme Disease Multiplex Testing for Dogs Background on Lyme disease and Lyme diagnostics in dogs Lyme disease is induced by the spirochete B. burgdorferi. Spirochetes are
More informationJoint Oireachtas Health Committee on Health and Childrean on Diagnosis, Treatment and Prevention of Lyme-Borreliosis 21 November 2013
Joint Oireachtas Health Committee on Health and Childrean on Diagnosis, Treatment and Prevention of Lyme-Borreliosis 21 November 2013 Dear Chairman and Members of the Committee, Thank you for inviting
More informationPractice Guidelines for the Treatment of Lyme Disease
S1 GUIDELINES FROM THE INFECTIOUS DISEASES SOCIETY OF AMERICA Practice Guidelines for the Treatment of Lyme Disease Gary P. Wormser, 1 Robert B. Nadelman, 1 Raymond J. Dattwyler, 2 David T. Dennis, 6 Eugene
More informationThis is not a valid request for information in accordance with the FOI Act as it does not ask for information held by PHE.
By email Public Accountability Unit Wellington House 133-155 Waterloo Road London SE1 8UG Tel: 020 8327 6920 www.gov.uk/phe Veronica Hughes request-313568-e1ecf364@whatdotheyknow.com Our ref: 01/02/jb/551
More informationSUMMARY REPORT 2005 Survey of Hospital Physician Recruitment Trends
SUMMARY REPORT 2005 Survey of Hospital Physician Recruitment Trends Overview Merritt, Hawkins & Associates (MHA) is a national physician search and consulting firm that periodically conducts surveys regarding
More informationLyme Disease in Pregnancy. Dr Sarah Chissell Consultant Obstetrician William Harvey Hospital, Kent
Lyme Disease in Pregnancy Dr Sarah Chissell Consultant Obstetrician William Harvey Hospital, Kent Conflict of interest My son has chronic Lyme disease Infections in pregnancy Transplacental infection Perinatal
More informationBORRELIA DIAGNOSTIEK: richtlijnen voor de praktijk
BORRELIA DIAGNOSTIEK: richtlijnen voor de praktijk Katrien Lagrou University Hospitals Leuven and KU Leuven, BELGIUM Old Lyme, Connecticut Ticks DISEASE OVERVIEW Most commonly reported tick-borne infection
More informationWhat You Should Know About Lyme Disease and Other Tick-Borne Diseases. Sudbury Board of Health
What You Should Know About Lyme Disease and Other Tick-Borne Diseases Sudbury Board of Health Goals of presentation Be aware of Lyme disease and other tick-borne diseases Recognize basic signs and symptoms
More information2-Tiered Antibody Testing for Early and Late Lyme Disease Using Only an Immunoglobulin G Blot with the Addition of a VlsE Band as the Second-Tier Test
MAJOR ARTICLE 2-Tiered Antibody Testing for Early and Late Lyme Disease Using Only an Immunoglobulin G Blot with the Addition of a VlsE Band as the Second-Tier Test John A. Branda, 1 Maria E. Aguero-Rosenfeld,
More information4,1 My Experience with Lyme Disease
My Personal History of Lyme Disease 4,1 My Experience with Lyme Disease Adrian Bjornson (October 2012) In May 2009 I experienced a strange sore on my back. Since I was about to take a trip, I went to the
More informationREVIEW ABSTRACT. KEYWORDS: Borrelia burgdorferi; Clinical trials; Lyme disease; Post-Lyme disease syndrome
REVIEW Treatment Trials for Post-Lyme Disease Symptoms Revisited Mark S. Klempner, MD, a Phillip J. Baker, PhD, b Eugene D. Shapiro, MD, c Adriana Marques, MD, d Raymond J. Dattwyler, MD, e John J. Halperin,
More informationThe International Lyme and Associated Diseases Society
The International Lyme and Associated Diseases Society Evidence-based guidelines for the management of Lyme disease The ILADS Working Group ILADS, P.O. Box 341461 Bethesda, MD 20827-1461, USA www.ilads.org
More informationAmrit pal S. Sandhu, M.D.
