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Purpose: To review the evidence and provide clinical recommendations for the management of acute exacerbations of chronic obstructive pulmonary disease (COPD). Methods: This guideline is based on a systematic review of randomized controlled trials from database inception to January 2, 2019. The target audience for the guideline includes all primary care clinicians, and the target patient population includes adults who are experiencing acute exacerbations of COPD. This guideline was developed using a modified version of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, a transparent approach to evaluating the certainty of the evidence and determining the strength of recommendations. Recommendation 1: The American Academy of Family Physicians (AAFP) recommends that clinicians prescribe systemic antibiotics for adults with acute exacerbations of COPD to improve clinical cure and reduce clinical failure (weak recommendation, moderate quality of evidence). Choice of antibiotic should be based on local resistance patterns, affordability, and patient history and preferences because there is insufficient evidence to support a preferential recommendation. Recommendation 2: The AAFP recommends that clinicians prescribe corticosteroids for adults with acute exacerbations of COPD to reduce clinical failure (weak recommendation, low quality of evidence). There is insufficient evidence to guide the dose, route of administration, or duration of treatment. [ABSTRACT FROM AUTHOR]

Purpose: To review the evidence and provide clinical recommendations for the screening and treatment of depression in patients who have had a recent acute coronary syndrome event. Methods: This guideline is based on a systematic review of randomized controlled trials and observational studies from January 1, 2003, to August 15, 2017. It is an update to a previous systematic review published in May 2005, which included studies up to March 2004. The target audience for the guideline includes all primary care clinicians, and the target patient population includes adults who are within the three months following an acute coronary syndrome event (unstable angina or myocardial infarction). This guideline was developed using a modified version of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, a transparent approach to evaluating the certainty of the evidence and determining the strength of recommendations. Recommendation 1: The American Academy of Family Physicians recommends that clinicians screen for depression, using a standardized depression screening tool, in patients who have recently experienced an acute coronary syndrome event (weak recommendation, low-quality evidence). Individuals should undergo further assessment to confirm the diagnosis of depression (good practice point). Recommendation 2: The American Academy of Family Physicians strongly recommends that clinicians prescribe antidepressant medication, preferably selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, and/or cognitive behavior therapy to improve symptoms of depression in patients who have a history of acute coronary syndrome and have been diagnosed with depression (strong recommendation, moderate-quality evidence). [ABSTRACT FROM AUTHOR]

Purpose: To review the evidence and provide clinical recommendations for appropriate blood pressure treatment targets for adults with hypertension. [ABSTRACT FROM AUTHOR]

The article comments on the U.S. Preventive Services Task Force's (USPSTF) recently updated recommendation statement, lowering the starting age for colorectal cancer screening. It notes that the American Academy of Family Physicians (AAFP) disagrees with USPSTF for lack of evidence to assess its benefits and harms. Also discussed is the potential cost to patients and the health care system of lowering the screening age to 45.

The article comments on the U.S. Preventive Services Task Force's (USPSTF) updated recommendation statement, lowering the starting age for colorectal cancer screening. It notes that the American Academy of Family Physicians (AAFP) disagrees with USPSTF for lack of evidence to assess its benefits and harms. Also discussed is the potential cost to patients and the health care system of lowering the screening age to 45.

An editorial is presented on the management of acute pain from musculoskeletal injuries has guidance for family physicians. Topics include the family physicians commonly encounter patients with pain from acute musculoskeletal injuries that do not involve the lower back, and the management of chronic pain and the appropriate prescribing of opioids with less emphasis on the treatment of acute pain.

Laboratory evidence suggests that intestinal permeability is elevated following either binge ethanol exposure or burn injury alone, and this barrier dysfunction is further perturbed when these insults are combined. We and others have previously reported a rise in both systemic and local proinflammatory cytokine production in mice after the combined insult. Knowing that long myosin light-chain kinase (MLCK) is important for epithelial barrier maintenance and can be activated by proinflammatory cytokines, we examined whether inhibition of MLCK alleviated detrimental intestinal responses seen after ethanol exposure and burn injury. To accomplish this, mice were given vehicle or a single binge ethanol exposure followed by a sham or dorsal scald burn injury. Following injury, one group of mice received membrane permeant inhibitor of MLCK (PIK). At 6 and 24 h postinjury, bacterial translocation and intestinal levels of proinflammatory cytokines were measured, and changes in tight junction protein localization and total intestinal morphology were analyzed. Elevated morphological damage, ileal IL-1β and IL-6 levels, and bacterial translocation were seen in mice exposed to ethanol and burn injury relative to either insult alone. This increase was not seen in mice receiving PIK after injury. Ethanol-exposed and burn-injured mice had reduced zonula occludens protein-1 and occludin localization to the tight junction relative to sham-injured mice. However, the observed changes in junctional complexes were not seen in our PIK-treated mice following the combined insult. These data suggest that MLCK activity may promote morphological and inflammatory responses in the ileum following ethanol exposure and burn injury. [ABSTRACT FROM AUTHOR]

