Primary Contact Research Articles

Primary care first contact practitioner’s (FCP) challenges and learning and development needs in providing fitness for work and sickness absence certification: consensus development

BackgroundAs yet, the benefit of the Fit Note has not been convincingly demonstrated, although a limited body of research suggests that provision of fitness for work advice and sickness absence certification may be improved with training and case-specific direction. The role of certifying sickness absence in the UK has traditionally been conducted by General Practitioners, but this role has now been extended to First Contact Practitioner (FCP) Physiotherapists in primary care. Therefore, FCPs may offer an ideal solution to the current challenges faced within primary care for those with a musculoskeletal (MSK) condition at risk of sickness absence from their work environment. ObjectivesThe main aim of this study was to identify the challenges and key learning and development needs of FCPs in response to providing Occupational Health (OH) information in the form of fitness for work advice and sickness certification for patients with MSK conditions within primary care. DesignConsensus was generated using an online modified version of the Nominal Group Technique (NGT) method. A priori consensus threshold of 60% was used in the voting stage. ParticipantsNGT participants included clinicians with experience in managing MSK conditions in primary care within the FCP model of care. All participants generated, voted, and ranked the items using an online platform. ConclusionsThis research adds new evidence regarding the challenges and learning and development needs identified by a group of FCPs working within primary care in consideration of sickness absence certification and fitness for work advice. The items highlighted provide evidence to complement Health Education England’s FCP A Roadmap to Practice educational pathway and informs on professional development needs in this area.

Comparing Plantar Pressure Distribution and Vertical Ground Reaction Force Between Healthy Subjects and Middle-aged Adults With Leg Length Discrepancy (LLD)

Introduction: This study aimed to compare plantar pressure distribution and vertical ground reaction force between middle-aged adults with Leg Length Discrepancy (LLD) and healthy subjects. Materials and Methods: This quasi-experimental study was conducted on 21 middle-aged adults with leg length discrepancy (1.5 to 3 cm), and 10 healthy subjects participated. The plantar pressure distribution of subjects was measured using five steps with an emed platform. The data were analyzed with paired t-test, 1-way ANOVA, and symmetry index (P≤0.05). Results: While the symmetry index did not show much asymmetry in healthy subjects, in LLD subjects, it showed lower contact time in the heel region of short limb, lower pressure, and force of the middle region of short limb, the higher pressure of forefoot region of short limb and higher pressure and force of long limb. Conclusion: It seems that the primary contact time and weight acceptance of short limb reduced that results in higher pressure of forefoot region of the foot before push-off phase. Therefore, to dispel this problem, the LLD subjects could use orthotics to make reasonable height to the heel region and thus increase the contact time.

Management of recent onset tendon-related pain in a primary contact setting: A survey of practice

Management of recent onset tendon-related pain in a primary contact setting: A survey of practice

Pharmacy practice architecture challenges in handling COVID-19 pandemic - sharing experience from a Kosovo pharmacy practice.

Background:Community pharmacies deliver an essential healthcare service, which is broadly established, encompassing the favored and primary contact for community members. The COVID-19 pandemic is continuing to shift the pharmacy roles and services in order to meet the needs of customers. The important value of community pharmacies was more underlined during the pandemic crisis when they were supposed to undertake abundant precautions to avoid cross-infection among users of the space. Their responsibility is also to create a compatible, efficient, and safe environment inside their premises during this outbreak. The built environment is an important share of pandemic solutions and emergency planning preparations.Objectives:The aim of this paper was to explore the preparedness of community pharmacies in Kosovo for the COVID-19 outbreak in regards to pharmacy design modifications while ensuring adequate medicine management, information, and public health. Consequently, at what stage can the pandemic affect the physical and built environment of pharmacies.Methods:The methods for this study include a cross-sectional survey of 104 community pharmacies operating in seven municipalities in Kosovo during the pandemic. Data collection was conducted from October 1 to October 14, 2021, using self-administered online questionnaires. The questionnaire consisted of a combination of closed and open-ended questions, optional statements, and multiple answers. Data were analyzed in SPSS for Windows version 20 using descriptive statistics.Results:The results show that communities should be prepared ahead in regard to the emergency situations and some of these preparations might be also part of the legislation requirements. Although the pandemic exposed many errors in the Kosovo community pharmacy system, it has also discovered a unique possibility for collaboration and novelty.Conclusions:The study concludes with the recommendation for the architectural design of pharmacies to be positioned as an active mediator in the fight against the COVID 19, with a critical lesson aimed at the flexibility of the space to accommodate emergent situations and create alternative areas for use.

