My favorite public health and health care books of 2022

My Christmas post is the 7th in an annual series listing my 10 favorite public health and health care reads of the past year. Not all of these were first published in 2022. Happy holidays and warm wishes for a healthy and rewarding New Year!

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1. Empire of Pain: The Secret History of the Sackler Dynasty, by Patrick Radden Keefe

2. The Good Nurse: A True Story of Medicine, Madness, and Murder, by Charles Graeber

3. A Good Time to Be Born: How Science and Public Health Gave Children a Future, by Perri Klass

4. The Price We Pay: What Broke American Health Care - and How to Fix It, by Marty Makary

5. Searching for the Family Doctor: Primary Care on the Brink, by Timothy Hoff

6. Sickening: How Big Pharma Broke American Health Care and How We Can Repair It, by John Abramson

7. A Silent Fire: The Story of Inflammation, Diet, and Disease, by Shilpa Ravella

8. The Song of the Cell: An Exploration of Medicine and the New Human, by Siddhartha Mukherjee

9. White Hot Light: Twenty-Five Years in Emergency Medicine, by Frank Huyler

10. Within Our Grasp: Childhood Malnutrition Worldwide and the Revolution Taking Place to End It, by Sharman Apt Russell

Decoding doctor-speak, redux

Eleven years ago, I wrote a post for my U.S. News Healthcare Headaches blog titled "Decoding doctor-speak: translations of common medical terms" that walked non-health professionals through explanations of common blood tests such as the complete blood count, basic metabolic panel, liver function tests, and low-density lipoprotein; and diagnoses such prediabetes and metabolic syndrome. It turned out to be an enduring hit; the cross-posted version on Common Sense Family Doctor has been viewed more than 11,000 times. But have I or physicians in general have gotten any better at keeping insider medical jargon out of our conversations with patients?

A few weeks ago, JAMA Network Open published a cross-sectional study that assessed the general public's understanding of English phrases that have different meanings in a medical context (jargon) than they do in everyday life. Researchers surveyed 215 adult volunteers without a history of medical or nursing training who visited the 2021 Minnesota State Fair. Of the 13 questions concerning various terms, the percentage of participants who answered correctly ranged from the high 90s ("negative" cancer test results being good news) to 20 or less ("impressive" x-ray results, NPO = nothing by mouth, occult infection).

More people believed that the phrase “had an occult infection” had something to do with a curse than understood that this meant that they had a hidden infection. Fewer than half knew that their neuro examination being “grossly intact” was a good thing, possibly because the word “gross” more often means “unpleasant” than “in general” in common usage. These terms may not necessarily be recognized by clinicians as jargon because they do not land in the commonly understood category of technical, medical terminology. However, they have been shown to be used frequently in clinical settings.

Although I now have more than twice as much clinical experience as I did when I wrote my original blog post, keeping my "doctor-speak" free from jargon remains a work in progress. It's easy to fall into the trap of thinking that patients understand what I'm saying if they are nodding or not asking questions, but as often as that may be true, it could also mean that they are too intimidated or embarrassed to admit that I've lost them. And the burden of assuring that effective communication occurs ought not to fall primarily on the patient. So I resolve to keep trying to do better.

Can prostate MRI reduce the harms of PSA screening?

Without question, PSA screening for prostate cancer in asymptomatic patients does them both harm and good; the difficulty in quantifying how much harm versus good has historically been the source of disagreements among primary care physicians and urologists over how much screening we ought to be doing, or if we should be screening men at all. In 2012, the U.S. Preventive Services Task Force took the position (which it partially reversed in 2018) that the way to prevent harm from PSA screening was to generally stop doing it. But those who believe that selective testing saves lives that otherwise would have been lost to prostate cancer argue that too much testing isn't the problem, it's too much treatment. For every potentially fatal tumor identified by PSA testing, we also "overdiagnose" numerous low-grade, indolent prostate cancers that should perhaps not be called "cancer" at all but are nonetheless treated or at least monitored, exposing patients to harm with very little likelihood of benefit.

It's instructive to compare the typical evaluation for a positive prostate cancer screening test with a positive breast cancer screening test. If breast surgeons diagnosed breast cancer the way urologists diagnose prostate cancer, they would not only biopsy the area of the breast corresponding to an abnormality on a mammogram or ultrasound, they would also systematically biopsy 12 to 20 additional normal-appearing areas of the breast to make sure that no cancer is missed. If that sounds crazy, that's because it is. Multiparametric MRI is increasingly being used for targeted prostate biopsy and active surveillance of low-risk prostate cancer, but whether MRI-targeted biopsy can safely replace systematic prostate biopsy remains an unanswered question.

