The most popular posts from 2013

- Kenny Lin, MD, MPH

It's been a terrific year for the AFP Community Blog. Page views have exceeded 5000 every month, with a high of 6,172 in November. To put these numbers into perspective, readers visited the blog nearly as much this year as in 2010, 2011, and 2012 combined! Looking back at the top ten most-read posts of 2013, two key themes emerge: potential harms from over-the-counter drugs and supplements (acetaminophen, NSAIDs, and calcium); and questioning the benefits of preventive services (vitamin D and cancer screening, diet and exercise counseling). The most-read post of the year was viewed more than 1200 times.

1. Are IUDs a reasonable option for birth control in adolescents? (May 21)

What are your thoughts about the intrauterine device for teens? If you are recommending it, what spurred you to do so? If not, what is making you hesitate?

2. USPSTF: Diet and exercise counseling not routinely recommended (June 17)

Given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is something more than just counseling necessary to effect behavior change?

3. Pros and cons of vitamin D screening (April 29)

No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone.

4. Steroids for pharyngitis? (July 15)

One dose of a corticosteroid (either dexamethasone PO, dexamethasone IM, or prednisone PO) increased the number of patients who reported resolution of pain in twenty-four hours (number needed to treat [NNT] = 4).

5. Is routine stress testing necessary for resolved chest pain? (May 29)

Are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?

6. Are calcium supplements bad for the heart? (February 5)

Is it time to abandon routine calcium supplementation in healthy adults? If not, what additional evidence might make you change your practice?
7. Does acetaminophen help nasal congestion from the common cold? (August 12)

A lack of high-quality studies supporting efficacy isn't the same as a high-quality study showing that it doesn't work. I still recommend acetaminophen for headache, myalgias, and fever, and if it gets some of those nasal symptoms, that'd be a nice bonus.

8. Providing culturally competent health care (January 25)

The increasing diversity of the U.S. population has made it more likely that family physicians will care for many patients with cultural backgrounds, beliefs, and practices that are dissimilar to their own.

9. Why don't physicians discuss cancer screening harms? (October 29)

If the results of this survey are representative of the practices of U.S. family physicians, then more than 90 percent of us aren't telling patients that there are any downsides to undergoing routine mammograms, colonoscopies, and Pap smears.

10. Another strike against NSAIDs? (July 1)

Long-term use of all non-steroidal anti-inflammatory drugs (NSAIDs), selective COX-2 or non-selective, doubled the risk of heart failure.

JNC 8 - hypertension management may never be the same

- Jennifer Middleton, MD, MPH

The Eighth Joint National Committee (JNC 8) released its "2014 Evidence-Based Guideline For the Management of High Blood Pressure in Adults" last week.  It's been 10 years since JNC 7, and I suspect that many family docs, like myself, have been eagerly awaiting its release.

In JNC 8, a group of experts from multiple fields, including Family Medicine, sifted through the enormous evidence base regarding hypertension treatment.  Where no or low-quality evidence exists, they stated as such and made an expert recommendation.  I appreciate their transparency in indicating these instances.

The committee sought to answer these 3 questions (directly quoted from the article):

1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

And made the following recommendations (summarized by myself):

1. For adults aged 60 and older, treat blood pressure (BP) to a goal of less than 150/90.  
2. For adults 18-59, treat BP to a goal of less than 140/90.  This includes patients with diabetes and/or chronic kidney disease (CKD).
3. Initiate treatment with a thiazide diuretic, an ACE inhibitor, an ARB, or a calcium channel blocker (CCB). This includes patients with diabetes.
4. No, there were no beta blockers on that last list.  Exhaust those other classes before adding a beta blocker.  JNC 8 backs this up with solid references; here's one to whet your appetite.
5. For African-American patients, consider initiating treatment with a thiazide or a CCB.  This includes patients with diabetes.
6. Patients with CKD should be on an ACE inhibitor or ARB, regardless of race or co-morbid diseases.

It's unclear, as of yet, how widely these recommendations will be adopted.  Will the American Academy of Family Physicians endorse them?  How about the American Heart Association and/or the American College of Cardiologists?  They will likely want time to examine JNC 8 before stamping a seal of approval upon it, along with the AAFP, who thoughtfully posted an overview of the guidelines along with their plan to review them last week.

I encourage you to check out the article for yourself and draw your own conclusions.  Should JNC 8 be the new standard of care?

Guest Post: To solve rural health shortages, train more family physicians

- Robert C. Bowman, MD

Training more family physicians is the obvious solution for all of the practice locations with low physician concentrations. Across 30 states behind in graduate medical education positions, across 40,000 zip codes with lower concentrations of physicians, across 2900 counties lower in physician concentrations, and especially for rural locations in need of workforce, family physicians are the multiple times solution.

It is a matter of mathematics. As concentrations of physicians decline due to health, economics, income, and other designs, the proportion of family physicians increases. Family medicine stays relatively constant at 30 per 100,000 while other specialties follow the pattern of higher concentrations found where other specialties are more concentrated. For rural workforce or for workforce where it is needed, family medicine is a 3 times greater solution.

Comparing the 2013 version of the American Medical Association Masterfile to the 2005 version, family physicians have increased to 28% of rural physician workforce and overall numbers are steady. Internists represent 13% of rural physicians and falling. Pediatricians are 6% of rural physicians. General surgery and obstetrics-gynecology each contribute 5%, and general orthopedics 3%, but all are declining. Rural areas have very specific workforce needs for generalists and general types of specialists: fields that are poorly addressed by current training designs.

Physicians coded by county concentrations yield the same proportions of physician specialty contribution for counties with lowest concentrations or less than 150 physicians per 100,000 (27% from family medicine, 13% from internal medicine, etc.). These 2438 urban and rural counties represent 28% of the American population most left behind. Typical training designs do not work well for counties lower to lowest in physician concentrations. Will the current recommendations to train more physicians actually result in care being provided where unmet demand is greatest?

To address physician shortages, the Council on Graduate Medical Education has recommended more trainees in internal medicine, in geriatrics, in psychiatry, and in general surgery. The evidence suggests that training more residents in internal medicine or general surgery will not resolve the major problem of few graduates remaining in general internal medicine or general surgery.

In rural America, it is most commonly the family physician who provides critically needed services in internal medicine, geriatrics, pediatrics, inpatient care, women’s health, emergency care, and mental health. In 1000 counties with the greatest rural workforce challenges, about 8% of the family medicine workforce serves this 8% of the U.S. population - the half of the rural population that is most disadvantaged in key areas such as health status, health access, education, income, employment, and insurance coverage.

The solution that can best increase the number of family physicians, add value to the care given, and increase family physicians where they are most needed is also common sense. All years of preparation, all training years, and all practice years must be specific to community-engaged family practice. Family physicians should guide middle school and high school children and patients and local family practice interest group students into a future of family medicine. Recent Graham Center Policy One-Pagers in AFP have demonstrated that comprehensive medical school rural programs targeting family medicine and support for in-state family medicine residencies produce family physicians where they are most needed.

We must not lose sight of family medicine's unique contribution to rural health care. We must also not lose sight of workforce solutions arising from rural areas that can benefit most Americans who remain in need of basic health care.

**

Dr. Bowman is a North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and a long term chair of the STFM Group on Rural Health. He maintains the World of Rural Medical Education and Physician Workforce Studies web sites and blogs at Basic Health Access.

