Thursday, February 20, 2020

Evidence-based guidance for two sleep disorders in adults

- Kenny Lin, MD, MPH

At an American Family Physician editors' meeting several years ago, a colleague, who marveled at amount of academic and clinical activities that I cram into a typical workweek, asked half-seriously, "Do you sleep?" Yes, I answered, not only do I need at least seven hours of uninterrupted sleep each night, I don't feel the least bit guilty about making it a priority. As Dr. Jennifer Middleton wrote in a previous AFP Community Blog post, the negative health consequences of chronic sleep deprivation are legion. Unfortunately, a recent survey found that nearly half of U.S. military personnel report poor sleep quality. From 2003 to 2011, the incidence of insomnia and obstructive sleep apnea (OSA) in active duty U.S. Army soldiers increased by 652% and 600%, respectively.

Concerns about these two common sleep disorders led the U.S. Departments of Veterans Affairs (VA) and Defense (DoD) to develop a joint clinical practice guideline for their diagnosis and management; a synopsis was published this week in Annals of Internal Medicine. Key recommendations for treating chronic insomnia (insomnia occurring for three or more nights per week for three or more months) generally agree with those from a 2016 American College of Physicians guideline and Agency for Healthcare Research and Quality review: offer cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, and reserve short-term pharmacologic therapy (low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists) for patients who are unable to access or complete CBT-I.

The VA/DoD panel suggests not using antipsychotic drugs, benzodiazepines, or trazodone for chronic insomnia due to harms outweighing benefits or lack of benefit. It also advises against two common ingredients in over-the-counter sleep aids, diphenhydramine and melatonin. The panel suggests that clinicians not use sleep hygiene education as a standalone treatment due to its limited effectiveness and potential to discourage patients from pursuing the more effective CBT-I.

For OSA, the VA/DoD guideline suggests using the STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure) to stratify risk in patients who report sleep symptoms and performing home sleep apnea testing rather than in-laboratory polysomnography in patients with a high pretest probability of OSA. Although continuous positive airway pressure (PAP) therapy is recommended for persons with severe OSA, mandibular advancement devices may be used as an alternative in mild or moderate cases. The VA/DoD panel did not evaluate positional therapy (techniques to promote side sleeping) for OSA. However, a recent Cochrane review found that patients are more likely to tolerate and adhere to positional therapy than PAP, compensating somewhat for the former's lower effectiveness.

Monday, February 10, 2020

Obtaining a detailed sexual health history: why and how

- Jennifer Middleton, MD, MPH

Conversations about sexual health are critical to ensuring that all persons eligible for PrEP (pre-exposure prophylaxis for HIV) receive it. The AFP review article on "Sexual Health History: Techniques and Tips," epublished ahead of print this past week, provides pragmatic guidance to obtain the often sensitive history elements required to meet these aims.

The authors encourage physicians to take a proactive approach to obtaining a sexual history. They review steps to creating an environment conducive to sexual history conversations, introduce the "5 Ps" model (partners, practices, past STI history, pregnancy plans, pleasure) for obtaining a detailed sexual history, and remind readers of trauma-informed care resources to minimize retraumatizing victims of prior abuse.

In addition to these universally useful tips, the February 1 AFP review article on "Screening and Counseling Young Adults" emphasizes the importance of providing adolescents with the opportunity to be evaluated confidentially by a physician, as teens are then more likely to disclose sensitive information. The SSHADESS tool advocates for a strengths-based interviewing approach instead of focusing solely on risks. "Clinicians should thank patients for disclosing personal information, share their concerns respectfully and empathetically..., and reflect patients' previously disclosed examples of resilience."

Both adolescents and adults can lower their risk of HIV infection with PrEP. As this editorial, also just epublished ahead of print, succinctly states:
Taking a thorough and complete sexual history can assist with screening and treatment of sexually transmitted infections, which are currently at record high levels and can facilitate HIV acquisition.
Roughly 1 million persons in the United States are candidates for PrEP, but only about 77,000 received prescriptions in 2016 (latest year for which data is available). Black and Hispanic men who have sex with men were less likely to receive PrEP prescriptions than white men in one study; this same study showed that rates for PrEP initiation are similar across all backgrounds if patients were offered PrEP by their physician. Obtaining an adequate sexual health history on all of our patients, regardless of their race or ethnic background, may help to correct this disparity.

