Friday, July 1, 2022

Race-based medicine and routine PSA screening in Black men

Five years ago on this blog, I asked whether routinely screening African American men for prostate cancer was warranted when evidence suggested that harms exceeded benefits in the general population. Even though many experts felt that it was, I disagreed:

What troubles me about this position is that race is as much a social construct as it is a biological one. Much of the disparity in prostate-cancer mortality between African-American and Caucasians can be explained by lower access to and quality of care, rather than a genetic predisposition for more aggressive and/or lethal cancers. In contrast to national data, studies of equal-access healthcare systems in the U.S. such as the Veterans Health Administration and the Department of Defense found no differences in prostate cancer mortality between Black and White men.

Since that time, the U.S. Preventive Services Task Force partially reversed itself and now states that "for men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one." Individual decision-making relies in part on assessing risk factors for potentially fatal prostate cancer, but aside from family history, the only other known risk factor is Black race.

Race-based medicine's drawbacks have become increasingly evident, however, and groups across the spectrum of medicine have been working to eliminate the inappropriate use of race from clinical decision-making. In this context, a group of urologists and oncologists recently updated a 2009 analysis of the effects of PSA screening in the U.S. and concluded that the benefit to harm ratio of screening over the past 3 decades was considerably more favorable in Black men than in the American population as a whole.

So was I wrong about not approaching Black men differently in PSA screening? Or as the title of the accompanying editorial asked, "Should recommendations for cancer screening differentiate on race?" Drs. Gil Welch (who authored the original analysis of PSA screening) and Adewole Adamson observed that assuming that the effectiveness of PSA screening or the harm of overdiagnosis are not substantially modified by race, then the higher prostate cancer death rate in Black men suggests that they would be more likely to benefit from screening than men of other races.

On the other hand, they argued, "in the context of addressing health disparities, cancer screening is a massive distraction. ... Cancer-associated health disparities not biased by early detection are related primarily to unequal treatment after diagnosis, not screening." All but a small fraction of the increased risk of lethal prostate cancer in Black men is likely to be mediated by social determinants of health and structural racism rather than genetics. Shockingly, "in Black men, the median age of prostate cancer death is 76 years, 4 years older than their average life expectancy [emphasis mine]," which is a strong argument for devoting more resources to improving the lives of the >95% of Black men who die from something other than prostate cancer (e.g., heart disease, lung cancer, chronic kidney disease).

I will continue to inform Black and multiracial patients in the age group highlighted by the USPSTF about population-level risks and the (increasingly inexcusable) paucity of empiric data on the benefits and harms of PSA screening in Black men. Some will choose to be screened, some will not. But I continue to believe that race-based screening for prostate cancer - i.e., screening a man only because of the color of his skin - is the wrong approach.

Friday, June 17, 2022

Podcasting in medical education: a review and example

A recent scoping review in Academic Medicine examined the published literature on the use of podcasts in undergraduate (medical school) and graduate medical education (GME; residency). The researchers identified a total of 62 articles; 44 studies reported descriptive outcomes and 38 reported educational outcomes. The latter group assessed learner reaction and attitudes, knowledge retention, and behavior change; no studies reported on system change or patient outcomes. Medical podcasts appeared to communicate knowledge as well as traditional teaching methods; are valued by learners for their portability, efficiency, and entertainment value; and measurably improved skills in documentation and selected clinical practices.

If you are new to medical podcasts, you can check out some of my favorites or a family medicine-specific list compiled by residents and faculty at the University of Arizona College of Medicine Phoenix Family Medicine Residency Program, which produces the American Family Physician podcast.

During the 2018-2019 academic year, I created two episodes of a podcast for a first-year medical course in health policy as my project for an interdisciplinary Technology-Enhanced Learning (TEL) Colloquium for Georgetown faculty. Below is an excerpt from my final report describing the project.

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I created an audio podcast to provide an overview of the U.S. health system in spring 2019. The podcast episodes replaced a 90-minute lecture from the previous year, enabling better integration between the background health system content and two small group sessions during the same week on the patient-centered medical home and implications of the Affordable Care Act for patients and physicians.

