Zika virus: what do family physicians need to know?

- Jennifer Middleton, MD, MPH

Zika virus continues to make headlines as researchers study both its spread and its possible connections with Gullian-Barre disease and microcephaly. Family physicians are likely to come across questions related to travel and the Zika virus, and we are also potentially the first source of contact for a returning infected traveler.

The Zika virus is a single-stranded RNA virus that is primarily transmitted via mosquito bite, but reports of sexual and mother-to-child transmission have also been described. The only documented cases in the mainland United States (not including Puerto Rico or other Caribbean U.S. territories) thus far are in travelers returning from affected countries. Many individuals with Zika virus are asymptomatic, but the 1 in 5 who do exhibit symptoms complain of fever, maculopapular rash, arthralgia, myalgia, conjunctivitis, and/or headache. The CDC provides a lengthy list of diagnoses to consider in the differential, and obtaining a detailed travel history is crucial to narrowing the list. Typically, Zika illness is not life-threatening, but correlations with an increased rate of microencephaly to infants born to infected mothers in Brazil and surrounding countries may worry parents-to-be. While the CDC has advised pregnant women to "consider postponing travel to any area where Zika virus transmission is ongoing," they have not yet advised pregnant women to completely avoid travel to Zika-affected areas. For travelers to affected areas, however, they do recommend that:

[P]rotection from mosquito bites is required throughout the day. Prevention of mosquito bites includes wearing long-sleeved shirts, pants, permethrin-treated clothing, and using United States Environmental Protection Agency (EPA)-registered insect repellents. Insect repellents containing ingredients such as DEET, picaridin, and IR3535 are safe for use during pregnancy when used in accordance with the product label. 

Family physicians should contact their local or state health department if they have a patient returning from a Zika-affected area who should be tested for Zika virus; all pregnant women, symptomatic or not, returning from affected areas should be offered testing, as should all potentially symptomatic individuals. Only the CDC and a few state health departments are currently equipped to test for Zika virus, and their expertise is necessary in interpreting the results since other flaviviruses like dengue and yellow fever can also give a positive result. Full instructions for sending samples to the CDC for testing can be found on this website, but, again, family physicians should consult with their local or state health department prior to doing so.

The above information is important for us to share with patients who come to see us for pretravel consultation, especially for pregnant women, women of child-bearing age, and their partners. Up-to-date travel health notices can be found on the CDC website, and they also have patient information resources here.

Under the Featured Content section of the AFP website's homepage are several useful resources about Zika virus from the AAFP, CDC, and others that are continually updated as new information becomes available. If you'd like to read more on travel medicine in general, there's an AFP By Topic on Travel Medicine which includes this useful 2009 article on pretravel consultation.

For acute low back pain, naproxen alone works best

- Kenny Lin, MD, MPH

In urgent and primary care settings, when a patient requests medication for acute low back pain without radicular symptoms, I typically prescribe naproxen and cyclobenzaprine, adding oxycodone/acetaminophen if the pain seems especially severe. But two recent articles in AFP will likely lead me to change my practice.

The first article is a Medicine by the Numbers in the February 1st issue that reviewed the number needed to treat (NNT) and number needed to harm (NNH) from a pooled analysis of trials evaluating cyclobenzaprine for low back pain. Compared to placebo, cyclobenzaprine was more likely to lead to global symptom improvement by day 10 of treatment, with an impressive NNT of 3. Unfortunately, it was also much more likely to cause dizziness, nausea, drowsiness, and dry mouth, with a NNH of 4 for any adverse effect. In other words, participants were almost as likely to feel worse on the drug as they were to feel better. Further, most trials did not use intention-to-treat analysis or had other important flaws in quality, making even this marginal benefit uncertain.

The second article is a POEM in the February 15th issue that summarized a randomized trial comparing functional outcomes in adults with acute, nontraumatic, nonradicular low back pain who received naproxen plus placebo, naproxen plus cyclobenzaprine, or naproxen plus oxycodone/acetaminophen for 10 days. Research associates blinded to treatment arm assignment assessed participants for pain and functional outcomes in telephone interviews conducted at 7 days and 3 months of follow-up. There were no statistical differences between groups in either outcome at either time point. However, the NNH for adverse effects was 7.8 for cyclobenzaprine and 5.3 for oxycodone/acetaminophen.

Based on this information, I plan to prescribe naproxen alone for most patients with acute low back pain and no contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs); reserve cyclobenzaprine for patients who can't use NSAIDs; and prescribe oxycodone/acetaminophen only in patients who can't tolerate NSAIDs or cyclobenzaprine.