Amrit pal S. Sandhu, M.D. 2011 Myhre Place Silverdale, WA 98383 (360) 830-1610 PLEASE READ THIS CAREFULLY PRIOR TO YOUR FIRST ARTHRITIS CLINIC VISIT!!! ARTHRITIS/RHEUMATISM SERVICES Arthritis and Rheumatism
More informationTest Request Tip Sheet
With/Without Contrast CT, MRI Studies should NOT be ordered simultaneously as dual studies (i.e., with and without contrast). Radiation exposure is doubled and both views are rarely necessary. The study
More informationLaboratory confirmation requires isolation of Bordetella pertussis or detection of B. pertussis nucleic acid, preferably from a nasopharyngeal swab.
Pertussis Epidemiology in New Zealand New Zealand has continued to experience outbreaks of pertussis in recent decades. This is in part due to historically low immunisation rates and in part because immunity
More informationCLINICAL GOALS OF PATIENT CARE AND CLINIC MANAGEMENT. Philosophical Basis of the Patient Care System. Patient Care Goals
University of Washington School of Dentistry CLINICAL GOALS OF PATIENT CARE AND CLINIC MANAGEMENT Philosophical Basis of the Patient Care System The overall mission of the patient care system in the School
More information4A. Types of Laboratory Tests Available and Specimens Required. Three main types of laboratory tests are used for diagnosing CHIK: virus
4. LABORATORY 4A. Types of Laboratory Tests Available and Specimens Required Three main types of laboratory tests are used for diagnosing CHIK: virus isolation, reverse transcriptase-polymerase chain reaction
More informationTHIS IS AN OFFICIAL NH DHHS HEALTH ALERT
THIS IS AN OFFICIAL NH DHHS HEALTH ALERT Distributed by the NH Health Alert Network Health.Alert@nh.gov August 13, 2015 1400 EDT (2:00 PM EDT) NH-HAN 20150813 Updated Centers for Disease Control (CDC)
More informationEffective Treatment of Lyme Borreliosis with Pentacyclic Alkaloid Uncaria tomentosa (TOA-free Cat s Claw)
Effective Treatment of Lyme Borreliosis with Pentacyclic Alkaloid Uncaria tomentosa (TOA-free Cat s Claw) Executive Summary Introduction In a six-month prospective cohort study designed to compare the
More informationZika Virus. Fred A. Lopez, MD, MACP Richard Vial Professor Department of Medicine Section of Infectious Diseases
Zika Virus Fred A. Lopez, MD, MACP Richard Vial Professor Department of Medicine Section of Infectious Diseases What is the incubation period for Zika virus infection? Unknown but likely to be several
More informationRheumatic Fever Vs. (?) Post Strep Reactive Arthritis ינואר 2009
Rheumatic Fever Vs. (?) Post Strep Reactive Arthritis ינואר 2009 Agenda Introduction Articles Poststreptococcal reactive arthritis in children: is it really a different entity from rheumatic fever? Poststreptococcal
More informationPHYSICIAN. JOB DESCRIPTION Employees in this job function as professional physicians in a general or specialized area of medicine.
MICHIGAN CIVIL SERVICE COMMISSION JOB SPECIFICATION PHYSICIAN JOB DESCRIPTION Employees in this job function as professional physicians in a general or specialized area of medicine. There are two classifications
More informationQUALITY OF LAST DOCTOR VISIT REPORTS: A COMPARISON OF MEDICAL RECORD AND SURVEY DATA
QUALITY OF LAST DOCTOR VISIT REPORTS: A COMPARISON OF MEDICAL RECORD AND SURVEY DATA Gina M. Jay, Robert F. Belli, & James M. Lepkowski, Research Center Gina M. Jay, Research Center, University of Michigan,
More informationMedical Diagnostic Laboratories, L.L.C.
