First, do no harm: preventing elective inductions before 39 weeks

A recent article published in the Journal of the American Board of Family Medicine reported that fewer than 1 in 5 board-certified family physicians provide routine prenatal care, and just over 13 percent perform deliveries. Therefore, more family physicians are referring patients for maternity care and have less influence over troubling national trends, such as declining rates of vaginal births after previous Cesarean delivery (VBAC) and increasing rates of "late" premature delivery (between 34 and 38 6/7ths weeks gestation) due for the most part to elective inductions.

In an editorial in the December 15th issue of AFP, Drs. Michael Cacciatore and D. Ashley Hill argue that the preponderance of evidence demonstrates that infants delivered before 39 weeks gestation without a medical indication have worse outcomes than those delivered closer to term:

The baseline neonatal intensive care unit (NICU) admission rate at 39 weeks was 2.6 percent, but this rate nearly doubled for each week before 38 weeks. Another group analyzed 13,258 elective cesarean deliveries, of which 35.8 percent were performed before 39 weeks, and found that infants born before 39 weeks had a significantly increased risk of adverse outcomes. Notably, this was also true for the neonates born at 38 weeks. A retrospective review of almost 180,000 births showed that the risk of severe respiratory distress syndrome was 22.5-fold higher for neonates born at 37 weeks and 7.5-fold higher for infants born at 38 weeks compared with those born at or after 39 weeks. The risk of an early term neonate being admitted to the NICU is approximately one in 20 deliveries, compared with about one in 50 for neonates born between 39 and 40 weeks.

If elective inductions before 39 weeks gestation are apparently harmful, why are so many patients consenting to them? The authors point to a variety of reasons, including lack of knowledge, maternal discomfort, convenience, and patient and physician preference. To improve pregnancy outcomes, they recommend the universal adoption of several health system interventions shown to prevent early elective inductions. In addition, family physicians and other primary care clinicians who do not provide maternity care themselves can educate their patients and colleagues about the unnecessary harms that may result from this practice.

Screening mammography decisions are close calls

A physician reader of AFP submitted the following post.

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I read with interest the December 1st Cochrane for Clinicians article by Dr. Joanne Wilkinson, "Effect of Mammography on Breast Cancer Mortality." On the first page of the article in big print is the "Evidence-Based Answer," which gives a SORT "A" recommendation in favor of mammography because of an approximate 15% reduction in mortality from breast cancer attributed to mammography screening. In small print inside are the conclusions from the Cochrane abstract, which note a 30% rate of overdiagnosis and overtreatment. The Cochrane authors write:

This means that for every 2,000 women invited for screening over 10 years, one will have her life prolonged, and 10 healthy women who would not have been diagnosed if there had not been screening will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false-positive findings. It is not clear whether screening does more good than harm.

Having read this - I wonder how many women would continue to opt for regular mammography screening if told that only 1 out of every 2,000 will benefit, whereas 10 out of 2,000 will be overtreated (some presumably with mastectomy), and 200 out of 2,000 (10%) will be temporarily overdiagnosed (and subject to important psychological distress for many months) because of a false-positive mammography reading. Given these statistics, observers outside of the medical community might wonder why "primary care physicians should continue to recommend mammography every two years in women 50 to 74 years of age," as the last paragraph of Dr. Wilkinson's commentary states.

As in much that the primary care clinician does, there are pros and cons to any intervention. For patients to give truly informed consent, it is essential for us to convey to them the numerical chance for life-prolonging benefit (1 in 2,000 for women who undergo yearly mammography for a decade) versus the 1 in 10 risk of a falsely positive mammogram report, and the 1 in 200 risk of overtreatment during that 10-year period. For some women who subscribe to the "n of 1" theory, screening mammography may be worth the risk, effort and cost because of the chance that it may save their lives. Others may decide that the odds of experiencing benefit are not in their favor. Shouldn't the choice to undergo mammography be up to the patient?

Ken Grauer, MD
Gainesville, Florida
http://ecg-interpretation.blogspot.com/

AFP By Topic is your 24-7 virtual Scientific Assembly

Since we first introduced AFP By Topic in June 2010, this online and mobile-friendly collection of the journal's best current content selected by AFP's medical editors has grown to include 52 topics that family physicians and other primary care clinicians commonly diagnose and treat in their patients. Recently, we compared the list of AFP By Topic collections to the most popular sessions at the 2011 American Academy of Family Physicians' Scientific Assembly in Orlando, Fla. Of the clinical subjects of 13 non-plenary sessions with an attendance of at least 500 physicians, 10 regularly rank among our most widely viewed topic collections, encompassing a diverse spectrum of acute (e.g., abdominal pain, pulmonary embolism) and chronic (e.g., diabetes, kidney disease, hyperlipidemia) health conditions.

Also at the Scientific Assembly, David T. Walsworth, MD, gave a presentation titled “Medical Applications: Finding the Right App for That." In his presentation, Dr. Walsworth discussed the utility of mobile devices and tablets, including the many uses for related apps in a family physician’s day-to-day practice. Some of the criteria he uses in appraising a medical app include asking the following questions: Does the app do something that I will use frequently? Do I trust the source? and Does the value justify the cost? Ranking highly on all of these criteria, the free AFP By Topic Mobile App not only made his personal Top Ten list, but came in at number 2!

Whether you access AFP By Topic collections on the Web or your mobile device, content links are updated continually to ensure that they remain as current and as useful as possible. The collections include pertinent AFP articles and departments, summaries of practice guidelines from major medical organizations, articles from Family Practice Management, and the AAFP's METRIC practice improvement modules. In short, we aim for AFP By Topic to be your 24-7 virtual Scientific Assembly. Please let us know how we're doing.

Managing symptoms in end-of-life care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of AFP, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review's main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care. A collection of previous Cochrane for Clinicians articles is also available online.