Thursday, September 22, 2016

Guest Post: Falls Prevention Awareness Day

- Stephen Hargarten, MD, MPH

Today is the 9th annual observation of Falls Prevention Awareness Day in the United States. Falls are the leading cause of both fatal and nonfatal injuries among older adults age 65 and over. The Centers for Disease Control and Prevention (CDC)’s latest Morbidity and Mortality Weekly Report (MMWR) article, Falls and Fall Injuries Among Adults Aged 65 Years and Over — ­­­United States, 2014 outlines the epidemiology of older adult falls, and how clinicians can use CDC’s evidence-based STEADI (Stopping Elderly Accidents, Deaths, & Injuries) initiative to help prevent them. STEADI provides tools for clinicians to use with older adult patients to screen for fall risk using three simple steps:

· Ask: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling?

· Review/Reassess/Discontinue any medications or combinations that can increase the risk of falling.

· Recommend at least 800 mg IU of vitamin D to improve bone, muscle, and nerve health in older adults.

Every hour of every day, in communities across the United States, a patient who either just fell or is a fall risk, is being evaluated by a family physician or emergency care clinician. It is critically important that clinicians in urgent and primary care settings ask, review, and recommend fall prevention strategies for older adults.

The new CDC article highlights that in 2014, over 27,000 older adults died because of falls, and 2.8 million people were treated in emergency departments (EDs) for falls-related injuries. In the same year, CDC discovered that one in four older adults reported falling, totaling almost 29 million falls, and seven million fall injuries.

Falls not only cause injuries and affect the independence of older adults—they also have an impact on the economy. The annual medical costs associated with older adult falls are estimated to be $31 billion per year. The article estimates that the older adult population will increase 55% by 2030. The incidence of falls among this growing population will continue to increase unless effective interventions like STEADI are implemented nationwide.

Older adult falls are preventable. For patients in the ED or inpatient setting, care givers need to constantly evaluate and reevaluate for fall risk. Hospital bed side rails always should be in place to avoid an unintended fall from the bed.

Clinicians can play a critical role by following STEADI’s comprehensive approach of: 1) Asking older adult patients about falls, 2) assessing gait and balance, 3) reviewing medications, 4) prescribing interventions such as strength and balance exercises, 4) and recommending least 800 mg IU of vitamin D every day to prevent falls among older adults. Because many patients do not discuss the problem with their doctor, clinicians must be vigilant about asking patients about their falls, screening for fall risk, and implementing STEADI into practice.

As we acknowledge Falls Prevention Awareness Day, I encourage you all to take a stand against falls by integrating into your daily practice: Ask, Review, and Recommend for older adults. It’s good medicine!

**

Dr. Hargarten is Chair of the CDC's National Center for Injury Prevention and Control, Board of Scientific Counselors, and Professor and Chair of the Department of Emergency Medicine and Associate Dean for the Global Health Program at the Medical College of Wisconsin.

Monday, September 19, 2016

Should family doctors treat opioid addiction?

- Jennifer Middleton, MD, MPH

The physicians in the office where I practice recently received the opportunity to train for a Drug Abuse Treatment Act (DATA) waiver for buprenorphine prescribing. A lively discussion among us ensued, with a few of us willing to be trained but the rest uncomfortable with the idea. As I've discussed this issue with others, it seems that many family physicians have strong feelings about not prescribing buprenorphine. The common argument seems to be that these often complex patients should be left to addiction specialists to treat.

Barriers cited in the medical literature to physician prescribing of buprenorphine include a lack of resources, time, and institutional support but also "mistrust of people with addiction...and [a] difficult patient population." 40% of physicians in a 2013 survey believed that buprenorphine diversion contributes to accidental overdoses and is thus dangerous to prescribe.

In the September 1 issue of AFP, though, physicians from the Robert Graham Center argue that family physicians need to be more involved in treating opioid addiction with buprenorphine. They cite a 2014 Cochrane systematic review that demonstrated buprenorphine's efficacy in treating patients with opioid addiction, and they call for policy changes to encourage more family physicians to prescribe buprenorphine. A study in the Annals of Family Medicine found that most physicians with DATA waivers were concentrated in urban areas, leaving 30 million in the U.S. without access to buprenorphine treatment; this same study also found that only 3% of family physicians had DATA waivers as of 2012.