Unanswered, that is, until last week, when the New England Journal of Medicine published the results of a randomized trial comparing MRI-targeted versus systematic biopsy in men with a PSA level of 3 ng/mL or higher. The researchers found that men in the systematic biopsy group were twice as likely as those in the MRI-targeted group to be diagnosed with an "insignificant" cancer (as judged by pathologists) but slightly less likely to be diagnosed with a clinically significant cancer. In other words, the cost of reducing prostate cancer overdiagnosis is that a small number of clinically significant cancers that would only have been diagnosed with systematic biopsy are missed and not caught until later in the disease course. Granted, pathology does not correlate perfectly with tumor behavior, and it may not predict clinical prognosis since many men have comorbid medical conditions that are more likely to cause death than prostate cancer. But I think these findings make sense; whether and how they will affect academic or community urology practices remains to be seen. As a family physician, would I feel more comfortable with doing PSA screening if I knew that our local urologists performed MRI-targeted rather than systematic prostate biopsies? Absolutely.

New AAFP practice guideline sets blood pressure targets for adults with hypertension

From 1977 to 2003, seven Joint National Committees (JNC), sponsored by the National Heart, Lung, and Blood Institute (NHLBI), produced consensus multi-specialty guidelines on the diagnosis and management of hypertension. In 2013, well into the development of JNC8, the NHLBI abruptly turned the process over to the American College of Cardiology/American Heart Association (ACC/AHA). The JNC8 committee independently published an evidence-based guideline in JAMA that raised the blood pressure treatment threshold in most older adults from 140/90 to 150/90 mm Hg. Concerned about conflicts of interest and other deviations from Institute of Medicine-recommended practices for developing trustworthy guidelines, primary care groups, including the American Academy of Family Physicians (AAFP), declined to participate in the ACC/AHA guideline panel. And the longstanding edifice of hypertension guidelines fractured.

In 2017, the ACC/AHA released its clinical practice guideline, which most notably re-defined hypertension as sustained blood pressure over 130/80 mm Hg and recommending, based largely on the controversial SPRINT trial, that treatment should aim to reduce blood pressure below this new threshold. The AAFP decided against endorsing the guideline and advised its members to continue following the JNC8 report and its own 2017 practice guideline, co-authored with the American College of Physicians, that largely reiterated JNC8’s treatment thresholds for adults aged 60 years and older.

Last month, American Family Physician published an updated AAFP hypertension guideline, written by a panel of family physicians (including me), which focuses on updated evidence for optimal blood pressure targets in adults. Based on a Cochrane systematic review of randomized controlled trials that compared higher and lower blood pressure targets for primary prevention of cardiovascular disease (76% of study participants did not have preexisting CVD), the AAFP strongly recommends treating to a standard blood pressure target of less than 140/90 mm Hg to reduce all-cause and cardiovascular mortality. Since a lower blood pressure target of less than 135/85 mm Hg further reduces the risk of myocardial infarction (number needed to treat = 137 over 3.7 years) but not mortality, the AAFP recommends that clinicians consider treating to this lower target with shared decision-making. Notably, although the lower target did not increase serious adverse events compared to the standard target, it required patients to take one more anti-hypertensive medication on average and increased non-serious adverse events (number needed to harm = 33).

The AAFP guideline also applies to adults with hypertension and existing CVD, as another recent Cochrane review comparing standard to lower blood pressure targets in this population found no differences in total or cardiovascular mortality, conclusions that were unchanged from an earlier version. The AAFP guideline is mostly consistent with guidelines from the International Society of Hypertension that recommend a treatment threshold of 140/90 in office settings and lower thresholds for blood pressures obtained with home monitoring or 24-hour ambulatory monitoring.

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This post first appeared on the AFP Community Blog.

How health care can break the "harm-treat-harm" climate emissions cycle

At the 27th United Nations Conference of the Parties (COP27) conference that concluded in Egypt yesterday, participants agreed that wealthy nations would provide financial aid in the form of a "loss and damage" fund to developing countries to reduce carbon dioxide emissions and mitigate climate impacts. Climate injustice, "a term used to describe the situation in which countries that contribute the least to the climate crisis nevertheless pay the highest price," is ever-present in the African continent, which has contributed only 3-4% of all emissions but suffers disproportionately from the resulting heat waves, droughts, scarcity of food and drinking water, and coastal flooding.

