One strategy that I've found ensures a long and productive academic career is collaborating with talented and curious colleagues. I first put it into practice as a medical officer at the Agency for Healthcare Research and Quality, writing evidence summaries and systematic reviews with other staffers and rotating Preventive Medicine residents. At Georgetown, I collaborated with a terrific team of health researchers to write papers on interpreting and managing test results for Zika virus and COVID-19. I've collaborated with members of the AAFP's Commission on Health of the Public and Science on clinical practice guidelines on COPD exacerbations and blood pressure targets in adults with hypertension. I've collaborated on articles on social media for doctors and advocacy curricula in family medicine residency programs. Through the Lown Institute, I have collaborated on original work estimating the U.S. rate of overuse of screening colonoscopy and the associated harms. And most recently, I worked with a longtime mentor and sometime mentee on an analysis piece in BMJ Evidence Based Medicine that assesses evidence thresholds for proposals for updating established screening strategies.
How this paper came about deserves some explanation. In spring 2021, a company interested in developing a new screening test approached me to ask whom they should consult about the type of evidence required for that test to be endorsed by guideline panels and be covered by insurance. I recommended Russ Harris, a former U.S. Preventive Services Task Force (USPSTF) member who had retired from his academic position at UNC-Chapel Hill but was still interested in pursuing new scholarly projects. Russ then reached out to me in an e-mail: "I don’t think the methods are well worked out for replacing an established screening strategy with a new one in the absence of a formal RCT. Do you have any interest in [doing] some scholarly work on making a contribution to this problem?"Wednesday, September 11, 2024
Assessing new screening strategies: collaboration and persistence pay off
Saturday, August 24, 2024
Strategies for earlier detection of type 1 diabetes in children
Not only does the presence of islet autoantibodies have prognostic significance, selected patients may be eligible for teplizumab (Tzield), a monoclonal antibody approved by the U.S. Food and Drug Administration in 2022 to delay the onset of type 2 diabetes in high-risk individuals. An international randomized, placebo-controlled trial tested a 14-day intravenous infusion of teplizumab in 76 nondiabetic relatives of patients with type 1 diabetes (including 55 children 8 to 17 years of age) with two or more autoantibodies and impaired glucose tolerance. The intervention group had a median time to diagnosis of type 1 diabetes of 48.4 months, compared with 24.4 months in the placebo group. A subsequent trial showed that teplizumab preserves β-cell function in patients with newly diagnosed type 1 diabetes but does not improve clinical outcomes.
Teplizumab’s exceptionally high price ($13,850 per vial; $194,000 for a 14-day course) and limited benefits—delaying type 1 diabetes onset for an average of 2 years—means that other strategies are needed to improve outcomes in at-risk children. Notably, 80% of patients with type 1 diabetes have no affected relatives. However, it is not known whether screening the general population for type 1 diabetes with genetic or autoantibody tests would lead to more benefits than harms.
One alternative to population-wide screening is using machine learning to predict type 1 diabetes in primary care. A June 2024 study in The Lancet used electronic health records from more than 2 million children in Wales to develop and validate a predictive algorithm for type 1 diabetes based on 26 symptoms, history elements, and timing of primary care visits. When the algorithm was set to generate an electronic alert at 10% of visits, 7 in 10 children with type 1 diabetes would have triggered an alert in the 90 days before diagnosis and been diagnosed an average of 9 days earlier. Fewer alerts (e.g., 5% of visits) reduced the number of early diagnoses. Although the researchers asserted that implementing the algorithm would “substantially reduce the proportion of patients with new-onset type 1 diabetes presenting in [DKA],” they acknowledged that further studies are needed to test the feasibility of this strategy and its relationship to “alert fatigue” and clinician burnout in practice.