Abstract: CD8+ T cells are important for resolution of HSV-2 lesions from the female genital epithelium. It is uncertain whether optimal clearance of viruses such as HSV-2 that cause a limited, non-systemic infection solely requires expression of effector functions by infiltrating CD8+ T lymphocytes, or if the clearance rate is reflective of the expression level of critical effector functions. To address this, CD8+ T cells from normal OT-I mice or OT-I mice deficient in IFNγ (IFNγ−/−) or the IFNγ receptor (IFNγR−/−) were activated in vitro in the presence of IFNγ or IL-4 to generate a series of effector populations (Tc1 and Tc2-like respectively) that secreted different levels of IFNγ and expressed different levels of HSV-specific cytolytic function. Compared with Tc1 cells, Tc2-like cells produced the type 2 cytokines IL-4 and IL-5, exhibited decreased IFNγ secretion, diminished proliferation in vitro, and decreased antigen-specific cytolysis in vivo. Clearance of an ovalbumin-expressing HSV-2 strain (HSV-2 tk− OVA) by adoptively transferred Tc2-like cells was delayed relative to Tc1 cell recipients. Because donor Tc2-like cells proliferated in vivo and infiltrated the infected genital epithelium similar to Tc1 cells, the diminished virus clearance by Tc2-like effector cells correlated with reduced expression of critical effector functions. Together, these results suggest that high level expression of protective T cell functions by effector T cells is necessary for optimal clearance of HSV-2 from the genital epithelium. These results have important implications for vaccines designed to elicit CD8+ T cells against viruses such as HSV-2 that infect the genital tract. [Copyright &y& Elsevier]

Abstract: Cell-mediated immunity is extremely important for resolution of infection and for proper healing from injury. However, the cellular immune response is dysregulated following injuries such as burn and hemorrhage. Sex hormones are known to regulate immunity, and a well-documented dichotomy exists in the immune response to injury between the sexes. This disparity is caused by differences in immune cell activation, infiltration, and cytokine production during and after injury. Estrogen and testosterone can positively or negatively regulate the cellular immune response either by aiding in resolution or by compounding the morbidity and mortality. It is apparent that the hormonal dysregulation is dependent not only on the type of injury sustained but also the amount of circulating hormones. Therefore, it may be possible to design sex-specific therapies to improve immunological function and patient outcome. [Copyright &y& Elsevier]

The article discusses the clinical practice guidelines issued by the American Academy of Family Physicians (AAFP) on atrial fibrillation (AF) diagnosis and management. Topics explored include the presentation of AF symptoms such as irregular heart rate and extreme fatigue, the need for primary care physicians to educate AF patients about medication cost and possible side effects of anticoagulants, and the use of lenient rate control instead of strict rate control in patients with AF.

Early clearance of a thymidine kinase-deficient strain of herpes simplex virus type 2 from the female genital tract required T-cell-produced gamma interferon (IFN-γ). Transfer of activated CD8+ T cells to irradiated C57BL/6 mice resulted in rapid virus clearance, but clearance was greatly delayed in recipients deficient in the IFN-γ receptor (IFN-γ R). Early virus clearance was demonstrated in radiation chimeras in which IFN-γ R expression was limited to parenchymal cells, but resolution was significantly delayed in chimeras deficient in IFN-γ R expression and chimeras expressing IFN-γ R only on hematopoietic cells. Together, these results suggest that early IFN-γ-mediated protection was manifested mainly by stimulation of genital parenchymal cells. [ABSTRACT FROM AUTHOR]