Low rate of transmission to triple-vaccinated contacts of an imported case of SARS-CoV-2 omicron infection: a contact tracing study in Israel.

Highlight (Word Count: 49):We conducted contact-tracing investigation of multiple patients and healthcare workers exposed to a pre-symptomatic physician, triple-vaccinated with BNT162b2 COVID-19 vaccine, infected with SARS-CoV-2 B.1.1.529 (Omicron) Variant. Of 51 contacts, 45(88%) were triple-vaccinated (boosted) with BNT162b2 vaccine and 47(92%) contacts were masked. One (1/51, 2%) triple-vaccinated primary contact became infected.

Over-the-top platform: A boon or bane during COVID-19 lockdown

COVID-19, an unprecedented global pandemic, has changed the way of media consumption by the audience. A new trend surfaced during this period – prioritizing over the tops (OTTs) over normal ongoing media channels. This points to the growing market and consumer appetite for content of choice available on OTT platforms. OTTs offer a naïve and consumer-friendly advantage – choice of content, simple access, and choice of device/mediums (hand phone, laptop, tablet, or TV screen). However, its rampant usage has also affected the mental and physical health of people of all generations. It is imperative to know the impact of growing content consumption on psychological behaviors across generations (children, adults, and elderlies) as there is limited censorship within the OTT space. As the mental health issues are on rise, the primary care physicians are the key role players to address this issue as they meet number of subjects as a primary contact. Hence, to find out the impact of OTT, an extensive literature search was done from PubMed and Google Scholar, and the relevant findings were noted down.

Telehealth voice assessment by speech language pathologists during a global pandemic using principles of a primary contact model: an observational cohort study protocol

IntroductionSARS-CoV-2, a highly contagious severe acute respiratory syndrome, has spread to most countries in the world and resulted in a change to practice patterns for the assessment and diagnosis of...

Retrospective Study of COVID-19 Positive Paediatric Patients Admitted in a Tertiary Care Hospital, Mizoram, India

Introduction: The clinical presentation and the difference in the pattern of presentation of Paediatric Coronavirus Disease-2019 (COVID-19) positive cases between the first wave and second wave have not been studied in North Eastern region of India. Aim: To study the socio-demographic factors, clinical presentations and also to compare the pattern of presentation of Paediatric COVID-19 positive cases between the first COVID 19 wave and second COVID-19 wave. Materials and Methods: A retrospective observational study of 85 Paediatric COVID-19 positive cases admitted in Zoram Medical College, Mizoram, India, during the period from July 2020 to June 2021 was conducted. Children of age group <14 years were included in the study. The data like age, sex, type of testing done, possible primary contact, symptoms , treatment given and prognosis were collected from the case sheets in Medical Records Department. Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency and proportion for categorical variables. Categorical outcomes were compared between study groups using Chi square test/Fisher's Exact test. Results: Records of total of 85 participants were included in the final analysis. The mean age of the study population was 6.59 years. 40 (52.94%) were male patients. Majority , 46 (54.11%) have contracted the infection from their parents. The most common symptoms reported were fever (36.47%), cough (24.71%) and cold (22.4%). A total of 9.42% had co-morbidity. The mean duration of hospital stay was 10.14±5.2 days. In age group <5 years, (58.33%) were symptomatic when compared with 5 to 10 years (16.67%) and 25% in children >10 years (p-value= <0.001). There was a significant difference in the mean age group admitted in first wave (2.91±2.94 years) versus second wave (11.38±2.91 years) (p-value <0.001). Conclusion: The children less than 5 years were more symptomatic when compared with other age groups. Also we can see a transition in age group being infected and it was greater than 10 years old in the second wave. Hence there is an urgent need to vaccinate the population less than 18 years old.

