Monday, March 27, 2023

Carried by deer ticks, babesiosis is spreading in the northeastern U.S.

The Centers for Disease Control and Prevention reported last week that the incidence of babesiosis rose substantially in 10 northeastern states from 2011 to 2019, including Maine, New Hampshire, and Vermont, where it was not previously considered to be endemic. Maps from a previous American Family Physician article on tickborne diseases illustrate the geographic distribution of babesiosis compared to other tickborne diseases such as Lyme disease. Babesiosis is usually transmitted to humans by the bite of an infected deer tick (Ixodes scapularis), though rare cases of transfusion-associated and perinatal transmission have been reported.

The Environmental Protection Agency has concluded that the expanding range of disease-carrying ticks to northern latitudes has been influenced by ongoing climate change:

Deer ticks are mostly active when temperatures are above 45˚F, and they thrive in areas with at least 85-percent humidity. Thus, warming temperatures associated with climate change are projected to increase the range of suitable tick habitat. … Because tick activity depends on temperatures being above a certain minimum, shorter winters could also extend the period when ticks are active each year. … Unlike some other vector-borne diseases, tick-borne disease patterns are generally less influenced by short-term changes in weather (weeks to months) than by longer-term climate change.

After an incubation period of one to nine weeks, patients with babesiosis can experience nonspecific flulike symptoms, including fever, generalized weakness, and myalgias. More severe complications may develop, including acute respiratory distress syndrome, congestive heart failure, and disseminated intravascular coagulation. The diagnosis can be made by polymerase chain reaction (PCR) or microscopic identification of intraerythrocytic organisms on a Giemsa-stained peripheral blood smear.

First-line treatment for mild to moderate babesiosis is oral atovaquone and azithromycin for 7 to 10 days. More severe infections should be treated with intravenous clindamycin and oral quinine. Exchange transfusions are “reserved for patients who are extremely ill – with blood parasitemia of more than 10 percent, massive hemolysis and asplenia.” Since co-infection with Lyme disease and ehrlichiosis can occur, clinicians can consider starting oral doxycycline while awaiting the results of serologic testing. Babesiosis may persist for more than two months after effective treatment and for months to years in patients with unrecognized infections.

A previous AFP editorial provided advice on use of effective insect repellents to prevent diseases carried by ticks and mosquitoes. A patient education handout reviewed strategies for preventing tick bites and safely removing attached ticks. Finally, readers interested in mitigating infectious and other health impacts of warming temperatures in their clinics and communities can consult a curated collection of articles on environmental health and climate change.


This post first appeared on the AFP Community Blog.

Wednesday, March 15, 2023

Aspirin, preeclampsia, and heart disease in later life and children

Preeclampsia affects an estimated 4 million pregnancies worldwide each year and has lifelong health consequences for women and children. The U.S. Preventive Services Task Force (USPSTF) recommends screening for preeclampsia with blood pressure measurements throughout pregnancy; last month it released an updated draft statement that expands the screening indication to identify all hypertensive disorders of pregnancy. Exercise during pregnancy is recommended to reduce risk of gestational hypertension and preeclampsia. Additionally, the USPSTF and the American College of Obstetricians and Gynecologists recommend that pregnant patients at high risk for preeclampsia start taking daily low-dose (81 mg) aspirin at 12 weeks’ of gestation and continue until delivery. The high prevalence of preeclampsia risk factors has made preventive aspirin use increasingly common in the U.S. An analysis of 2019 birth certificate data found that low-dose aspirin was indicated in more than half of all pregnancies and could have been considered in more than 85 percent based on USPSTF criteria.

Since aspirin may increase peripartum bleeding risk, an open-label, noninferiority randomized trial in Spain compared discontinuing aspirin at 24 to 28 weeks’ gestation to continuation until 36 weeks (the standard of care in Europe) in pregnant patients judged to be at lower risk of preeclampsia based on second-trimester biomarkers. The incidence of preterm preeclampsia, the primary outcome, was similar between the groups. Of note, the aspirin dose was 150 mg daily, and high risk individuals were identified in the first trimester based on a screening algorithm that combined clinical factors with objective measurements such as mean uterine artery pulsatility index and serum placental growth factor. Differences in the European approach to preeclampsia prevention make it difficult to determine this study’s implications for U.S. practice.