During the TEL colloquium, I read about using podcasts for teaching in publications identified in PubMed and utilized resources on the Gelardin New Media Center website. Then, I became familiar with the recording and editing software program Audacity by viewing a tutorial on Lynda.com, accessed through the Georgetown University library. I posted finished podcast episodes on the P3 Canvas webpage and, through the podcast hosting service Libsyn, made them available on popular podcast directories, including Apple ITunes, Google Play, and Stitcher. I wanted to give students the option of listening to the podcast on their commutes or during workouts, rather than sitting at a desk or a library carrell.

Listening to and reflecting on the podcast episodes was not a stand-alone assignment, but instead incorporated into preparation for the small group sessions. I adjusted my teaching strategies in several ways. First, in the absence of a live audience, I switched to a less lecturing, more conversational tone of voice when recording. Although I posted a few key visuals (e.g., pie charts of insurance coverage types, percentages of national spending on various health services) from the previous year’s lecture slide set on Canvas for students to view during or after the podcast, most of the slides containing text simply weren’t necessary to reproduce. It was a little humbling to realize how much “slide reading” I must have been doing the year before.

My originally stated goal in joining the 2018 TEL Colloquium was to develop a blended learning project to “help me and course faculty engage in new and deeper ways with future [GUSOM] classes to better prepare them to be well-rounded physicians who are prepared to advance and advocate for their patients’ health outside of medical settings.” My two major objectives were to reduce course didactic time and to integrate online / asynchronous and in-person learning activities. I didn’t change my overall goal or specific objectives as the Colloquium progressed, but I did change the timing of the project in response to feedback from CNDLS faculty and peers. I originally envisioned the podcast beginning during the October intensive course week, continuing through the months in between, and concluding during the March course week. I fairly quickly realized that this timing was impractical, as students would not have time or motivation to listen to P3 podcasts while they were taking other courses with tests. So I instead decided to focus on the March course week, where the U.S. health system overview lecture was most amenable to being converted into a podcast because 1) I was the assigned lecturer; 2) the content had been identified by past students as being too much to digest in a single sitting.

Were students able to better absorb and engage with this material in a podcast versus a lecture? It’s hard to say for certain. Unfortunately, I did not think to add a specific question or questions about the podcast to the student course survey, and none of the free text comments from students thus far mentioned the podcast. Anecdotally, several students in my own small group of 10 said that they found the podcast to be informative and easy to digest, and course faculty e-mailed some encouraging comments about it:

“I definitely think you should write this up as an innovative way of teaching!”
“Your podcasts are excellent!
“I think it is so nice for them to get this info via a different medium than lectures or reading.”


I came into the TEL Colloquium with the prior experience of having blended learning (specifically, team-based learning exercises) not having gone particularly well in the past – a lot of time and effort invested, but mostly negative feedback. In contrast, the podcast was fun to create and seemed to have a positive, or at least neutral, effect on the faculty and student experience. Although I don’t have any specific plans to integrate podcasts into my other teaching roles, I certainly would consider doing so if an opportunity arises.

Monday, June 13, 2022

Supervised injection sites prevent overdose deaths, improve public safety

In a fortuitous alignment, the medical journals with the three largest print circulations (JAMA, American Family Physician, and The New England Journal of Medicine) each recently published editorials or features making the case for opening supervised sites for injection drug use in the United States as a form of harm reduction for patients with substance use disorders.

A news feature in JAMA observed that these sites come in many varieties depending on agency resources and patient needs: 

Supervised consumption sites can be as modest as a social service agency restroom stall, the door shortened at the bottom to make it easier to spot an unconscious person, or as expansive as Vancouver’s trailblazing Insite, which averaged 312 injection room visits per day in 2019 and offers detox rooms with private bathrooms, transitional housing for people in recovery, and other wraparound services.

In the U.S., a legal statue forbidding the operation of establishments where illicit drugs are consumed has generally forced these sites underground. Nonetheless, a research report on the outcomes an unsanctioned site located in an undisclosed U.S. city reported that over 5 years, 33 overdoses were successfully treated with naloxone administered by trained staff, with no patients requiring transfer to an outside medical institution. Advocates of supervised consumption sites argue that they do not "enable" substance use; rather, they relocate use that otherwise occur without medical supervision, often in public places, and prevent deaths from overdoses. The JAMA article quoted Sam Rivera, executive director of a nonprofit organization that operates two sites in New York City, as saying: “Every person who walks in has tried treatment and detox. We want them to be able to try again when they're ready, and in order to do that they have to be alive.”