Ly m e D i s e a s e Te s t i n g Medical Diagnostic Laboratories, L.L.C. Why Use Medical Diagnostic Laboratories for Lyme Disease Testing? The clinical symptoms of Lyme disease vary among individuals
More informationOther Causes of Fever
T e c h n i c a l S e m i n a r s Other Causes of Fever Febrile Illness Causes Fever After Seven Days Referral Relapsing Fever - Borreliosis Overview JHR Adaptation Sore Throat Overview Prevention Management
More informationLCD L30256 - C-Reactive Protein High Sensitivity Testing (hscrp)
LCD L30256 - C-Reactive Protein High Sensitivity Testing (hscrp) Contractor Information Contractor Name: Novitas Solutions, Inc. Contractor Number(s): 12501, 12101, 12102, 12201, 12202, 12301, 12302, 12401,
More informationAcute Care Pediatric Nurse Practitioner Certification Exam. Detailed Content Outline
Acute Care Pediatric Nurse Practitioner Certification Exam Description of the Specialty This exam is for the pediatric nurse practitioner (PNP) who has graduated from a formal acute care PNP program with
More informationFrequently Asked Questions
Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 Frequently Asked Questions Table of Contents Background... 1 Treatment Recommendations... 2 Treatment of Contacts... 4 Administration
More informationPolicy Brief November, 2006
Policy Brief November, 2006 The Role of Pediatricians in Children s Mental Health A Policy Brief from Philadelphia Citiz itizens for Children and Youth Introduction The number of children identified as
More informationExpedited Partner Therapy (EPT) for Sexually Transmitted Diseases Protocol for Health Care Providers in Oregon
Expedited Partner Therapy (EPT) for Sexually Transmitted Diseases Protocol for Health Care Providers in Oregon Oregon Health Authority Center for Public Health Practice HIV/STD/TB Section Principles of
More informationAntibiotic Guidelines: Ear Nose and Throat (ENT) Infections. Contents
Antibiotic Guidelines: Ear Nose and Throat (ENT) Infections. Classification: Clinical Guideline Lead Author: Antibiotic Steering Committee Additional author(s): Authors Division: DCSS & Tertiary Medicine
More informationANTIBIOTICS IN SEPSIS
ANTIBIOTICS IN SEPSIS Jennifer Curello, PharmD, BCPS Clinical Pharmacist, Infectious Diseases Antimicrobial Stewardship Program Ronald Reagan UCLA Medical Center October 27, 2014 The power of antibiotics
More informationSOGC recommendation on ZIKA virus exposure for clinicians caring for pregnant women and those who intend to get pregnant
SOGC recommendation on ZIKA virus exposure for clinicians caring for pregnant women and those who intend to get pregnant Foreword The rapid emergence of Zika virus as a potential causative agent for fetal
More information21st Century Cures Request for Feedback: A Modernized Framework for Innovative Diagnostic Tests
January 5, 2015 VIA email to: cures@mail.house.gov Honorable Fred Upton, Chairman Committee on Energy and Commerce 2125 Rayburn House Office Building Washington, DC 20515 RE: 21st Century Cures Request
More informationNurse Initiated STI Treatment Code
Nurse Initiated STI Treatment Code Public Health and Clinical Services Division June 2012 FORWARD The Nurse Initiated STI Treatment Code establishes the competencies which must be achieved and criteria
More informationComments: Regarding Lyme disease (LD) treatment recommendations
Comments: Regarding Lyme disease (LD) treatment recommendations David Volkman, Ph.D., M.D. Emeritus Professor of Medicine and Pediatrics SUNY, Stony Brook, NY Background: Ph.D. and M.D., Emeritus Professor
More informationLyme Disease Assays HPV Genotyping Kit
About DiaMex Luminex Technology: Lyme Disease Assays HPV Genotyping Kit The System Luminex xmap technology 3 Consumables 5 Lyme Disease Assays Optiplex Borrelia IgG and IgM 6 Lyme Disease Assays Optiplex
More informationBorrelia IgM Blot Immunoblot for the confirmation of Borrelia burgdorferi sensu lato specific IgM antibodies in human serum
Borrelia IgM Blot Immunoblot for the confirmation of Borrelia burgdorferi sensu lato specific IgM antibodies in human serum Product Number: LYM110 (10 strips) Intended use Borrelia Blot is a qualitative
More informationLYME DISEASE. Lijing Yao, MD
