Tracey: she whips out her phone with a picture and it had one red line on it.
I'm like, that's not a positive test.
She says, but look, it's got a C next to it.
It means I have COVID.
I said, no, the C is control, not positive for COVID.
Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine,
where urgent care meets evidence.
I'm Joe Toscano, senior research editor for Emergency Medicine Practice,
and a member of the evidence-based Urgent Care editorial board.
Tracey: Hi there, and I'm Tracy Davidoff.
I'm editor in chief of Evidence-Based Urgent Care, and we're practicing
urgent care physicians with years of experience, probably too many years
of experience, on the front lines.
And for us, diagnosis is detective work and the clues are in the history,
the exam, and of course the evidence.
That thrill of solving the patient's puzzle is really
what keeps us coming back.
Joe: Each month we unpack the latest issue of evidence-based urgent care tackling
common chief complaints from presentation.
Through diagnosis to disposition, we highlight the best evidence, the key
takeaways, and the clinical pearls.
Tracey: And by the end of every episode, you'll have sharper skills, deeper
knowledge, and more sound strategies that you can use on your very next shift.
So let's dive in.
The evidence starts now.
And remember, you can always find more at www.ebmedicine.net.
Welcome everybody to this episode of Evidence-Based Urgentology
with me, Tracy Davidoff
Joe: And me Joe Toscano.
Before we get started, we have some promos to announce.
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Promo code for this is 3FREE.
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Tracey: Also, the December issue of evidence-based urgent
care and the podcast for the discussion will be on hypertension.
This is really timely because the American College of Cardiology and the
American Heart Association recently released new guidelines in August,
and the next issue and the Urgentology podcast will cover all you need to know
about the key changes, specifically about lowered blood pressure targets,
earlier intervention, and an increased focus on lifestyle modifications.
Joe: That sounds cool.
Well, right now let's discuss the November issue titled laboratory
testing and urgent care best practices for choosing and interpreting
respiratory and genital urinary tests.
We're actually here in person with the authors, Chris Chao and Joe Hwang to
discuss some of the important points.
Chris works as a physician and medical director at WakeMed in Raleigh, North
Carolina, and Joe works as a PA at a proxy urgent care in Madison, Alabama as well.
He is laboratory director at Urgent Care of Oconee in Athens, Georgia, and he's
also adjunct faculty member at Mercer University and South College in Atlanta.
So let's get into it.
Tracey: Awesome.
Yeah, this is so great to do it live.
We did this once about a year ago, and we just had so much fun doing
it, and I'm really looking forward to chatting with some of my friends
about this issue, which I think was just really spectacular and I hope
everybody really digs into the article.
I've had a lot of people that have told me that, what do you mean a test
is not just positive and negative?
I have to interpret it.
I mean, it is positive and negative, right?
No, it's not.
And you really need to know how to interpret these tests and this issue
really kind of digs into that and teaches you how to interpret tests.
So guys, we know from your discussion that molecular testing is more
sensitive than antigen testing.
But we have to acknowledge that those tests are definitely more expensive.
So we have to factor that into any analysis about the pros and cons
of which tests you're gonna use.
But are there any reasons why a clinician would not want to use a molecular
test over an antigen test every time?
And are there times where for the clinician decision making and accuracy
that an antigen test might actually be preferred over a molecular test?
And let's start with Chris.
Chris: Well, I think first of all, Tracy and Joe, we have to consider
that for the end user, they may not have a choice between whether or not
they choose antigen or molecular test.
Tracey: True.
Chris: If you're working at an urgent care center, that
decision's often made for you.
You have to test at hand, but if you do have a choice, we do know that
molecular test is more sensitive.
It's more sensitive in that it can pick up disease states earlier than antigen test.
But one of the drawbacks of the molecular test.
It's called a post-test residual.
We know that from COVID-19, that testing someone with a molecular
test can be positive for months after the acute infection.
Every disease state has a post-test positive phase, and it is very
interesting to see that some are shorter and some are longer.
In terms of accuracy and clinical decision making, you have to realize
when is an antigen test good enough?
There are clinical disease states where antigen test is probably good enough.
The example of that would be an antigen test for strep, in an adult population
over 18, or in children under three.