I wrote about current recommendations for opioid use and monitoring a few months ago, and certainly family physicians have an obligation to be responsible regarding opioid prescribing. We have an obligation as a specialty, however, to consider our response to opioid addiction as well. Just under 4000 physicians in the U.S. are board certified by the American Board of Addiction Medicine, which is far insufficient to meet the needs of the estimated 2 million individuals in the U.S. currently struggling with opioid addiction.

The medical literature to date provides little guidance regarding measures to increase buprenorphine prescribing. Providing training in treating addiction during residency increased psychiatry residents' use of buprenorphine in their practices after residency; training Family Medicine residents might be similarly effective. Institutional support and adequate local mental health resources are also likely key. The AAFP recently updated their position paper on chronic pain management and opioid misuse (including a section on buprenorphine use) which includes this call to action:
[T]he AAFP challenges itself and its members at the physician, practice, community, education, and advocacy levels to address the needs of a population struggling with chronic pain and/or opioid dependence.
You can read here about how to obtain a DATA waiver. This 2006 AFP article provides information about initiating and managing buprenorphine treatment, and there's also an AFP By Topic on Substance Abuse.

Are you currently prescribing buprenorphine, or are you considering obtaining a DATA waiver to do so?

Monday, September 12, 2016

New developments in the Zika epidemic

- John E. Delzell, Jr, MD, MSPH

In her AFP Community Blog post on February 29th, Dr. Jennifer Middleton provided a great overview of the health risks associated with the Zika virus and the recommendations from the Centers for Disease Control and Prevention (CDC). To a family doctor in South Florida, the risk of Zika seems very acute, so I have been thinking about it a lot this summer. Over the past month, 40 new patients have contracted Zika from local mosquitoes. The affected area includes the popular tourist destination, Miami Beach, and an area just north of downtown Miami. The CDC has taken the historic step of recommending against travel to these two areas. The recommendation states:

· Pregnant women should not travel to these areas.
· Pregnant women and their partners living in or traveling to these areas should follow steps to prevent mosquito bites.
· Women and men who live in or traveled to these areas and who have a pregnant sex partner should use condoms to prevent infection every time they have sex or not have sex during the pregnancy.
· Effective contraception to prevent pregnancy in women and their partners who want to delay or prevent pregnancy is a key prevention strategy for Zika.
· All pregnant women in the United States should be assessed for possible Zika virus exposure and signs or symptoms of Zika during each prenatal care visit.
· Pregnant women who live in or frequently travel to these areas should be tested in the first and second trimester of pregnancy.
· Women with Zika should wait at least 8 weeks after symptoms began before trying to get pregnant, and men with Zika should wait at least 6 months after symptoms began.

Aedes aegypti mosquitoes can transmit several emerging viral infections, including chikungunya, dengue, and Zika. The Aedes aegypti female mosquito can lay up to 1,000 eggs, and they love to live indoors. Since 2014, the chikungunya virus has begun to have local transmission from infected mosquitoes in Florida and Puerto Rico. Dengue fever had a resurgence in 2013 in Florida, and so far in 2016 there have been 40 travel related cases and one case of local transmission.

Why are we seeing and hearing about these new tropical diseases now? There are several reasons that South Florida (the three-county area of Miami-Dade, Broward, and Palm Beach counties plus the Everglades and the Keys) is at high risk. The climate is tropical with daily rain and average high temperatures in the 80s most of the year, making for an ideal breeding ground for mosquitoes. People come from all over the world to enjoy the beaches in Miami and Fort Lauderdale. Finally, South Florida includes large, diverse immigrant populations from affected countries such as Haiti, the Dominican Republic, Venezuela, Brazil, and Cuba.

