Virtuous cycling: lower diabetes risk, but wear a helmet

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

I (Jennifer) live in a community with a wonderful bicycle path system, and around this time of year it gets a lot of use. In a 2011 Letter to the Editor titled "The Virtuous Cycle," AFP Deputy Editor Mark Ebell, MD, MS encouraged readers to advocate in their communities for "safe, convenient, and enjoyable places to walk, run, and bike" rather than continuing to "harangue our patients about exercise and be frustrated when they do not listen to us."

Sensible advice, but do recreational and commuter cyclists have better health outcomes than non-cyclists, is it enough to cycle during only part of the year, and is it ever too late to get on the bike? A prospective cohort study of more than 50,000 Danish men and women recruited between the ages of 50 and 65 and followed for an average of 14 years recently provided answers to these questions. In a multivariable analysis, both seasonal and year-round cyclists had up to a 20 percent reduced relative risk for developing type 2 diabetes, even if they started cycling late in life.

The health benefits of cycling can be easily negated, though, by the risks of not wearing a helmet. Even though helmet-wearing cyclists are more likely to survive trauma than those not wearing helmets, and despite laws mandating helmets across the country, many bicycle riders continue to go bareheaded. A 1999 survey found the most common reasons for not wearing a helmet included "uncomfortable," "annoying," "it's hot," "don't need it," and "don't own one." This survey also found that peer and/or parent wearing of helmets increased the likelihood that children wore them too.

A review of children's cycling accidents from the National Trauma Data Bank found that white children and/or children with private insurance were much more likely to wear a helmet than African-American children and/or children with Medicaid. Another study in Los Angeles County found lower helmet use among older children, non-white children, and children from a low socioeconomic status. Programs that give away free helmets to children either in schools or in physicians’ offices increase helmet use and may reduce health disparities. Although physician counseling also increases helmet wear in patients under age 18, in one survey less than half of physicians providing care to this age group provided it. Unfortunately, there haven't been any studies of interventions to increase helmet wearing in adults.

The bottom line is that encouraging patients to start cycling for long-lasting health benefits should be accompanied by counseling on the importance of wearing helmets.

Guest Post: preventing sexual assualt

- Yalda Jabbarpour, MD

“You don’t know me, but you’ve been inside me, and that’s why we’re here today.” So began the statement of Brock Turner’s victim at his sentencing this spring. Turner, a former Stanford University student, was found guilty of three counts of sexual assault, but his 6 month sentence sparked outrage. Although this case brought renewed interest to the problem of sexual assault, the sad truth is that it is not unique. A recent poll conducted by the Washington Post and Kaiser Family Foundation found that 20 percent of young women reported being sexually assaulted on their college campuses in the past four years. 1 in 5 women. As a mother and family physician who cares for adolescents, these statistics are frightening, especially considering the life-long physical and psychological consequences for the victims.

According to a 2010 article in AFP, sexual assault is associated with sexually transmitted infections (STIs), posttraumatic stress disorder, anxiety, depression, chronic pain syndromes, drug and alcohol abuse, irritable bowel syndrome, headaches, fibromyalgia and sexual dysfunction. Sexual assault is a true public health crisis. What can family physicians do to curb this epidemic?

Much of the literature on the physician’s role in sexual assaults deals with the aftermath: collection of the rape kit, post-exposure STI prophylaxis, identifying and treating long term physical and psychological sequelae. But I would argue that, as is the case in much of what we do, prevention is the key. I propose we start by defining the problem for our patients. In the Post/Kaiser poll, 46 percent of college-aged respondents said it’s unclear whether sexual activity that occurs when both people have not given clear agreement constitutes sexual assault. This means that we need to have open and honest conversations with adolescents and young adults about the need for both parties to give consent before having sex. Establishing rapport is key to broaching sensitive topics with adolescents, and to do this, it is important to ask adolescents specific questions about their practices rather than stating general facts.

Once we have defined the problem, we need to counsel patients on the risk factors associated with it and how to mitigate those. Race, ethnicity, social class, study habits or religious practices were not related to sexual assault in the Kaiser poll. However, women who said they sometimes or often drink more than they should are twice as likely to be victims of completed, attempted or suspected sexual assault compared with those who rarely or never do. Therefore, counseling men and women on responsible drinking strategies—such as using a buddy system, pouring their own drinks, and knowing their limits—is key.

Certainly, physicians alone cannot solve the issue of sexual assault, but we should consider addressing it in every preventive health discussion we have with college-aged students. When sharing her solidarity with other victims of sexual assault, the Stanford victim appropriately quoted Anne Lamott: “Lighthouses don’t go running all over an island looking for boats to save; they just stand there shining.” It may not be within our power, or our job description, to stamp out sexual assault, but physicians can serve as lighthouses, helping to illuminate for our patients a safe path through their college careers.