But there are also disease states where antigen test is almost never appropriate.
For example, an antigen test for RSV just does not hit the detection
thresholds in an adult population.
Therefore the molecular test is really the only test that's
gonna give you a reliable result.
Joe, do you have anything else to add?
Joe Wong: Just from a workflow perspective, generally, antigen tests are
a little bit faster than molecular tests.
Although as molecular tests get better and better, that turnaround time decreases.
So if you have the option to do both, you know, you've gotta consider during busy
season if you're trying to get patients in and out, is that increased turnaround
time worth it for molecular tests?
Chris: Yeah and one other thing too is that antigen tests are often standalone.
They're lateral flow tests, so you just pull it out of a cartridge, put
the test, in , you get a result.
Whereas a molecular test generally has to have interpretive reader and amplification
platform or amplification technique.
So it is definitely much more robust.
You can have antigen tests, you can just pull it out and run it
without electricity, without any other technology, and that is a
consideration where you're looking at antigen tests versus molecular test..
Joe: Great points.
Tracey: Awesome.
Joe: You know, The clinical pathways in this issue were great.
In the one for STIs, there's a decision branch for patients who
are asymptomatic, are worried.
Well, I think clinicians may wonder why we shouldn't just test for
everything if someone has general concerns, you guys appropriately
recommend using sexual history and risk factors to guide the workup.
Can you elaborate on that?
Joe Wong: Sure.
So absolutely we get a lot of patients come in and they just
want to be tested for everything.
We hear that a lot and I think as clinicians we really need to help
guide the patients into what's actually needed and what's not.
So inappropriate testing, over testing and picking up things that are not
pathologic, can lead to overtreatment and really confusing, especially in
the urgent care setting where you're not always following your own patient.
Sometimes you're picking up someone else's results and you can
only go off their clinical note.
So, appropriate testing at the onset is very, very important.
So, generally as far as asymptomatic presentation, if there is a
known exposure, that's kind of generally where I'll start with.
And kind of the most common testing here is gonna be gonorrhea,
chlamydia, and trichomonas.
A lot of those tests are bundled together.
Depending on the patient's history and risk factors it's
gonna also guide your specimen.
So if there's been history, potential of oral sex that we want to consider swabbing
the pharynx if you're not gonna pick that up on just a vaginal or a urine specimen.
So asking the appropriate questions, getting a good HPI and Rs and
really having that discussion can help guide the initial testing.
I think some of the important things to keep in mind are,
bacterial vaginosis, these pathogens potentially that could be normal.
And if there's not any symptoms, there's no fishy odor, there's no vaginal itching,
irritation, and you just test a bunch of people, you're gonna get positives.
And what do you do with that?
We don't wanna put everybody on metronidazole if they're asymptomatic.
And so again, having that conversation upfront, knowing what the symptoms
are, if there are any, and directing the initial test is very important.
Chris: Yeah, I think to add on to what Joe said.
Everything about testing is assessing the pretest probability
and the predictive value.
Your approach is going to be different if someone is truly asymptomatic
exposure with low risk versus someone who is symptomatic with exposure,
because regardless of what the test shows, if it's a send out test,
you don't have immediate results.
There's a difference between whether or not you want to empirically treat
the patient with antibiotics or if you want to basically wait for the test.
Also, depending on what type of kind of testing platform we do.
For example, in a female patient, we know that urine GC and chlamydia
testing are going to be less sensitive than a swab molecular test.
And if the patient is truly asymptomatic, pretest probability is gonna be
different than someone who's symptomatic.
And that helps guide test selection as well as interpreting the test
in terms of predictive value.
This may have been in the article, I just can't remember.
I used the term spray and pray.
The worst thing you can do is when someone comes in and
says, Hey, I want STI testing.
I need to know their risk.
I need to know what to test them for.
And there is a whole litany of tests that we can run.
The ones that are particularly problematic or could be ureaplasma
and mgen mycoplasm genitalium, because the interpretation of a positive
test is very, very, very difficult.
If you just blast test out and test everything, you're gonna get
positive test results that may not be clinically significant, and it's
gonna actually be a problem if we have to explain that to the patient.
Joe Wong: I got one more thing here.
Some of our clinics are using different labs that have preset panels, right?
