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.

Monday, October 1, 2018

Exercise for chronic back pain: tips for success

- Jennifer Middleton, MD, MPH

The article on "Mechanical Low Back Pain" in the current issue of AFP provides an overview of diagnosis and treatment for the 1 in 5 adults who suffer from low back pain. The article reminds us that NSAIDs alone work just as well as opioids, muscle relaxers, and/or oral corticosteroids. Non-pharmacologic pain relief is emphasized, with some evidence of benefit found with physical therapy, osteopathic manipulative treatment, and exercise. Patients want more than just exercise advice, though; they also want to have their experiences with both pain and exercise considered to develop personalized recommendations.

Patients want physicians to listen to their prior experiences with back pain and exercise, taking their perceived fitness ability into account when recommending exercise. They prefer plans that consider their exercise likes and dislikes. Patients also want an exercise plan that they feel they can be successful with, partially because they fear judgment from their physician if they don't improve. Validating patients' experiences with their pain, eliciting their exercise preferences, and having resources to discuss with patients may increase the likelihood of their success with a new exercise regimen.

Engaging regularly in exercise is challenging for many people, let alone someone with chronic low back pain. Simply counseling patients regarding physical activity is a critical first step, one that many patients don't ever recall hearing from their physician. Working with patients to create a tailored exercise prescription may help. Several fitness apps, as recently reviewed in FPM, also provide a wide range of motivational methods, from raising money for charity to running from simulated zombie chases.

AFP has additional resources you may find useful, including the AFP By Topic on Health Maintenance and Counseling along with patient education at familydoctor.org, where "sports and exercise at every age" is the site's current monthly focus.

Monday, September 24, 2018

Chronic insomnia: therapies to start, therapies to stop

- Kenny Lin, MD, MPH

Can't sleep? Then spend your extra awake time reading the latest installment of Implementing AHRQ Effective Care Reviews in the September 1 issue of AFP, on management of insomnia disorder in adults. This evidence review, which supported an American College of Physicians practice guideline, examined the effectiveness of behavioral therapies and medications for adults with insomnia disorder, defined as "poor sleep quality or quantity that causes distress or dysfunction and lasts for longer than three months."

The most beneficial sleep intervention overall is cognitive behavior therapy for insomnia (CBT-I), which produced sustained improvements for at least 6 months. CBT-I consists of cognitive therapy, sleep restriction and stimulus control, and sleep hygiene education. Medications that have sufficient evidence demonstrating improvement in short-term (3 months or less) sleep outcomes include eszopiclone, zolpidem, and suvorexant; there was insufficient data to evaluate benzodiazepines or over-the-counter sleep aids (diphenhydramine, doxylamine, or melatonin). For most patients, medications should not be prescribed for longer than five weeks.

Physicians commonly prescribe antipsychotics off-label to treat insomnia in older persons. The Practice Guidelines in the September 15 issue summarized a Canadian guideline for deprescribing antipsychotics for behavioral and psychological symptoms of dementia and insomnia, produced by the Deprescribing Guidelines in the Elderly Project. Due to the potential harms of these medications and the lack of evidence of benefits (a single randomized trial with 13 participants found nonsignificant differences in sleep latency in patients taking quetiapine), the guideline recommends that antipsychotics prescribed for primary or secondary insomnia in which comorbidities are under control be discontinued without tapering, regardless of treatment duration.

AFP's sister journal, FPM, recently published an article on deprescribing unnecessary medications that featured a four-step process (review current medications; identify inappropriate, unnecessary, or harmful medications; plan deprescribing with the patient; and regularly re-review medications) and links to additional resources on medication reconciliation and deprescribing. You can find more information on sleep disorders in adults in our AFP By Topic collection.

Monday, September 17, 2018

Cervical cancer screening in the age of HPV vaccination

- Jennifer Middleton, MD, MPH

A POEM (Patient-Oriented Evidence that Matters) in the current edition of AFP suggests the potential for change in cervical cancer screening practices; screening younger women only with human papillomavirus (HPV) testing, and not cytology, resulted in better identification of high grade pre-cancerous disease in individuals who have received the HPV vaccine.

This study from Australia enrolled nearly 5,000 women aged 25-64 presenting for cervical cancer screening to one of three groups: liquid-based cytology screening followed by HPV testing if abnormal, HPV screening followed by liquid-based cytology as indicated, or HPV screening followed by dual-stained cytology (staining for high-risk HPV markers) as indicated. At the time of the study, women 33 years old or younger had been eligible to receive the HPV vaccine when it was first available in Australia; in these women, both of the HPV screening groups had a higher rate of pre-cancerous disease detection than the cytology-based screening group.

The United States Preventive Services Task Force (USPSTF) currently recommends HPV screening every 5 years as an option only for women aged 30 and older along with screening every 3 years with cytology alone or screening every 5 years with cytology and HPV co-testing; they recommend discussing risks (HPV screening alone and HPV/cytology co-testing both have an increased rate of false positive screening results, while cytology alone may miss some true positives) of each method with individuals to personalize screening decisions. For women aged 21-29, the USPSTF only recommends cervical cancer screening with cytology alone every 3 years. The American College of Gynecology and Obstetrics does not allow for the option of HPV testing alone for women of any age, but otherwise their recommendations align with the USPSTF.