E-cigs: promise & perils

- Jennifer Middleton, MD, MPH

Do e-cigarettes containing nicotine help patients quit smoking? A Cochrane for Clinicians in the February 1 issue of AFP reports that their efficacy is better than placebo and roughly equivalent to nicotine patches in helping patients quit. The U.S. Preventive Services Task Force (USPSTF), however, takes a less definitive stance, and providers must weight the possible benefits of e-cigs against the risk of them leading to tobacco smoking initiation among youth.

The Cochrane systematic review identified 13 studies that met their inclusion criteria, 11 cohort studies and 2 randomized controlled trials (RCTs). The placebo in these 2 RCTs was an e-cigarette that did not contain nicotine; 1 study also compared e-cigarettes containing nicotine to the nicotine patch. Pooling the results from these 2 studies, the reviewers found that more participants quit tobacco cigarettes for at least 6 months using e-cigarettes containing nicotine than those who did not (relative risk 2.29, 95% confidence interval [CI] 1.05 to 4.96). The RCT comparing e-cigarettes to patches found no difference in quit rates, though a significant number of e-cig participants did decrease their overall tobacco usage compared to those using the patch. Low event rates led to wide CIs in the RCTs and cohort studies, and the reviewers described their overall confidence in their findings as low, citing both the wide CIs and the overall small number of studies done to date.

The USPSTF gives an "I" grade (insufficient evidence to assess balances of benefits and harms) to recommending e-cigarettes containing nicotine for tobacco cessation; the evidence base just isn't rigorous enough yet to meet their standards. One of those potential harms revolves around youth use. Although most states do not permit e-cigarette sales to minors, use in the under-18 age group is rising. Even more troubling, adolescents who have ever tried e-cigarettes containing nicotine are twice as likely to eventually try smoking tobacco cigarettes. The risk increases with younger age; 11 to 13-year-olds are four times as likely to eventually try smoking tobacco.

E-cigarettes containing nicotine may be useful for tobacco harm reduction in adults who currently smoke, but their availability may be increasing the number of adolescents who start smoking tobacco. Physicians who care for adolescents do a good job of screening for tobacco use, but few are asking specifically about e-cigarette use. Many adolescents believe that e-cigarettes are not only safer than tobacco cigarettes but are more socially acceptable.

As family physicians, we have the opportunity to interact both with adults who want to quit smoking and adolescents whom we hope to keep from initiating tobacco smoking. These studies provide some early guidance while we await further research: e-cigarettes containing nicotine may help adult tobacco smokers quit, and we need to screen for e-cigarette use in our adolescents.

If you'd like to read more, here's a 2014 AFP editorial on e-cigarettes, a 2015 AAFP FMX presentation on e-cigarettes, and the AAFP's Healthy Interventions Tobacco and Nicotine Toolkit.

How are you talking with your patients about e-cigarettes?

New USPSTF and ACP guidelines on depression screening and treatment

- Kenny Lin, MD, MPH

Major depressive disorder is a common condition that responds to psychotherapy and medications, and several screening tools have been validated for use in primary care. However, screening tools will not work if doctors are unable or unwilling to use them; a 2011 analysis by the Robert Graham Center found that family physicians and general internists screened for depression in only 2 to 4 percent of visits. Also, it is not clear if adults with screen-detected depression benefit from treatment to the same extent as those with clinically evident symptoms. This distinction is important since antidepressants may increase suicide risk, and a recent analysis suggested that suicidal ideation is underreported in trials of antidepressants.

In this context, the U.S. Preventive Services Task Force recently reiterated a previous recommendation for primary care clinicians to routinely screen adults for depression, and for the first time found sufficient evidence to screen pregnant and postpartum women. In the Task Force's supporting evidence summary, Dr. Elizabeth O'Connor and colleagues reported:

Among pregnant and postpartum women 18 years and older, 6 trials (n = 11,869) showed 18% to 59% relative reductions with screening programs, or 2.1% to 9.1% absolute reductions, in the risk of depression at follow-up (3–5 months) after participation in programs involving depression screening, with or without additional treatment components, compared with usual care.

A new clinical practice guideline from the American College of Physicians (ACP) reviewed the comparative effectiveness of treatment for major depressive disorder and recommended that "clinicians select between either cognitive behavioral therapy or second-generation antidepressants ... after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient." The ACP arrived at this relatively non-specific guidance after finding few differences between multiple comparisons: psychotherapy vs. medications; medications vs. exercise; medications vs. St. John's Wort; and switching medications vs. adding cognitive therapy. Benefits and harms of treatments were similar between men and women and in subgroups defined by race and ethnicity.