And so if you order a vaginitis panel, it's gonna be different
depending on which lab you use.
Some of them it's just gonna be BV and yeast.
Other of those are going to include ureaplasma and mycoplasma, where that's
not an appropriate test off at the onset.
So initially when we brought on a lab, we saw a lot of these vaginitis
panels being ordered, and a lot of people receiving doxycycline because
clinicians just weren't used to seeing a name of a pathogen on a panel.
When they see something that's there it's not gonna tell you that it's normal flora.
And they're going to usually go throw an antibiotic at it.
Yeah.
Tracey: Yeah.
That happens a lot.
I mean, you really gotta know what you're testing for and
how to interpret the results.
Again, it's not just positive or negative.
It does require some degree of interpretation, which people
really need to be aware of.
Chris: Tracy, the other thing too is that once upon a time, some urgent
cares would not do asymptomatic screening, and what we found out is
that patients would lie, oh, I'm sorry.
We don't do asymptomatic screening.
Well, I'm having discharge.
Tracey: Yeah.
Chris: Okay, so from a medical director standpoint, instead of basically trying
to define, do you do asymptomatic screening or is it diagnostic?
I just want the patient to be very truthful with me.
What is your worry?
What is your pre-test risk?
'Cause that greatly affects how I implement testing, what tests I use, and
whether or not do an empiric treatment.
Tracey: Definitely.
Definitely.
All right, so let's shift a little bit.
We're seeing all sorts of home tests.
It seems like they're popping up every day.
You can actually buy a test for GC and chlamydia on Amazon these
days, which is kind of ridiculous.
This kind of seemed to start with COVID when they initially started doing COVID
home testing, which was kind of a game changer with how we dealt with COVID.
And also recently we have some influenza home testing and similar, there's
home tests and results for UTIs.
We're even seeing this, like I said, the send out test for the GC and
chlamydia and the send out blood sticks for herpes and other STIs.
How should patients coming in with positive tests of things that they've
done at home and wanting to be treated, how should you handle that?
Do you retest them?
Do you go back to whatever their result is?
Do you just start all over again with an h and p and deal with it from there?
How do we understand the sensitivity and specificity of all these home tests?
This is just, an incredibly loaded question, so go ahead.
Have at it.
Chris: Well, it's a loaded question, but it's a very fair question.
Tracey: Yeah.
Chris: We are seeing a lot of home tests and home testing options.
I think there's a couple of comments I'd like to make.
Just because a test is offered by a CLIA accredited lab doesn't mean
that they're doing a good test.
In fact, some of these testing centers will test for things that are
clinically irrelevant and then you're the one that has to deal with it.
Let's start with the simplest situations.
If someone comes in with a positive COVID test, they have COVID.
Okay?
That's easy peasy.
You do not need to repeat the test.
Same with flu.
If the flu home test is positive, then they have flu.
Tracey: I have one caveat to that though.
I make the patients show me the, on their phone.
'Cause they all take pictures of it, right?
So I make them show me on the phone because a lot of times they
don't interpret it correctly.
I had one lady the other day, not too long ago that she's like, but there was a,
and my nurse went and tested her anyway, even though she had a positive test.
I tell 'em not to, 'cause what am I gonna do?
Tell you no, you don't have COVID.
When you had a positive home test.
But anyway, so I said you're negative here.
And the lady says, well, that's not possible.
'cause I was positive at home, see?
and she whips out her phone with a picture and it had one red line on it.
I'm like, that's not a positive test.
She says, but look, it's got a C next to it.
It means I have COVID.
I said, no, the C is control, not positive for COVID.
So, confirm that positive test at home before you jump all over that.
Chris: No, absolutely.
In fact, when we were looking at occupational health and certifying people
with COVID, one of the requirements was you had to have a picture of the test with
the date written on it and attest to it.
But generally, I think if someone comes in with a positive COVID test or positive
flu test and have symptoms consistent with the disease, it's gonna be very,
very, very hard for me to basically say, no, this is probably invalid.
You really do have to look at the epidemiological distribution of
what's going around in your community.
I mean, if COVID is prevalent, you probably don't even need
a test to call it COVID.
But I understand that we are in the world where patients want testing,
and clinicians want testing.