Cervical cancer screening: USPSTF and ACOG align

- Jennifer Middleton, MD, MPH

Professional societies' disagreements regarding cancer screening have dominated the medical landscape of late.  USPSTF says some women may appropriately defer breast cancer screening until age 50, while the American College of Radiography and American Cancer Society both recommend starting at age 40.  USPSTF grades prostate cancer screening a "D" (not recommended) yet the American Urological Association advises shared decision making regarding the prostate specific antigen (PSA) test with all men aged 55-69 years.  21st century media-savvy patients are aware of these differences, and discussions about screening often occupy quite a bit of my time with patients these days.

How refreshing it is, then that the American College of Obstetrics and Gynecology (ACOG)'s new cervical cancer screening guidelines align well with the USPSTF's published last year.  Last week's AFP summarized ACOG's stance nicely:

• No screening before age 21.  EVER.
• Screen every 3 years between ages 21-29 only with cytology.  (Because the rate of incidental HPV infection is so high in this age group, add HPV testing only when the pap test is abnormal.)
• Screen every 5 years between ages 30-65 with cytology and HPV.  (Alternatively, screen every 3 years with just cytology.)
• No screening after age 65 unless 1 of the last 3 pap tests was abnormal or there is a history of high-grade dysplasia.

As Dr. Lin pointed out earlier this year, screening for cancer is not a zero risk proposition, and discussing cancer screening with patients is frequently more complex than a simple directive to "get a mammogram/PSA/etc." The AFP By Topic on Cancer includes several AFP articles from the last few years summarizing the evidence for multiple types of cancer screening if you'd like further reading.

Thankfully, the sensitivity and specificity of the pap test are both quite high, making the risks of a false positive or a false negative exponentially much lower than mammography or PSA.  The jury may still be out on breast and prostate cancer screening (as for me, I follow the USPSTF's guidelines and discuss this openly with patients), but for cervical cancer screening, at least, we have consensus and clear recommendations as above.

New statin guidelines and other notable medical reversals

- Kenny Lin, MD, MPH

The recently published American College of Cardiology / American Heart Association cholesterol treatment guideline, which updates the National Heart, Lung, and Blood Institute's Adult Treatment Panel III recommendations that have guided clinicians for more than a decade, has generated controversy for several reasons: primary care groups did not participate in development of the guideline; several panelists had financial conflicts of interest; its cardiovascular risk calculator may substantially overestimate risk in certain populations; and the lowered risk threshold for prescribing medication, if adopted worldwide, could potentially result in more than a billion people taking statin drugs. American Family Physician will provide readers with concise summaries and critical analyses of the ACC/AHA guideline in future issues.

Family physicians who have grown comfortable with ATP III's "treat to target" paradigm for cholesterol management were likely surprised by the new guideline's "fire and forget" approach, which advises prescribing fixed doses of statins based on cardiovascular risk assessments and not routinely rechecking cholesterol levels. The latter approach is more consistent with the evidence from randomized controlled trials, but this change is, nonetheless, a significant reversal of an established medical practice. Although such reversals are surprisingly common, they can be unsettling to clinicians.

In an editorial in the December 1st issue of AFP, Drs. Caroline Wellbery and Rebecca McAteer review reasons for other dramatic reversals such as hormone replacement therapy and tight glucose control in diabetes, which include poor design and small size; focus on disease-oriented evidence, application of findings to nonstudy populations; unidentified harms; and economic factors. They have several related suggestions to help physicians avoid pitfalls associated with currently accepted practices that may be vulnerable to later reversal:

To minimize the dizzying impact of changing recommendations, physicians should focus on patient-oriented evidence, and not be distracted by disease-oriented evidence. Physicians should become familiar with the basic principles of good research, and avoid drawing premature conclusions from observational studies or studies with design flaws. Physicians should also recognize the pharmaceutical industry's influence on research studies and practice recommendations.

What we say to patients with low back pain matters

- Jennifer Middleton, MD, MPH

I have recommendations for patients with benign low back pain (LBP) that I have repeated many times already in my career:

"It appears to just be a problem with the muscles. I don't think that it's anything more serious than that."

"Lift with your kness, not with your back."

"The abs and low back should work together to keep you upright.  A lot of people have weak abs, so getting the abs stronger can help back pain."

I always thought that I was giving good advice, but a study from the current issue of Annals of Family Medicine suggests otherwise.  This excellent qualitative study, titled "The Enduring Impact of What Clinicians Say to People With Low Back Pain," examined how patients interpret the phrases we physicians tell them about their LBP.

The researchers and participants of this entirely qualitative study were in New Zealand.  They included patients with both chronic and acute LBP that were at least 18 years old, had never had back surgery, and spoke English.  Almost all participants had seen a family doctor for their symptoms. The researchers conducted individual face-to-face interviews, and they continued recruiting participants until the findings from these interviews reached saturation, meaning that they were hearing no new themes or information.

Physicians hear "back" and think of all of the muscles, bones, and spinal cord, but this study found that when patients hear "back," they often only think "spine."  Physician advice to protect the back by lifting with the knees or strengthening the abs gave many of this study's participants the impression that their spine was vulnerable.  Because of this perceived vulnerability, several patients limited their activities, which likely worsened their symptoms since inactivity worsens most benign LBP.  Additionally, these back protection recommendations "may result in increased vigilance, worry, frustration, and guilt" for patients.

Happily, most participants responded positively when their physicians recommended that they stay active while recovering.  Physicians' "reassurance about prognosis or safety of movement could be very powerful," stated the researchers, as long as the participants had confidence in their physician; a history and exam perceived to be perfunctory and/or continued symptoms despite following the physician's advice both underminded this confidence.

This article will change my practice.  I'll make sure, in the future, to reinforce to patients that their spinal bones and cord are okay and not at risk from damage or injury.  I'll emphasize that back protection measures are not because I think their spine is at risk but instead to help reduce occurences.

I highly recommend reading this article in its entirety, as there are several more fascinating insights that space doesn't permit me to delve into further here.  AFP also published a helpful review of evaluation and treament of acute LBP last year, and there is also an AFP By Topic on Musculoskeletal Care if you'd like further reading.

Tackling the problem of too few family physicians

- Kenny Lin, MD, MPH

Researchers at the American Academy of Family Physicians' Robert Graham Center have estimated that the U.S. will require 52,000 additional primary care physicians by 2025 due to the effects of population growth, aging, and insurance expansion. Since it takes at least eleven years of post-secondary education to train a family physician, even a renewed surge of student interest in primary care careers is unlikely to meet this anticipated need. Another recent Graham Center study concluded that expanding the scope of practice of nurse practitioners and physician assistants would still result in an overall shortage of primary care clinicians.

This month's issue of Health Affairs contains several proposals to expand the capacity of the existing primary care workforce. Scott Shipman and Christine Sinsky review effective strategies for reducing waste and improving efficiency in office practice: delegating clerical and administrative tasks, using medical assistants as work "flow managers," establishing non-physician protocols for routine chronic care and test ordering, and moving some types of acute care visits online. If each practicing primary care clinician could free up capacity to see one more patient each working day, that would translate into 30 to 40 million additional visits per year.

Another review by Jonathan Weiner and colleagues projects increases in efficiency and reductions in future demand for office visits from expansion of health information technology and e-health applications. Based on the published literature, they estimate that even incomplete implementation of existing technologies could increase physician visit capacity by up to 21 percent.