HPV vaccine acceptance and uptake has been quite high in Australia, with the study authors citing that 70-78% of women aged 12-17 years were fully vaccinated in 2013. In the United States, HPV vaccine uptake has been less successful; the Centers for Disease Control (CDC) estimates that half of US teens have not completed the HPV series (you can find specific data for your state using this interactive map). It's possible that this POEM's findings may not be generalizable to the US given this difference in vaccination rates, but studies have also supported the sole use of HPV screening in women who were beyond vaccination age when HPV vaccine was introduced in the US.

Regardless, HPV vaccination rates have plenty of room for improvement in the US. Barriers to increasing HPV vaccination in the US, as outlined in this 2016 AFP Community Blog post by Dr. Lin, include safety concerns and parental worry about the vaccine encouraging earlier initiation of sexual activity (it doesn't). Physicians, too, are sometimes reluctant to discuss or recommend the vaccine. Strategies to overcome these barriers include reviewing vaccinations at every visit (not just well visits) as recommended by the authors of this 2015 AFP editorial on "HPV Vaccination: Overcoming Parental and Physician Impediments." The CDC also advises physicians to recommend HPV vaccine "the same way, the same day as other vaccines." Identifying office workflow barriers, implementing previsit planning, and permitting walk-in vaccinations can help increase vaccine uptake as well. There's an AFP by Topic on Immunizations (excluding Influenza) with several other resources on discussing vaccine hesitancy and increasing vaccination rates if you'd like to read more.

Monday, September 10, 2018

Continue to Choose Wisely: updates to the AAFP Choosing Wisely recommendations

- Sarah Coles, MD and James Stevermer, MD

Providing high value, safe, and cost-effective care is the cornerstone of family medicine. However, there remains significant overutilization of low-value or even harmful care in the U.S. health care system. The American Academy of Family Physicians (AAFP) partnered with the Choosing Wisely Campaign to identify care that may be overused or misused and tackle this pressing issue. Founded in 2012 as an initiative of the American Board of Internal Medicine Foundation, the Choosing Wisely campaign collates lists of procedures and tests that add little or no value to medical care. The AAFP was one of the first organizations to participate, submitting 5 initial recommendations and a total of 15 recommendations by 2013.

Once again, the AAFP has added 5 new recommendations to the Choosing Wisely campaign. Developed by the AAFP's Commission on Health of the Public and Science, these evidence-based recommendations are based on sources such as the Cochrane Collaboration and the Agency for Healthcare Research and Quality systematic reviews. Each recommendation focuses on a practice that is either harmful or has very little supporting evidence of benefit.

Here are the new recommendations:

Don’t perform pelvic exams on asymptomatic nonpregnant women, unless necessary for guideline-appropriate screening for cervical cancer.

Screening pelvic examinations, except for the purpose of performing cervical cancer screening at recommended intervals, have not led to reduction in mortality or morbidity. Additionally, they increase costs and expose asymptomatic women to unnecessary invasive testing.

Don’t routinely recommend daily home glucose monitoring for patients who have Type 2 diabetes mellitus and are not using insulin.

Self-monitoring of blood glucose (SMBG) has no demonstrated benefit in patients with type 2 diabetes mellitus who are not on insulin or medications associated with hypoglycemia. SMBG should be reserved for patients during the titration of their medication doses or during periods of changes in patients’ diet and exercise routines.

Don’t screen for genital herpes simplex virus infection (HSV) in asymptomatic adults, including pregnant women.

Serologic testing for HSV infection has low specificity and a high false-positive rate. No confirmatory test is currently available and the serologic tests cannot determine the site of infection. Given the prevalence of the infection in the United States, the positive predictive value of the test is estimated at about 50%. A positive test can cause considerable anxiety and disruption of personal relationships.

Don’t screen for testicular cancer in asymptomatic adolescent and adult males.

There is no benefit to screening for testicular cancer due to the low incidence of disease and high cure rates of treatment, even in patients who have advanced disease. Potential harms include false-positive results, anxiety, and harms from diagnostic tests or procedures.

Don’t transfuse more than the minimum of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable patients).

Unnecessary transfusion exposes patients to potential adverse effects without any likelihood of benefit and generates additional costs.

Using tools like Choosing Wisely, family physicians can lead change and reduce unnecessary care in the US to cut costs, improve health outcomes, and limit harms. To help you put Choosing Wisely into practice, you can find the lists from the AAFP and over 80 other specialty organizations at choosingwisely.org and a search tool for primary care-relevant recommendations on the AFP website.

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Drs. Coles and Stevermer are members of the AAFP's Commission on Health of the Public and Science. Dr. Coles is also an AFP Contributing Editor and Assistant Editor, AFP Podcast.