I do have a little bit more of a issue with finger sticks and having blood
samples sent for other tests like herpes and other pathogens, because some of those
you just don't know how to interpret.
You don't know the context, you don't know the laboratory.
You don't know what was actually done.
And so the question is, do you retest?
you can't answer that as a yes or no.
It's gonna have to be based on the clinical situation, based on what
the patient is coming in for and what the potential treatment options are.
Joe Wong: Sure.
I think there's sometimes in my clinic where especially in busy seasons, the
patients get swabbed before I see them.
The time as clinician.
Yeah.
And sometimes it will it'll be different than their home tests, positive
home tests negative in the clinic.
I do have a little bit of conversation with the patient about how they did
the test, how long did it sit for?
Did it sit overnight?
Is there some backflow in that lateral assay that's causing a false positive.
But in general, the specificity of these tests is pretty high . And
sensitivity might be a little less, but overall a positive is if it's
consistent with clinical symptoms.
I agree with Chris And no need to retest.
Yeah.
Chris: Yeah, I think the key point is positive is generally valid.
It's the negative test of the home tests that are the problem, because
those are the ones where they could be a false negative or the swab was done
incorrectly, or the actual test was performed incorrectly but I do think
that as we see more and more home testing options, including laboratory options,
the urgent care clinician is going to have to face more and more of these
decisions, ultimately go back to basics.
Take the history.
Understand what the test is trying to achieve diagnostically and
make a decision with the patient.
Joe: Yeah.
Yeah.
It's almost like you have to go back to square one and do the h and p that
wasn't done prior to the person doing their own test and then put it together
with the results to, to figure out, like you said, Interpreting a positive test.
Most people don't worry about interpreting positive tests.
A positive test is positive, but there are times where you don't
necessarily treat a positive test.
so
Hey in the issue you talked about, and we'll talk about herpes again,
I guess as a specific example the kind of problems with interpreting
serologic testing for herpes.
And that's also one of those send out tests.
What's the best approach for diagnosing this infection?
You have a good algorithm in there.
If you could summarize it.
Joe Wong: Sure.
Typically herpes simplex is a clinical diagnosis.
It's not like we're unroofing every single one of these vesicles and sending
it off for molecular confirmation.
Um, So generally yeah, if there's a vesicle there, it is clear, then
you go ahead and treat with your antiviral if that's appropriate.
As far as confirmation testing goes the best way is to, if there's
active lesion there, unroof it, swab that vesicular fluid, send it
off, that is the best way to do it.
Some of these labs have actually taken off some of the serologies,
particularly IGM because it's just not a good test in the acute phase.
It doesn't show up quickly.
There's confusion and interference between type one and type two.
So it's just not a great test.
Some of them don't even offer it anymore.
We get a lot of patients that want serologic testing for HSV just to see
if they're positive, and it kind of goes back to the I want be tested for
everything, or my partner has herpes.
I I need to be tested.
You ask them, well, have you ever had an outbreak before uh, cold sore genital
lesions that look like little pimples?
And the answer is no.
What do you do with that test result?
I mean, if it comes back positive there's a risk of a false positive,
there's a chance that they're exposed to it sometime in the past.
But that doesn't necessarily mean they'll ever have an
outbreak or ever need treatment.
So it just makes it really confusing for the patient.
A negative test could also provide false assurance that they don't have
it or haven't been exposed to it.
So, serology testing I'm not a big fan of, I don't really bring
this up with most patients.
If they do bring it up, I'll have that conversation with them and try to dissuade
them generally from testing for that.
I think the one exception would be if there's been recent vesicular
lesions that have fully resolved.
Then we can talk about IgG testing for HSV.
Chris: Actually, Joe, I'm gonna double down and actually go a
little bit stronger on that.
I think serology testing for herpes simplex is inappropriate for urgent care.
Absolutely.
And there's several reasons why the readers and what the listeners really need
to let it sink in is that for HSV one, there is a significant percentage of the
population that will have antibodies to HSV one and a less significant population
with HSV two, but it's not insignificant.
It's like 16% globally, so that means one outta six patients who go test positive.
It never fails that at least one or two times a month, we get a patient come
into urgent care saying, well, I got herpes testing and it says I'm positive.
What does this mean?