A 2017 systematic review and meta-analysis of 22 studies found that preeclampsia is associated with a 4-fold increase in future heart failure risk and 2-fold increases in heart disease, stroke, and cardiovascular death. Should a history of adverse pregnancy outcomes be considered in atherosclerotic cardiovascular disease (ASCVD) risk assessments? To shed light on this question, Swedish researchers did a cross-sectional study of a population-based cohort of 10,000 women with one or more deliveries in 1973 or later who underwent coronary computed tomography angiography at age 50 to 65 years as part of a study from 2013-2018. Patients with histories of gestational hypertension and preeclampsia were more likely to have coronary atherosclerosis and significant stenosis even if their predicted ASCVD risk was low. Whether intensive primary prevention with statin therapy would improve outcomes in these patients is not known.

Finally, maternal preeclampsia has been associated with increased cardiovascular risks in children. In a population-based cohort study of individuals born in Denmark, Finland, and Sweden from 1973 to 2016, offspring of pregnancies with preeclampsia had increased risks of ischemic heart disease (adjusted hazard ratio, 1.33) and stroke (aHR, 1.34), independent of preterm or small for gestational age birth.


This post first appeared on the AFP Community Blog.

Sunday, March 12, 2023

Springing forward and building my Substack

Today marks the first day of daylight saving time in 2023. Many U.S. health reporters and bloggers have devoted newsprint or digital space to the pros and cons of shifting our clocks one hour forward so that there is more late-day sunshine during the warmer months. In 2019, my colleague Jen Middleton discussed how to minimize sleep disruptions caused by the time change. This year, Rita Rubin wrote a terrific news article in JAMA that highlighted the contrast in public support for making daylight saving time year-round with the positions of major medical organizations, including the American Academy of Sleep Medicine and the American Medical Association, that support abolishing daylight saving and sticking with permanent standard time.

For nine months in 1974, the U.S. actually instituted year-round daylight saving time in the hope of reducing energy consumption during the OPEC oil embargo. Unfortunately, noted Rubin, "the shift to daylight saving time in the middle of winter meant that many schoolchildren had to go to school in the dark," contributing to the publicized deaths of 8 Florida students in early-morning car accidents. Public support for the change waned rapidly, and President Gerald Ford signed a law that reverted to standard time that fall.

Switching topics, I've been working to build Common Sense Family Doctor's presence on Substack, where I started cross-posting in January after I was briefly locked out of Twitter. Although my Twitter access was eventually restored, that platform is going rapidly downhill, with qualified health professionals fleeing in droves while purveyors of misinformation have been emboldened by Elon Musk's "anything goes as long as it can be monetized" stance. So I appreciated a recent shout-out from fellow blogger Hans Duvefelt, MD, whose long-running A Country Doctor Writes features thoughtful and absorbing observations on the pleasures and pains of practicing family medicine in rural Maine, and is now available as a subscription on Substack. Hans has also written three books based on his blog writings and videos, the first of which entertained my family for many hours as we drove back from Salt Lake City to Washington, DC in the summer of 2021. If you haven't previously visited his blog or Substack, they are well worth a few minutes of your day, regardless of your feelings on daylight saving.

Wednesday, March 8, 2023

"I want to be a regular doctor" - making primary care the norm

Today I spent a few hours updating my "Introduction to the U.S. health care system" lecture for the first-year medical student course I directed before my 2020-21 Salt Lake City sabbatical and last year's move to Lancaster, Pennsylvania. (I continue to hold a Georgetown faculty appointment as a guest lecturer for this course and a health policy elective for 4th year students and residents.) The last several slides are taken from a series of reports from the Commonwealth Fund illustrating that as U.S. health care spending has accelerated in comparison to spending in peer countries, key health outcomes, such as infant and maternal mortality and average life expectancy, have fallen farther and farther behind. I then ask the students: why are our outcomes worse than those of other countries that spend much less?