In an October 19 editorial that was simultaneously published in more than 200 health journals, following last year's editorial on the climate emergency, the editors-in-chief of African journals highlighted the ongoing health impacts of climate change in their countries:

Droughts in sub-Saharan Africa have tripled between 1970–1979 and 2010–2019. In 2018, devastating cyclones impacted 2.2 million people in Malawi, Mozambique, and Zimbabwe. In West and Central Africa, severe flooding resulted in mortality and forced migration from loss of shelter, cultivated land, and livestock. Changes in vector ecology brought about by floods and damage to environmental hygiene have led to increases in diseases across sub-Saharan Africa, with rises in malaria, dengue fever, Lassa fever, Rift Valley fever, Lyme disease, Ebola virus, West Nile virus, and other infections. Rising sea levels reduce water quality, leading to waterborne diseases, including diarrheal diseases, a leading cause of mortality in Africa. Extreme weather damages water and food supply, increasing food insecurity and malnutrition, which causes 1.7 million deaths annually in Africa.

The authors emphasized that the international community should not only be concerned for Africa for moral reasons, but also because "knock-on" effects of "poverty, infectious disease, forced migration, and conflict" are global in nature. "In an interconnected world," they argued, "leaving countries to the mercy of environmental shocks creates instability that has severe consequences for all nations."

As a clinically-focused journal, American Family Physician has devoted much environmental health content to what individual physicians can do in their offices to mitigate the health effects of climate change on patients and counsel them about actions that can help address the problem. In a recent position paper, the American College of Physicians went further by recommending "that the health sector must adopt environmentally sustainable and energy-efficient practices to aggressively reduce its greenhouse gas emissions." As noted in an accompanying editorial, the U.S. health care system accounts for an estimated 8.5% of national greenhouse gas emissions. Left unaddressed, these emissions cause harm that requires health care interventions, which generate more emissions that lead to more harm: the "harm-treat-harm" cycle.

What actions can clinics, hospitals, and health systems take to break this cycle? The Agency for Healthcare Research and Quality has released an evidence-informed primer for health care organizations from the Institute for Healthcare Improvement on measures and actions to reduce carbon emissions. An article in STAT News discussed energy efficiency initiatives at Boston Medical Center, the Cleveland Clinic, and Kaiser Permanente that have reduced carbon emissions associated with excess power consumption and saved millions of dollars. Notably, nonprofit hospitals are now eligible to receive renewable energy credit payments from the Inflation Reduction Act for investing in energy-saving projects.

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This post first appeared on the AFP Community Blog.

Facing the "tripledemic": RSV, influenza, and COVID-19

During the first two winters of the pandemic, social distancing and mask wearing protected many persons - particularly infants and older adults - from SARS-CoV-2 and other potentially serious viral respiratory infections. With most people having returned to pre-pandemic social interactions, the viruses are making a comeback. Children's hospitals in several states are filled to capacity with patients infected with respiratory syncytial virus (RSV); high levels of influenza-like illness are being reported across most of the South; and with waning immunity and low uptake of bivalent vaccine booster shots, many scientists predict another COVID-19 winter surge. Health officials are concerned that the combination of RSV, influenza, and SARS-CoV-2 variants may produce a "tripledemic" that could overwhelm outpatient practices and hospitals.

Prior to 2020, 2 to 3 percent of U.S. infants younger than 12 months were hospitalized for RSV bronchiolitis, and RSV was estimated to cause 177,000 hospitalizations and 14,000 deaths annually in adults aged 65 years and older. For the family physician evaluating a child with bronchiolitis, accurate risk stratification remains a key skill. Unfortunately, aside from oxygen supplementation, no other therapies offer significant benefit: bronchodilators do not improve oxygen saturation, hospitalization rate or duration; and the American Academy of Pediatrics practice guideline recommends against using systemic corticosteroids, antibiotics, nebulized hypertonic saline (unless the child is hospitalized), or chest physiotherapy. RSV prophylaxis in the first year of life with the monoclonal antibody palivizumab (Synagis) is recommended only for infants born before 29 weeks of gestation or infants with chronic lung or heart disease, neuromuscular disease, or profound immunocompromise. No vaccines have been approved by the U.S. Food and Drug Administration (FDA) to prevent RSV infections in infants or older adults.

Although not in time for this RSV season, new prevention tools are around the corner. Earlier this year, a placebo-controlled trial of 1490 late-preterm (>35 weeks gestation) and term infants reported that the monoclonal antibody nirsevimab provided reduced medically attended RSV bronchiolitis by 75 percent and hospitalization by 62 percent, with no difference in adverse events. The FDA and the European Medicines Agency are both considering approval. Several companies are also in the late stages of developing a vaccine against RSV for older adults, with two reporting positive outcomes in unpublished Phase 3 trials.

In the meantime, nonpharmacologic interventions (handwashing, avoiding sick persons, and mask wearing) remain the mainstay of preventing respiratory virus infections. Finally, to increase lagging COVID-19 and influenza vaccine uptake, the American Academy of Family Physicians has assembled an Immunizations & Vaccines web page with up-to-date clinical and patient education resources.

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This post first appeared on the AFP Community Blog.