Finally, Arthur Kellermann and colleagues propose creating the new occupation of "primary care technician," analogous to the existing profession of emergency medical technicians (EMTs), who provide the vast majority of first-contact emergency medicine in the field. This is their job description:

What we need are primary care extenders with local ties and cultural competence of community health care workers, the procedural skills of PAs, and ready access to the knowledge of NPs and primary care physicians. They should be easy to train, inexpensive to employ, and capable of working miles apart from their supervising providers. ... Primary care technicians could be quickly trained to deliver basic preventive, minor illness, and stable chronic disease care to populations that currently lack access to care.

Are these proposals, taken individually or in combination, adequate solutions to the problem of too few U.S. family physicians?

Just drinking water may not prevent another kidney stone

- Jennifer Middleton, MD, MPH

"I know what it is, doc - I've had stones lots of times before."
A patient of my colleague's said this to me a few weeks ago in the office, and, sure enough, the patient was correct.  2 days of colicky left flank pain and dysuria had, indeed, turned out to be recurrent nephrolithiasis.

My training regarding the counseling of these patients to prevent recurrence basically consisted of "drink water.  2 liters a day."  This patient had been doing that, yet still ended up with a stone again.  I vaguely recalled that there were some other things patients could try to reduce nephrolithiasis recurrences, but I couldn't remember anything specific.  I realized, then, that I had abdicated that decision making to the specialists who usually follow these patients.

One of this week's American Family Physician's POEMs discussed Fink et al's systematic review on this very topic.  The researchers examined 28 studies regarding prevention of recurrent nephrolithiasis using appropriate systematic review methodology and found that water works fine for preventing the second episode after an initial event.  But after the second episode, water by itself didn't do as well.  Participants with multiple stone episodes who added a thiazide diuretic, a citrate (for example, potassium citrate), or allopurinol to their 2 liters of water a day, though, had fewer recurrences.

This systematic review did a nice job of discussing how to tailor prevention based on the patient. Patients with calcium stones benefited from citrates and thiazides, regardless of their baseline calcium level. Allopurinol, of course, worked for patients with high serum uric acid levels or low urinary uric acid excretion.  Unfortunately, for struvite stones, findings were less promising; the reviewers looked at 3 studies that touted acetohydroxamic acid (AHA) as a preventive, but they felt that the strength of evidence from these only fair-quality trials was too low to recommend AHA at this time.  The reviewers also found that serum or urinary calcium levels didn't help to predict if a patient was more or less likely to have a recurrence, though serum uric acid levels can.

As a family doc, I want to be aware of what my specialist colleagues do, so I can appropriately reinforce their counseling and recommendations with our mutual patients.  I appreciated AFP's discussion of this systematic review and am very glad to have expanded my nephrolithiasis prevention toolkit.

Why don't physicians discuss cancer screening harms?

- Kenny Lin, MD, MPH

Last month, I attended a conference that included an exercise where attendees were asked how many patients they thought it was acceptable to diagnose and treat needlessly (or "overtreat") in order to prevent one death from cancer. We stood at various points along a wall that represented different thresholds: at one end, 100 persons overtreated for every 1 life saved; at the other, 1 person overtreated for every 1 life saved. Not surprisingly, attendees held a wide range of opinions (I stood somewhere in the middle), but the exercise illustrated the tradeoff inherent in effective screening tests for breast, colorectal, and cervical cancer: for every person who benefits from screening, others will be harmed. This fact has led many physicians to advocate that shared decision-making be used more widely to integrate patients' preferences and values with the decision to accept or decline a screening test.

How often do physicians take the time to explain the harms of cancer screening to their patients? A research letter published in JAMA Internal Medicine explored this question in an online survey of 317 U.S. adults between 50 and 69 years of age. 83 percent of participants had attended at least 1 routine cancer screening; 27 percent had undergone 3 or more. However, less than 10 percent of participants had ever been informed by their physicians of the risk that the screening test(s) could lead to overdiagnosis and overtreatment. The few physicians who did attempt to quantify this risk generally provided information that was inconsistent with the medical literature.

If the results of this survey are representative of the practices of U.S. family physicians, then more than 90 percent of us aren't telling patients that there are downsides to undergoing routine mammograms, colonoscopies, and Pap smears. Why not? Is it because we aren't familiar enough with the data to accurately describe these harms? Or is it because we fear that patients who receive information about cancer screening harms will choose to decline these tests?

FIT colorectal screening: is annual testing necessary?

- Jennifer Middleton, MD, MPH

One of the POEMs in last week's American Family Physician discussed a recent study from the Netherlands regarding fecal immunochemical testing (FIT) for colorectal cancer screening; the researchers studied the prevalence of screening, rate of positive screening results, and rate of identified colorectal neoplasia.  They found that screening annually did not increase the yield of new colorectal cancer cases compared with screening every 2 to 3 years.

Having a viable alternative to colonoscopy is vitally important to ensuring that our patients get colorectal cancer screening.  Colorectal cancer is the fourth most common form of cancer in the U.S., but at least 1/3 of U.S. adults aged 50-75 are not getting adequate screening.  A survey by the Colon Cancer Alliance found that fear of the bowel prep and procedure keeps many adults from getting a screening colonoscopy.  I have several patients who appreciate having the option of a less invasive screening tool.

At first, our only alternative to offer was the fecal occult blood test (FOBT), but then FIT came onto the scene with several advantages. Certain fruits and vegetables, along with red meat, can cause false positives with FOBT, and vitamin C supplementation can cause false negatives.  FIT, by looking at globin instead of heme, eliminates the effect from these heme-based test confounders.

I still remember convincing our practice to switch from FOBT to FIT after learning these points.  But we experienced an unexpected result - fewer of our patients were returning the FIT than the FOBT.  It turned out that the FIT kit instructions were difficult for many of our patients to follow. Take a look and compare for yourselves:

FIT: http://www.insuretest.com/resources/InSureFIT-Patient_Instructions.pdf
FOBT: http://health.gov.on.ca/en/public/programs/coloncancercheck/docs/fobt/English_FOBT_instructions.pdf

With FOBT, patients just have to smear some stool onto a card.  But, with FIT, patients have to use a paintbrush over the surface of the stool, transferring this water instead of stool to the card, all the while making sure that no toilet paper gets into the toilet bowl.  So, which is worse: dietary restrictions with FOBT, or more complicated instructions with FIT? Perhaps the answer for your patients is different than it was for ours.

What I appreciated about the article featured in AFP, though, was the change in screening interval.  The researchers found that more patients participated in the biannual and triannual screening than they did if it was annual; screening less often resulted in more people getting screened.  If other researchers can validate this point on a larger scale, this expanded screening interval may tip the balance in favor of FIT once and for all. For now, the American College of Physicians, as reviewed in AFP last year, advises that physicians may offer average risk patients FIT, FOBT, flexible sigmoidoscopy, or colonoscopy.  This article, and several more, are available in the AFP By Topic for colorectal cancer.

So, how are you tackling colorectal cancer screening in your office?

Updates in HIV screening and prevention

- Kenny Lin, MD, MPH

Although the introduction of highly active antiretroviral therapy for HIV has led to substantial declines in AIDS diagnoses and deaths from their peaks in the mid-1990s, an estimated 50,000 persons in the U.S. are infected with HIV each year, and more than 236,000 persons living with HIV are unaware of their diagnoses, according to the Centers for Disease Control and Prevention. Noting that many HIV infections occur in persons without identifiable risk factors, earlier this year the U.S. Preventive Services Task Force recommended that clinicians routinely screen all adolescents and adults ages 15 to 65 years (the American Academy of Family Physicians recommends starting routine screening at age 18).

Identifying infected persons through screening allows for earlier initiation of effective therapy, but there is limited evidence that the diagnosis affects sexual and injection drug use behaviors that could prevent transmission of HIV. Recently, several randomized trials of antiretroviral preexposure prophylaxis in high-risk populations have demonstrated reductions in new HIV infections; a Cochrane review concluded that 56 persons needed to receive prophylaxis to prevent one new infection.

The October 15th issue of AFP includes a STEPS drug review of emtricitabine/tenofovir (Truvada) for HIV preexposure prophylaxis. Although this drug is effective and generally well tolerated in persons with normal renal function, it comes at a steep price: more than $1200 for a one-month supply. Whether it makes sense to prescribe an expensive and potentially toxic drug to uninfected persons who might acquire HIV due to high-risk behaviors such as injection drug use remains a topic of debate. The CDC and other U.S. public health agencies plan to publish comprehensive guidance on the use of antiretroviral preexposure prophylaxis within the next year.

How have the expanded HIV screening recommendations and the availability of preexposure prophylaxis regimens affected your practice?

Meniscal tears in arthritic knees: refer to physical therapy first

- Jennifer Middleton, MD, MPH

Meniscal injuries in arthritic knees challenge me. While some patients are more than willing to start with physical therapy (PT), some like the idea of a "quick" surgical fix over the perceived drudgery of a course of PT.  I struggle, too, at times, trying to judge who and when to refer to orthopedics, knowing full well that the patients I refer are likely to end up undergoing arthroscopy.

Kirkley et al showed in 2008 that arthroscopy for osteoarthritis makes no difference in pain or mobility scores. The AFP By Topic on Arthritis and Joint Pain includes this 2011 AFP article on knee osteoarthritis treatment that goes into more detail regarding the lack of evidence showing benefit following knee arthroscopy.  The jury is still out regarding whether surgery is necessary for meniscal tears even in patients without arthritis; a 2000 Cochrane review found insufficient evidence to conclude that surgery or PT is superior to the other.  Until recently, though, no one had specifically studied if arthroscopy benefits adults with osteoarthritis who suffer a meniscal tear.

A study published this past spring in the New England Journal of Medicine, which American Family Physician will be reviewing in its upcoming issue, may give us an answer.  The authors found no difference in pain and mobility after 6 and 12 months among patients who had had arthoscopic surgery followed by PT versus patients who only had PT.  In this trial, researchers randomized adults with painful meniscal tears (verified by MRI) who also had radiologic evidence of osteoarthritis to either surgery followed by PT or just PT alone. (Interestingly, patients did not have to have had symptomatic osteoarthritis prior to their meniscal tear; the appearance of arthritic changes on MRI alone got them enrolled in the study.)  The researchers then followed participants with previously validated pain and knee function questionnaires 6 and 12 months after their therapy or surgery. They found no statistically significant difference in these scores between groups.

Although the authors state that they conducted an intention-to-treat analysis in the article's abstract, in the methods section they qualify this as having been a "modified intention-to-treat approach in which patients who did not withdraw from the study were evaluated in the group to which they were randomly assigned."  Participants in the PT arm did have the opportunity to cross over to the surgical arm if they failed therapy, and 51 of the participants initially assigned to the PT group did so.  The authors appropriately included these patients in their intention-to-treat analysis but chose not to include the participants who dropped out before the 12 month follow-up.

31 of the study's inital 351 participants dropped out, and not including them in the statistical analysis could have skewed the results.  It's possible, for example, that the patients who dropped out of the PT arm went somewhere else for surgery and did better than they otherwise would have.  I applaud the authors for their transparency regarding this decision but remain unsure why they chose not to include the drop-outs in their final analysis.

That small misgiving aside, their findings still make intuitive sense given what we already know about knee arthroscopy.  This study's findings will make me more likely to refer patients with suspected meniscal tears to physical therapy first, even if they already have osteoarthritis.

Will this study change your management of meniscal tears in your older adults with known or suspected knee arthritis?

Health checks increase diagnoses, but do they improve health?

- Kenny Lin, MD, MPH

After moving into our current home nine years ago, my wife and I purchased a basic security system - the kind with a programmable keypad, multiple door alarms and a motion sensor. The alarm has sounded about a dozen times since then. None of these times was a burglary actually in progress. On several particularly windy days, one of us forgot to lock the back door after leaving, and it blew open. Two or three other times, departing early for work, I accidentally hit "Away" on the keypad (arming the motion detector at the foot of the stairs) rather than "Stay," causing the klaxon to sound when my unsuspecting son came down the stairs later in the morning. We've also set off the fire alarm a few times while cooking. Although our security system cost little to purchase, by now we've spent more money in monitoring fees than the value of what we might conceivably have lost in an actual burglary.

There are intangible benefits to having a home security system - peace of mind being the most important. But our peace of mind has been achieved at the cost of temporarily diverting multiple municipal police and fire units, disturbing our neighbors, receiving inconvenient cellular phone calls from the monitoring company, and terrifying a 5 year-old on his way to breakfast.

I think about my home security system every time I do a physical examination on an apparently healthy adult. Although the general health check is an established medical tradition, a Cochrane for Clinicians review in the October 1st issue of AFP concluded that health checks increase the number of diagnoses but don't reduce morbidity or mortality. So are these visits a waste of time? Not necessarily, argued Dr. Krishnan Narasimhan:

Although the general health check has not been shown to decrease morbidity or mortality, there is some evidence that designating a specific visit for the provision of preventive services may increase the likelihood that patients will receive them. ... Adding preventive services to other patient visits, sending reminders to patients to use these services, and using community linkages, such as screening at job sites or schools, could be potential avenues for effective delivery of preventive services. Evaluating better models for the delivery of evidence-based preventive services is an area for further research.

Unfortunately, a 2012 study in the Annals of Family Medicine found that patients often overestimate the benefits of preventive interventions that primary care physicians commonly provide at health checks: breast cancer screening, colorectal cancer screening, and medications to prevent hip fractures and cardiovascular disease. In most cases, patients' "minimum acceptable benefit" (the lowest level of benefit that in their mind was required to justify the preventive intervention) far exceeded the actual benefit of the service established in randomized trials. Further, the study considered only the benefits of these services, and not the false alarms, which occur, for example, in more than 60 percent of women receiving annual mammography after 10 years.

Small Effect of Inhaled Steroids on Height in Children with Asthma

- Jennifer Middleton, MD, MPH

Childhood asthma is a frequent diagnosis in many Family Medicine offices, and inhaled corticosteroids are often the mainstay of treatment for kids with moderate or severe persistent disease.  Previous retrospective studies were reassuring regarding how these inhaled medications might affect height; children may not grow quite as fast when they're using inhaled steroids for asthma - but these studies suggested that, once the steroids are stopped, children catch up without any lifelong loss of height.

A recent randomized controlled trial, reviewed in this month's Journal of Family Practice (JFP), challenges this notion. The researchers found that children (ages 5-13 years at the beginning of the study) on long-term budesonide treatments for moderate persistent asthma did lose about half-an-inch (actually 0.47 inches or 1.2 cm, to be precise) of height during the 4-6 year trial that was sustained when they were followed up in their mid-20s.

The JFP authors point out that the enrolled children were on the same dose of budesonide throughout this lengthy study, which may be a bit atypical. The Expert Panel Review 3 (EPR-3) recommends that physicians consider tapering down chronic asthma therapy for adults and children if their symptoms have been controlled for three months (see page 288 of this document). This trial does add a bit of additional weight to that recommendation; we don't know whether intermittent use of these medications would mitigate this height loss, but it's probably still reasonable to limit their use when possible.

On the flip side, I wouldn't like to see 0.47 inches of height get in the way of adequately treating a child with moderate persistent asthma, either. (The researchers intentionally didn't include children with severe persistent asthma, assuming that the benefit of inhaled steroids for them would absolutely outweigh the risk of a few millimeters of height.) Like so many things in medicine, our discussion of this trial's finding with parents and families should include both the risks and benefits of these medications.  But this trial is a good example of how important it is to follow-up assumptions from retrospective studies with more rigorous, prospective trials.

AFP By Topic has a rich collection of resources on asthma which includes several articles related to the care of children with asthma.

Will this trial affect how you prescribe inhaled corticosteroids to children and adolescents?

Managing progressive disability in older adults

- Kenny Lin, MD, MPH

One in seven Americans suffer from disability, which an article by Dr. Cathleen Colon-Emeric and colleagues in the September 15th issue of AFP defines as "limitation in the ability to carry out basic functional activities." Progressive disability, or functional decline, commonly affects older adults with multiple chronic health conditions. First steps in the evaluation of an older adult with a new or progressive disability include characterizing the time course, associated symptoms, effects on specific tasks (including activities of daily living), and compensatory strategies. The authors then recommend that clinicians identify potentially modifiable health conditions, comorbid impairments, and contextual factors. All of this information should be considered and integrated into a treatment plan that enhances the patient's capacity and/or reduces task demands.

A Close Ups in the same issue of the journal provides insight on the perspective of a patient and family member who benefited from a comprehensive evaluation for functional decline. C.W. writes about her late mother's positive experience:

Twenty-minute visits were inadequate to address all of the diagnoses and medications, let alone her falls, constipation, insomnia, and cognitive decline. It seemed no one was appreciating the big picture. ... With full support from her family physician at home, we arranged for her to undergo a comprehensive assessment [that] focused on mom's primary goal—the ability to continue the activities she loved. She was evaluated by a geriatrician, a nurse, and a social worker. My family was also interviewed, and the appointment concluded with a meeting involving the whole team. We were given recommendations to consolidate and simplify her regimens for pain, insomnia, and constipation; initiate medication for depression; and make sure she exercised and socialized regularly, with concrete recommendations for overcoming barriers to these goals, such as transportation. Additionally, we received referrals for physical therapy and low vision rehabilitation.

In a related editorial, Dr. V.S. Periyakoil observes that progressive frailty that does not respond to optimal management of reversible conditions is in fact a terminal illness, even if it is often not recognized as such. He criticizes a recent decision by the Centers for Medicare and Medicaid Services to stop accepting the ICD codes for "debility not otherwise specified" and "adult failure to thrive" as principal hospice diagnoses, arguing that "these older adults may be subjected to ineffective interventions, including repeated emergency department visits and hospitalizations that are burdensome and expensive, and erode their quality of life."

Do you have the time and resources to evaluate functional decline in older adults in your practice, or do you refer these patients to other health professionals? How do you recognize when a patient is transitioning from a reversible state of frailty to a potentially terminal one? Will the information in these articles change your approaches to disability and end-of-life care, and if so, how?

Ruling out DVT: doppler or D-dimer?

- Jennifer Middleton, MD, MPH

Yesterday I saw an older patient with a swollen leg. Although I was reasonably confident that the swelling and pain was due to an early cellulitis, I still felt compelled to rule out a deep venous thrombosis (DVT). I ordered a stat ultrasound doppler of the leg, which was negative for DVT. I was left wondering if I shouldn't have wasted the patient's time and his insurance dollars on this test; I wasn't terribly worried about a DVT, but I also knew that I couldn't afford to miss one.

One of the POEMs in AFP last week reviewed a recent article from the Annals of Internal Medicine regarding testing for DVT.  The researchers evaluated the use of Wells' criteria to determine whether ultrasound (doppler) or a D-dimer was used first to evaluate for possible DVT.  The researchers divided the patients into two groups; one group consisted of outpatients with a low or moderate pre-test probability according to their Wells' score, and one group consisted of outpatients with a high pre-test score along with inpatients.  The patients in the first group with a positive D-dimer went on to ultrasound.  They found that stratifying patients by pre-test probability decreased the use of both D-dimer and ultrasound but did not negatively affect patient outcomes.

I know I should use clinical decision rules like the Wells criteria more often to help me eliminate unnecessary testing; there are a few rules that I do use regularly, but for less frequent diagnoses like this one, I often forget to look for an applicable rule.  There are many inexpensive smartphone apps that can make this process easier for clinicians, too.  I suspect that my patient yesterday would have preferred a quick blood test in the office instead of having to trek over to the hospital's vascular lab.  It seems, though, when I'm in the middle of a busy office session, that I often only think about using these tools after the day is done.  This POEM was an excellent reminder to me to think about incorporating these tools more into my everyday decision-making process.

There is a useful AFP by Topic about DVT and Pulmonary Embolism if you'd like more information about this topic.  And, here's the original study that validated Wells' criteria for DVT.

How are you currently working up possible DVTs?  Is it realistic to integrate the use of clinical calculators into your day-to-day practice?

Why do clinical questions go unanswered?

- Kenny Lin, MD, MPH

What do you do when you have a clinical question that ideally requires an answer before the patient leaves your office? Do you flip through a textbook or a back issue of American Family Physician? Look up the topic in a online reference? Consult an smartphone app? Ask a colleague in the office or curbside a specialist by telephone?

Family physicians take many approaches to answering clinical questions, some more efficient and effective than others. For example, using AFP By Topic or the journal website search function is more likely to yield relevant results than hunting through a stack of print issues for that article on community-acquired pneumonia that you remembered reading at some point. Unfortunately, Deputy Editor Mark Ebell, MD, MS reported in a 2009 article that on average, 15-20 clinical questions come up each day, and most of these go unanswered.

A recent study published in JAMA Internal Medicine examined barriers to answering clinical questions at the point of care. Researchers affiliated with the Mayo Clinic conducted several focus groups with a total of 50 family and internal medicine physicians in academic medical center and community settings. Not surprisingly, the barrier most commonly mentioned by physicians was insufficient time. Some physicians with convenient access to computers and online references complained of not knowing which resource to search, and having doubts about whether the search was likely to yield an answer. Others were concerned that looking up information while in the examination room might diminish a patient's confidence in them. Finally, some physicians found that available resources simply did not contain the answers they needed.

The editors of AFP are interested in learning more about how you use our journal - in its print, online, and mobile versions - to answer your clinical questions. Are you able to find current, relevant answers at the point of care, or do you prefer to browse AFP at home and subsequently incorporate what you learn into practice? What could we do to improve your searching and reading experiences?

You don't snooze, you lose

- Jennifer Middleton, MD, MPH

The consequences of insufficient sleep can be significant.  Children and teens who don't get enough sleep not only get worse grades in school but are also more likely to have parents who worry about their mood and behavior.  Sleep-deprived adults are more likely to be involved in a motor vehicle or work accident, are more likely to have hypertension, and are more likely to be obese (even controlling for changes in diet patterns).  Perhaps logically, then, sleep-deprived adults incur higher health care costs than adults who get at least 6 hours of sleep a night.