There isn't a single correct answer to this question. Culprits include high administrative costs, poor continuity of care due to lack of insurance portability, and the fact that too many people (insured and uninsured) can't access routine health care services because they are not affordable or not convenient. But the explanation that resonates with me most, as a family physician who has worked in public health, is that public health and primary care have been systematically undervalued and have insufficient resources to do their jobs well. Consider the latest evidence: a primary care scorecard developed by the Robert Graham Center shows that primary care's share of overall U.S. health care expenditures fell from 6.2% in 2013 to a paltry 4.6% in 2020.

Providing primary care is generally inexpensive, and no one is arguing that it should have a 50% or even 25% share, but achieving even the 8% average share among Organization for Economic Co-operation and Development countries would be transformative for American medicine. Absent new investments, the primary care workforce will continue to shrink and fewer and fewer adults will be able see a primary care clinician without waiting for weeks to months. Efforts to date to improve income equity between generalists and subspecialists have been anemic; a recent study found that adjustments to the Medicare Physician Fee Schedule designed to increase the value of "cognitive work" (activities that don't involve performing procedures or using technological tools) that went into effect in 2021 only narrowed the payment gap by 2%.

Other well-intentioned efforts to prime the primary care pipeline that may yield modest gains. Several, like Texas Tech University's Family Medicine Accelerated Track, condense medical school into 3 years for students who commit early to family medicine or primary care careers. This approach eliminates one year of tuition payments and allows the medical school graduate to start earning an attending physician's salary one year sooner. A less conventional path to primary care is switching medical specialties mid-career. One of my friends, a longtime colleague and previous personal physician, began her career as a radiation oncologist and later re-trained in family medicine, where she practiced until her retirement. Doing so required that she complete a second residency, with long hours and relatively low pay, and the strain that this arrangement might put on significant others and families is not insignificant. Thus it's unlikely even if artificial intelligence eventually reduces demand for some subspecialties (e.g., pathology and radiology) that enough doctors will migrate into primary care to address future workforce shortages.

A recent episode of the Society of Teachers of Family Medicine (STFM) podcast featured Dr. Margot Savoy, one of the most talented family physicians I know and the Senior Vice President of Education for the American Academy of Family Physicians. Asked to describe the origins of her interest in a family medicine career, she spoke about wanting to be a "regular doctor," the health professional you saw when you needed a checkup or had an acute injury or illness. Innocent of the divisions that existed in medicine, she had to be educated that this type of "regular doctor" was called a primary care physician and about the differences between physicians who took care of kids only, adults only, and family physicians. Countless others have begun medical school considering primary care careers to be the norm before being seduced by the siren song of higher paid subspecialties with narrower bodies of knowledge to master. We need schools to continue producing subspecialists, of course, but to bring U.S. health outcomes back to par with the rest of the world, we need primary care physicians more.

Tuesday, February 28, 2023

Individualizing drug therapy for adults with major depressive disorder

Managing patients with depressive disorders constitutes a significant portion of the typical family physician’s practice. A serial cross-sectional study in Health Affairs estimated that the percentage of U.S. adult primary care visits that addressed mental health concerns rose from 10.7% in 2006 to 15.9% by 2018. Previous AFP Community Blog posts have discussed the primary care evidence base for psychologic and pharmacologic treatments and screening and treatment guidelines from the U.S. Preventive Services Task Force and the American College of Physicians (ACP). In the February issue, Dr. Heather Kovich and colleagues provided an update on pharmacologic treatment and tapering strategies to minimize the risk of discontinuation syndrome. When initiating medication, the authors recommend using shared decision-making, considering factors such as “prior treatment and response, comorbidities, costs, and risk of adverse effects.”

