Monday, November 12, 2018

Putting the "family" in family physicians' care of children with type 2 diabetes

- Jennifer Middleton, MD, MPH

The current issue of AFP includes a review on Type 2 Diabetes Mellitus in Children, reviewing current guidelines for screening, diagnosis, and treatment. Children with type 2 diabetes mellitus (DM2) have optimal success with their treatment regimens when their families are engaged in their care. This engagement is crucial to success with both lifestyle and pharmacologic treatments.

Improving nutrition and exercise can lower A1Cs and improve clinical outcomes in children with DM2. Physicians can guide these changes by providing dietician referrals, exercise prescriptions, and screen time limits. Just as children and adolescents with DM2 tend to be obese, their families also tend to have similarly elevated body mass indices along with "high fat intake, minimal physical activity, and a high incidence of binge eating." Encouraging the entire family to work together to improve their nutrition and exercise improves the pediatric diabetic patient's chance of success with these changes. 

Sometimes, though, engaging children and families in the office alone is insufficient. Interdisciplinary interventions, such as multi-systemic therapy led by a trained family therapist, lowers A1Cs, reduces hospitalizations, and reduces costs in children with type 1 diabetes mellitus; though these interventions have not been systematically studied in children with DM2, it seems reasonable to assume that they would be similarly effective. Interestingly, parents often under-estimate their children's health-related quality of life; it may be that these interdisciplinary interventions help younger diabetic patients better understand the severity of their disease and, consequently, increase their adherence.

Unfortunately, children initially prescribed only lifestyle change after a DM2 diagnosis rarely succeed at sustained blood sugar improvement; lifestyle measures alone only effect meaningful change in hemoglobin A1C values in 10% of pediatric DM2 patients. As such, the American Academy of Pediatrics recommends that all children be started on metformin, in addition to lifestyle counseling, at the time of diagnosis. Pairing medication taking with daily family routines significantly increases medication adherence, as does multi-systemic therapy as outlined above. Encouraging parents to adopt a more permissive parenting style may be another technique to increase adherence to both lifestyle and medication recommendations; "[y]outh with T2DM who perceive more autonomy (less parental control) in day-to-day and diabetes tasks are more likely to adhere to medication regimens." 

Working collaboratively with families and other disciplines are strengths of our specialty and can greatly benefit our younger patients with DM2. You can read more about DM2 in the AFP By Topic on Diabetes: Type 2, which includes both further reading for physicians and patient resources.

Tuesday, November 6, 2018

For mild hypertension in low-risk adults, harms of drug therapy outweigh benefits

- Kenny Lin, MD, MPH

Prior to publication of the controversial 2017 ACC/AHA clinical practice guideline, stage 1 or "mild" hypertension was defined as a systolic blood pressure of 140-159 mm Hg and/or diastolic blood pressure of 90-99 mm Hg. Although guidelines have recommended that persons with mild hypertension receive anti-hypertensive drug therapy if lifestyle modification does not lower blood pressure below 140/90, a Cochrane review found that such therapy did not reduce cardiovascular disease (CVD) events, stroke, or mortality compared to placebo. A 2015 meta-analysis that included high-risk persons (patients with diabetes and/or who had received prior antihypertensive treatment) suggested that drug therapy for mild hypertension may prevent CVD events, but others have argued that this analysis mixed apples with oranges and did not establish benefits for adults at low CVD risk.

A retrospective cohort study recently published in JAMA Internal Medicine sought to clarify the benefits and harms of drug therapy in low-risk adults with mild hypertension using data from 40,000 patients in an electronic health records database in the United Kingdom. The authors compared the outcomes of persons aged 18 to 74 with mild hypertension who were prescribed anti-hypertensive medications within 12 months of diagnosis to those in similar untreated persons. Persons with a history of CVD, left ventricular hypertrophy, atrial fibrillation, diabetes, chronic kidney disease, or a family history of premature heart disease were excluded from the study.

After a median follow-up duration of 5.8 years, there were no differences between the groups in all-cause mortality, stroke, myocardial infarction, acute coronary syndrome, or heart failure. However, the treated group had an increased risk of hypotension (number needed to harm = 41 at 10 years), syncope (NNH = 35), electrolyte abnormalities (NNH = 111), and acute kidney injury (NNH = 91).

