Monday, November 13, 2017

Caring for patients with asthma: tools & apps

- Jennifer Middleton, MD, MPH

A recent AFP article on "Chronic Cough: Evaluation and Management" states that the prevalence of asthma in patients with chronic cough is between 24-29%. Asthma in adults can be a tricky diagnosis to make and manage, but several tools and apps can help family physicians provide excellent care to these patients.

In-office spirometry can help make the diagnosis of asthma in an adult patient with chronic cough; an obstructive pattern with an FEV1 or FVC that improves with bronchodilator challenge is highly suggestive of asthma and should then prompt an assessment of asthma severity to guide treatment. The Choosing Wisely campaign encourages physicians to "not diagnose or manage asthma without spirometry." If you'd like a refresher on interpreting spirometry, this 2014 AFP article on "A Stepwise Approach to the Interpretation of Pulmonary Function Tests" provides a helpful overview.

If your office doesn't have spirometry, however, a simple peak flow meter can still be useful in making an asthma diagnosis. A patient with as-yet-undiagnosed asthma won't know their personal best peak flow value, but apps like Calculate by QxMD or MDCalc can estimate a personal best based on your patient's age, height, and gender. If a patient with chronic cough produces a peak flow less than 80% of that predicted value, empiric treatment for asthma is reasonable pending formal outpatient pulmonary function testing.

Managing an asthma diagnosis can feel overwhelming to patients, especially given the complexities inherent in managing and monitoring symptoms. Helping patients learn how to use their medications correctly is a critical early step. A sizable proportion of asthma patients do not use their metered dose inhalers (MDIs) correctly; providing written patient education material can help, but demonstrating how to use an MDI in the office improves patients' technique even more. Monitoring symptoms and peak flow readings is also important, since teaching patients how to monitor and interpret their peak flows can reduce urgent treatment visits for asthma.

Available online tools to help physicians monitor their asthma patient population include the Interactive Asthma Action Plan available from the Agency for Healthcare Research and Quality and the Association of Clinicians for the Underserved's Asthma Clinical Support Tool. Family Practice Management has a Disease Management Toolbox for Asthma which includes flow sheets and patient self-assessment surveys. There's an AFP By Topic on Asthma highlighting AFP's best content on diagnosis and treatment along with patient education materials. Using the search box on the Community Blog (upper right hand corner of this page) will display recent posts describing new studies about asthma management and treatment. Any of these resources might be useful links to add to your AFP Favorites page.

What resources do you find helpful to diagnose and care for patients with asthma?

Monday, November 6, 2017

Do statins benefit patients at low risk of cardiovascular disease?

- Kenny Lin, MD, MPH

There has been no shortage of recent guidance on statin use for the primary prevention of cardiovascular disease (CVD). The American College of Cardiology / American Heart Association and the U.S. Preventive Services Task Force (USPSTF) disagree about the appropriate 10-year CVD event risk threshold at which clinicians should recommend statins - 7.5% and 10%, respectively - but both agree that the benefits significantly outweigh the harms. So what should clinicians make of the Medicine By the Numbers in the Nov. 1 issue of AFP, which gave a Red (no benefits) rating to statins in persons at low (less than 20% 10-year) risk of cardiovascular disease?

Dr. John Abramson calculated the numbers needed to treat (NNT) to benefit and harm based on data from the 2012 Cholesterol Treatment Trialists (CTT) meta-analysis and the USPSTF's 2016 systematic review. Excluding patients with existing cardiovascular disease or a greater than 20% 10-year CVD event risk, the results showed no statistically significant mortality benefit, but 1 in 217 persons avoided a nonfatal myocardial infarction and 1 in 313 avoided a nonfatal stroke. On the harms side of the scale, 1 in 21 persons experienced pain from muscle damage, and 1 in 204 developed diabetes mellitus as a result of taking statins. Dr. Abramson acknowledged that his conclusion of "no benefit" relied on value judgments about the importance of these harms compared with cardiovascular events prevented:

In summary, studies have found no significant overall mortality benefit with statin therapy in low-risk patients, as well as no reduction in the risk of serious illness overall and very small benefits for nonfatal heart attack and stroke. Statins also appear to cause diabetes. Although this is uncommon, diabetes may occur more often than the prevention of a heart attack or stroke in patients taking statins. ... With no mortality benefit, no reduction in serious illness, an approximately 1% chance of avoiding a nonfatal heart attack or stroke, a similar or greater chance of developing diabetes, and a one in 21 chance of muscle damage, it seems wiser to focus on lifestyle changes (such as adopting a Mediterranean diet, exercising, and not smoking) instead of cholesterol drugs in low-risk patients.

These findings are broadly consistent with a 2011 Cochrane for Clinicians that noted that because "most trials included large numbers of persons with known CVD, ... clear evidence of the effectiveness of statins to prevent a first cardiovascular event is lacking." Other Cochrane reviews have found that statins reduce all-cause mortality in patients with non-dialysis chronic kidney disease, but do not prevent dementia or cognitive decline. A previous AFP article summarized considerations for safe use of statins, which should be part of shared decision making discussions with patients when the benefits and harms are so closely balanced.