Suitability indices for assessing functional quality of urban surface water

Urban surface waters are used in many different ways. With increasing demand for human use functions, improved insight is required into the functional quality of these waters. A method to assess this functional quality in a systematic way and for a wide variety of use functions is not available. We propose to use suitability indices (SIs) for assessing the suitability of urban water bodies for a variety of specific human uses. This study provides a new protocol for this, building on the water quality index and ecosystem services approaches in literature, by extending traditional water quality parameters with other characteristics of water bodies that determine suitability for a specific use function. By assessing suitability instead of traditional water quality, the functional quality of a water body for all kinds of uses can be determined in a consistent way. The protocol was demonstrated to be effective in developing SIs for three specific urban water use functions, namely: thermal energy extraction, transportation of goods and primary contact recreation. Application of the suitability indices in a case study in the city of Amsterdam, The Netherlands, resulted in spatially explicit information about suitability of surface waters for the three selected use functions. Sub-scores per parameter showed which characteristics of the urban water bodies should be changed to improve the suitability for these three functions. In this way, the SI approach for assessment of the functional quality of urban surface waters can be used to support function-oriented planning, design and maintenance of urban surface water systems.

Awareness about Eye Health in Kerala

Awareness about Eye Health in Kerala

Knowledge, Attitude and Practices Regarding Utility of CBNAAT in the Diagnosis of SARSCoV-2 Disease among Medical Interns: A Cross-sectional Study

Introduction: Coronavirus Disease-2019 (COVID-19) causes respiratory tract infections in human beings ranging from mild illnesses like common cold to severe disease like pneumonia. Currently, nucleic acid amplification tests Reverse Transcriptase Polymerase Chain Reaction (RT-PCR), Cartridge Based Nucleic Acid Amplification Test (CBNAAT) and Truenat) and rapid antigen detection tests are approved for diagnostic purpose by Indian Council of Medical Research (ICMR). Medical Interns, the primary contact health-care personnel, need to be sensitised regarding proper utilisation of CBNAAT, so that rapid and accurate diagnosis of Severe Acute Respiratory Syndrome Corona Virus 2 (SARSCoV-2) can be made in comparison to the more commonly used RT-PCR technique. Aim: To evaluate the Knowledge, Attitude and Practices (KAP) of Bachelor of Medicine and a Bachelor of Surgery (MBBS) interns towards accessibility of CBNAAT in SARS-CoV-2 infection in a tertiary care hospital. Materials and Methods: A cross-sectional study was performed through questionnaire shared via online platform amongst 102 Medical interns working at College of Medicine and Sagore Dutta Hospital from 22nd August 2021 to 21st September 2021. Based on their response, KAP was assessed by using a threepoint Likert Scale. The collected data was entered in Microsoft excel, and reported as frequencies and percentages. Results: Among 102 internees, 84 interns responded. Among 84 medical interns 31% had good, 50% had average whereas 19% had poor level of knowledge. About 58 (69%) agreed that CBNAAT can be used as a method for rapid diagnosis of SARS-CoV-2. About 75 (89.3%) answered that they are sending samples for COVID-19 testing. Only 56 (66.7%) agreed that CBNAAT should be recommended. Conclusion: This study revealed that majority of the MBBS interns had positive attitude towards different aspects of CBNAAT utility but most of them had gaps in their KAP. This demands extra efforts to sensitise and train them adequately.

Burden Associated with Telephone Calls on COVID-19: Results of a Flash Mob Study in Family Practices.

Family practices are the primary contact for inquiries relating to COVID-19. This study reveals the reasons why German family practices are called during the pandemic and which burden is associated with patients' inquiries related to COVID-19 among practice assistants (PAs). On April 28, 2021 a cross-sectional flash mob study was conducted in family practices across Germany. The study material and invitation were disseminated via social media and postal or electronic mails. During half a day, participating practices counted every incoming call. For calls addressing COVID-19, the reason, duration, and perceived stress level were documented. Descriptive statistics and regression analyses were performed using SPSS. 5,646 calls, 1,826 of which were related to COVID-19 (32.3%), were documented by 73 practices (practice average: 25.0 ± 17.7) within a single Wednesday morning. Most calls addressed vaccination (n = 1,050, 59.0%). During 22.0% (n = 388) of COVID-19-related calls, PAs felt stressed, which was mainly influenced by the call duration (calls of 5 minutes and longer were perceived significantly more stressful [OR 8.94, 95% CI 6.47-12.37]). Feeling well-prepared to meet patients' inquiries relating to COVID-19 was a protective factor for the average stress perceived per PA. Overall, less than 10% of calls on COVID-19 were transferred to a physician. Family practice teams experience a high volume of partly stressful phone calls about COVID-19 but are often able to handle the pandemic challenges. PAs play a central role in advising the practice population on issues related to COVID-19. This deserves greater recognition.