The August 15, 2013 AFP featured an article regarding the Management of Common Sleep Disorders. The first section of this article dealt with insomnia; I don't know about you, but I see a lot of patients in the office who are struggling with falling and staying asleep at night. The authors wisely suggest reframing patients' thoughts about sleep using Cognitive Behavioral Therapy (CBT), and Table 4 contains most of the advice that I routinely dispense to patients: limit caffeine and stop nicotine, only use the bedroom for sleep and sex, get up if you haven't fallen asleep within 20 minutes, etc. I liked how the authors cited evidence showing that these simple physician interventions can be quite effective.

Decreasing time with electronics (TV, computers, tablets, mobile phones) may also help.  The American Sleep Foundation's annual poll in 2011 found that use of a smartphone, computer, and/or television the in hour before falling asleep correlated with lower quality sleep.  They also reported that the average number of caffeinated beverage servings among adolescents and adults was around 3 a day - perhaps to make up for the fatigue from decreased sleep quality?

I recommend that patients get television sets and other electronics out of the bedroom if at all possible, and spend the last hour of the day disconnected from technology.  You can probably imagine how my patients often respond to that advice; smartphones, computers, and televisions seem to be ubiquitous in the US, and certainly have many positives regarding inter-connectivity and just plain old entertainment.

But, as the above studies demonstrate, helping our patients to get restful sleep may help prevent a lot of problems.  There are AFP by Topics on sleep disorders for both adults and children if you'd like to check out more resources about this issue.

Do you have any special advice for your patients regarding sleep?

The most popular posts of January - July 2013

- Kenny Lin, MD, MPH

Following up on our successful previous collection of the most popular posts of 2012 (which has been viewed more than 1300 times), here are the AFP Community Blog's top 5 most viewed posts from the first seven months of 2013.

1. Are IUDs a reasonable option for birth control in adolescents? (May 21)

What are your thoughts about the intrauterine device for teens? If you are recommending it, what spurred you to do so? If not, what is making you hesitate?

2. Pros and cons of vitamin D screening (April 29)

No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone.

3. Providing culturally competent health care (January 25)

The increasing diversity of the U.S. population has made it more likely that family physicians will care for many patients with cultural backgrounds, beliefs, and practices that are dissimilar to their own.

4. USPSTF: Diet and exercise counseling not routinely recommended (June 17)

Given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is something more than just counseling necessary to effect behavior change?

5. Is routine stress testing necessary for resolved chest pain? (May 29)

Are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?

Does acetaminophen help nasal congestion from the common cold?

- Jennifer Middleton, MD, MPH

I don't know about you, but when I get a upper respiratory tract infection (URI or "cold"), one of the first things that I reach for is acetaminophen. I've never thought that it did much for the nasal congestion, but it at least seems to take the edge off of the headache, muscle aches, and fever.

Cold and flu season is right around the corner - except for my household, where it unfortunately arrived this weekend.  So, I am finding Cochrane's recent review of acetaminophen for the common cold rather timely.  The reviewers only found 4 small studies of "low to moderate quality," but 2 of these studies did show that acetaminophen reduced nasal congestion, and 1 showed that it reduced rhinorrhea.

I had never thought of acetaminophen as a treatment for nasal symptoms before, but the Cochrane reviewers wisely recommend caution in interpreting these small studies, stating that they are insufficient "to reach a conclusion."

Does this mean that I will be less likely to use and recommend acetaminophen for cold symptoms? Nope. A lack of high-quality studies supporting its efficacy isn't the same as a high-quality study showing that it doesn't work.  I still like recommending acetaminophen for headache, myalgias, and fever, and if it gets some of those nasal symptoms, that'd be a nice bonus.  What this review will hopefully spark, though, is some higher-quality prospective studies to more precisely define acetaminophen's utility for URI symptoms.

So, we'll keep on using acetaminophen in our house until this current virus runs its course.  AFP also recently reviewed "Treatment of the Common Cold in Children and Adults" with pragmatic evidence-based recommendations for patients (and doctors) with URIs.  And, when all of those over-the-counter options for colds get overwhelming, this AFP Cochrane for Clinicians article can provide guidance.  We're also drinking plenty of fluids, resting when possible, and my husband is taking zinc lozenges (though the taste isn't worth it to me, given zinc's only modest effect on URIs).

Will Cochrane's review change your recommendations for acetaminophen use in the common cold?

Is prevention or treatment the heart of family medicine?

- Kenny Lin, MD, MPH

The comprehensive scope of family medicine has always made it a challenge to describe, in a nutshell, what family physicians do. Unlike subspecialists or general internists, surgeons, or pediatricians, family physicians do not define their patient populations by age, gender, or organ system. A series of editorials published a few years ago in the Annals of Family Medicine argued that family physicians practice a "science of connectedness" that includes a distinct approach to clinical problem-solving. A more recent study in Family Medicine asserted that the training and attitudes of family physicians make them uniquely qualified to provide cost-effective health care. The emergence of the Patient-Centered Medical Home model has emphasized the role of the family physician as a facilitator and leader of care teams for patients with multiple preventive and chronic care needs.

Dr. John Hickner, editor of The Journal of Family Practice, worries that well-intentioned initiatives to improve family physicians' skills at providing screening tests and facilitating behavioral change may come at the cost of neglecting patients' acute concerns. He wrote in a recent editorial:

At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”

Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.

As a family physician who teaches public health and preventive medicine, I appreciate the tension between prevention and treatment in my own practice. Previous studies concluded that paying exclusive attention to providing guideline-recommended preventive and chronic disease services would leave literally no time to address the many other reasons that patients come into the office. As Dr. Hickner noted, "The 'number needed to treat' to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!" So is prevention or treatment the heart of family medicine? Is the answer to this question different today than it would have been a generation ago, and is it likely to be different a generation from now?

Is all substance misuse really abuse?

- Jennifer Middleton, MD, MPH

I appreciated AFP's article last week about "A Primary Care Approach to Substance Misuse" and its practical review of screening and treatment options for patients struggling with this issue.  The article appropriately included discussion about prescription drug abuse.

Prescription painkiller deaths have been on the rise in the United States. Drug overdose (60% of which are pharmaceutical drug overdoses) is now the number 1 cause of injury-related death in the U.S.  The Centers for Disease Control and Prevention (CDC) states that every 3 minutes a middle-aged woman presents to the Emergency Department for prescription opioid "misuse or abuse."   Every single one of those prescription medications originated from a doctor's prescription pad (paper or virtual).

I continue to ruminate, though, about the word "misuse" in the AFP article. Usually, when I think about problems with inappropriate substance use, I think of the word "abuse," not "misuse."  Clearly these words share a similar meaning, but, for me at least, the connotation of "misuse" is a bit gentler than "abuse."  "Misuse" sounds more like a mistake than the intentional impropriety of "abuse."

I have previously thought of the substance "abusers" as those who are inappropriately requesting prescription painkillers.  My office, as I'm sure many others do, has a controlled substance policy that supports frequent urine drug screens, and we discontinue prescribing for patients with discordant results.

But what about the "misusers?"  What about the patients who have some legitimate pain source but don't always use their prescription opioids as prescribed?  Or the patients who never tell me that they're borrowing someone else's prescription medications?  After all, the CDC found that 55% of the people misusing or abusing prescription pain medications obtain them for free from a friend or relative. Only 11% buy their pills from friends or family, and only 4% purchase their meds from a dealer.  Learning that most of my patients using these medications inappropriately are getting them at no cost from friends and family changes how I think about who those patients might be.