So how are public health officials responding to the Zika virus? In downtown Miami, there has been an aggressive ground and aerial spraying campaign to control the mosquito population. This has caused some controversy in the Miami Beach area with protests and a delay in aerial spraying. In the Florida Keys, there is an unpopular proposal to release genetically modified mosquitoes that will produce sterile offspring and (hopefully) decrease the overall mosquito population. On August 5, the U.S. Food and Drug Administration approved these modifications as posing little to no risk of harm to humans, but the project has yet to begin.

Right now preventing Zika infection consists mostly of mosquito control and avoidance, but efforts to develop a vaccine have accelerated and may only be a year or two away, as reported in a fascinating story in the New Yorker. In the meantime, it is important for family physicians to stay up to date on the latest information about the Zika virus. The Featured Content section of the AFP homepage includes other useful resources on this evolving epidemic from the American Academy of Family Physicians, the CDC, and the World Health Organization.

**

Dr. Delzell (@Ed_in_Med) is Assistant Editor at AFP and Vice President and Designated Institutional Officer of Broward Health Medical Center in Fort Lauderdale, Florida.

Monday, September 5, 2016

Raynaud phenomenon: clinical pearls

- Kenny Lin, MD, MPH

Reversible pallor of the tips of the fingers and/or toes on exposure to cold or emotional stress, known as Raynaud phenomenon, is a common manifestation of systemic lupus erythematosus (SLE) highlighted in the August 15th issue of AFP. As discussed in an earlier Photo Quiz, the differential diagnosis may include acrocyanosis, acute peripheral arterial occlusion, and frostbite. Raynaud phenomenon can be primary (idiopathic) or secondary to / associated with systemic conditions, such as SLE or systemic sclerosis/scleroderma.

Image from AFP's Photo Quiz. Get the AFP Photo Quiz app.

How can family physicians distinguish primary from secondary Raynaud phenomenon? According to a recent review in the New England Journal of Medicine, patients with primary Raynaud phenomenon typically have a younger age of onset and thumb sparing. Patients with an age of onset over 40 years and severe, frequent events are more likely to develop connective tissue disease. Although most patients with primary Raynaud phenomenon have a normal erythrocyte sedimentation rate (ESR), neither a normal ESR nor a negative antinuclear antibody titer are necessary to make the diagnosis.

If trigger avoidance does not adequately control symptoms, the BMJ Clinical Evidence Handbook and Cochrane for Clinicians concur that an effective drug treatment for primary Raynaud phenomenon is a calcium channel blocker, particularly nifedipine. Although calcium channel blockers (CCBs) reduce average frequency of attacks by 1-2 per week, they do not affect severity or physiologic measurements (e.g., finger systolic pressure or skin temperature), and can be associated with headache, flushing, tachycardia, or edema. Both BMJ and Cochrane conclude that there is a close trade-off between benefits and harms. In their Practice Pointers, Drs. Dean Seehusen and Joseph Huang recommend that "a frank discussion of the benefits and risks should take place before prescribing CCBs to patients with Raynaud phenomenon." Other less well-studied medications for Raynaud phenomenon include phosphodiesterase type 5 inhibitors, topical nitrates, fluoxetine, and losartan.

Monday, August 29, 2016

Who isn't receiving colorectal cancer screening?

- Jennifer Middleton, MD, MPH

The U.S. Preventive Services Task Force recently updated its colorectal cancer screening recommendations, affirming its prior “A” grade for adults aged 50 to 75. While screening rates in the U.S. have increased over the past decade, there is still room for improvement, especially among uninsured individuals, some minority populations, and immigrants. A 2010 systematic review found lower rates of colorectal cancer screening among Hispanic and Asian Americans, along with anyone born outside of the United States. A more recent study found even lower rates among Spanish-speaking Hispanics compared to English-speaking Hispanics. Differences in access to care only accounted for some of these disparities.

Successful strategies that increase screening rates include providing fecal occult blood tests in a manner that addresses language barriers, and providing culturally appropriate patient education materials and/or 1-on-1 contact with a nurse or health educator. Additionally, the state of Michigan partnered with a large health insurer to mail reminder cards about colorectal cancer screening, which increased uptake by 16%; in Wisconsin, providing grants for screening events in underserved communities also increased screening rates. Adding a telephone call to a reminder letter increased screening rates in New York, but telephone calls by themselves did not. Ensuring adequate physician access for minority and underserved populations also increases screening; one study found that the distribution and supply of family physicians and gastroenterologists correlates with better screening rates.

Although many practices track their overall colorectal cancer screening rates, this figure may mask variations by race, ethnicity, or foreign-born status. Recognizing screening disparities is an important first step. Trying one or more of the above interventions to improve screening rates in underserved populations with a Plan, Do, Study, Act (PDSA) cycle might then be a reasonable next course of action. There’s a recent AFP article on Colorectal Cancer Screening and Surveillance if you’d like a refresher on recommended screening methods.

Monday, August 22, 2016

Overcoming obstacles to HPV vaccination

- Kenny Lin, MD, MPH

Human papillomavirus (HPV) vaccines, which prevent infection with HPV genotypes that cause cervical, anal, vaginal, and penile cancers, are hardly new. The quadrivalent and bivalent HPV vaccines were reviewed in AFP in 2007 and 2010, respectively, and a 9-valent vaccine was approved by the U.S. Food and Drug Administration in 2014. Although long-term studies have yet to demonstrate that HPV vaccines reduce cancer rates, a recent systematic review found that introduction of the quadrivalent vaccine in 9 countries (including the U.S.) was associated with a 90% reduction in infections from the targeted genotypes and similar reductions in genital warts and high-grade cervical abnormalities. Women who receive HPV vaccine are at considerably lower risk for undergoing colposcopy and associated invasive diagnostic or therapeutic procedures.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends that all boys and girls receive the 3-dose HPV vaccine series at age 11 to 12. However, CDC data from 2014 show that only 40% of girls and 21% of boys had completed the series by age 17. In contrast, 80% of 13 to 17 year-olds had received meningococcal vaccine, and 88% had received TdaP (tetanus, diphtheria, and acellular pertussis) vaccine, which provide protection against serious, but comparably rare, infections. Earlier this year, all 69 National Cancer Institute-designated Cancer Centers released a consensus statement expressing concern about persistently low HPV vaccination rates in the U.S. compared to other countries, which they labeled a "serious public health threat."

A 2015 AFP editorial by Drs. Herbert Muncie, Jr. and Alan Lebato examined parental and physician impediments to HPV vaccination. Parents often express concerns about vaccine safety and worry that their children may be more likely to start having sex after receiving the vaccine. Family physicians can reassure parents on both of these questions:

Parental safety concerns about the HPV vaccine increased from 4.5% in 2008 to 16% in 2010, although the reported adverse effects have been minor (e.g., injection site reactions, syncope, dizziness, nausea, headache). Studies have shown that adolescents who receive the HPV vaccine do not initiate sexual activity earlier, nor is their risk of acquiring an STI increased.

In other cases, physicians have been the primary obstacles to vaccination: they are sometimes reluctant to bring up the topic of sex, they believe the vaccine is unnecessary because Pap smears will detect early cervical cancer, or they present the vaccine as "optional" or don't offer it at all. Drs. Muncie and Lebato suggested several effective strategies for improving HPV vaccination rates:

Instead of discussing the vaccine as a means of STI prevention, physicians can present it as a way to prevent cervical cancer in women and oropharyngeal cancer in men. They can mention that immunologic response is greater in younger adolescents, so earlier immunization is prudent. Physicians should encourage HPV vaccine administration at the same time that other adolescent vaccines are given. They should review immunization status at every visit, and administer the HPV vaccine at any time—including during sick visits.


An editorial in AFP's July 15th issue by Drs. Jamie Loehr and Margot Savoy provided additional tips for physicians on addressing and overcoming vaccine hesitancy in general. More immunization resources, including the latest childhood and adult immunization schedules from the ACIP, are available in AFP's Immunizations Topic Collection.