Tuesday, August 13, 2024
Vaccines protect patients from complications of measles, RSV, and COVID-19
Recent publications have reinforced the protective effects of vaccines against complications of measles, respiratory syncytial virus (RSV), and COVID-19. In an American Family Physician editorial, Dr. Doug Campos-Outcalt alerted family physicians to this year’s measles resurgence and its association with a small decline (95% to 93%) in the percentage of kindergarten-age children who have received two doses of measles, mumps, and rubella (MMR) vaccine. Measles is a highly contagious illness that is not free from complications, as some people believe:
Before the introduction of the measles vaccine in 1963, there were an estimated 3 million to 4 million cases of measles each year, leading to 48,000 hospitalizations, 1,000 cases of encephalitis, and 400 to 500 deaths.
Although not technically a vaccine, the monoclonal antibody nirsevimab was approved by the U.S. Food and Drug Administration in July 2023 for the prevention of RSV bronchiolitis in infants younger than 12 months. A prospective, matched case-control study examined the real-world effectiveness of nirsevimab in preventing hospitalization for RSV bronchiolitis in France during the 2023-2024 season, before that country’s implementation of maternal RSV vaccination. Nirsevimab was 83% protective against hospitalization for RSV-associated illness and reduced pediatric intensive care unit admissions by 70%.
COVID-19 vaccines have been shown to reduce the risk of infections and hospitalizations; however, there have been conflicting data about whether they are protective against postacute sequelae of SARS-CoV-2 (PASC, also known as long COVID). An analysis of a national primary care registry found that breathing difficulties, fatigue, and sleep disturbances often persist after having COVID-19. A large U.S. Department of Veterans Affairs case-control study showed that the rate of PASC decreased during the pre-Delta, Delta, and Omicron eras of COVID-19 and was significantly lower among vaccinated people after vaccines became available. Of the overall decrease in PASC, researchers estimated that 28% was attributable to viral changes and 72% attributable to vaccines.
**
This post first appeared on the AFP Community Blog. Although it's hard to put a price on the suffering and deaths prevented by vaccines, an analysis published last week estimated that during the past 30 years in the U.S., childhood immunizations have produced a net savings of $540 billion in direct costs and $2.7 trillion in societal costs.
Saturday, August 3, 2024
The case for supporting more American immigrants, not less
As a senior faculty member at a medical school and now a residency program, I'm used to writing letters of recommendation (LOR) for students, residents, and junior faculty applying for promotions. A few years ago, I received a LOR request from a fellow (a physician who has completed residency and is pursuing specialized training) whom I'd never met before and who wasn't applying for faculty position or promotion. Instead, this foreign-born physician was applying to stay in the U.S. The reason he was asking me to support his application is that one of my papers had cited one of his research studies. As a "well-known physician and researcher in the field of Family Medicine," I could testify to the importance of his contribution to medical science in this country. He hoped to extend his visa in the EB-2 National Interest Waiver category, which requires that applicants "have an advanced degree or extraordinary ability and prove their work can significantly contribute to the US economy." I wrote the LOR, and though I did not hear back about the outcome, I recently Googled his name and was pleased to see that he was able to complete his training and is now an attending physician at a respected medical institution.
The contribution of international medical graduates (IMGs) to the U.S. physician workforce is, and has always been, substantial. My late grandfather (a neuropsychiatrist), uncle (an emergency medicine physician) and aunt (an ophthalmologist), all attended medical school in China before immigrating to the U.S. to teach and practice medicine. According to a recent article in JAMA, "there are currently more than 230,000 licensed IMGs who graduated from more than 2000 different medical schools in 169 countries." Some of these IMGs were immigrants like my relatives, while others were U.S. citizens who attended medical schools outside of the U.S. (most often in the Caribbean). Since U.S. medical school graduates tend to settle and practice in urban areas and enter higher-paying medical subspecialties, IMGs fill essential gaps in primary care and underserved rural areas - though a recent study suggested that fewer of them are choosing to do so.