An accompanying editorial by Drs. Andrew Buelt and John McQuaid compared the three major U.S. clinical guidelines for major depressive disorder from the ACP, the American Psychological Association (APA), and the U.S. Department of Veterans Affairs and Department of Defense (VA/DoD). (The ACP released an update to its 2016 guideline while the article and editorial were in press.) All of the guidelines recommend initial treatment with evidence-based psychotherapy or pharmacotherapy. Pharmacogenetic tests such as GeneSight Psychotropic “[have] not been shown to improve patient-oriented outcomes and [are] not recommended to assist in drug choice.” Most patients will not experience additional benefit from combining psychotherapy and pharmacotherapy; however, the VA/DoD suggests that this combination is appropriate for patients with severe, persistent (more than two years), or recurrent (two or more episodes) depression.

A Canadian group recently developed a visual evidence-informed decision support tool based on a literature review and the Canadian Network for Mood and Anxiety Treatments depression treatment guidelines. The tool consists of two Figures that guide primary care clinicians in antidepressant selection based on specifiers (sleep disturbance, cognitive dysfunction, anxious distress, somatic symptoms), comorbid conditions, adverse effects, drug interactions, and administration. Physicians using this tool should note that the costs of antidepressants in Canada are considerably lower than those in the U.S., even for Medicare beneficiaries. Another helpful decision tool for antidepressants and other psychiatric drugs is the Waco Guide to Psychopharmacology in Primary Care, which is available as a downloadable app for Apple users.


This post first appeared on the AFP Community Blog.

Tuesday, February 21, 2023

Diagnosing ovarian and other cancers with human and artificial intelligence

The Ovarian Cancer Research Alliance recently released a consensus statement that encourages women who have completed childbearing to consider having their fallopian tubes removed if they are having pelvic surgery for benign conditions. This surgical strategy for reducing ovarian cancer mortality acknowledges the negative results of the UK Collaborative Trial of Ovarian Cancer Screening, which Dr. Jennifer Middleton previously discussed. Studies have found that early ovarian cancer frequently causes constitutional, abdominal, urinary, and pelvic symptoms, which can be used in combination with a cancer antigen 125 level to estimate ovarian cancer risk. However, the low sensitivity and specificity of this “symptom index” means that it misses early cancers and leads to unnecessary cancer evaluations for benign conditions.

A population-based United Kingdom (UK) cohort study assessed the underlying cancer risk of patients aged 30 years and older who presented to primary care with new-onset fatigue and co-occurring vague symptoms. After excluding persons with anemia or alarm symptoms (e.g., dysphagia), researchers followed patients for up to 9 months for a diagnosis of cancer. Cancer risk increased with age, reaching 3% or more in patients in their mid-60s. For all age groups combined, cancer risk was highest for women with fatigue and abdominal bloating and men with fatigue and weight loss, constipation, dyspnea, or abdominal pain.

A Danish research group developed an artificial intelligence (AI) based model that used results from common blood tests (complete blood count, electrolytes, and/or liver function tests) to generate a risk score that predicted cancer within 90 days. This laboratory data is often readily available; another UK study of patients who were diagnosed with cancer found that 41% received common blood tests in primary care as part of their diagnostic process. However, relying solely on blood tests neglects the value of primary care physicians’ non-analytical “gut feelings” that the patient has a benign or serious condition.

In an observational study of 155 general practitioners in Spain, a “sense of alarm,” present in 22% of consultations for new symptoms, had a sensitivity of 59% for cancer and other serious diseases and a negative predictive value of 98%. Thus, AI may also assist in cancer diagnosis by imitating the intuitive behavior of groups of family physicians. In an editorial in Annals of Internal Medicine, Dr. Gary Weissman and colleagues proposed that AI clinical decision support systems (CDSSs) utilize a “wisdom of crowds” approach that, like the best chess-playing AI systems, “reli[es] on imitation learning and collective intelligence” rather than set rules:

Averaging the judgments of many clinicians may outperform even the best clinician in the group. Training models to learn these consensus behaviors could lead to clinically significant improvements in accuracy. Furthermore, most diagnostic errors are the result of overlooking common diagnoses rather than very rare ones. … An AI CDSS that offers human-like suggestions may improve the reliability of clinical care by helping to avoid these clinical blunders. … Having an AI system that acts more like a thoughtful human guide rather than a black-box arbiter of truth may be the best next move.


This post first appeared on the AFP Community Blog.