What I appreciate about the term "misuse" is its reminder that, as a prescriber of these medications, I need to be on the alert for more than just the "abusers."  I should probably be asking all of my patients the single question screen for substance disorders outlined in last week's AFP article (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) on a regular basis.  I need to broaden who I think of as at risk from problems related to substance misuse and abuse.

How often do thoughts of prescription medication misuse and abuse occur during your practice day? Does the term "misuse" help you to think more widely about prescription medication problems, or is it an unnecessary term?

Estimating osteoporosis risk in older men

- Kenny Lin, MD, MPH

According to a recent review in American Family Physician, 1 to 2 million American men have osteoporosis, 13 percent of white U.S. men older than age 50 will experience an osteoporotic fracture in their lifetimes, and men are twice as likely as women to die in the hospital following a hip fracture. However, unlike screening guidelines in women, there is no consensus on when to screen for osteoporosis in men. The American College of Physicians recommends an individualized osteoporosis risk assessment for men age 65 or older, and dual energy x-ray absorptiometry (DXA) scans to measure bone density in men at increased risk. On the other hand, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, although it observed that "men most likely to benefit from screening would have 10-year risks of osteoporotic fracture equal to or greater than those of 65-year-old white women with no additional risk factors."

Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.

In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.

Will the results of this study make you more likely to use MORES to assess the risk of osteoporosis in older men in your practice? Or would you prefer to screen all men older than a certain age with DXA to avoid missing any patients with osteoporosis?

Steroids for pharyngitis?

- Jennifer Middleton, MD, MPH

This month, The Journal of Family Practice (JFP) published a review of a recent Cochrane meta-analysis regarding the use of steroids for patients with "exudative or severe sore throat." The Cochrane researchers found that even one dose of a corticosteroid (either dexamethasone PO, dexamethasone IM, or prednisone PO) increased the number of patients who reported resolution of pain in twenty-four hours (number needed to treat [NNT] = 4).  The Cochrane researchers included studies of patients with both viral and bacterial pharyngitis.

Despite evidence-based tools such as the modified Centor score, which can determine the pre-test probability of streptococcal pharyngitis and guide treatment (described nicely in this AFP article), physicians still overprescribe antibiotics for upper respiratory infections, including pharyngitis.  This AFP by Topic on Upper Respiratory Infections provides a useful review of current treatment guidelines for these prevalent conditions; several articles in that grouping advise caution regarding overuse of antibiotics.  It may be that patients with painful pharyngitis don't necessarily want antibiotics, though, but just something to control their pain.  This new Cochrane meta-analysis, with that excellent NNT regarding improvement of pain after only one day of treatment with a steroid, suggests that steroids may be another useful tool in our pharyngitis treatment kit.

The JFP reviewers are quick to point out that these corticosteroids weren't used alone; the studies in the meta-analysis used them in addition to either antibiotics or analgesics.  Hopefully we will see some randomized controlled trials (RCTs) in the next few years that determine whether steroids are useful by themselves for patients not needing an antibiotic. In the meantime, since the RCTs in the Cochrane meta-analysis used varying methods, we don't have a clear guideline about which patients might benefit or what dose and administration route of corticosteroid to use.

Do you already prescribe steroids for patients with severe pharyngitis (viral or bacterial)?  If not, would this Cochrane meta-analysis encourage you to try it?

Medicating mild hypertension: is more evidence needed?

- Kenny Lin, MD, MPH

In the July 1st issue of American Family Physician, Dr. Janelle Guirguis-Blake commented on a Cochrane Review that found no benefits from pharmacotherapy for mild hypertension (systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood pressure of 90 to 99 mm Hg) on cardiovascular outcomes or mortality. However, the randomized trials' relatively small number of participants (fewer than 9000) and short follow-up periods (five years or less) left open the possibility that a significant benefit could still exist. Therefore, Dr. Guirguis-Blake concluded: "Larger double-blinded RCTs in this population of patients with stage 1 hypertension are needed to clarify the potential long-term benefits of pharmacologic therapy."

When existing research does not adequately answer an important clinical question - in this case, are medications superior to lifestyle modifications or no treatment for mild hypertension? - researchers invariably recommend collecting more evidence. But is performing a large randomized trial of mild hypertension management feasible, given that the standard of care set in 2003 by the Seventh Report of the Joint National Committee (JNC-7) (and reflected in this AFP Point-of-Care Guide) is to routinely identify and treat blood pressures in this range? The U.S. Preventive Services Task Force apparently thinks so; after previously declaring that the benefits of screening were "well established," the USPSTF has released an extensive draft research plan to reevaluate benefits, harms, best methods, and recommended intervals for screening for high blood pressure in adults.

With the next USPSTF statement at least a few years down the road, current evidence-based guidance on hypertension management is limited. The U.S. National Heart, Lung, and Blood Institute, which convened the previous JNC panels, recently announced in a cardiology journal its intention to stop producing guidelines. Instead, it says it will partner with outside medical groups to release its long-delayed JNC-8 hypertension guideline. Since guidelines sponsored by subspecialty societies are less likely to adhere to Institute of Medicine standards for producing unbiased guidelines, family physicians and other primary care clinicians should advocate for their organizations to participate in this process.

Another strike against NSAIDs?

- Jennifer L. Middleton MD, MPH

One of the issues family docs deal with on a daily basis is pain control.   I usually think about pain medication as falling into one of three categories: acetaminophen, NSAIDs, and opioids.  I frequently recommend acetaminophen, but patients often tell me "it's not strong enough for me" (maybe an unintentional consequence of those commercials touting Tylenol's gentleness?).  And, of course, I defer opioid regimens if possible given the risks of addiction and diversion.

Perhaps you've already heard about The Lancet's NSAID meta-analysis article from about a month ago.   The authors performed a robust literature search and included hundreds of trials with several outcome measures, one of which was the rate of "major coronary events" (a composite of non-fatal myocardial infarction and coronary death).  The authors found that long-term use of all non-steroidal anti-inflammatory drugs (NSAIDs), selective COX-2 or non-selective, doubled the risk of heart failure.  I'd like to focus on two non-selective NSAIDs, ibuprofen and naproxen, for the rest of this post.

I found this meta-analysis unsettling, as I like having an option in between acetaminophen and opioids to offer my patients.  True, the authors only examined patients taking high dose NSAIDs (2400 mg ibuprofen/day and 1000 mg naproxen/day) for at least 4 weeks.  Is it safe, then, to extrapolate that lower doses and/or shorter periods of time are safer?

AFP had a nice article about osteoarthritis treatment last year that discussed the pros and cons of all of these medication classes. Rereading that article this past week reminded me that every 12th patient taking an NSAID, even short-term, will experience a gastrointestinal (GI) bleed, kidney problem, or elevated blood pressure (number needed to harm [NNH] = 12 for that composite outcome).  As NNHs go, that's a pretty impressive number.

For now, at least, NSAIDs probably should be off the table for patients at an increased risk of heart disease.  Myself, I will probably continue recommending NSAIDs in patients without a history of GI bleed, with normal kidney function, and without a history of heart disease, but I will recommend more modest doses and shorter periods of use.  I will probably spend more time counseling patients, too, about the risks of ibuprofen and naproxen.

I encourage you to take a look at these related AFP By Topic collections:
Heart Failure
Pain: Chronic 
Arthritis and Joint Pain (includes this AHRQ-EHC review's discussion of NSAID risks)

How frequently have you been recommending NSAIDs?  Will this meta-analysis change your NSAID prescribing?