LYME DISEASE Lijing Yao, MD Definition Lyme disease is a multi-system disorder caused by the spirochete Borrelia burgdorferi (B. burgdorferii) that is transmitted to humans by the bite of a tick with symptoms
More informationHeadache: Differential diagnosis and Evaluation. Raymond Rios PGY-1 Pediatrics
Headache: Differential diagnosis and Evaluation Raymond Rios PGY-1 Pediatrics You are evaluating a 9 year old male patient at the ED brought by his mother, who says that her son has had a fever, cough,
More informationCROSS-CULTURAL EDUCATION PRIMER
CROSS-CULTURAL EDUCATION PRIMER Goal of Primer Background Key Components of Cross-Cultural Care References Developed by the Culturally Competent Care Education Committee at HMS, the following is a brief
More informationDocumentation Guidelines for Physicians Interventional Pain Services
Documentation Guidelines for Physicians Interventional Pain Services Pamela Gibson, CPC Assistant Director, VMG Coding Anesthesia and Surgical Divisions 343.8791 1 General Principles of Medical Record
More informationHomepage. Neuroborreliosis (Lyme disease)
Homepage Neuroborreliosis (Lyme disease) Lyme disease is an infectious disease contracted through a tick bite. The disease exists worldwide, except in areas with very extremely climates. While many infected
More informationAs you know, the CPT Editorial Panel developed two new codes to describe complex ACP services for CY 2015.
December 30, 2014 SUBMITTED ELECTRONICALLY VIA http://www.regulations.gov Marilyn Tavenner Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS
More informationExamination Content Blueprint
Examination Content Blueprint Overview The material on NCCPA s certification and recertification exams can be organized in two dimensions: (1) organ systems and the diseases, disorders and medical assessments
More informationTwo-Year Evaluation of Borrelia burgdorferi Culture and Supplemental Tests for Definitive Diagnosis of Lyme Disease
JOURNAL OF CLINICAL MICROBIOLOGY, Oct. 2005, p. 5080 5084 Vol. 43, No. 10 0095-1137/05/$08.00 0 doi:10.1128/jcm.43.10.5080 5084.2005 Copyright 2005, American Society for Microbiology. All Rights Reserved.
More information1. What is the prostate-specific antigen (PSA) test?
1. What is the prostate-specific antigen (PSA) test? Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. The PSA test measures the level of PSA in the blood. The doctor
More informationPDF hosted at the Radboud Repository of the Radboud University Nijmegen
PDF hosted at the Radboud Repository of the Radboud University Nijmegen The following full text is an author's version which may differ from the publisher's version. For additional information about this
More informationAlgorithm for detecting Zika virus (ZIKV) 1
Algorithm for detecting Zika virus (ZIKV) 1 This algorithm is addressed to laboratories with established capacity (molecular, antigenic and/or serological) to detect dengue (DENV), Zika (ZIKV) 2, and chikungunya
More informationNeuroborreliosis: Challenges and experiences from Norway London 250315
Neuroborreliosis: Challenges and experiences from Norway London 250315 PhD Randi Eikeland Leader of the Norwegian National Advisory Unit on Tickborne Diseases Distribution Ixodes ricinus in Norway Jore
More informationEPIDEMIOLOGY OF HEPATITIS B IN IRELAND
EPIDEMIOLOGY OF HEPATITIS B IN IRELAND Table of Contents Acknowledgements 3 Summary 4 Introduction 5 Case Definitions 6 Materials and Methods 7 Results 8 Discussion 11 References 12 Epidemiology of Hepatitis
More informationPaediatrica Indonesiana. Limitations of the Indonesian Pediatric Tuberculosis Scoring System in the context of child contact investigation
Paediatrica Indonesiana VOLUME 51 November NUMBER 6 Original Article Limitations of the Indonesian Pediatric Tuberculosis Scoring System in the context of child contact investigation Rina Triasih 1,2,
More informationUse of Antidepressants in Nursing Home Residents. A Joint Statement of the Members of the Long Term Care Professional Leadership Council (LTCPLC)
Use of Antidepressants in Nursing Home Residents Item 1L A Joint Statement of the Members of the Long Term Care Professional Leadership Council (LTCPLC) SUMMARY The LTCPLC wishes to provide information
More informationPSA Testing 101. Stanley H. Weiss, MD. Professor, UMDNJ-New Jersey Medical School. Director & PI, Essex County Cancer Coalition. weiss@umdnj.