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Dr. Jabbarpour is the Robert L. Phillips, Jr. Health Policy Fellow at Georgetown University School of Medicine.

Stepping up counseling about sun safety

- Jennifer Middleton, MD, MPH

The U.S. Preventive Services Task Force (USPSTF) is currently updating its 2012 recommendations regarding counseling to prevent skin cancer, and it couldn’t come at a better time, as the incidence of malignant melanoma continues to rise. The USPSTF found previously that counseling fair-skinned individuals aged 10-24 increases the use of sun-protective behaviors, but this counseling isn’t happening frequently enough in primary care.

A 2004 study of family physicians found that only 60% were routinely providing counseling about sun protection and skin cancer prevention; commonly cited barriers to doing so included lack of time and limited information about the effectiveness of counseling. A more comprehensive survey in 2014 found that family physicians provided sun safety counseling far less frequently, and usually only in association with specific patient diagnoses such as actinic keratosis or a history of other skin problems. In contrast to what the evidence supports, the age group most likely to receive counseling in this study was adults in their 70s; counseling at child and young adult visits was rare. Since only 30% of adults regularly follow sun safety practices, and tanning in young adults remains highly prevalent, there are ample opportunities for family physicians to make a difference for our patients by providing this counseling.

Other effective interventions may be worth incorporating into your practice as well. Mailing personalized handouts about skin cancer prevention increased sun safety behaviors (use of sunscreen, protective clothing, hats, and sun avoidance) more than providing generic handouts in one study. In another study, calculating a melanoma risk score (SAMScore) and targeting counseling to patients at higher risk decreased sunbathing. Counseling young adults about tanning should elicit the specific reasons why they tan; physicians can then target their messages, such as discussing sunless tanning products, alternative methods to relax, or debunking the myth that a tan protects against further skin damage. 

Helping patients adopt healthier behaviors is an important part of the primary care clinician's role, and applying motivational interviewing techniques along with tailoring our counseling to each patient’s stage of change may be useful. Having a structured practice intervention to help patients adopt sun safety measures may also reduce the burden on individual clinicians.

25 podcast episodes every family physician should listen to

- Marselle Bredemeyer

As an associate editor in the AFP editorial offices in Leawood, KS, I work alongside our authors and other non-physician staff to help craft each issue of the journal. We use checklists, stylebooks, and calculators to prepare articles for press, guided by our readers and their needs throughout the process. More than merely gauging the readability of a sentence, this means visualizing the big picture: the information we provide being used at the point of care, as research material, or for continuing education. This picture comes together over time, by staying tuned in to comments we receive on the website, phone, through e-mail, and via social media (Twitter and Facebook), where I love to see replies and messages about the content I am sharing.

My sketch of the family medicine specialty has largely been shaped by these experiences, but the voice that sticks in my mind as I work comes from a podcast, an early episode of Slate’s “Working” that featured a family physician from Washington, D.C. Whether you’re new to podcasts or a long-time listener, the format’s storytelling power and lasting impact are what make it stand out.

As the number of podcasts continues to grow, so has an emphasis on the deep-listening strategies that can improve patient care in the office setting. Shared decision making is often a central part of care, from screening practices to end-of-life planning. Hearing what patients are saying and communicating with them in a way that meets their needs can transform their health, even at routine visits.

With that in mind, podcasts, and their ability to make us engage with others’ stories, might be useful to physicians as they look for ways to take in new information, and above all, try to stay tuned in to the underlying messages their patients are sharing. Want to start listening or add new favorites to your queue? With the help of AFP Podcast hosts Steve Brown, MD, Jake Anderson, DO, and Luke Peterson, DO, the four of us have come up with a family medicine podcast playlist that features a variety of shows talking about medicine, public health, and patient relationships. If the tweet might help medical students learn better note-taking, the podcast might help us all be better listeners.

What are you listening to? Share this post and add your own favorite episodes when you do!

AFP Podcast
Bonus Episode with J. Lloyd Michener, MD

Only Human
Doctor Stories: The Patient I’ll Never Forget
How to Stop an Outbreak

This American Life
Something Only I Can See

Embedded
The House
The Hospital

Questioning Medicine
The Dexa Scam

Sawbones: A Marital Tour of Misguided Medicine
Syphilis
Heroes of Patent Medicine

Invisibilia
The Secret History of Thoughts
The Problem with the Solution

Best Science Medicine
Televised Medical Talk Shows (paid subscription required; listen to new episodes for free on iTunes)

Radiolab
The Cathedral
Staph Retreat
Patient Zero: Updated
Elements
Birthstory

A Gobbet o’ Pus 810
Occam and Fallacies

99% Invisible
Fountain Drinks

Planet Money
The Experiment Experiment
Black Market Pharmacies
Your Organs Please
Clipping Coupons for Health Care

Freakonomics
How to Become Great at Just About Anything
How Many Doctors Does It Take to Start a Healthcare Revolution?

