Canadian Family Physician最新文献

Question: A 9-year-old child with elevated low-density lipoprotein cholesterol (LDL-C) levels was diagnosed with familial hypercholesterolemia (FH) and received high-intensity statin therapy, but their LDL-C levels are still elevated. What are the current recommendations for early diagnosis and treatment of FH to reduce the risk of early-onset atherosclerosis and improve long-term cardiovascular outcomes, and how safe and effective are these therapies for pediatric patients?

Answer: FH is a complex genetic disorder causing highly elevated levels of LDL-C and risk of cardiovascular disease. Any child with homozygous FH should be referred to a specialist for consultation. Monoclonal antibodies are recommended by guidelines as adjunct treatments for FH when statins are insufficient. They have been studied as treatment for adults with FH, but direct evidence for pediatric patients is limited. Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors and angiopoietin-like protein 3 (ANGPTL3) inhibitors can provide meaningful reductions in LDL-C levels when conventional therapies alone, including statins and ezetimibe, are inadequate. Evolocumab, a PCSK9 inhibitor, has demonstrated safety and efficacy in adult patients with heterozygous FH and a moderate effect in children with homozygous FH. Evinacumab, an ANGPTL3 inhibitor, has shown greater efficacy than evolocumab for treating homozygous FH in limited pediatric studies. Longer-term and larger-scale research on evolocumab and evinacumab use in children will help elucidate long-term effects.

Objective: To determine which non-clinical elements should be included in the transition-to-practice curriculum of a residency training program.

Data sources: A rapid review was conducted following Cochrane methods guidance using a predefined registered protocol. MEDLINE was searched and studies reporting on transition-to-practice curricula published in English were included. Manifest content analysis was used to identify and report the frequency with which various transition-to-practice curricular elements appeared in the literature. Grey literature, non-English studies, and those reporting on nonphysician health professionals were excluded.

Study selection: A total of 40 articles met inclusion criteria. Most (92.5%) were from North America.

Synthesis: The most common study design was a survey (42.5%), followed by focus groups (12.5%) and semistructured interviews (12.5%). The most common non-clinical themes of transition to practice were financial and administrative aspects (37.0%), followed by personal well-being and work-life balance (21.0%), career planning and professional development (16.0%), and interpersonal skills and professional behaviour (16.0%). Other topics included legal knowledge related to medical practice (6.9%) and scholarly aspects of independent practice (3.8%).

Conclusion: Medical residents face a steep learning curve as they transition to independent practice. This study identified the most frequently discussed areas of training in non-clinical transition to practice discussed in the literature. Inclusion of these ideas into a dedicated transition-to-practice curriculum could support family residents as they move into independent practice. Further research should seek to evaluate the most effective ways to teach these elements, to identify elements specific to family medicine residency, and to explore learning opportunities for early-career physicians.