You can find more information about identifying persons who may benefit from PrEP in the CDC's 2017 Clinical Practice Guideline, which is summarized on the CDC PrEP website. Relevant AFP resources include this overview of the United States Preventive Services Task Force (USPSTF) "A" recommendation to prescribe PrEP, this POEM on "Preexposure Prophylaxis with Tenofovir/Emtricitabine Prevents HIV Infection in Men Who Have Unprotected Anal Intercourse," and the AFP By Topic on HIV/AIDS.

Tuesday, February 4, 2020

Preparing to respond to the novel Wuhan coronavirus

- Kenny Lin, MD, MPH

In a 2015 editorial on global health in American Family Physician, Drs. Ranit Mishori and Jessica Evert noted that "the world is not only smaller than ever, but it is also more intricately connected," with transportation networks facilitating the spread of exotic infectious diseases across oceans and borders. These words seem prescient today as China, the World Health Organization, and the international community work feverishly to contain the outbreak of the 2019 novel coronavirus (2019-nCoV), which was initially reported in patients with pneumonia in Wuhan, Hubei Province, China but has spread via travel and person-to-person transmission to 24 other countries, including 11 confirmed cases in the United States as of February 3. As scientists race to answer basic questions about this new respiratory infection, travel to China has been heavily restricted, U.S. citizens have been evacuated from the region, and travelers recently returned from Hubei Province are being quarantined by state governments.

To keep clinicians up-to-date on the evolving epidemic, the Centers for Disease Control and Prevention (CDC) has posted a comprehensive collection of resources for health care professionals who encounter patients with suspected 2019-nCoV, including an assessment flowchart and interim management guidance for patients with confirmed infection. Forward-thinking family physicians can also consult a previous Family Practice Management (now FPM) article for tips on on preparing your office for an infectious disease epidemic. Key points highlighted in this article include:

- Begin planning now.
- Master the detection, prevention and management of seasonal influenza and community-acquired pneumonia.
- Practice scrupulous infection control - "wash in and wash out."
- Communicate at all levels, and coordinate with public health agencies.
- Focus on staff management and business continuity.

Although the origin of the 2019-nCoV is not known, the linkage of the majority of early infections to a wholesale seafood market suggests the existence of an animal reservoir. A previous novel coronavirus outbreak that began in China, severe acute respiratory syndrome (SARS), was eventually traced to infected bats. However, the estimated 2% fatality rate of 2019-nCoV is substantially lower than the 10% fatality rate of SARS. In addition, it's important to remind worried patients that the CDC projects that the less lethal but far more prevalent (and preventable) seasonal influenza virus will cause 180,000-310,000 hospitalizations and 10,000-25,000 deaths during the current flu season.

Monday, January 27, 2020

Decreasing opioid use with mind-body therapies

Jennifer Middleton, MD, MPH

Decreasing the amount of opioids patients with acute or chronic pain use is often desired, as opioid medications carry a sizable risk of adverse effects, including the risk of addiction. Less well understood, though, has been just how to decrease the amount of opioid pain medication needed without undertreating patients' pain. A recently published systematic review may have the answer; the studied "mental techniques to ameliorate pain" may improve pain and decrease the amount of opioid pain medication patients require.

The researchers' literature search identified 60 articles, including Cochrane meta-analyses, that examined the effect of adding various mind-body techniques (MBTs) to opioid pain medication for patients with either acute or chronic pain. They sought to focus on psychological treatments:
We elected to focus our review on MBTs that primarily use mental techniques because they may be more accessible to people whose mobility is compromised by pain or used for pain relief during inpatient procedures when patients are immobilized.
Most of the included studies were randomized controlled trials. Outcome variables included pain severity, opioid misuse, time to opioid cessation, and amount of opioid use. The most effective modalities were meditation, hypnosis, and cognitive behavioral therapy. Included studies regarding relaxation, guided imagery, and therapeutic suggestion found less consistent benefit for these modalities. The authors included a bias assessment which found most included studies designated an appropriate control group and had a low risk of bias.