Because they went to a testing center, they got the result, and
they now test IgG HSV one positive.
And they're like, what does this mean?
And hey it's, good for us because that's a really easy visit.
You ask, well, what do you tell the patient?
I just explained to them what I just said.
Yeah that just simply means that we have detected antibodies to HSV one.
Well, what does that mean?
Does that mean that I'm gonna have a future outbreak?
Well, I can't tell you if it's gonna be in the oral area or if
it's gonna be in a genital area, but you may never get a lesion.
Ever.
And so it kind of goes back to the earlier question that you guys asked.
Is there ever a test that is a potentially bad test?
Do you just test for everything?
Well, if you know how to interpret this and explain this to the patient,
then I think that's one thing.
But some of these labs will just run to test at the whim and then
it's like, go figure it out.
That's no bueno.
Tracey: Yeah.
I just wanna add the other thing.
You know, The HSV one versus HSV two, I mean, there was a time, whereas if you
had HSV one that meant you had a cold sore and it was herpes labialis, and if
you had two, it meant you had genitalia.
We can't say that anymore, because of.
You know, Sexual practices over the years, one and two doesn't mean anything.
You know it's a clinical diagnosis.
If you have it on your lip, you have herpes labialis.
If you have it in your genitals, it's herpes genitalia, so you can't
really go by the herpes one and two.
And I hear people all the time, telling people that, oh, it's
just a cold sore 'cause it's one, no, that's not the case anymore.
You can't say that anymore.
I think our listeners need to know that
. Chris: Yeah.
Joe.
Hit it right on the spot where he says.
Really the test that you deroof the lesion.
Yeah.
You send it for molecular NAA.
Right.
That is really the only appropriate test in urgent care.
Tracey: I tell people, you know, if you have no lesions, I can't test you.
And that's it.
Right there,
Joe: concur.
Yeah.
And for the purposes of treatment, you're only gonna really, unless you're
talking about prophylaxis, which takes more than a test result, you're only
gonna treat active disease anyway.
People have all these questions about what their results are and
who'd they get it from, which is even harder thing to figure out sometimes.
But yeah, the treatment part of it requires active disease and
sometimes you can't even wait for the test results to come back
'cause you wanna start treatment.
If you make the clinical diagnosis, the test result would confirm
it, but you're still gonna treat based on your clinical diagnosis.
Yeah.
Tracey: All right.
Let's shift gears a little bit and let's start talking about
some PCR testing for strep.
You know, Traditionally we were all using antigen tests, which, honestly
I think is probably still good enough.
The sensitivity and specificity on that is high enough.
But you know, now we have the PCR testing.
So what happens if you think that somebody has a clinical concern for strep
pharyngitis and you're kind of surprised that your antigen comes back negative.
Can you walk through the process of, you know, should we do
PCR, should we do culture?
Or how should we do that?
And should we do that for everybody or should we just do that for kids?
does the h and p factor into any of that?
Chris: actually, Tracy, the historical gold standard was culture.
Of course.
It wasn't until we actually had antigen tests that we started
having a point of care solution
Tracey: kind of scary, but I remember that and so does Joe.
Chris: Sure.
Oh, come on.
You guys are showing your age now.
Yeah, we are.
Definitely.
Yeah.
The nice thing is the listeners can't tell our age, but you guys just outed yourself.
There you go.
Yeah, so, so I think that strep is actually very interesting because.
I'm gonna say a few things that may shock some of our listeners
that at the end of the day, most strep is a self-limited disease.
Tracey: Absolutely.
Chris: And the two primary reasons why we treat for strep is one to
prevent non suppurate of complications.
Specifically acute rheumatic fever that in the 1920s, rheumatic fever
and strep was actually leading cause of morbidity and mortality.
And once we had widespread use of penicillin and antibiotics, we
started noticing a significant drop in the rate of rheumatic fever.
Now, there are several reasons why we think that is, and that one of
the primary ones is that strep has various variants, and that over time
we have selected out the strep that is much more tolerant, which is why
we're seeing more colonizations.
And that the strep that actually causes rheumatic fever is not circulating or is
very rare, at least in the United States.
So the question then goes to why is an antigen test good
enough for certain populations and why is antigen test require
confirmation for other populations?