PSA Testing 101 Stanley H. Weiss, MD Professor, UMDNJ-New Jersey Medical School Director & PI, Essex County Cancer Coalition weiss@umdnj.edu September 23, 2010 Screening: 3 tests for PCa A good screening
More informationPENNSYLVANIA DEPARTMENT OF HEALTH 2015 PAHAN 307 04-02-ADV Pertussis in Centre County
PENNSYLVANIA DEPARTMENT OF HEALTH 2015 PAHAN 307 04-02-ADV Pertussis in Centre County DATE: 04/02/2015 TO: Health Alert Network FROM: Karen M. Murphy, PhD, RN, Acting Secretary of Health SUBJECT: DISTRIBUTION:
More informationBAPTIST MEDICAL CENTER JACKSONVILLE
BAPTIST MEDICAL CENTER JACKSONVILLE Baptist Medical Center Jacksonville, a 444-bed tertiary hospital that is the flagship of Baptist Health in Jacksonville, Florida, is centrally located on the south bank
More informationSuggested Reporting Language for the HIV Laboratory Diagnostic Testing Algorithm
Suggested Reporting Language for the HIV Laboratory Diagnostic Testing Algorithm November 2013 Introduction In March 2010, the Centers for Disease Control and Prevention (CDC) and the Association of Public
More informationAppendix B: Provincial Case Definitions for Reportable Diseases
Infectious Diseases Protocol Appendix B: Provincial Case Definitions for Reportable Diseases Disease: West Nile Virus Illness Revised December 2014 West Nile Virus Illness 1.0 Provincial Reporting Confirmed
More informationWilliam Atkinson, MD, MPH Hepatitis B Vaccine Issues June 16, 2016
William Atkinson, MD, MPH Hepatitis B Vaccine Issues June 16, 2016 Advisory Committee on Immunization Practices (ACIP) The recommendations to be discussed are primarily those of the ACIP composed of 15
More informationLyme Disease IgM. Cat # 1424-2Z. For in vitro diagnostic use
DIAGNOSTIC AUTOMATION, INC. 23961 Craftsman Road, Suite D/E/F, Calabasas, CA 91302 Tel: (818) 591-3030 Fax: (818) 591-8383 onestep@rapidtest.com technicalsupport@rapidtest.com www.rapidtest.com See external
More informationThe Role of Education in Safe and Effective Pain Management Kevin L. Zacharoff, MD
The Role of Education in Safe and Effective Pain Management Kevin L. Zacharoff, MD 1 Multiple opportunities for training do not necessarily lead to quality instruction When something has a bunch of different
More informationEye and Vision Care in the Patient-Centered Medical Home
1505 Prince Street, Alexandria, VA 22314 (703) 739-9200200 FAX: (703) 739-9497494 Eye and Vision Care in the Patient-Centered Medical Home The Patient Centered Medical Home (PCMH) is an approach to providing
More informationDiagnosis and Treatment Regimes for Syphilis By Dr John Bannister
Diagnosis and Treatment Regimes for Syphilis By Dr John Bannister Syphilis: Serological Testing Introduction In an ideal world a practitioner would have assessed a patient s medical history with regards
More informationHealth Benchmarks Program Clinical Quality Indicator Specification 2013
Health Benchmarks Program Clinical Quality Indicator Specification 2013 Measure Title USE OF IMAGING STUDIES FOR LOW BACK PAIN Disease State Musculoskeletal Indicator Classification Utilization Strength
More informationA known significant immunocompromising condition b and being unable/unwilling to follow the described protocol for sample collection.