Although hypnosis and cognitive behavioral therapy typically require referral to a trained practitioner, patients can engage in simple meditation techniques with only a little guidance. A 2018 FPM article reviews "Five Mobile Apps for Mindfulness," some of which are subscription-based, but all of which include at least some content for free (and Insight Timer, available for iOs and Android, has thousands of free mediations). Mindfulness-based interventions, such as meditation, have shown promise for improving mental health and quality of life in the primary care setting. Most patients are willing to consider alternative treatment modalities after discussion with their primary care physician. Expanding our toolkit for treating pain beyond medication may not only benefit our patients but may also protect them from unnecessary opioids.

There's a recent Curbside Consultation on "Tapering Long-Term Opioid Therapy" and an AFP By Topic on Complimentary and Alternative Medicine that includes a sub-section on Mind-Body Modalities if you've like to read more.


Tuesday, January 21, 2020

America needs more family doctors: working toward the 25 x 2030 goal

- Kenny Lin, MD, MPH

Last summer, a Graham Center Policy One-Pager reported that the percentage of the active U.S. physician workforce in primary care practice declined from 32 percent in 2010 to 30 percent in 2018. Although family physicians represent 4 in 10 primary care physicians, in several states a large percentage of family physicians are older than 55 years and anticipated to transition to part-time practice or retire by 2030. Recognizing the imperative to not only maintain, but expand the family medicine workforce to meet the population's needs, the Workforce and Education Development team of Family Medicine for America's Health recommended adoption of a shared aim known as 25 x 2030: to increase the percentage of U.S. medical students choosing family medicine from 12% to 25% by the year 2030. Supported by the American Academy of Family Physicians and seven other national and international family medicine organizations, the America Needs More Family Doctors: 25 x 2030 collaborative was officially launched in August 2018.

In an editorial in the January 15 issue of American Family Physician, Dr. Jacob Prunuske, a member of the 25 x 2030 Steering Committee, described the collaborative's guiding principles, benefits to physicians at all levels of experience, and how family doctors in the trenches can support progress toward this ambitious aim:

Recruit before medical school. Encourage children and young adults to not only go to medical school, but to become a family doctor. Active recruitment is especially valuable in underserved or rural communities and for those underrepresented in medicine.

Change the medical school experience. When you have the opportunity to work with medical students, say yes. If you must say no, reflect on what it would take to get you to say yes, and share your reflections with your health care system, institution, or the 25 × 2030 working groups so that they can address barriers to teaching. As preceptors for medical students, family doctors not only teach family medicine principles, but also serve as mentors and role models. Embrace this role. Debunk myths and counter negative stereotypes of family medicine. Family doctors provide high-value care by delivering high-quality outcomes while controlling costs. Medical students need this experience with practicing family doctors to combat the alternative messages of other specialties.

Advocate for family medicine. Legislative leaders need to hear about the value of family medicine from voters. Respond to advocacy calls, and advocate at the local, state, and national levels for changes that support family medicine. Share your advocacy efforts with your patients and tell them why these issues matter to you, them, and all of us.

Embrace change. Patient expectations, technology, and health systems will evolve. Rather than react, help guide these changes to fit the principles of family medicine.


An excellent resource for interested medical students is AFP's 2016 article, "Responses to Medical Students' Frequently Asked Questions About Family Medicine," which answers common questions about the importance of the specialty, residency and fellowship training, procedural skills and scope of practice, economic realities, and future prospects. The article advised students that "the best way to know if family medicine is the right fit for you is to work with family physicians in action, by doing a rotation with a family physician in practice." An upcoming AFP editorial will discuss why even more community family physicians should take the time and effort to precept students in their practices.

Monday, January 13, 2020

Should schools screen for adolescent idiopathic scoliosis?

- Jennifer Middleton, MD, MPH

I still remember lining up with my female peers in junior high gym class, clad only in undergarments (quite the height of teenage mortification), to bend over and have our spines checked for scoliosis. Such school-based screenings remain commonplace across the US, though there is considerable debate regarding their benefit. The January 1 AFP review on "Adolescent Idiopathic Scoliosis: Common Questions and Answers" discusses the current United States Preventive Services Task Force "I" statement regarding screening and its rebuttal by several medical organizations including the American Academy of Pediatrics and the American Academy of Orthopedic Surgeons. Although the evidence base leans away from screening, family physicians are still likely to encounter adolescents and their worried parents with positive screens in our offices.

