Tuesday, August 28, 2012

Screening for chronic kidney disease

- Kenny Lin, MD

In patients without diabetes or hypertension, there is not enough evidence to assess benefits and harms of screening for chronic kidney disease with a serum creatinine level or urine albumin testing, the U.S. Preventive Services Task Force reported yesterday. A 2011 AFP article on chronic kidney disease detection and evaluation noted that multiple organizations recommend screening in patients with cardiovascular disease or diabetes, and a systematic review performed to support the USPSTF recommendation found that angiotensin-converting enzyme inhibitors slowed progression to end-stage renal disease and decreased mortality if prescribed in the early stages of this condition. However, few studies included patients without diabetes or hypertension.

For family physicians, the bottom line from this recommendation is that there is no clinical indication for ordering a basic metabolic profile or urinalysis in an asymptomatic patient as part of a preventive health evaluation. Ordering such unnecessary tests frequently does more harm than good, and has been discouraged by the AAFP-supported Choosing Wisely initiative and a previous AFP editorial.

Wednesday, August 22, 2012

Prescribing opioids for chronic pain: avoiding pitfalls

- Kenny Lin, MD

For years, family physicians who treat patients with chronic nonterminal pain have been caught between a rock and a hard place: national surveys show that chronic pain is undertreated, but opioids often have serious adverse effects and can lead to dependence, addiction, and abuse. A recent AFP review article advised comprehensive assessments for patients with chronic pain, careful patient selection using an opioid risk tool, and use of written agreements that "outline appropriate intervals for follow-up, refill policies, participation in any indicated multimodal management plan (e.g., physical therapy, psychological treatment), use of only one prescriber and one pharmacy for all controlled medications, and prohibition of illicit substance use or prescription diversion." In July, the U.S. Food and Drug Administration, in consultation with the AAFP, required that manufacturers of prescription opioids pay to support new voluntary educational programs for clinicians and patient education materials designed to reduce opioid misuse and its consequences.

An editorial in this week's Archives of Internal Medicine questioned whether there is a true difference between opioid "dependence" and "addiction," noting that a Washington state law that limited the amount of opioid that can be prescribed for chronic pain led to many patients experiencing persistent withdrawal effects after being tapered to lower doses. The authors concluded: "Dependence on opioid pain treatment is not, as we once believed, easily reversible; it is a complex physical and psychological state that may require therapy similar to addiction treatment, consisting of structure, monitoring, and counseling, and possibly continued prescription of opioid agonists." What has been your experience in prescribing opioids for patients with chronic nonterminal pain?

Thursday, August 16, 2012

Screening for hepatitis C in Baby Boomers

- Kenny Lin, MD

Today, the Centers for Disease Control and Prevention finalized new recommendations for one-time screening for the hepatitis C virus (HCV) in all persons born between 1945 and 1965, a generation better known as the "Baby Boomers." The CDC's new recommendations are published in the Annals of Internal Medicine. Previously, the CDC only recommended that persons with behavioral or medical risk factors for HCV be routinely tested. The rationale for expanded screening in persons age 47 to 67 is that more than 75% of persons with antibodies to HCV (demonstrating evidence of prior infection) belong to this age group,  due to a higher prevalence of injection drug use. Since more than half of adults with HCV are unaware that they are infected, the CDC recently estimated that routine screening and treatment of infected persons in this "birth cohort" would be cost-effective.

It remains unclear what impact the new CDC recommendations will have on primary care, given that the American Academy of Family Physicians continues to follow the U.S. Preventive Services Task Force's 2004 guideline, which states that there is insufficient evidence to screen persons at high risk of HCV infection, and recommends against screening adults in the general population. The CDC's and USPSTF's contrasting views previously provoked a lively debate in the editorial pages of American Family Physician, with the USPSTF arguing that screening had not been shown to reduce morbidity or mortality from HCV, and the CDC countering that disease-oriented benefits should eventually translate into positive long-term health outcomes for patients. In fact, the new CDC guideline makes it a point to explain why the two organizations may continue to differ in their recommendations:

The USPSTF prefers data from randomized, controlled trials that begin with randomization into screened and nonscreened groups and follow participants through to morbidity and mortality, yet these data are not available. Although these types of studies provide the most conclusive evidence about the benefits and harms of a screening intervention, they also are resource-intensive and require long periods of follow-up. The CDC based its HCV testing recommendations on the prevalence in the target population, the many persons who are unaware of their infection status, potential benefits of care and treatment, and projections of increasing morbidity and mortality in the absence of an intervention.