Monday, October 30, 2017

Is short-term hormone replacement therapy reasonable?

- Jennifer Middleton, MD

A recent follow-up study of the Women's Health Initiative (WHI) trial is bringing hormone replacement therapy (HRT) back into the news. The WHI aimed to demonstrate that HRT improved cardiovascular outcomes in women, but instead they found not only an increased risk of coronary artery disease (CAD) and stroke but also breast cancer and venous thromboembolism (VTE) in participants taking HRT compared to those who were not taking HRT. The WHI intervention trial was stopped due to these findings, but researchers continued following these women for the next several years. They found that all-cause mortality did not differ between groups who had and had not been taking HRT when the intervention was halted.

When the WHI intervention was halted, women with a uterus who were taking estrogen and progesterone (and their corresponding control group taking placebo) had been enrolled for a median of 5.6 years, and women without a uterus taking estrogen only (and their corresponding control group taking placebo) had been enrolled for a median of 7.2 years. Following all of these women for a median of 18 years after the intervention groups stopped taking their HRT,* the hazard ratio (HR) for all-cause mortality in the estrogen and progesterone group compared to placebo was 1.02 (95% confidence interval 0.96-1.08); for the estrogen only group compared to placebo, the HR was 1.00 (95% confidence interval 0.88-1.01). HRs for deaths due to cardiovascular disease and cancer were similarly non-significant.

Breast cancer, CAD, stroke, and VTE are all serious conditions that certainly give me pause before prescribing HRT, and I have done so for only a small number of women. That small number of women, however, have disabling symptoms from menopause, and they have been willing to accept the risk of those complications in exchange for the ability to function during the day and sleep restfully at night. It is somewhat reassuring to know that, while their risk of these complications is significant, their overall mortality risk appears to be unchanged compared to women not taking HRT.

Using HRT to prevent chronic conditions still has a D grade from the United States Preventive Services Task Force (USPSTF), and this new study won't have me rushing to prescribe HRT to women with mild to moderate menopausal symptoms. There are several safer alternatives to ameliorate hot flashes and vaginal dryness as described in this 2016 AFP article on "Hormone Therapy and Other Treatments of Menopause." If you'd like to read more, there's also an AFP By Topic on Menopause.

*Less than 4% of enrolled women reported taking HRT at some point after the WHI intervention was halted in 2002.

Monday, October 23, 2017

Can social media misuse be a downer?

- Kenny Lin, MD, MPH

As previous AFP Community Blog posts have mentioned, social media use provides several professional benefits for family physicians: it can promote one's practice and engage patients, increase the dissemination of insightful or practice changing conference findings, and amplify the voice of our specialty to advocate on public health concerns. Similarly, patients can also benefit from social media's networking and community-enhancing functions. However, social media's potential downsides include cyberbullying, which targets persons of all ages but may be particularly damaging to children, and problematic internet use / Internet gaming disorder. The American Academy of Pediatrics issued a policy statement last year on office counseling for families and children five to 18 years of age on media use.

Curbside Consultation in the October 15 issue of AFP explored the relationship between social media and mood disorders. For some persons, particularly in the millenial age group, social media misuse can cause or contribute to the anxiety-related condition "fear of missing out" (FOMO), wrote Drs. Kaitlyn Watson and David Slawson:

Viewing social media intensifies feelings of irritability, anxiety, and inadequacy. Additionally, the drive to stay in the loop can contribute to a cycle of unhealthy social media use. The more time individuals spend on social media, the more likely they are to feel that they are missing out on something, which many will then try to alleviate through more social media activity. Higher FOMO scores, as measured by a validated 10-question scale, are significantly associated with lower feelings of competence, autonomy, and connectedness with others compared with persons who do not worry about being left out.

For patients whose social media misuse is causing adverse emotional or physical symptoms, physicians can recommend any of several free or low-cost apps that help users "unplug" by limiting total social media time per day or restricting use of certain sites (e.g., Facebook, Snapchat) to specific time windows. Other suggested interventions include "changing notification settings to daily or weekly instead of instantly, developing offline relationships, committing to daily personal improvement practices (e.g., yoga, meditation, exercise), and cutting back on the number of social media formats on which the same person is followed." Finally, cognitive behavioral therapy and mindfulness exercises may also be helpful.

What has been your experience with managing symptoms of depression or anxiety linked to patients' social media use?