Although ideally the findings from this observational study should be confirmed in a randomized, controlled trial, it is unlikely that a trial will ever be performed due to the large number of participants that would be needed in order to provide enough statistical power to detect a difference in mortality or rare CVD events in this population. In the meantime, the best available evidence suggests that the harms of drug therapy outweigh benefits for low-risk adults with a systolic blood pressure of 140-159 mm Hg and/or diastolic blood pressure of 90-99 mm Hg (recently redefined by the ACC/AHA as stage 2 hypertension). In these patients, family physicians and other primary care clinicians should emphasize nonpharmacologic management strategies such as a diet with a high intake of vegetables, fruits, and whole grains; moderating excessive sodium intake and alcohol consumption; and at least 150 minutes per week of moderate-intensity aerobic physical activity.

Monday, October 29, 2018

Acute Flaccid Myelitis: what family physicians should know

- Jennifer Middleton, MD, MPH

Although still quite rare, occurrences of acute flaccid myelitis (AFM), a polio-like condition that results in sudden limb weakness, have been increasing in the United States (US). Most of the affected individuals are children, and a definitive cause is not yet known. Family physicians can aid the Centers for Disease Control and Prevention (CDC)'s investigation by recognizing AFM's presentation and reporting suspected cases to their local health departments.

AFM is not a new condition, but its prevalence in the United States has been increasing, with 386 confirmed cases across 34 states since August of 2014. AFM's prevalence has been higher in the summer months during this time, but cases have been reported year-round. Patients present with sudden loss of strength in one or more limbs, with associated loss of muscle tone and reflexes. Some patients may also have facial drooping or speech changes. Urinary retention has occasionally been noted, and, rarely, some patients even experience respiratory failure. MRI of the spine reveals a gray matter lesion, and cerebrospinal fluid (CSF) typically shows excess white blood cells.

Often, a viral syndrome precedes these neurologic symptoms, but CDC researchers have yet to identify a clear etiology, viral or otherwise. Testing of affected individuals for poliovirus has consistently been negative. The increase in AFM cases does coincide with increased enterovirus D68 activity in the US, but testing in AFM patients has been inconsistent re: accompanying enterovirus infection. With no clearly identified cause, the CDC advises general prevention strategies such as hand washing and mosquito bite avoidance. Treatment for AFM is supportive, with the involvement of neurologists, physical therapists, and occupational therapists.

Physicians should promptly report any patient who presents with sudden flaccid limb weakness, regardless of lab or imaging findings; gathering information from affected individuals will be critical to identifying AFM's etiology. Family physicians can report cases by contacting their local health department and completing this patient summary form, available on the CDC website. For patients with muscle weakness that don't fit the clinical picture of AFM, this AFP article on "Evaluation of the Patient with Muscle Weakness" may be helpful. Since West Nile virus can also cause AFM, this 2016 AFP article on "Emerging Vector-Borne Diseases" may also be of interest.

Monday, October 22, 2018

PSA screening: USPSTF recommendations changed, but the evidence did not

- Kenny Lin, MD, MPH

Comparing the 2018 U.S. Preventive Services Task Force (USPSTF) recommendation statement on prostate cancer screening in the October 15th issue of AFP with its previous recommendation, the first question family physicians ought to ask is: what new evidence compelled the USPSTF to move from recommending against PSA screening in all men to determining that there was a small net benefit for screening in some men? Did another major randomized trial show a reduction in all-cause or prostate cancer-specific mortality in men invited to screening? Did other systematic reviewers re-analyze the evidence and find a mortality benefit where none previously existed? Have urologists or radiation oncologists developed new treatments for localized prostate cancer that no longer cause erectile dysfunction, urinary incontinence, or infections?

No, no, and no.

One of the Top 20 Research Studies of 2017 for Primary Care Physicians, the only U.S. trial of PSA-based screening for prostate cancer, reported that after a median followup of 15 years, there were still no differences in mortality between the two groups. In 2018, a large U.K. randomized trial of a single PSA screening also reported no effect on prostate cancer mortality after a median followup of 10 years. In both trials, more prostate cancers were diagnosed in the groups assigned to routine screening, but treating these cancers did not lead to improved health outcomes.

Last month, the authors of a 2010 Cochrane review of PSA screening (previously summarized in AFP's Cochrane for Clinicians) published an updated meta-analysis in the BMJ that incorporated the U.K. trial findings and extended followup of the U.S. and European screening trials and concluded that "at best, screening for prostate cancer leads to a small reduction in disease-specific mortality over 10 years but does not affect overall mortality." They also estimated that "for every 1000 men screened, approximately 1, 3, and 25 more men would be hospitalized for sepsis, require pads for urinary incontinence, and report erectile dysfunction, respectively." Another U.K. trial comparing active surveillance for localized prostate cancer with immediate surgery or radiation therapy found higher rates of clinical progression in the active surveillance group, but no differences in health-related quality of life or mortality.