According to a recent AFP review article, chronic HCV infection "leads to cirrhosis in about 10 to 20 percent of patients, increasing the risk of complications of chronic liver disease, including portal hypertension, ascites, hemorrhage, and hepatocellular carcinoma." Due to the increased risk of alcohol-induced liver damage in patients with HCV, the CDC also recommends brief screening and intervention for alcohol misuse at the time of HCV diagnosis, a position supported by the USPSTF.

Thursday, August 9, 2012

Checking the resurgence of pertussis

- Kenny Lin, MD

According to several news stories, more than twice as many cases of pertussis (whooping cough) have already been reported in the U.S. this year than in all of 2011. Although some of the disease resurgence may be due to increasing rates of vaccine refusal, experts are concerned that another culprit may be waning immunity from the acellular pertussis vaccine that has been used in the U.S. since the 1980s. Although a recent Cochrane review concluded that acellular pertussis vaccines (preferred due to their lower incidence of side effects) were as effective as whole-cell vaccines, the review relied mostly on indirect comparisons and limited follow-up intervals. In contrast, an Australian study published in the August 2nd issue of JAMA found that acellular vaccines were clearly inferior to whole-cell vaccines in preventing pertussis 10 to 12 years after vaccination.

In order to prevent new pertussis infections, especially in infants who are too young to be immunized, all adolescents and adults should receive Tdap immunizations instead of the traditional Td booster. To encourage patients to receive age-appropriate immunizations, parents should be counseled about vaccine safety, and standing orders and patient reminders instituted to prompt physicians and support staff when immunizations are recommended. Additional information on immunizations for pertussis and other vaccine-preventable diseases is available in the AFP By Topic collection.

Thursday, August 2, 2012

Treating common ailments of Olympic athletes

- Kenny Lin, MD

As I write, competitors at Summer Olympic Games in London are pushing their bodies to their physical and mental limits, leading to plenty of work for family physicians and other sports medicine clinicians. Elite endurance cyclists and long-distance runners encounter a host of common problems, ranging from overuse injuries to heat-related illnesses. Runners and gymnasts also are at increased risk for lower extremity stress fractures. Tennis players traditionally suffer from lateral epicondylitis, while basketball and soccer players are vulnerable to ankle sprains and anterior cruciate ligament injuries when they step on to the court or field of play. Beach volleyball star Kerri Walsh recently underwent multiple surgeries for acute shoulder injuries suffered during championship-level competitions. Swimmer Jessica Hardy, competing in several events at the current Games, also qualified for the 2008 Summer Games in Beijing but withdrew and served a one-year ban from the sport after testing positive for a banned sports supplement.

With such an extensive variety of ailments that might surface during the Summer Games, U.S. team physicians and medical personnel can at least breathe a sigh of relief that the athletes' medical records are, for the first time, being stored digitally. As Alice Park recently wrote in Time magazine:

While fans can follow their favorite Olympian via Twitter and texts, and get real-time updates on their activities, until this Games, medical records were handled in a conspicuously old-school way — shipped, in dozens of palettes, to the Games. For Beijing, the files literally took a slow boat to China, says Dr. Bill Moreau, managing director of sports medicine at the USOC. “Heaven forbid that an athlete would actually need something from their record while it’s being shipped, or on the ocean, or stuck in a harbor,” he says. With the electronic records, anyone caring for an Olympic athlete, from a trainer to a physical therapist to a physician treating an emergency injury, can get a quick look at the athlete’s medical history at a glance, and update it with the latest developments.

That's medical progress that all of us watching from home can cheer about!