🗞️ TLDR Primary Care - Rapid Fire Guidelines (#062)

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Date: Nov 1, 2023 • Issue no: #062

This week's issue:

⚡️Rapid guideline summaries for:

⛰️ Acute Altitude Illness

✂️ Anal Fissures

😨 Prostate Cancer

🍺 Alcohol Use Disorder

❄️ Adhesive Capsulitis

🗞 Rapid Fire: Guideline Summaries

Do-not-miss guidelines, broken down for you

You’ll find some of the newest guidelines relevant to Primary Care below, along with a few key takeaways from each one of them.

Some of these guidelines are dense – but don’t worry, over at Pathway, they’re all neatly summarized and broken down into digestible chunks to make them easier to understand.

⛰️ Acute Altitude Illness - from the Wilderness Medical Society (WMS 2023):

Administer supplemental oxygen when available to achieve SpO₂ of > 90% or relieve symptoms while waiting to initiate descent when descent is not feasible and during descent in severely ill patients. (A)
Consider administering acetazolamide for the treatment of patients with acute mountain sickness. (B)
Consider administering dexamethasone for the treatment of patients with acute mountain sickness. (B)
Administer dexamethasone for the treatment of patients with high-altitude cerebral edema. (B)
Administer nifedipine for the treatment of patients with high-altitude pulmonary edema only when descent is impossible or delayed and reliable access to supplemental oxygen or portable hyperbaric therapy is unavailable. (B)
Consider administering tadalafil or sildenafil for the treatment of patients with high-altitude pulmonary edema when descent is impossible or delayed, access to supplemental oxygen or portable hyperbaric therapy is impossible, and nifedipine is unavailable. (C)
Advise descent in patients with severe acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema. (A)
Consider offering acetazolamide to travelers at moderate or high risk of acute mountain sickness. (B)

✂️ Anal Fissures - from the American Society of Colon and Rectal Surgeons (ASCRS 2023; 2017), the Italian Unitary Society of Colon-Proctology (SIUCP 2023), the World Society of Emergency Surgery (WSES/AAST 2021), and the American College of Gastroenterology (ACG 2021), among others:

Consider offering nonoperative management as first-line therapy in patients with acute anal fissure. Consider performing surgical treatment in the chronic phase in patients unresponsive after at least 6 weeks of conservative treatment. (B)
Consider offering topical nitrates (0.4% nitroglycerin) as first-line therapy in patients with chronic anal fissures and typical clinical presentation (intense anal pain associated with suspected anal sphincter hypertonia on physical examination). (B)
Consider offering topical sphincter muscle relaxers, such as calcium channel blockers, particularly 0.3% nifedipine plus 1.5% lidocaine, in patients with acute anal fissure with poor adherence to dietary and behavioral medical prescriptions. (C)
Consider offering topical metronidazole in patients with acute anal fissure. (C)
Consider offering common analgesics, topical anesthetics, and ointments with thermogenic and myorelaxant effects for the treatment of acute anal fissures in case of inadequate pain control. (E)
Consider offering fiber supplements and bulk-forming laxatives in patients with persisting hard stools. (E)
Administer botulinum toxin injection as first-line therapy in patients with chronic anal fissures and as second-line therapy following failed treatment with topical therapies. (B)

😨 Prostate Cancer - from the American Urological Association (AUA/SUO 2023), the European Society of Medical Oncology (ESMO 2023; 2020), the American Society of Clinical Oncology (ASCO 2023; 2022; 2021; 2020), and the Canadian Urological Association (CUA 2023), among others:

Engage in shared decision-making with persons eligible for prostate cancer screening and proceed based on the person's values and preferences. (B)
Consider beginning prostate cancer screening and obtaining a baseline PSA test in males aged 45-50 years. (C)
Obtain regular prostate cancer screening every 2-4 years in males aged 50-69 years. (A)
Repeat PSA before a secondary biomarker, imaging, or biopsy in patients with newly elevated PSA. (E)
Do not obtain PSA-based screening for prostate cancer in ≥ 70-year-old males. (D)
Consider using validated risk calculators to inform the shared decision-making process regarding prostate biopsy. (C)
Consider obtaining a prostate MRI before the initial biopsy to increase the detection of grade group ≥ 2 prostate cancer. (C)

🍺 Alcohol Use Disorder - from the Canadian Research Initiative in Substance Misuse (CRISM 2023), the American Association for the Surgery of Trauma (AAST 2022), the French Society of Alcohology (AFEF/SFA 2022), and the American Association for the Study of Liver Diseases (AASLD 2020), among others:

Screen for above low-risk alcohol use routinely in all adult and young patients. (B)
Use the AUDIT-Concise questionnaire (first 3 questions of AUDIT) in general practice and specialist consultations to detect excessive alcohol consumption. (A)
Consider setting the initial goals of treatment of AUD (abstinence from alcohol use, reduction or moderation of alcohol use, or other elements of harm reduction) agreed on between the patient and clinician and document this agreement in the medical records. (C)
Offer naltrexone as first-line pharmacotherapy to achieve patient-identified treatment goals (either abstinence or a reduction in alcohol consumption) in adult patients with moderate-to-severe AUD. (A)
Offer acamprosate to adult patients with moderate-to-severe AUD with a treatment goal of achieving abstinence. (A)
Offer information about and referrals to specialist-led psychosocial treatment interventions, peer-support groups, and other recovery-oriented services in the community for adult and young patients with mild-to-severe AUD. (B)
Counsel patients with heavy alcohol use (> 3 drinks per day in males and > 2 drinks per day in females for > 5 years) that they are at an increased risk for liver disease. (B)

❄️ Adhesive Capsulitis - from the American College of Radiology (ACR 2018) and the American Physical Therapy Association (APTA 2013):

Recognize that patients with adhesive capsulitis present with a gradual and progressive onset of pain and loss of active and passive shoulder motion in both elevation and rotation. (E)
Recognize that adhesive capsulitis is more prevalent in:
- females
- individuals 40-65 years old
- patients with diabetes mellitus and thyroid disease
- patients who have had a previous episode of adhesive capsulitis in the contralateral arm. (B)
Use validated functional outcome measures, such as the DASH, the American Shoulder and Elbow Surgeons shoulder scale, or the Shoulder Pain and Disability Index, utilized before and after interventions intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated with adhesive capsulitis. (A)
Obtain shoulder MRI when initial radiographs are normal or inconclusive in patients with suspected adhesive capsulitis. (B)
Instruct patients with adhesive capsulitis to perform stretching exercises and guide the intensity of the exercises by the patient's tissue irritability level. (B)
Perform intra-articular corticosteroid injections in addition to advising shoulder mobility and stretching exercises to improve short-term pain relief and function. (A)

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