Objective: To focus on the intersection of perception, diagnosis, stigma, and weight bias in the management of obesity and obtain consensus on actionable steps to improve care provided for persons with obesity., Methods: The American Association of Clinical Endocrinology (AACE) convened a consensus conference of interdisciplinary health care professionals to discuss the interplay between the diagnosis of obesity using adiposity-based chronic disease (ABCD) nomenclature and staging, weight stigma, and internalized weight bias (IWB) with development of actionable guidance to aid clinicians in mitigating IWB and stigma in that context., Results: The following affirmed and emergent concepts were proposed: (1) obesity is ABCD, and these terms can be used in differing ways to communicate; (2) classification categories of obesity should have improved nomenclature across the spectrum of body mass index (BMI) using ethnic-specific BMI ranges and waist circumference (WC); (3) staging the clinical severity of obesity based on the presence and severity of ABCD complications may reduce weight-centric contribution to weight stigma and IWB; (4) weight stigma and internalized bias are both drivers and complications of ABCD and can impair quality of life, predispose to psychological disorders, and compromise the effectiveness of therapeutic interventions; (5) the presence and of stigmatization and IWB should be assessed in all patients and be incorporated into the staging of ABCD severity; and (6) optimal care will necessitate increased awareness and the development of educational and interventional tools for health care professionals that address IWB and stigma., Conclusions: The consensus panel has proposed an approach for integrating bias and stigmatization, psychological health, and social determinants of health in a staging system for ABCD severity as an aid to patient management. To effectively address stigma and IWB within a chronic care model for patients with obesity, there is a need for health care systems that are prepared to provide evidence-based, person-centered treatments; patients who understand that obesity is a chronic disease and are empowered to seek care and participate in behavioral therapy; and societies that promote policies and infrastructure for bias-free compassionate care, access to evidence-based interventions, and disease prevention., Competing Interests: Disclosures The Task Force was empaneled in accordance with AACE Conflict of Interest (COI) Policy and approved by the AACE COI Subcommittee. All members of the expert Task Force completed AACE’s disclosure form regarding any multiplicities of interests related to commercial and direct financial relationships within the preceding 12 months with companies that develop products connected with endocrine disorders. Categories for disclosure include employment, stock or other ownership, direct financial relationships (eg, speaker or consultant), research funding, authorship or panel involvement on a guidance document related to an overlapping topic, or other situations related to a perceived COI. The AACE COI Subcommittee reviewed these disclosures against an AACE-approved list of ineligible companies for this consensus statement and reached consensus regarding members who could serve on the Task Force in the nonconflicted majority, those who could serve in the conflicted minority with management strategy, and those who were disqualified from serving on the Task Force. The AACE CPG Oversight Committee reviewed and approved the AACE COI Subcommittee’s decisions regarding manageable COI and empanelment. Members of this Task Force were reminded to update potential disclosures if new potential conflicts arose during their appointments and to verify currency of disclosures. AACE made every effort to minimize the potential for conflicts of interest that could influence the recommendations of this CPG. Disclosures related to obesity are provided below; however, none were deemed as conflicts of interest as there were no discussions of treatment or management options in the development of the consensus statement. B.A. serves on speakers’ bureaus for Astra Zeneca, Corcept, Eli Lilly, and Novo Nordisk. J.A. serves on advisory boards for Eli Lilly and Novo Nordisk. W.G. serves as a volunteer consultant on advisory boards for Jazz Pharmaceuticals, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, and Pfizer without financial compensation, serves on advisory boards for Alnylam Pharmaceuticals, Boehringer Ingelheim, Eli Lilly, Fractyl Health, and Novo Nordisk with financial compensation, and receives research support as a site principal investigator for clinical trials sponsored by his institution and funded by Eli Lilly, Novo Nordisk, Epitomee, and Pfizer. T.K. is the owner of Ted Kyle Consulting, LLC and a consultant for Gelesis, Johnson & Johnson, Novo Nordisk, and Nutrisystem. K.N., M.A., M.B., and M.C. have nothing to disclose., (Copyright © 2023 AACE. Published by Elsevier Inc. All rights reserved.)

Clinical and experimental evidence demonstrates that ethanol exposure prior to injury alters local and systemic inflammatory responses, increasing morbidity and mortality. Moreover, the aberrant inflammatory responses can directly and indirectly lead to the poor prognosis after injury by altering leukocyte infiltration into the wound site and remote organs and by suppressing immunity leading to increased susceptibility to opportunistic infections. Recent studies from our laboratory have focused on inflammatory responses at the wound site and in other distal organs after exposure to acute ethanol and burn injury. This combined insult leads to increased mortality after dermal or intratracheal pseudomonas infection, relative to infected mice given ethanol or burn injury alone. The increased mortality in mice given ethanol and burn injury parallels elevated serum levels of proinflammatory cytokines, IL-6 and TNF-alpha, marked infiltration of leukocytes into the lung and gut, as well as immunosuppression at the sites of infection. Bacterial translocation from the gut is likely to be responsible, in part, for the aberrant accumulation of leukocytes in the lungs of ethanol-exposed, burn-injured mice. Additionally, other factors, such as expression of adhesion molecules, increased chemokine production, and leakiness of the vascular endothelium, may also be involved.