Supplemental Table S1. Repository inclusion and exclusion criteria for Lyme disease patients Category Inclusion Criteria Exclusion Criteria Additional Information Obtained Early localized with EM 18 years
More informationREGISTERED NURSE PRACTITIONER (RNP) PRACTICING IN AN ACUTE CARE SETTING October 2009 Adopted by the Board 11/19/09 Background
Janice Brewer Governor Joey Ridenour Executive Director Arizona State Board of Nursing 4747 N. 7 th Street Phoenix, AZ 85014-3653 Phone (602) 771-7888 Fax (602) 771-7800 E-Mail: prandolph@azbn.gov Home
More informationEducation Goals and Objectives in Physical Medicine and Rehabilitation for the Medical School Graduate
Education Goals and Objectives in Physical Medicine and Rehabilitation for the Medical School Graduate Medical student education in Physical Medicine and Rehabilitation has been a favored topic for over
More informationHEALTH DEPARTMENT BILLING GUIDELINES
HEALTH DEPARTMENT BILLING GUIDELINES Acknowledgement: Current Procedural Terminology (CPT ) is copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
More informationAntibiotic Prophylaxis for the Prevention of Infective Endocarditis and Prosthetic Joint Infections for Dentists
PRACTICE ADVISORY SERVICE FAQ 6 Crescent Road, Toronto, ON Canada M4W 1T1 T: 416.961.6555 F: 416.961.5814 Toll Free: 1.800.565.4591 www.rcdso.org Antibiotic Prophylaxis for the Prevention of Infective
More informationNURSE PRACTITIONER STANDARDS FOR PRACTICE
NURSE PRACTITIONER STANDARDS FOR PRACTICE February 2012 Acknowledgement The Association of Registered Nurses of Prince Edward Island gratefully acknowledges permission granted by the Nurses Association
More informationUse of Typhidot in the Diagnosis and Treatment of Typhoid Fever*
Use of Typhidot in the Diagnosis and Treatment of Typhoid Fever* Adrian C. Peña, M.D.** and Edwin Pasumbal*** (*Paper presented in part during the 2 nd Annual Convention of the Philippine College of Physicians,
More informationPERTUSSIS SURVEILLANCE AND RESPONSE PROTOCOL
PERTUSSIS SURVEILLANCE AND RESPONSE PROTOCOL Public Health Action 1. Educate the public, particularly parents of infants, about the dangers of whooping cough and the advantages of initiating immunization
More informationTreating Rheumatoid Arthritis to Target : multinational recommendations assessment
Treating Rheumatoid Arthritis to Target : multinational recommendations assessment The results of the physicians survey Data presented from the publication: B. Haraoui, et al. Ann Rheum Dis. 2011;70:1999-2002.