Social media guidance for family physicians

- Kenny Lin, MD, MPH

How do you use social media for professional purposes? An increasing number of family physicians use channels such as blogs, Facebook, and Twitter to keep up with the medical literature, network with other health professionals, and provide health education to current and prospective patients and their communities. When AFP launched its Community Blog and Facebook and Twitter accounts in 2010, there was little published guidance for physicians on how to get started in social media. Guidelines from the American Medical Association focused on avoiding unprofessional behavior, while the American Academy of Pediatrics reviewed the risks of social media use in children and adolescents, including cyberbullying and sexting. The author of a 2011 Curbside Consultation on whether physicians should be "friends" with their patients on social networking websites remarked: "In terms of universally accepted standards for interacting with patients using social media, it is kind of like the Wild West."

The Wild West got a little bit tamer last week, when the American Academy of Family Physicians released "Social Media for Family Physicians: Guidelines and Resources for Success." Designed to meet the needs of family physicians with varying levels of social media experience, this 15-page document offers a valuable road map that includes a concise orientation to major social media channels; a suggested initial approach; guidance on protecting patient privacy; and commonsense recommendations for social media policies in private and employed physician practices.

USPSTF: Diet and exercise counseling not routinely recommended for healthy adults

- Jennifer Middleton, MD, MPH

I was surprised to come across the United States Preventive Services Task Force (USPSTF) update in the June 15 AFP this weekend regarding nutrition and physical activity counseling for healthy adults:

[E]xisting evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small. 

And, they listed a potential harm to providing this counseling:

Harms may include the lost opportunity to provide other services that have a greater health effect.

As a family physician, I want to help my patients to live the best lives they can, and I feel strongly that good nutrition and exercise are both critical to doing so.  So, this is a difficult USPSTF recommendation for me to absorb.

Of course, to clarify, the USPSTF only said that counseling regarding these matters is not effective. They did not make any value statements about diet and exercise.  But given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective?  Is it that we just don't counsel well?  Or, is something more than just counseling necessary to effect behavior change?

A review article from 1999 and a more recent systematic review suggest that individual, computerized nutrition counseling may result in positive changes. Telephone interventions may also be effective for improving nutrition and exercise habits.  Targeting counseling about nutrition that focuses on two concepts from health behavior theory, self-efficacy ("I believe I have what I need to make the change") and outcome expectations ("Making this change will result in a good outcome") also can make a difference. 

Perhaps we need to both 1) make our counseling more effective, and 2) employ a more interdisciplinary approach to help our patients make sustainable changes.

This AFP USPSTF update is included in the AFP By Topic for Health Maintenance and Counseling.  There is a lot of nice information there about health counseling in general (I especially like this Family Practice Management article on motivational interviewing).

Will this USPSTF update change your approach to diet and exercise counseling in the office?

Rosiglitazone for diabetes: helpful, harmful, or neither?

- Kenny Lin, MD, MPH

Last week, an advisory panel convened by the U.S. Food and Drug Administration (FDA) voted to relax safety restrictions on the diabetes drug rosiglitazone (Avandia) that were put in place in response to previous evidence that rosiglitazone may increase the risk of heart attacks and cardiovascular deaths. American Family Physician first highlighted these safety concerns in its March 15, 2008 Tips From Other Journals, which Dr. Kenneth Moon concluded:

There is substantial circumstantial evidence that rosiglitazone is associated with higher risks of heart failure and myocardial infarction. Despite the awkwardness of persuading a patient to use a drug that may provide similar benefits but pose greater risks than other proven agents, the legitimate concerns raised by these studies make this a serious issue. Until there is conclusive evidence about the safety of rosiglitazone, many physicians and their patients may be more comfortable using alternative treatments.

Subsequent AFP articles on management of blood glucose in type 2 diabetes and rosiglitazone vs. pioglitazone reinforced cautionary messages about rosiglitazone. However, the results of a large randomized trial published in 2009 found similar risks for cardiovascular hospitalizations and death in patients using rosiglitazone compared to patients taking other oral diabetes drugs. This trial, which was sponsored by rosiglitazone's manufacturer GlaxoSmithKline, was criticized for methodological problems, but an independent re-analysis of the trial's data persuaded the FDA advisory panel that the drug's safety risks had been exaggerated in previous studies.

If the FDA acts on the advisory panel's recommendations and makes rosiglitazone more widely available, should family physicians prescribe it? It is worth noting that the panel considered only the drug's safety, not its effectiveness. A previous AFP Journal Club reminded readers that the disease-oriented outcome of improved glycemic control does not necessarily lead to patients living longer or better. Rosiglitazone causes more weight gain and congestive heart failure than metformin, and is more expensive than metformin and sulfonylureas. For those reasons, it should be a second- or third-line drug choice for patients with type 2 diabetes.

The safety risks of backyard trampolines

- Jennifer Middleton, MD, MPH

I've been watching trampolines sprout up in backyards all over our neighborhood this spring, and seeing them has resurrected some memories from residency.  Like many family physicians, I spent time in a children's emergency department (ED) as a resident.

What I saw during my rotation made me wonder about the safety of these bouncy backyard devices.  I saw an injury related to backyard trampolines during nearly every shift that summer.  These children typically either fell off the trampoline onto the ground or got caught in the gap between the mat and the metal support.  Some of these injuries were just contusions and sprains, but I also helped evaluate several broken bones and a couple of head injuries.

It turns out that my ED experiences were not atypical.  The American Academy of Pediatrics (AAP) has been advising against recreational backyard trampoline use since 1977, with their most recent update last fall. (1)  Similarly, the American Academy of Orthopedic Surgeons also has a position statement against backyard trampoline use. (2) Despite these recommendations, trampoline use and trampoline injuries in the US are on the rise, from an average of about 41,000/year in the early 1990s to about 88,000/year in the early 2000s. (3) More children are injured directly on the mat, though around a third of injuries are from falls to the ground. (4,5)

I could find no rigorous evidence base to demonstrate that counseling against backyard trampoline use reduces injuries, but at least one literature review suggests that physician counseling about other childhood safety issues does reduce injuries. (6)  And, here's a recent AFP article about unintentional childhood injury prevention: http://www.aafp.org/afp/2013/0401/p502.html.  

My suspicion is that many parents remain unaware of these dangers (perhaps like this mother was), and a brief question about trampoline use would be a simple addition to our safety counseling at well child visits.

Is this topic worth discussing with families in the office?  I welcome your thoughts.


(1) Trampoline Safety in Childhood and Adolescence.  Council on Sports Medicine and Fitness.  Pediatrics; originally published online September 24, 2012. http://pediatrics.aappublications.org/content/early/2012/09/19/peds.2012-2082.full.pdf+html
(2) http://www.aaos.org/about/papers/position/1135.asp
(3) Linakis et al. Emergency department visits for pediatric trampoline-related injuries: an update. Acad Emerg Med. 2007 Jun;14(6):539-44. Epub 2007 Apr 20. http://www.ncbi.nlm.nih.gov/pubmed/17449791
(4) Black and Amadeo. Orthopedic injuries associated with trampoline use in children. Can J Surg. 2003 June; 46(3): 199–201.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211739/
(5) McDermitt, Quinlin, Kelly. Trampoline injuries in children. J Bone Joint Surg Br. 2006 Jun;88(6):796-8. http://www.ncbi.nlm.nih.gov/pubmed/16720776
(6) Bass et al. Childhood injury prevention counseling in primary care settings: a critical review of the literature. Pediatrics. 1993 Oct;92(4):544-50. http://www.ncbi.nlm.nih.gov/pubmed/8414825