An Assessment, with NICE Guidelines as a Benchmark, of Delay to Care in a Cohort of Colorectal Cancer Patients Seen in the Witwatersrand University Academic Complex

Background: Colorectal cancer (CRC) in South Africa (S.A) is the second most common in women and the third in men. Worldwide it is the second most deadly cancer. As a subset, colon cancer is the fifth most deadly with an estimated 551,000 deaths in 2018. CRC makes up 5.8% of all cancer-related deaths globally. Despite this, there are no screening programmes in S.A, with a diagnosis being largely dependent on symptomatology. Additionally, there is no clear understanding of the significance of the outcome imposed by delay in referral and treatment. Unlike countries in Europe, South Africa has no guidelines defining cut-offs for acceptable delays in this context. Methods: A retrospective study was done on the delay in referral, diagnosis, and treatment of CRC patients. A cohort of patients in which surgery was the primary treatment that was presented to Witwatersrand Academic Hospitals was studied. Delays were benchmarked against fourteen days from primary contact to consultation with a specialist and consultation to treatment delay of more than 31 days. Definitive treatment delay was defined as the time from referral to the treatment centre and tumour resection of more than 62 days. Outcomes were evaluated by defining the 90-day mortality. Results: The median referral delay was 78 days, for treatment delay was 54 days and for definitive treatment delay was 175 days. Of the 587 patients analysed, 341 had therapeutic surgery, 17 demised within 90 days post-surgery. Longer delays and higher mortality rates were seen in the public sector and a lower socio-economic group of patients. Conclusion: The time parameters set out by the NHS and Europe were not met. There were greater delays seen in patients with lower socio-economic backgrounds and in those attending the public sector. The effect of delays on 90-day mortality is doubtful. Delays to care both outside of hospitals and in hospitals may be a point of investigation in future studies.

The development of Future Health Today: piloting a new platform for identification and management of chronic disease in general practice.

Chronic disease identification and management is a significant issue in Australia, with general practice being the primary contact point for those at risk of, or living with, chronic disease. However, there is a well-described gap between guideline recommendations for chronic disease management and translation in the general practice setting. In 2018, a group of researchers, clinicians and software developers collaborated to develop a tool to support the identification and management of chronic disease in general practice, with the aim to create a platform that met the needs of general practice. The co-design process drew together core principles and expectations for the establishment of a technological platform, called Future Health Today (FHT), which would sit alongside the electronic medical record (EMR) management system within general practice. FHT used algorithms applied to EMR data to identify patients with, or at risk of, chronic disease and requiring review. Using chronic kidney disease as a clinical focus, the FHT prototype was piloted in a large, metropolitan general practice, and a large regional general practice. Based on user feedback, the prototype was further developed and improved. This paper provides a report on the key features and functionalities that participants identified and implemented in practice.

An Assessment, with NICE Guidelines as a Benchmark, of Delay to Care in a Cohort of Colorectal Cancer Patients Seen in the Witwatersrand University Academic Complex

Background: Colorectal cancer (CRC) in South Africa (S.A) is the second most common in women and the third in men. Worldwide it is the second most deadly cancer. As a subset, colon cancer is the fifth most deadly with an estimated 551,000 deaths in 2018. CRC makes up 5.8% of all cancer-related deaths globally. Despite this, there are no screening programmes in S.A, with a diagnosis being largely dependent on symptomatology. Additionally, there is no clear understanding of the significance of the outcome imposed by delay in referral and treatment. Unlike countries in Europe, South Africa has no guidelines defining cut-offs for acceptable delays in this context. Methods: A retrospective study was done on the delay in referral, diagnosis, and treatment of CRC patients. A cohort of patients in which surgery was the primary treatment that was presented to Witwatersrand Academic Hospitals was studied. Delays were benchmarked against fourteen days from primary contact to consultation with a specialist and consultation to treatment delay of more than 31 days. Definitive treatment delay was defined as the time from referral to the treatment centre and tumour resection of more than 62 days. Outcomes were evaluated by defining the 90-day mortality. Results: The median referral delay was 78 days, for treatment delay was 54 days and for definitive treatment delay was 175 days. Of the 587 patients analysed, 341 had therapeutic surgery, 17 demised within 90 days post-surgery. Longer delays and higher mortality rates were seen in the public sector and a lower socio-economic group of patients. Conclusion: The time parameters set out by the NHS and Europe were not met. There were greater delays seen in patients with lower socio-economic backgrounds and in those attending the public sector. The effect of delays on 90-day mortality is doubtful. Delays to care both outside of hospitals and in hospitals may be a point of investigation in future studies.