This year's race for the Republican Presidential nomination, which concluded with the nomination of Donald Trump for the third election in a row, had the distinction of including two candidates who are the children of Indian immigrants: Nikki Haley and Vivek Ramaswamy. Both candidates, sensitive to the prevailing anti-immigrant sentiment in the GOP, were careful to note that their parents were "legal immigrants," presumably in contrast to the thousands of "illegals" migrating across the Mexican border. There are, of course, well-established pathways for highly educated foreign-born persons like their parents and mine to enter and remain in the U.S. That influx of talented doctors, scientists, engineers, and others is essential to maintaining America's technological preeminence.
But the U.S. doesn't just need highly educated professionals - it also needs factory laborers, construction workers, farm workers, nannies, housecleaners, and other working-class professions that don't qualify for EB-2 National Interest Waivers. Even if "mass deportation" of tens of millions of undocumented immigrants living in the U.S. was possible - and contrary to popular belief, the Biden administration expelled more migrants (2.8 million) during its first two years than Trump did during his entire 4-year term - it would result in wholesale economic disaster. What America needs isn't a way to get rid of more immigrants who are holding useful jobs and making our country better; instead, as I wrote ten years ago, it needs to create more legal pathways to citizenship that don't require a LOR from a professor of family medicine.
Monday, July 29, 2024
Despite recent study findings, jury is still out on screening ECGs
The U.S. Preventive Services Task Force (USPSTF) has consistently recommended against using ECG to screen for coronary heart disease in asymptomatic, low-risk adults. This recommendation was also included in the Choosing Wisely campaign. The rationale for not testing is that ECGs are unlikely to benefit these patients but can initiate harmful cascades of care. Nonetheless, research on the use of ECGs to identify patients with undiagnosed atrial fibrillation and other potentially serious abnormalities has continued. A 2019 report summarized previous studies that found associations between abnormal screening ECGs and worse cardiovascular outcomes after adjusting for traditional risk factors.
A recent study took advantage of the practice of performing ECGs as a mandatory part of annual health checks in Japanese adults 35 to 65 years of age. In the study, 3.7 million individuals with no history of cardiovascular disease or prior abnormal ECGs had an ECG in 2016 and were followed for a median of 5.5 years for the composite outcome of all-cause death or hospital admission for cardiovascular disease; 17% had one minor ECG abnormality, 4% had two or more minor abnormalities, and 1.5% had a major abnormality. Compared with people with normal ECGs, those with any ECG abnormality had a greater risk of experiencing the composite outcome.
In an accompanying commentary, former USPSTF member and family physician Alex Krist, MD, MPH, explained why these results probably will not change current recommendations:
For clinicians and patients, merely knowing that someone is at risk for an adverse event is not helpful without knowing what should be done to reduce that risk. There are multiple effective and recommended strategies to reduce people’s risk of CVD, including statin use for people at risk, screening for and managing hypertension, and counseling for healthy diet, exercise, and smoking cessation. Clinicians should routinely offer all of these preventive services to patients irrespective of whether their ECG result is normal or abnormal. Before recommending screening ECG, future studies will need to show that doing something different in response to an abnormal ECG changes a health outcome for a person.
A 2018 Lown Right Care article by Drs. Alan Roth, Andy Lazris, and Sarju Ganatra discussed overuse of cardiac tests in asymptomatic patients, including ECG, stress tests, and coronary artery calcium scoring.
Saturday, July 13, 2024
Can large language models handle the complexity of family medicine?
In an editorial on chatbots and LLMs in the June 2024 issue of American Family Physician, Dr. Aaron Saguil discussed how family medicine practices are turning to LLMs to “help decrease administrative burden and combat burnout.” These tools can already compose visit notes, remotely monitor patients with interactive chats, and draft replies to patient portal messages.
In the future, LLMs may be integrated into electronic health records to provide real-time clinical decision support, suggesting “diagnostic possibilities, recommended ancillary evaluations, and possible treatment strategies.” To minimize the risks of LLMs propagating biased data, generating misinformation, or usurping the family physician’s role on health care teams, Dr. Saguil advised being actively involved in their implementation:
The best defense against AI risks becoming realities is conscientious physicians guiding the development and implementation of LLMs into clinical care settings, pointing out what LLMs can do and what they cannot. In family medicine, no LLM can yet address a complex patient in a unique sociocultural situation with overlapping comorbidities and health states from the vantage point of a longitudinal relationship.
A related FPM article by Dr. Steven Waldren, chief medical informatics officer at the American Academy of Family Physicians, explored other uses of LLMs in primary care, such as rewriting medical or legal forms for patients with lower health literacy or native languages other than English; summarizing information from a medical record, guideline, or research articles; drafting referral letters, prior authorization requests, and insurance appeals; and populating clinical registries. Dr. Waldren recommended three safeguards when using AI in medical practice: using LLMs only “when the physician or other user is able to easily verify the accuracy of the AI output”; not entering protected health or private organizational information in open online LLMs such as ChatGPT; and for now, using LLMs only in low-risk (nonclinical) situations. Echoing Dr. Saguil, Dr. Waldren called on family physicians to “weigh in on the design, development, and deployment of AI in medicine to ensure it is more helpful than harmful to patients, primary care physicians, and practices.”
Monday, July 1, 2024
Clinical documentation and health inequities
A Lown Right Care article in the June 2024 issue of American Family Physician addresses the consequences of stigmatizing clinical documentation. In the case scenario, a patient feels stereotyped by his new primary care physician, who incorrectly describes him as African American (he self-identifies as Dominican Hispanic) and noncompliant for not filling a prescription or seeing a subspecialist he could not afford. Drs. Alan Roth and Andy Lazris explain how this language could negatively affect encounters with other clinicians:
Patients who identify as Black are more likely than those who identify as White to have comments using negative words or connotations in their history and physical documentation and may be subject to systemic bias in physicians' perceptions of their credibility.… The stigmatizing language used to describe patients in medical records can influence other clinicians and physicians-in-training in their attitudes toward the patient and their medication-prescribing behavior. This is an important and potentially damaging pathway by which bias can be propagated from one clinician to another.
In a previous AFP editorial, Drs. Megan Healy and Khameer Kidia presented several strategies to reduce bias and avoid stigmatizing language in medical records and other clinical communications. These strategies include not using labels, not blaming patients for their conditions, and not beginning presentations with race, ethnicity, language, socioeconomic status, or other social identifiers that may activate unconscious bias.
In 2021, a controversial JAMA social media post questioned the existence of structural racism and made the incredible claim that “no physician is racist.” This unfortunate episode contrasted with AFP’s active approach to advancing health equity, including sharing and promoting antiracist practices. Nonetheless, the medical profession has a long way to go to align its behaviors with its ideals. In a first-person narrative published in the New England Journal of Medicine, a Black health equity researcher visiting the emergency department receives callous treatment from two nurses and is mocked by a physician for suggesting that her area of expertise had something to do with the indifferent care she received. Making excuses for the health professionals involved (e.g., the emergency department was overcrowded, the nurses were tired and harried, the doctor was just having a bad day) amounts to being part of the problem. Instead, family physicians and other primary care clinicians can choose to be part of the solution to eliminating health inequities in kidney transplant, infertility care, skin conditions, asthma and lung diseases, cardiovascular disease, end-of-life care, and preventive care, among others.
Tuesday, June 18, 2024
Contemplating colorectal cancer screening choices
Invitations to patients eligible for colorectal cancer screening need not be limited to office visits. A 2018 systematic review and meta-analysis of 73 randomized clinical trials of U.S.-based interventions found that mailing fecal tests more than doubled the likelihood that targeted patients received colorectal cancer screening. A recent trial in Clinical Gastroenterology and Hepatology compared screening completion in community health center patients randomly offered one of three options in an outreach mailing: colonoscopy referral only, fecal immunochemical test (FIT) only, or an active choice of colonoscopy or FIT. At 6 months, 12.8% of patients in the active choice arm had completed screening compared with 11.3% in the FIT-only arm and 5.6% in the colonoscopy-only arm.
As I discussed in a previous post, one problem with screening colonoscopy is that it is frequently repeated at shorter intervals than the recommended 10 years without a good reason. In fact, 10 years may not be long enough. A cohort study in JAMA Oncology suggested that a 15-year rescreening interval may be appropriate for average risk patients without a family history of colorectal cancer and with negative findings on their first screening colonoscopy. Using Swedish register-based data sources, researchers showed that individuals meeting these two criteria between 1990 and 2016 had 15-year standardized colorectal cancer incidence and mortality ratios that were lower than the 10-year cumulative risks in a matched control group.
A U.S. cross-sectional study that relied on data from the national Gastrointestinal Quality Improvement Consortium registry found that most patients with an episode of acute diverticulitis were not more likely to have colorectal cancer diagnosed on a follow-up colonoscopy than asymptomatic patients undergoing a screening colonoscopy. Only those with complicated diverticulitis (i.e., diverticulitis with perforation or abscess) were significantly more likely to have colorectal cancer (adjusted odds ratio = 3.57; 95% CI, 1.59 to 8.01).
Regarding the multitarget stool DNA (MT-sDNA) test for colorectal cancer screening, a study of 500 randomly selected patients in a Midwest health system found that about 1 in 5 had the test ordered inappropriately. The most common reasons for inappropriate ordering were having had a colonoscopy within the previous 10 years, having a family history of colorectal cancer, reporting symptoms suggestive of possible colorectal cancer, being younger than 45 years old, and having a previous diagnosis of adenomatous polyps.
A multitarget stool RNA (MT-sRNA) test with performance characteristics similar to those of the MT-sDNA test was approved in May 2024 by the U.S. Food and Drug Administration. Both tests are more sensitive for colorectal cancer and advanced adenomas than FIT but have lower specificity, resulting in higher false positive rates and more diagnostic colonoscopies. Of note, a research letter demonstrated that lowering the threshold for a positive FIT produced similar sensitivities and specificity as the MT-sRNA test, even without the RNA component of the test.
**
This post first appeared on the AFP Community Blog.
Thursday, June 13, 2024
Canadian mammography kerfuffle echoes U.S. screening debate, 15 years later
In November 2009, I was a medical officer with the U.S. Preventive Services Task Force (USPSTF) at the Agency for Healthcare Research and Quality. The health reform legislation that would eventually become law as the Affordable Care Act (or "Obamacare" after then-president Obama) was being fiercely debated in Congress. Politicians who opposed expanding health insurance to the poor, self-employed, and employees of small businesses launched all sorts of spurious charges, the worst being that the law would establish "death panels" that would determine whether elderly patients with chronic medical conditions would be allowed to live or die. Into this political maelstrom stepped the USPSTF, releasing an ill-timed update that recommended against routinely screening women aged 40-49 for breast cancer. Contrary to popular belief, this language didn't mean they were advising all women in this age group NOT to be screened; instead, they were empowering patients to make this decision individually in consultation with their physicians, based on their preferences and values.
The current Task Force looked at essentially the same evidence and come to a different conclusion: start screening everybody at age 40, never mind the potential harms. In a Medscape commentary, I explained why I don't believe this change is justified. However, it put a great deal of pressure on our neighbors to the north and the Canadian Task Force on Preventive Health Care to reassess its recommendations and come to a similar conclusion. If Americans are getting screened for breast cancer in their 40s, why shouldn't Canadians too?
The Canadian Task Force released its draft recommendations two weeks ago. In short, they echo the USPSTF's recommendations in 2009 and 2016 and maintain that breast cancer screening should be a "personal choice," particularly for females younger than age 50. "For women aged 40 to 49, based on the current evidence (trials, observational studies, modelling and a review on values and preferences), we suggest not to systematically screen with mammography [emphasis mine]. Because individual values and preferences may differ, those who want to be screened after being informed of the benefits and harms should be offered screening every 2 to 3 years." The supporting data, much of it derived from systematic reviews, is extensive and compelling, including discussion tools for women in various age groups.
Unlike the U.S. 15 years ago, Canada isn't in the midst of a major health reform debate - they've already had an equitable universal health care system for decades, thank you very much. But that hasn't stopped one health official from trying to score cheap political points. The Canadian Minister of Health, Mark Holland, a lifelong politician without any health professions training, has forcefully objected to the CTFPHC's draft recommendations and ordered an unprecedented "external review" that will, no doubt, include conflicted experts such as radiologists who have obvious financial incentives to perform as many mammograms on asymptomatic women as possible.
Here is Holland being interviewed on an Ottawa news channel. When the anchor asks him what he would do if the external review confirms the Task Force's recommendations, he dodges and weaves and avoids answering.
As a former USPSTF member once said, "we can follow the evidence wherever it leads," or we can start with a preordained conclusion and cherry-pick data that supports what we already know to be true. Canada, Mark Holland, and the CTFPHC would do well not to mimic the most expensive, inequitable health care system in the world and associate higher percentages of women receiving mammography in their 40s with better preventive care "quality."
Tuesday, June 4, 2024
Why medications for AUD should be as popular as GLP-1 agonists for obesity
Given the magnitude of the problem, which worsened during the pandemic, an American College of Physicians policy brief advocated “training, payment, and delivery system policies to enable physicians and other qualified health professionals to screen, diagnose, and treat excessive alcohol use and AUD.” Recognizing patients with excessive alcohol use remains a challenge despite a U.S. Preventive Task Force recommendation to routinely screen adults, including pregnant patients, for unhealthy alcohol use and provide brief behavioral counseling interventions to persons engaged in risky or hazardous drinking.
A systematic review in JAMA’s Rational Clinical Examination series concluded that the Alcohol Use Disorders Identification Test (AUDIT) is most the useful tool for identifying AUD in adults and postpartum individuals, while the abbreviated AUDIT-Consumption (AUDIT-C) best identifies excessive alcohol use in children aged 9 to 18 years and older adults. Other studies have found that a single question alcohol screen (“How many times in the past year have you had five (men)/four (women) or more drinks in a day?”) is comparable to the AUDIT-C in detecting unhealthy alcohol use and current AUD in primary care.
Articles in the January 2024 and May 2024 issues of American Family Physician discussed FDA-approved and off-label pharmacotherapies for adults with AUD. According to an Agency for Healthcare Research and Quality review, oral naltrexone, acamprosate, and topiramate have the strongest evidence for reducing alcohol consumption, while injectable naltrexone, baclofen, and gabapentin have weaker supporting evidence. Of the two first-line treatments approved by the FDA for AUD, acamprosate is contraindicated in patients with a creatinine clearance of ≤ 30 mL/min, while naltrexone should be avoided in patients who use opioids or have advanced liver disease. Disulfiram is not more effective than placebo in reducing alcohol consumption.
Friday, May 31, 2024
Measles outbreaks and the future of public health
In early March, a one year-old boy living in a shelter in Chicago was diagnosed with measles. Since measles is a highly contagious virus, more than 2000 shelter residents, many without confirmed histories of measles vaccination, were considered to be exposed. Over the next 3 days, the Chicago Department of Public Health (CDPH) swung into action, vaccinating 882 residents and confirming previous vaccination status in several hundred more, resulting in an estimated measles, mumps, and rubella (MMR) vaccine coverage of 93%. Nonetheless, in the next two months, 57 more cases of measles had been diagnosed among people residing in or having contact with residents of the shelter. A dynamic disease simulation model from the Centers for Disease Control and Prevention (CDC) estimated that in the absence of mass vaccination and case finding by CDPH, there was a 69% probability that this single infection would have led to more than 100 new measles cases.