Repeating the forward bend test in the office and looking for an abnormal appearance of the back or ribs is a reasonable first step. The AFP authors review a study that found the forward bend test has a 92-100% sensitivity for detecting a Cobb angle of at least 20 degrees. While the patient is bending over, clinicians may also use a scoliometer or a scoliometer app to quantify trunk rotation. Sensitivity to detect a Cobb angle of at least 10 degrees is highest with a scoliometer cutoff of 5%, but a cutoff of 7% has a better specificity (87% compared to 47%) with a small corresponding loss of sensitivity (down to 83%). Radiography can definitively make the diagnosis and quantify severity.

The AFP authors point out that evidence is lacking regarding the benefit of referring all but the most severe cases of scoliosis (Cobb angle of 40 degrees or greater) to an orthopedic surgeon. Family physicians should also discuss the prognosis for mild to moderate scoliosis with their patients and parents; the evidence review that informed the USPSTF's "I" decision found that:

Quality of life [measures]...were similar between observed and braced participants at adult followup, though braced participants felt their body appearance was more distorted than did untreated participants, and braced participants reported more negative treatment experiences than those treated surgically. No significant adult outcome differences were found between braced and surgically-treated participants on the Oswestry Disability Index, general well-being, or self-esteem and social activity. Pulmonary outcomes and childbearing and pregnancy outcomes were similar in braced and surgically-treated participants.

School-based nursing programs might more effectively target their efforts toward other disease processes (and their risk factors). In an era of school nursing shortages across the US, prioritizing school-based health efforts is more important than ever. The National Association of School Nurses does not include reference materials about scoliosis anywhere on their website, focusing instead on more prevalent and more impactful issues such as childhood obesity, drugs of abuse, mental health, and reproductive health.

There's an AFP By Topic on Musculoskeletal Care if you'd like to read more, and here is additional AFP content specifically regarding scoliosis as well.

Tuesday, January 7, 2020

AAFP-endorsed practice guideline supports limiting testosterone prescriptions

- Kenny Lin, MD, MPH

Is age-related low testosterone normal or a disease? If it is a disease, what are the benefits and harms of testosterone therapy? A previous AFP Community Blog post reviewed the controversy surrounding screening for low testosterone in older men and the U.S. Food and Drug Administration's requirement that prescription testosterone product labeling include warnings about a possible increased risk of heart attacks and strokes. A recent analysis of Medicare data found that testosterone prescribing peaked in 2013 and has since declined, but that prescribing rates were actually higher for men with coronary artery disease (CAD) than men without CAD. Meanwhile, another study suggested that men prescribed testosterone therapy have an increased risk of developing venous thromboembolism in the first 6 months of use.

Today the American College of Physicians (ACP) published a clinical practice guideline, endorsed by the American Academy of Family Physicians (AAFP), to provide evidence-based recommendations for primary care and subspecialist clinicians on treatment of men with age-related low testosterone. Based on an independent systematic review of the efficacy and safety of testosterone treatment, the ACP and AAFP suggested that clinicians discuss potential benefits, harms and costs of therapy with patients with age-related low testosterone and sexual dysfunction. The guideline recommended against initiating testosterone treatment for the purpose of improving energy, vitality, physical function, or cognition, due to the lack of benefits in randomized trials. Since some men will not respond to treatment, the guideline suggested re-evaluating symptoms within 12 months of initiating testosterone therapy, and discontinuing treatment if sexual function does not improve.

Studies assessing patient preferences reviewed by the ACP showed mixed preferences for injectable versus topical testosterone; the most bothersome symptoms were erectile dysfunction, decreased sex drive, and loss of energy; and moderately high therapy discontinuation rates in two studies (30 and 62 percent). Since transdermal testosterone costs an average of 14 times as much as intramuscular ($2135 vs. $156 for a year's supply in 2016, respectively) and has similar clinical effects and harms, the ACP and AAFP suggested considering intramuscular rather than transdermal formulations.

Although the guideline did not directly address the relatively common phenomenon of testosterone treatment in men without low testosterone levels, the American Society of Clinical Pathology, the American Urological Association, and the Endocrine Society have all advised against this type of prescribing to improve erectile dysfunction or any other symptom.