And it all boils down to what is the population that is at the
highest risk for rheumatic fever, and that is ages three to 18.
And that is the specific population where a confirmation test is recommended.
Now, if you have an adult who has strep, there are some very special cases.
We may have touched it in the article, but we didn't really elaborate.
If you have a patient that has a history of rheumatic fever, if you have
a patient that has come from an area where rheumatic fever is endemic, okay.
If you have a patient that is significantly or severely
immunocompromised, those are some of the special circumstances where
even in an adult, an antigen test may need confirmation testing.
So the other thing that we need to keep in mind is that IDSA pulled
a little bit of a surprise on us, specifically in mid-October, right after
our article had gone to peer review.
And in validation, they basically made it a recommendation to use clinical decision
trees as a factor into who should test.
The previous recommendation was test everyone with pharyngitis unless there's
overt evidence of viral infection.
Joe Wong: Again, we see patients with sore throat a lot and even
a lot of them come in with tonsil or hypertrophy and exudates.
They even might have that strep smell and comes back as negative.
With the increasing popularity of molecular testing, I'm not saying
that we need to do molecular testing in any of the cases in fact in
the article the recommendation is just to look at group A strep.
But every now and then you get, you know, some other people
who order a pharyngitis panel.
And I think in school a lot of times we're taught, if it's tonsil exudates
and strep negative, think about mono.
We're seeing a lot more adenovirus and rhinovirus causing these
tonsil hypertrophy and exudates lymphadenopathy than Epstein Barr virus.
And so, again, following the guidelines.
American Academy of Pediatrics, uh, CDC guidelines, three to 18 years
old with a negative rapid strep.
Get a group a strep culture in with the exceptions that Chris talked about.
Everybody else we can treat it as a viral infection and they're
gonna be a self-limited condition.
Chris: Yeah I think what we need to pay attention to is that the
vast majority of pharyngitis or sore throat is not caused by strep.
And some of this may actually be a function of the widespread development
of molecular testing so that we now can start looking to see what is
actually causing the pharyngitis.
So it, it just is very interesting because there's a lot more to
strep and it's probably worthy of a greater discussion in the future.
Tracey: All right, so we got one more question.
Let's talk about test of cure.
I don't think we're used to doing those and we shouldn't really have
to for most infections, but usually recovering from disease is really good
enough but what infections require test of cure and what you do if
somebody asks you for a test of cure.
Joe Wong: sure.
Primarily this is gonna be in the setting of sexually transmitted infections.
So test of cure for gonorrhea, chlamydia primarily.
And generally if you're giving the first line treatment and patients are recovered,
you don't need a test of cure . if for some reason they couldn't take first line
treatment, if they got second or third line treatment, maybe there's concern that
they didn't finish out the full course.
Or that they're still having symptoms, then you would do a test of cure.
And generally that's gonna be done about four weeks after
the initial onset of treatment.
I think the one exception that we mentioned in the article that would
get tested a little bit sooner is gonna be your gonococcal pharyngitis.
Antibiotics in that area of the body are not as potent and it's
a little bit harder to treat.
So there's higher failure rates with treating gonoccocal pharyngitis
and the recommendation's seven to 14 days, a preference for 14 days
as far as test of cure for that.
Just because of the potential for a molecular test being so sensitive that
it's picking up dead bits of bacteria.
Chris: Joe, I think it's very interesting that we think of test of cure as being
STIs, but I assure you that in urgent care we see patients come in for test of
cure for probably everything, including strep, including flu, including COVID.
What I'd like the listeners to really keep in mind is that there's always
going to be a period of time when a test is gonna remain positive, even
though the patient may be cured, or if the patient is non-infectious.
It's gonna be much more lengthy with a molecular test.
But even an antigen test can persist positive even past an infectious state.
In terms of test of cures, it really is a conversation to have with the patient.
Why are you interested in test a cure?
What are your concerns?
Usually a patient is gonna want to test a cure because they don't feel
like they're a hundred percent better or because they want to make sure,
like in STDs, that they are clear to be intimate with their partner.
So there are certain disease states where a test of cure is not recommended.
There's certain disease states where a test of cure is recommended and Joe
mentioned the oropharyngeal gonorrhea as one that is definitely recommended.