Monday, October 16, 2017

Interview with AFP's incoming editor-in-chief

- Jennifer Middleton, MD, MPH

On February 1, 2018, AFP will have its first new editor-in-chief in 29 years. In an interview this past week, Dr. Sumi Sexton shared some of her ideas with me about the journal's online presence (hyperlinks below are my additions):

How do AFP's online platforms (Facebook, Twitter, Community Blog, podcast, website) fit into your overall goals for the journal going forward?
I'd like to engage readers through the various platforms to generate discussion ranging from comments on various articles or AFP features to feedback on what we can do to improve.  We don't always have room to include everything we want on a topic in print, so it is nice to be able to include some of these online. I love the concept of Twitter chats, and how the most recent one on antibiotic prescribing incorporated an AFP editorial, a Cochrane for Clinicians, an AHRQ review, and was mentioned on the Community Blog. I look forward to seeing more of that.
AFP's Facebook page, Twitter feed, podcast, and Community Blog offer several different ways for readers to connect with us online, but the number of readers who engage with us on those platforms is a relatively small proportion of total AFP subscribers. How might AFP encourage more readers to connect with these platforms?
I intend to brainstorm with the AFP team on how we can enhance an article on a clinical topic through these platforms. For example, the "Diabetes Self-Management" article in the September 15 issue could be enhanced by a more personal story akin to Diary from a Week in Practice which I used to edit and dearly miss. Another example would be to provide information to family docs on what their colleagues are doing; in the September 1 issue, for example, the article on "Aseptic and Bacterial Meningitis" mentions the meningococcal type B vaccines. How many of our readers are giving this vaccine and why or why not?
In your recent AAFP news interviewyou mentioned wanting to speak with readers "in person and online to see how we can better meet their needs." How do you envision connecting with readers online? What information would you like to learn from them?
It would be interesting to see responses from readers to online polling for certain features like editorials (for example, Controversies in Family Medicine) or articles on more controversial topics (like the article and editorial on "Testosterone Therapy" in the October 1 issue). While it may take a little time to post a comment, it is easy to click on a link to answer a quick yes or no on Twitter or Facebook. In addition to knowing what our readers think about medical topics, I'd like to know how they like to receive information. How could AFP be more accessible at the point of care? Is there anything we can do to make CME through the journal easier for them?
AFP's online presence will certainly continue to grow under Dr. Sexton's leadership, and we'll keep you updated about new tools and ways to connect. In the meantime, what additions would you like to see in AFP's online content? 

Monday, October 9, 2017

Key updates in preventive services from the USPSTF

Kenny Lin, MD, MPH

In the third installment of a series that began in 2015 and continued with last year's one-page Preventive Health Care schedule, American Family Physician recently published "USPSTF Recommendations: New and Updated in 2016," authored by Deputy Editor and former U.S. Preventive Services Task Force (USPSTF) member Mark Ebell, MD, MS. Dr. Ebell's editorial summarized 15 recommendations released by the USPSTF in 2016 and provided more details about several key updates.

1) Colorectal cancer screening: "the USPSTF now recommends that physicians offer any one of seven options for colorectal cancer screening:

- Annual fecal immunochemical testing (FIT);
- Colonoscopy every 10 years;
- FIT plus fecal DNA (Cologuard) every one to three years;
- Computed tomographic colonography every five years;
- The combination of flexible sigmoidoscopy and FIT;
- Flexible sigmoidoscopy alone every five years; or
- Annual guaiac-based fecal occult blood testing."

The recommended duration of routine screening remains from ages 50-75, with selective screening advised for adults aged 76-85 years, based on the patient's overall health, prior screening history, and personal preferences.

2) Aspirin for primary prevention of cardiovascular (CV) disease and colorectal cancer: "the USPSTF now recommends aspirin use only in adults 50 to 69 years of age who have a 10-year risk of a CV event of at least 10%, are willing to take aspirin for at least 10 years, and are not at increased risk of bleeding."

3) Statins for prevention of CV disease: "Like the [2013 ACC/AHA guidelines], the USPSTF recommendations for statin use base the decision on the patient's 10-year CV risk and do not identify specific low-density lipoprotein targets. They differ from the ACC/AHA guidelines in that they give a B rating for a low- or moderate-dose statin for patients with a 10-year CV risk event of 10% or greater, but a C rating for those with a 7.5% to 10% risk."

4) Depression screening in adults: "The recommendation ... now explicitly includes pregnant and postpartum women. The Edinburgh Postnatal Depression Scale is the recommended screening tool."

5) Screening for autism spectrum disorder (ASD): "Although there have been several small clinical trials showing the benefit of treatment in children with ASD, all trials were conducted in children who were identified by parents or caregivers and who have relatively severe symptoms. The USPSTF [insufficient evidence] recommendation covers screening in asymptomatic children whose parents and teachers have not identified any concerns."

For a complete list of Task Force recommendations on clinical preventive services, family physicians can consult the USPSTF's website or the Agency for Healthcare Research and Quality's Electronic Preventive Services Selector (ePSS) tool. For easy reference, AFP and the American Academy of Family Physicians have also collected USPSTF recommendations for children, adolescents/young adults (ages 11-26), and adults (ages 18 and older).