Representing the views of American Academy of Family Physicians (AAFP), Drs. James Stevermer and Kenneth Fink explained in an editorial why "the AAFP believes that the net benefit [of PSA screening] does not justify routine screening or routinely offering shared decision making." The AAFP took the unusual step of declining to endorse the USPSTF recommendation statement and instead writing its own clinical preventive services recommendation that emphasizes the harms of routine screening. Men who bring up the topic of PSA screening should engage in shared decision-making with their physicians about the benefits and harms of screening and express a clear preference to be screened before undergoing the test.

Monday, October 15, 2018

Influenza vaccine in pregnancy decreases hospitalizations

- Jennifer Middleton, MD, MPH

According to the Centers for Disease Control and Prevention (CDC), pregnant women with influenza infection are more likely to be hospitalized than non-pregnant women of the same age. It seems intuitive that influenza vaccination would help reduce these hospitalizations, but data demonstrating as such has only been published in the last week. A large multi-center retrospective study found that influenza vaccination reduces influenza-related hospitalizations among pregnant women by 40%.

Organizations from several countries, including the CDC, comprise the Pregnancy Influenza Vaccine Effectiveness Network (PREVENT), who conducted this retrospective study that reviewed over 19,000 hospitalization records from Australia, Canada, Israel, and the western United States (US). A significant limitation to the study is that, overall, only 6% of pregnant women admitted for flu-like illness had documented influenza virus testing; among these women, 13% with confirmed influenza had been vaccinated, compared with 22% with confirmed influenza who had not been vaccinated. The authors note that vaccine uptake was low across all studied countries, with the US having the highest vaccination rates at just 50%. (The authors' findings correlate with CDC data from the 2016-17 influenza season, when 53.6% of pregnant US women were vaccinated.)

Given the many documented benefits of influenza vaccine in pregnancy, we need to improve vaccination rates. Safety concerns, especially in pregnancy, continue to be a major barrier to vaccination. The CDC has a website devoted to allaying these safety concerns that cites multiple studies demonstrating the vaccine's safety and efficacy in pregnancy. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) both also strongly recommend influenza vaccination in pregnancy; ACOG has an online fact sheet for patients as does AAFP's familydoctor.org.

Studies also cite low rates of physician recommendation as a factor in suboptimal influenza vaccination rates in pregnant women, even though physician recommendation to vaccinate correlates with higher vaccination rates. Even though many family physicians do not provide direct obstetric care, we can still work with our pregnant patients to encourage influenza vaccination. FPM has a resource describing "How to Talk to Reluctant Patients About the Flu Shot," and the latest issue of AFP includes the CDC's Advisory Committee on Immunization Practices (ACIP) update for 2018-2019. There's also an AFP By Topic on Influenza with more references and patient handouts.

Monday, October 8, 2018

Rise in congenital syphilis highlights pregnancy screening gaps

- Kenny Lin, MD, MPH

Last month, the Centers for Disease Control and Prevention (CDC) announced that the number of reported cases of congenital syphilis in the U.S. rose from 362 in 2013 to 918 in 2017, paralleling increases in syphilis infections in reproductive-age women during this time period. From 2016 to 2017, congenital syphilis cases rose from 16 to 23 per 100,000 live births. Although two-thirds of affected infants have no symptoms at birth, congenital syphilis is associated with increased neonatal mortality and a variety of early (through 48 months of age) and late complications, detailed in a previous AFP article.

The first line of prevention against congenital syphilis is screening for syphilis in all pregnant women at the first prenatal visit, a well-established standard of care that the U.S. Preventive Services Task Force (USPSTF) recently reaffirmed. Although some cases occur in infants whose mothers receive no prenatal care, about one-third of women who delivered a baby with congenital syphilis in 2016 were screened during their pregnancies.

The CDC, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists all recommend repeat syphilis screening in women at high risk for syphilis at around 28 weeks of gestation and at time of delivery. Women at high risk include those living in higher-prevalence communities or geographic areas; those living with HIV infection; those with a history of incarceration or commercial sex work; and those exposed to a sexual partner with confirmed syphilis infection. Early penicillin treatment of infected pregnant women reduces the risk of congenital syphilis.

The USPSTF has also previously recommended screening nonpregnant adults and adolescents at increased risk for syphilis infection. Higher risk groups in nonpregnant adults are similar to those in pregnant women, but also include men who have sex with men (MSM), particularly men aged 20 to 29 years, whose prevalence of primary or secondary syphilis is nearly 3 times higher than that of the general U.S. male population. Finally, the USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults at increased risk for sexually transmitted infections.