Challenges and Issues in Relation to COVID-19 Contact Tracing Strategy in Mahara MOH Area, Gampaha District

<strong>Introduction: </strong>COVID-19 was declared as public health emergency of international concern (PHEIC) by World Health Organization (WHO) on 30th of January 2020 as it was spreading all over the world. There was a rise in the number of cases of COVID-19 during the second wave in Sri Lanka. The epicenter was in Gampaha district. Ministry of Health embarked several strategies in preventive sector. Contact tracing is one of such strategy. <strong> </strong> <strong>Objective: </strong>To identify the challenges and issues of contact tracing in Mahara Medical Officer of Health (MOH) area in Gampaha district. <strong> </strong> <strong>Methodology: </strong>This descriptive cross-sectional study was carried out in Mahara MOH area using qualitative and quantitative methods. <strong> </strong> <strong>Results: </strong>The study revealed that a total number of 1532 cases were identified as contacts and they were subjected to Polymerase Chain Reaction (PCR) testing. The total number of positive cases was 575 out of 1532 contacts (37.5%). Mahara MOH region had a relatively higher incidence rate during the study period compared to district and national figures. <strong> </strong> <strong>Discussion: </strong>Public health staff faced many challenges during contact tracing. As contact tracing is a subjective procedure, when an index case is identified, the public health staff had to engage in various contact tracing processes during which, they faced difficulties in tracking the contacts. For example, some of them were not willing to reveal true primary contact details due to stigma and experienced that, giving false addresses added further burden to this challenging task. Recall bias had also affected contact tracing to a certain extent. <strong> </strong> <strong>Conclusion &amp; Recommendation: </strong>Increasing public awareness through continuous public education would reduce the stigma of the disease and further strengthen the contact tracing.

The Experience of Family Members in Long-Term Care Facilities During the SARS COV2 (COVID-19) Pandemic

In-person visits are one form of care support offered by family members for residents in a Long-term Care Facility (LTCF). Family member visitation may extend to close social relationships with the residential care staff, which can be important in managing care. The long-term care population has been significantly impacted by a high number of SARS-COV2 (Covid-19) cases in morbidity and mortality but, in-person visits were limited due the public health concern. This study aimed to describe the experience of family members of persons in LTCFs during the Covid-19 pandemic. We used an online survey of 34 questions. Forty-six family members were recruited through online caregiver support platforms, and 22 completed the survey. Average participant age was 57. Majority were female with high-moderate (M=3.48) Kessler psychological distress scores. Participants reported less frequent communication with their family members in LTCFs. Difficult to reach nursing staff, who were the primary contact, was a concern. Their preferred means of communication was the telephone followed by window visits; residents preference remained for in-person visits followed by telephone. Participants described a decrease in relationship closeness with staff and a decrease in confidence in the quality of care. These results, limited by sample size, offer a beginning insight into the importance of communication between the family member and nursing staff, including the contact frequency. Structural disparities such as LTCF nursing staff levels may partly explain these deficits in supporting families during the Covid-19 pandemic. Opportunities to support family members remain a needed focus of long-term care reforms.

“I’m Getting Older Too”: Challenges and Benefits Experienced by Very Old Parents and Their Children