An editorial in AFP by Drs. Jorge Finke and Jie Chan cited abundant evidence demonstrating that supervised injection sites improve health outcomes for persons who use illicit drugs and the surrounding community:

One study found a 26% net reduction in overdose deaths in the area surrounding a supervised injection site in Vancouver, Canada, compared with the rest of the city. A supervised injection site in Barcelona, Spain, was associated with a 50% reduction in overdose mortality from 1991 to 2008. People who inject drugs are significantly less likely to share needles if they regularly use supervised injection sites. ... Supervised injection sites can also reduce the number of publicly discarded syringes, and they improve public safety. ... One study in Vancouver, Canada, observed an abrupt, persistent decrease in crime after the opening of a supervised injection site.

In addition, modeling studies predict that opening supervised injection sites could be cost-saving "by preventing HIV, hepatitis C, hospitalizations for skin and soft-tissue infections, overdose deaths, ambulance calls, and emergency department visits and by increasing uptake of addiction treatment."

NEJM Perspective article asserted that the Biden administration should take action to "[make] it clear that the federal government won't stand in the way of organizations or state or local governments that want to establish overdose-prevention centers," given that the Department of Justice under the Trump administration asked courts to block the opening of a sanctioned site in Philadelphia in 2019. Arguably, Section 856 of the Controlled Substances Act (also known as the "crack house statute") was not intended to limit the operations of public health facilities, but continued legal ambiguity makes it difficult for state health officials to gain support for supervised injection sites. In a related NEJM Perspective, two clinicians at a primary care and buprenorphine clinic in Chicago emphasized that these sites are desperately needed to save people's lives:

We hand out naloxone, distribute cookers and syringes, and counsel our patients on safer injection practices — such as not injecting alone — but this work isn’t enough to keep them safe. In the clinic, we use a low-threshold model for prescribing buprenorphine to reduce harm and increase access to lifesaving medications for opioid use disorder, offering same-day buprenorphine initiation, van-based outreach, telehealth appointments, and recovery-support services. It still isn’t enough. Our patients continue to die in the largest numbers we’ve ever seen.

The largest numbers we’ve ever seen. The Centers of Disease Control and Prevention reported that in 2021, more than 107,000 people died of a drug overdose, a 15% increase over the previous record high in 2020 and "roughly one U.S. overdose death every 5 minutes." By publishing pieces that provide compelling rationales for opening supervised injection sites, the top three journals in medicine have made a statement that these effective public health interventions should be employed widely to reverse this terrible trend.

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This post first appeared on the AFP Community Blog.

Monday, June 6, 2022

Monkeypox: catching up with the next viral outbreak

The World Health Organization (WHO) has been tracking an outbreak of monkeypox in 27 non-endemic countries that, as of June 2, included at least 780 laboratory confirmed cases, including 17 confirmed cases in 9 U.S. states. This outbreak is highly unusual because many infected persons do not have a history of travel to an endemic country or contact with infected animals. During the only other large U.S. outbreak (involving 77 individuals) of monkeypox in 2003, patients contracted the virus through contact with infected prairie dogs purchased as pets; a case-control study found that case patients were more likely than controls to have cleaned cages and bedding of a sick animal or touched a sick animal. Although no patients died, 19 were hospitalized. In July 2021, monkeypox was diagnosed in a Dallas, Texas emergency department in a traveler returning from Nigeria. This patient was hospitalized for one month, and no secondary infections developed in any of the 223 identified U.S. contacts.

Monkeypox is a zoonotic double-stranded DNA poxvirus that causes clinical disease in humans that is similar to, but less severe than, smallpox. It is endemic to western and central Africa, particularly the Democratic Republic of Congo. The virus was originally isolated from a monkey in 1958, and the first human case was identified in 1970. African rodents are believed to be the virus's natural reservoir. Transmission occurs through contact with bodily fluids, skin or mucosal wounds, respiratory droplets, or contaminated objects. The usual incubation period is 7-14 days, and symptoms resolve within 14-21 days. Infected persons are considered to be contagious for one day before and 21 days after the onset of symptoms. 