The outlook for measles in the next decade in the U.S. is mixed, at best. Driven by the COVID-19 pandemic, vaccine skepticism and anti-vaccine sentiment has led to increases in religious and philosophical exemptions, causing the national kindergarten vaccination rate to fall to 93% in 2021-2022. Each percentage point decline increases the risk of a measles outbreak, as illustrated by the CDC's National Center for Immunization and Respiratory Diseases, with 93% MMR vaccination coverage associated with a 36% risk that a single infectious child could create an outbreak at a school with 100 children.
Unfortunately, decreasing childhood vaccination rates were not the only negative effect of the pandemic. The compelling PBS mini-series "The Invisible Shield" juxtaposes the historical successes of public health officials in controlling diseases and saving lives with the angry and occasionally violent pushback they received for ordering business closures and masking mandates to slow the spread of COVID-19. A recent Health Affairs article documented 112 judicial decisions from 2020-2023 that constrained public health's legal powers. As a result, the health commissioner for Columbus, Ohio was unable to close a daycare center where a measles case was reported in 2021, and a county in Michigan came close to shutting down the entire county health department over a dispute about masks.
An even bigger threat to public health is awaiting a decision from the Supreme Court:
On January 17, 2024, the US Supreme Court heard oral arguments in 2 combined cases, Loper Bright Enterprises v Raimondo and Relentless, Inc v Department of Commerce, that will determine the fate of Chevron deference, a bedrock principle of administrative law that obligates courts to defer to an agency’s reasonable interpretations of ambiguous statutes. ... Agencies like the FDA and CMS have, for decades, regulated medicine and public health in reliance of these principles.If the Supreme Court decides that this deferential statutory framework is unconstitutional, it would effectively open every federal health regulation that does not derive directly from specific legislative language (the vast majority of thousands and thousands of regulations) to a lawsuit, and it would put the burden on a dysfunctional Congress to account for "all possible regulatory scenarios and unforeseen circumstances" in writing unambiguous legislation. This would be a disaster.
I wonder how federal and state governments would respond if public health actions became necessary to protect people from H5N1 ("bird flu"), which so far has only been confirmed in 3 dairy workers this year but has likely infected many more? So far H5N1 has only caused mild symptoms in humans, but the fact that this virus has spilled over from cows to people and little surveillance is being done in to track its spread in either population is worrisome.
Sunday, May 19, 2024
Treating elevated BP in the hospital: more harm than good?
The first study evaluated adults hospitalized in 2017 for noncardiac diagnoses at 10 hospitals in the Cleveland Clinic health system; 78% had at least one elevated BP reading prior to discharge. About 1 in 3 of these patients received acute hypertension treatment, defined as “administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment.” After controlling for potential confounding factors, treated patients had statistically higher rates of acute kidney injury (10.3% vs. 7.9%) and myocardial injury (1.2% vs. 0.6%) than untreated patients. In patients whose antihypertensive medications were increased at discharge, BP control did not improve in the following year.
The second study focused on patients 65 years or older in a Veterans Health Administration hospital for noncardiac diagnoses between October 1, 2015, and December 31, 2017, who had elevated BPs within 48 hours of admission. Using a propensity score overlap weighting analysis to control for confounders, patients who received intensive BP treatment (defined the same as “acute hypertension treatment” in the first study) during this time period were more likely (8.7% vs. 6.9%) to experience a composite outcome of inpatient mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation.