Very old parents and their “old” children are a growing group in industrialized countries worldwide. Since most very old persons have outlived spouses and friends, their children, many of whom have reached old age themselves, are likely to become their primary social contact and to shoulder the care provision role. However, virtually nothing is known about the nature and implications of this relationship constellation. To fill this gap, the present study explored the challenges and rewards of the very old parent-child relationship. In-depth interviews were conducted with 114 parent-child dyads (parent age ≥ 90; child age ≥ 65). Narrative interview data on challenges and rewards were audiotaped, transcribed, and then systematically reviewed and coded, identifying recurrent themes and defining categories that reflected these themes. While both challenges and rewards were present, more rewards than challenges were reported overall. However, comparing parent and child perspectives revealed that the balance of challenges and rewards was less favorable for children. Narrative data further showed that the sense of burdening their children heavily weighed on at least a fourth of parents, reflecting this as a serious concern not only for children but also for parents. Challenges reported by children were often characterized by references to children’s own advanced age and health problems, and the prolonged caregiving involvement due to their parents’ longevity. Healthcare professionals, policy makers, and families should be made aware of this increasingly common phenomenon, and specific services and policies will be needed to adequately support very old adults and their families.

Häusliche Gewalt und Partnerschaftsgewalt – eine Herausforderung im Gesundheitssektor

Domestic violence evidently endangers health. Since physicians are seen as primary contact persons by victims of violence it is necessary to understand their perception of their role. 1346 of all physicians and dentists registered in 2015 with the Saxony Board of Physicians filled in a questionnaire on contact with victims, knowledge on support structures and willingness to take part on specific medical education. Frequency of contact was estimated to be low, while readiness to approach patients in case of suspicion was high. There was uncertainty about where to refer, as well as a limited level of awareness of existing support structures. Most indicated a high request in further education. In conclusion, motivation and readiness contrast with uncertainty and lack of awareness. Education focusing on key players and major network interfaces should endorse physicians in their significant role within the care and prevention system of violence.

106. Pandemic Pinch: The Impact of COVID Response on Antimicrobial Stewardship Program (ASP) Resource Allocation

BackgroundThe COVID-19 pandemic placed a strain on inpatient clinical and hospital programs due to increased patient volume and rapidly evolving data on best COVID-19 management strategies. However, the impact of the pandemic on ASPs has not been well described. MethodsWe performed a cross-sectional electronic survey of stewardship pharmacy and physician leaders in 37 hospitals within the Duke Antimicrobial Stewardship Outreach Network (DASON) (community) and Duke/UNC Health systems (academic) in April-May 2021. The survey included 60 questions related to staffing changes, use of COVID-targeted therapies, related restrictions, and medication shortages.ResultsTwenty-seven facilities responded (response rate of 73%). Pharmacy personnel was reduced in 17 (63%) facilities by an average of 16%. Impacted pharmacy personnel included the stewardship lead in 15/17 (88.2%) hospitals. Converting to remote work was rare and only reported in academic institutions (n=2, 7.4%). ASP personnel were reassigned to non-stewardship duties in 12 (44%) hospitals with only half returning to routine ASP work as of May 2021. Respondents estimated that 62% of routine ASP activities were diverted during the time of the pandemic. Non-traditional, pandemic-related ASP activities included managing multiple drug shortages, of which ventilator support medications (91%) were most common affecting patient care at 52% of facilities. Steroid and hydroxychloroquine shortages were less frequent (44% and 22%, respectively). Despite staff reductions, pharmacists often served as primary contact for remdesivir approvals either using a criteria-based checklist at dispensing or as part of a dedicated phone approval team (Figure). Most (77%) hospitals used a criteria-based pharmacist review strategy after remdesivir FDA approval. Restriction processes for other COVID-19 therapies such as tocilizumab, hydroxychloroquine, and ivermectin were reported in 64% of hospitals.Remdesivir Allocation Strategy Proportion of facilities implementing specific remdesivir allocation strategies from the time of the first US Food and Drug Administration (FDA) Emergency Use Authorization (EUA) through FDA approvalConclusionPandemic response diverted routine ASP work and has not yet returned to baseline. Despite the reduction in pharmacy personnel due to the pandemic, the ASP pharmacy lead took on a novel and critical stewardship role throughout the pandemic exemplified by their involvement in novel treatment allocation for COVID patients.Disclosures Melissa D. Johnson, PharmD, MHS, Astellas (Consultant, Grant/Research Support)Charles River Laboratories (Grant/Research Support)Cidara (Consultant)Merck & Co (Consultant, Research Grant or Support)Paratek (Consultant)Pfizer (Consultant)Scynexis (Scientific Research Study Investigator)Theratechnologies (Consultant)UpToDate (Other Financial or Material Support, Author Royalties) Sonali D. Advani, MBBS, MPH, Nothing to disclose Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties)