Monday, November 7, 2016

300 posts and still going strong

- Kenny Lin, MD, MPH

Today's post is the 300th for the AFP Community Blog, which I began writing in August 2010. Fellow medical editor Jennifer Middleton, MD, MPH because our second regular contributor in April 2013. In recognition of this milestone, I thought I would revisit some earlier wayposts - namely, our 100th, 150th, 200th, and 250th posts - and provide updates.

#100 - The spiritual assessment: unnecessary or essential? (9/20/12)

While one reader opined that spiritual concerns have "little to do with improving the health of our patients," another countered, "I do not think this article goes far enough in promoting this type of spiritual health assessment." ... Some readers expressed concerns that physicians might seek to impose their religious beliefs on vulnerable patients, while another suggested that "many physicians seem to have more fear of [discussing] spiritual issues than the patients do."

The debate continues about how best to incorporate the spiritual assessment into clinical practice. Earlier this year, the National Cancer Institute's Physician Data Query (PDQ) database published a comprehensive review of spirituality in cancer care that included a list of standardized assessment measures and suggested options for assisting patients with spiritual concerns.

#150 - Preventing recurrent kidney stones (11/4/13)

Researchers examined 28 studies regarding prevention of recurrent nephrolithiasis ... 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, or allopurinol to their 2 liters of water a day, though, had fewer recurrences.

A related POEM in the January 15, 2015 issue of AFP discussed a randomized controlled trial that concluded that ultrasonography is the best initial imaging test for kidney stones in the emergency department (ED), reducing overall radiation exposure compared to initial computed tomography (CT) without differences in rates of return to the ED, pain scores, or complications.

#200 - Lung cancer screening (11/18/14)

Shared decision-making is increasingly recommended by screening guidelines, but I worry that these difficult discussions may not actually take place, even if family physicians are paid to initiate them with patients eligible for LDCT [low-dose computed tomography] screening. Will clinicians merely go through the motions and just order the test?

A 2016 study in a University of Minnesota–affiliated health system found that counseling and shared decision making were documented in less than half of outpatient visits for patients who underwent LDCT for lung cancer screening after publication of the USPSTF guidelines. Although we don't know if this experience is representative of national practice, it certainly isn't good news.

#250: SPRINT and lower systolic BP goals (11/23/15)

Aggressively adjusting medication doses based on what may be inaccurate office BP readings could potentially cause patients significant harm. Most of the time, the JNC 8 guidelines are likely to be more applicable to the patients in our offices than SPRINT's narrowly defined parameters.

No new hypertension guidelines have been issued since the publication of the SPRINT trial, but in August 2016, a majority of cardiologists at the European Society of Cardiology meeting gave a "thumbs down" to lowering blood pressure targets based on the trial's results. An article published in Circulation explained how the measurement technique used in SPRINT would have led to blood pressure readings 5-10 mm Hg lower than in clinical practice.