More informationThe percentage of people with food allergy in the community
The percentage of people with food allergy in the community By Pia Nørhede Why is it important to know the percentage of people with food allergy in the community? Individuals with food allergy develop
More informationUrinary Tract Infections
Urinary Tract Infections Overview A urine culture must ALWAYS be interpreted in the context of the urinalysis and patient symptoms. If a patient has no signs of infection on urinalysis, no symptoms of
More informationPhysical Therapy Self-Referral ( Direct Access )
Physical Therapy Self-Referral ( Direct Access ) Summary of Statutes and Regulations by State December 2007 The American Association of Orthopaedic Surgeons (AAOS) supports a patient-centered approach
More informationEmergency Department Palliative Care Information Paper
Emergency Department Palliative Care Information Paper Developed by Members of the Emergency Medicine Practice Committee June 2012 Emergency Department Palliative Care an Information Paper The purpose
More informationMedical Record Documentation Standards
Medical Record Documentation Standards Medical Record Documentation Standards and Performance Measures Compliance with the Standards is monitored as part of our Quality Improvement Program. Practitioner
More informationLyme Disease and services in the HPA
Open Government Status: Open ACDP/99/P6 Lyme Disease and services in the HPA Contents Introduction... 3 Background... 3 Pathogenesis of Lyme disease... 3 Table 1: Properties of selected Borrelia antigens
More informationIDSA GUIDELINES EXECUTIVE SUMMARY
IDSA GUIDELINES The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America
More informationEvaluation of SNAP Lepto in the Diagnosis of Leptospirosis Infections in dogs: Twenty two Clinical Cases
Evaluation of SNAP Lepto in the Diagnosis of Leptospirosis Infections in dogs: Twenty two Clinical Cases Winzelberg, S 1 Tasse, SM 2 Goldstein, RE 1 Chapman, PS 3 Benedict, AG 4 Mason, GD 5 Noble, SJ 5
More information- 301-17. SICKLE CELL SCREENING AND SELECT TOPICS IN PREVENTION OF COMPLICATIONS Mark Schuster, M.D., Ph.D.
- 301-17. SICKLE CELL SCREENING AND SELECT TOPICS IN PREVENTION OF COMPLICATIONS Mark Schuster, M.D., Ph.D. We used the following sources to construct indicators for sickle cell disease screening for newborns
More information10. Treatment of peritoneal dialysis associated fungal peritonitis
10. Treatment of peritoneal dialysis associated fungal peritonitis Date written: February 2003 Final submission: July 2004 Guidelines (Include recommendations based on level I or II evidence) The use of
More informationTesting for Tick Borne Diseases: How and When?
Testing for Tick Borne Diseases: How and When? Rick Alleman, DVM, PhD University of Florida C. Guillermo Couto, DVM The Ohio State University Tick borne diseases (TBDs) used to be quite common in Greyhounds,
More informationKey words: primary care, gatekeeper, coordination of care, self-referrals, health policy
Primary Care Physicians in Israel: Self-Perception of Their Role in the Healthcare System and Policy Makers' and Patients' Perception of Them as Gatekeepers Hava Tabenkin MD MSc LLB 1, Revital Gross 2,
More informationCERTIFICATION OF HEALTH CARE PROVIDER FAMILY AND MEDICAL LEAVE ACT
OF HEALTH CARE PROVIDER FAMILY AND MEDICAL LEAVE ACT PART A: For Completion by the EMPLOYEE: Please complete all applicable sections of Part A before giving this form to your family member or your/their
More informationROLE DESCRIPTIONS BY COMPETENCY LEVEL
Description of Work: Positions in this class provide patient evaluation and care in area of assignment. Duties include but are not limited to development and presentation of educational programs, assessment,
More informationHOST DEFENSE SMALL GROUP PROBLEM SOLVING SESSION. B-CELL, T CELL, AND B&T CELL DEFICIENCIES Small Group Classrooms
HOST DEFENSE SMALL GROUP PROBLEM SOLVING SESSION B-CELL, T CELL, AND B&T CELL DEFICIENCIES Small Group Classrooms LEARNING GOALS You will be able to identify the implication(s) of impaired/defective T
More informationChemobrain. Halle C.F. Moore, MD The Cleveland Clinic October 3, 2015
Chemobrain Halle C.F. Moore, MD The Cleveland Clinic October 3, 2015 Terminology Chemotherapy-associated cognitive dysfunction Post-chemotherapy cognitive impairment Cancer treatment-associated cognitive
More informationThe Nurse Practitioner in HIV Care. Laura Vicol MN, NP(F) Monica Gregory MScN, NP(F)
The Nurse Practitioner in HIV Care Laura Vicol MN, NP(F) Monica Gregory MScN, NP(F) NURSE PRACTITIONERS First. Who Are we? Nurse Practitioners A New Health Care Provider in the Province of British Columbia
More information