Point-of-care tests reduce antibiotic use for acute respiratory infections

- Kenny Lin, MD, MPH

In last week's blog post, Dr. Jennifer Middleton discussed the strengths and limitations of rapid strep testing for patients with acute sore throats. In patients with an intermediate pre-test probability of having streptococcal pharyngitis, a negative rapid strep test lowers the post-test probability enough to feel comfortable withholding antibiotics. Wouldn't it be nice if other point-of-care tests could effectively rule out bacterial infections and reduce antibiotic prescribing rates in patients with acute respiratory symptoms?

A FPIN Clinical Inquiry published in the July 1st issue of AFP evaluated the effects of a procalcitonin-guided antibiotic therapy algorithm on antibiotic use and clinical outcomes. A Cochrane review and meta-analysis of 14 randomized, controlled trials (RCTs) comparing procalcitonin-guided to standard care in European adults with acute respiratory infections found that patients in the procalcitonin group received 3.47 fewer days of antibiotic therapy with no differences in 30-day mortality or treatment failure. In a single RCT of 337 children presenting to pediatric emergency departments in Switzerland, patients in the procalcitonin group were as likely as the standard care group to receive antibiotic prescriptions, but received nearly 2 fewer days of therapy.

A 2015 Cochrane for Clinicians examined the performance of point-of-care measurement of C-reactive protein (CRP) on similar outcomes. Although treatment thresholds varied, most studies considered a CRP level of less than 20 mg per L to suggest a viral infection and no need for antibiotics. A Cochrane review of 6 RCTs conducted in primary care settings (mostly in adults) in Europe and Russia found that groups assigned to CRP-assisted evaluation were 22 percent less likely to receive antibiotic prescriptions for acute respiratory infections, with no differences in clinical improvement at day 7, complications, or mortality. However, Dr. Irbert Vega observed in the Practice Pointers that "the meta-analysis did not identify an optimal algorithm and therefore should be considered proof of concept until further research can be performed, including research in the U.S. population."

Upcoming editorials and features in AFP will discuss the effectiveness of other interventions aimed at reducing unnecessary antibiotic use for respiratory infections in primary care settings, including those evaluated in a recent systematic review from the Agency for Healthcare Research and Quality.

To rapid strep test or not to rapid strep test?

- Jennifer Middleton, MD, MPH

My medical assistant will routinely ask me if I want a rapid strep test for patients presenting with sore throat. I'm pleased that she asks, because it doesn't seem that long ago that every patient who walked in the door with a sore throat got tested. As the authors of Common Questions About Streptococcal Pharyngitis review in the July 1 issue of AFP, only patients with an intermediate risk of strep pharyngitis should get a rapid strep test; point-of-care tools can help physicians quickly make that assessment.

The authors assert that:

Results from rapid antigen detection testing (RADT) should be used in conjunction with a validated clinical decision rule such as the modified Centor score or the FeverPAIN score. Patients at low risk of GABHS pharyngitis can be treated symptomatically, RADT should be ordered for those at intermediate risk, and empiric antibiotics are an option for those at high risk.

Unfortunately, the rapid antigen test for streptococcal pharyngitis is not perfect. A recent meta-analysis found a combined sensitivity for the various types of rapid strep tests of 80% (95th confidence interval [CI] 77-82%) for pediatric patients and 94% (95th CI 80-99%) for adult patients; for specificity, use of rapid tests in pediatric patients was 93% (95th CI 92-93%) and in adults was 69% (95th CI 54-81%). Because this test can result in either a false positive or a false negative result a significant minority of the time, it is most useful in patients with an intermediate pre-test probability of having strep pharyngitis. If you're clinically convinced that the patient does or does not have strep pharyngitis, this imperfect test shouldn't change your clinical management.

The AFP article authors review the scoring systems most commonly used to assess the pre-test probability of strep pharyngitis, the Centor score and the modified Centor score. Both of these clinical decision rule scores are available in several point-of-care applications ("apps") for smartphones and tablets: MediMath, Qx Calculate, and MDCalc all include the Centor and modified Centor scores, to name a few. Scrolling through the scores and risk calculators on these apps, I'm continually surprised by what I see; often, I'm reminded of something that I had once heard of, intended to use in my practice, and then promptly forgot about.

Since many of these calculators involve inputting basic clinical information, office staff could easily be trained to use them. Integrating them directly into an electronic health record (EHR) system makes a lot of sense, too - wouldn't it be useful if your EHR could calculate the Centor score based on the history and exam you've documented while assessing the patient?

Family Practice Management has an ongoing feature that uses the "SPPACES" criteria to rate the quality of medical apps; you can find the collection of their app reviews here if you're interested in learning more about what's available for your smartphone and/or tablet. Of course, you can also link to online reference calculators using the AFP home page "Favorites" feature if you prefer to work off your desktop or laptop computer.

How are you using point-of-care tools in your practice?