Joe Wong: That is an interesting point that now we're in respiratory
season, it usually is the patient that's coming in wanting to visit
a family member who's high risk.
Should I get a negative test before I go?
And then you just get into this gray area.
I mean, just because you're negative doesn't mean you're
still not contagious anymore.
Remember it's gonna be dependent on how good of a swab you got on the viral load.
And again, antigen tests not as sensitive.
The molecular of the test is gonna be tricky to interpret also, because it's
gonna be persistent, false positive for a longer time down the end.
So again, it's that conversation of helping patients kind of understand
what the testing is for, the pros and cons, and then, in those specific cases,
making a patient provider decision on testing negative before seeing,
their grandmother who's got several comorbidities that's at high risk.
Chris: Joe, that's a really, really, really good point.
'cause we see patients come in, generally he's right.
People come in for test of cure because they wanna make sure
they're okay to go back to work.
They're okay to go see grandma, they're okay.
And some employers actually require a test of cure before they allow
someone to come back to work.
Joe: Still still doing that.
Oh yeah.
Chris: Still do.
I've had a few, yeah.
Still do.
Joe: Yeah.
Chris: And so it is education, but also recognizing what the best practices,
guidelines for return to work?
For most upper respiratory viral illnesses, it's gonna be fever free plus
symptom improvement, minimum three days.
But that doesn't mean that for something like hand foot mouth
disease, you can shed virus for longer.
So it is a conversation that weighs in what is the ultimate risk that the
patient has and what is the situation that the patient wants to test of cure.
Tracey: Good point.
Yeah.
Alright.
That was a fantastic discussion.
Thank you guys.
Again, this article is fantastic and anybody who doesn't subscribe, please do
so that you can read this article because it really, it takes your interpretation
of testing to the next level.
I certainly learned something from it and I think my practice has
definitely improved after reading it.
So I strongly suggest that you read the article.
Joe: Yeah, definitely.
You guys are acknowledged, experts on this.
It was great To have you write the article and a real pleasure to speak with you.
Thanks very much.
Thank you so much for coming.
I add
Chris: one, one closing comment.
Sure, of course.
keep in mind that the technology of testing changes rapidly.
Tracey: Good point.
Chris: And one of the biggest asks that I have is that in some of my
previous talks, I said, please keep up to date by subscribing to a resource
like evidence-based urgent care or whatever resource you want to do,
because relying on outdated information is going to lead to poor results.
It changes so rapidly because if you took a time warp and went back 20
years ago, the standard of care for chlamydia and gonorrhea was culture.
Okay.
Yeah.
Well there was
Tracey: nothing for chlamydia.
Yeah.
There,
Chris: there was nothing.
Tracey: If the gonorrhea was negative, it must be chlamydia.
You treat it
Chris: And molecular testing has been a game changer.
Yeah.
Now is molecular tests always gonna be this gold standard or standard of care?
There is newer technology that's out there.
Some of it hasn't been proven using ai, photo detection,
using host-based diagnostics.
These are technologies that are evolving.
And it is absolutely critical that as a clinician, you keep up to date with
this because otherwise you're gonna be using outdated information and
potentially not following best practices.
Tracey: So true.
And that's not just for testing, too, that's treatment as well.
Joe: Fantastic.
Well, thanks everyone.
Tracey: Yeah.
So next time we got uh, hypertension.
Hypertension, which is really awesome.
And then January is gonna be motor vehicle accidents written
by um, Shelly Jansen, which I've.
I've had a peek at it, believe it or not.
And it's really phenomenal and fantastic.
So we got some really good stuff coming down the pike.
Stuff that, we all need to know as urgent care clinicians and that
we could definitely use some help doing a little bit better at.
So look forward to those.
Joe: Alright, take care everyone.
Yeah.
Thanks for having Happy holidays.
Bye bye-Bye bye.
Tracey: I want to thank everybody to listening to this month's evidence based
urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net
and read the full issue if you want more information, if you haven't already,
Joe: And if you're not a subscriber head to the site.
That's ebmedicine.net to check out what they have.
If you subscribe you'll get access to the article as well as future articles
and the whole archive of all past issues.
Tracey: Look forward to seeing you there.