Since routine smallpox vaccination ended in the U.S. in the 1970s, a large proportion of the population is susceptible to monkeypox infection. JYNNEOS, a live, nonreplicating vaccine that is recommended by the Advisory Committee on Immunization Practices for prevention of smallpox and monkeypox in persons at occupational risk aged 18 years or older, may be given for post-exposure prophylaxis within 4 days from the date of exposure to prevent disease and is preferred over the older smallpox vaccine (ACAM2000) due to a lower risk of adverse effects, though 100 million doses of the latter have been stockpiled in the event of a widespread bioterrorist attack.

Early reports from the current outbreak suggest that it has been causing minimal prodromal symptoms (fever, chills, lymphadenopathy) and that the rash is first appearing in patients' genital or perianal areas before progressing to the extremities, rather than more typically beginning in the mouth and face. Although monkeypox is not considered a sexually transmitted infection, many of the initial confirmed case patients are men who have sex with men. It remains unclear if, or to what extent, human-to-human transmission of monkeypox is occurring. "Given the current unfolding outbreak," advised two physicians from the Johns Hopkins Center for Health Security, "clinicians seeing patients with new onset of febrile illness and rash should consider monkeypox, especially if lymphadenopathy is also present."

Along with SARS-CoV-2, monkeypox is another example of the potential of increasingly frequent interactions between humans and wildlife to spread infectious diseases. As this latest viral outbreak continues to evolve, it underlines the importance of physicians and veterinarians taking a One Health approach to optimizing the health and well-being of humans and animals.

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This post first appeared on the AFP Community Blog.

Tuesday, May 31, 2022

Confronting the hidden toll of alcohol use disorders

Over the past two years, many of my patients have been drinking more alcohol than in the past, reflecting a troubling national response to COVID-19 pandemic-related stress. Two recently published studies assessed the increased death toll of unhealthy drinking habits. Alcohol-related deaths occur due to direct effects of alcohol on the body, such as alcoholic hepatitis (severe cases have a 16-30% mortality rate at 28 days and 56% at one year) or via indirect contributions to fatal traffic and nontraffic injuries (e.g., drowning, falls, aspiration, hypothermia, firearm injuries).

The first study used death certificate data from the National Center for Health Statistics to compare numbers and rates of alcohol-related deaths among individuals 16 years or older in 2019 and 2020. Both the absolute number and age-adjusted rate of deaths involving alcohol increased by about 25%, greater than the 16-18% increases in all-cause deaths and death rate during this period. The largest increases (37-40%) were observed in adults aged 25 to 44 years. A second study used data from the National Vital Statistics System to evaluate mortality trends in adults with the diagnosis of alcohol use disorder (AUD) before (2012-2019) and during (2020-2021) the pandemic. Similarly, deaths with AUD listed as a primary or contributing cause during 2020 and 2021 exceeded projected deaths based on pre-pandemic data by 25% and 22%, respectively, with the 25 to 44 year-old age group demonstrating the largest increases (40% and 34%).

For patients who survive alcoholic hepatitis and other alcohol-related life-threatening injuries, it is critical for physicians to offer evidence-based medical therapy for AUD, outlined in a 2020 American Family Physician article. Since the effects of risky drinking and AUD may not be clinically evident, the U.S. Preventive Services Task Force recommends screening and brief behavioral counseling interventions in adolescents and adults to reduce unhealthy alcohol use. Managing alcohol withdrawal syndrome and referring patients to Alcoholics Anonymous and other 12-step facilitation programs for AUD are also important mitigation strategies.

What about patients who have long been told that having a glass of wine with dinner is good for the heart? Setting aside the question of whether patients underestimate personal alcohol consumption, a large (n=371,463) United Kingdom cohort study recently challenged the theory that light alcohol use lowers cardiovascular risk. Investigators found that after adjustment for healthier lifestyles, light alcohol use (up to 1 drink per day) was associated with increased risk for hypertension and coronary artery disease compared to no use, and heavy use (more than 2 drinks per day) was associated with exponentially increasing cardiovascular risks.

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This post first appeared on the AFP Community Blog.

Tuesday, May 24, 2022

Making schools safe for students and staff during the pandemic

Since fall 2020, I have served as a medical and public health consultant for a private K-12 school system in the Washington, DC area. At that time, many schools were trying to figure out how to safely reopen for in-person instruction after having taught students online after the COVID-19 pandemic began with unacceptable results. With vaccines for adults and children still in development, schools were implementing a variety of interventions in the hope that some would mitigate viral spread: spacing students six feet apart, universal masking, temperature and symptom screening, regular testing, frequent sanitizing, improving ventilation, hybrid scheduling, cohorting, and quarantines. New studies appeared constantly, and it was my job to sift through the imperfect data to advise the best course of action in the context of changing community infection rates and parents who either felt that the school system wasn't doing enough to protect their children or was doing "too much" and unnecessarily restricting classroom or extracurricular activities.

When effective and safe vaccines became available, first for adults, then adolescents, then for children aged 5 or older, we strongly encouraged everyone to receive them, and I personally hosted virtual and in-person question and answer sessions for employees. The schools I advised required that students and staff wear masks until February 2022, after the vast majority had been vaccinated and boosted, if eligible. Given the increasing frequency of (mostly mild) infections in vaccinated persons and continued skepticism about the value of masks in preventing viral spread, though, I have continued to keep up with the literature on these topics. Two recent large observational studies are worth highlighting.

During the 2021-22 school year, schools could require that everyone wear masks (universal masking), that some grades wear masks or that masks be required at a community infection threshold (partial masking), or make masks optional. A study of more than 1 million students and 150,000 staff across 61 school districts in 9 states found a clear benefit of universal compared to optional masking: "Districts that optionally masked throughout the study period had 3.6 times the rate of secondary transmission as universally masked districts; and for every 100 community-acquired cases, universally masked districts had 7.3 predicted secondary infections, whereas optionally masked districts had 26.4." This finding was consistent with a prior study that compared COVID-19 incidence in school districts in Arkansas during the tail end of the delta wave (August-October 2021) and found that "districts with universal mask requirements had a 23% lower incidence of COVID-19 among staff members and students compared with districts without mask requirements."

Masks are not perfect, and some types of masks work better than others. But they do work!

An online survey of more than 1 million respondents living with school-aged children in all 50 states and Washington, DC examined the COVID-19 risk associated with in-person schooling during spring 2021, when most adults were vaccine-eligible but most students were not.  By June, about 75% of respondents had received at least one COVID-19 vaccine dose, a slightly higher proportion than the general population at that time. As expected, living in a household with a child in full-time in-person schooling was associated with an increased odds of experiencing COVID-19-like illness (adjusted odds ratio, 1.32). However, as the number of school-based mitigation measures increased, the risk decreased: "By May to June, risks of all COVID-19 related outcomes disappeared when four or more mitigation measures were reported." Among more than 116,000 teachers included in the survey, those who taught students in person had a higher risk of testing positive (aOR, 2.04) and losing one's taste or smell (aOR, 1.37). However, being vaccinated lowered this risk, to the point where "vaccinated teachers working outside the home were less likely to report COVID-19-related outcomes than unvaccinated teachers reporting no work outside the home."

Vaccines are not perfect, and they are more protective against some viral variants than others. But they do work!

We have reached the point where reinstituting community mask mandates is politically impossible in most parts of the U.S. and mandatory vaccination policies have limited by the courts to employees of the federal government (including active military) and health care organizations. Closing schools and businesses early in the pandemic did buy time to develop vaccines and antiviral drugs, but the societal and economic costs were devastating. By comparison, masks are uncomfortable and vaccines have rare adverse effects that are many orders of magnitude lower than the risks associated with COVID-19. Keeping schools open without facilitating community transmission will continue to remain a challenge as variants continue to evolve. It's been a humbling experience for me, as it has been for all professionals doing our best to protect the public's health.