In an accompanying editorial, Drs. John Williams, Jr. and Gary Maslow urged generalist physicians to "seize the day" to improve diagnosis and treatment of depression through integrated primary and mental health care models, which they defined as consisting of "support for self-management, follow-up that includes careful assessment of treatment adherence and response, coordination with mental health specialists to increase access to psychological treatments, and more intensive treatment of refractory depression."

Myth-busting and fact-sharing about Family Medicine

- Jennifer Middleton, MD, MPH

What career options exist for family physicians?
Can I afford to be a family physician?
How do family physicians keep up with the evidence base?

Medical students, other specialists, and even the lay public often have questions about Family Medicine. Kozakowski et al answer these questions and many more in "Responses to Medical Students' Frequently Asked Questions About Family Medicine" in the current issue of AFP. They provide information that debunks common myths about Family Medicine and also demonstrate Family Medicine's incredible breadth of career options:

Myth 1. Family physicians only work in outpatient settings seeing simple/boring problems like colds and minor injuries.

The authors review the numerous practice options available for family physicians:

As a family physician, you will be uniquely trained to provide comprehensive care for acute and chronic conditions, provide wellness care and disease prevention, perform a variety of procedures, and manage care through collaboration with other specialties.

True, most family physicians primarily practice in an outpatient setting, but many also provide inpatient and/or maternity care. Some work part- or full-time in urgent care centers or emergency departments. Most incorporate at least some procedures into their work, and some do a lot of them (see Table 2 for a comprehensive list). On average, we deal with a greater number of patient issues per visit than other specialists, and we're experts in understanding how co-morbid diseases affect each other. One of the reasons that I became a family doctor is the incredible variety of patients and conditions I see; I am never bored!

Myth 2. There's too much to keep up with in Family Medicine; I can't possibly know it all!

The authors tackle this one adeptly:

Family medicine residencies give you the core skills to manage most patient concerns comfortably, acknowledge your limitations, use your resources, and give you lifelong learning skills that allow you to grow and evolve with your patients and interests.

Students should actively seek Family Medicine residency programs that offer a comprehensive evidence-based medicine curriculum; the days where a monthly journal club might suffice are long past. Make sure that you will learn how to critically evaluate new studies, along with having ample mentoring regarding your personal reading plan. Using high-quality secondary literature review resources like AFP, it's more than possible to keep abreast of changes in the evidence base that should affect your practice, and residency is the perfect time to determine what resources you like and how you will integrate reviewing them into your schedule. Many family physicians also rely on social media to stay current with changes in medicine; AFP has a strong Facebook and Twitter presence, as do many other medical journals.

Myth 3. I won't be able to pay off my student loans if I become a family physician.

Family physician salaries are growing quickly in response to the increased need for primary care physicians in the United States. In addition, many health systems are offering sizable loan repayment benefits in their zeal to recruit family physicians (try putting "loan repayment family medicine" into your internet search engine and see what pops up). Fears about loan repayment should not keep individuals passionate about primary care out of our specialty.

On the flip side, here are some powerful facts about our specialty from the article:

Fact 1. A strong primary care infrastructure = higher quality health care at lower cost.

The authors review data showing that countries with a strong primary care base deliver better care for less cost; counties in the U.S. with the right proportion of primary care providers compared to other specialists show the same. Yes, we will always need the assistance of our colleagues in other specialties at times, but if you want to be part of the solution to improve health outcomes in the U.S., you can't go wrong choosing Family Medicine.

Fact 2. Training in Family Medicine provides excellent preparation for global health work.

Global health is about more than tropical diseases and unmet acute care needs; the authors point out that, increasingly, providing care for chronic diseases is equally important. No other specialty provides the breadth of training to prepare for the multitude of acute and chronic conditions at every age and stage of life that you may see across the globe besides Family Medicine.

Fact 3. Family physicians make great health care leaders.

Because we deal with whole human beings, and not isolated disease states, we are uniquely trained to look at the big picture with all of its inherent complexities. Besides this natural inclination to think broadly about challenges, no other specialty devotes as much time in residency training to understanding systems of care than Family Medicine. In addition, if you are passionate about advocating for your patients, AAFP provides a myriad of outlets to do so.

In an accompanying editorial to this special feature, Dr. Winklerprins and AFP's editor, Dr. Siwek, encourage all family doctors to share this article widely, especially with any medical students that you might mentor, since rotating with a family physician is often the most important factor influencing students' decision to join our specialty.