In an article in the February 2024 issue of American Family Physician, Dr. Robert Gauer and colleagues advised taking a conservative approach to elevated BP in the hospital. Clinicians should address causes of transient BP elevations (e.g., pain, agitation, anxiety, fluid overload) rather than reflexively treating the numbers. Noting that “hospitalized patients with elevated BP often see a decrease of 20 mm Hg with subsequent measurements,” the authors suggested that 30 minutes of rest, rather than medications, should be first-line therapy. Patients with severe asymptomatic hypertension (BP > 180/110 mm Hg) should be treated with oral therapy only if they are at high risk for inpatient complications and if secondary causes have been excluded or addressed. Intravenous therapy should generally be avoided.
Thursday, May 9, 2024
19th century mental disorders and the American Civil War
Earlier this week, I gave this lecture as part of the "Lunch and Learn" webinar series sponsored by the Lancaster Medical Heritage Museum. I appreciated the opportunity to combine my interests in history and medicine to discuss how post-traumatic stress disorder manifested in former Civil War soldiers and its historical and present-day treatment.
Monday, May 6, 2024
Are beta-blockers always beneficial after a myocardial infarction?
A 2014 meta-analysis of 12 randomized trials performed in the “reperfusion era” reexamined the benefits and harms of adding beta-blockers to modern interventions in patients after MI. Beta-blockers did not improve mortality, and their benefits were limited to the first 30 days. An AFP POEM synopsis reported that while beta-blockers reduced the risk of recurrent MI (number needed to treat = 209) and angina symptoms (NNT = 26), they also increased rates of heart failure (number needed to harm = 79) and cardiogenic shock (NNH=90).
On the other hand, a 2020 Cochrane for Clinicians on beta-blockers after suspected or diagnosed acute MI, while noting that “most trials were conducted before the introduction of what is now considered standard reperfusion therapy,” found reduced risks of MI, cardiovascular and all-cause mortality even in patients who had not received PCI, thrombolytics, or coronary artery bypass grafting. Consequently, the authors recommended, “family physicians should continue to incorporate beta-blocker therapy in the care of patients with a history of MI.” The current American College of Cardiology / American Heart Association guideline for management of patients with chronic coronary disease splits the difference. As stated in a POEM in the March 2024 issue, “Long-term beta blockers are no longer routinely recommended and should be limited to patients with heart failure, myocardial infarction in the past year, or another indication.”
To clarify the effects of beta-blocker therapy post-MI, a randomized, open-label trial published earlier this month assigned more than 5,000 patients with an acute MI and preserved left ventricular ejection fraction (LVEF) of at least 50% to long-term therapy with metoprolol or bisoprolol or no treatment. After a median of 3.5 years, there was no difference between the groups in the primary composite outcome of death from any cause or new MI. Other potential benefits and harms, including hospitalization for atrial fibrillation or heart failure and hospitalization for bradycardia, hypotension, or syncope, were also statistically similar between the groups. Although these findings suggest that beta-blockers have no effects in post-MI patients without heart failure, an accompanying editorial observed that several more trials addressing this important clinical question will be completed in the next few years.
**
This post first appeared on the AFP Community Blog.
Sunday, May 5, 2024
STFM Research Paper of the Year
Thanks to Dr. Laura Blinkhorn for snapping this photo, since I wasn't able to travel to the Society of Teachers of Family Medicine conference this year. It's an honor to be recognized!
Wednesday, April 24, 2024
How artificial intelligence will make my work easier
A recent article in the Pittsburgh Post-Gazette outlined the various ways that artificial intelligence (AI) is improving health care in Pennsylvania. For example, AI software can serve as a "virtual scribe," listening to the doctor-patient conversation during an office visit and drafting a note, freeing the doctor to focus on the patient for 100% of the time. AI can "draft letters to health insurers on behalf of patients who need specialty medications, medical equipment or other care that's not standard in their insurance benefits," saving time for doctors and office staff. In the future, AI could respond to patient portal messages, triage phone calls, or even suggest diagnoses.
That all sounds great, but a lot of people thought that electronic health records would make clinicians' work easier when they were implemented, too, and we know how that worked out (or didn't). So what's the evidence that AI will actually deliver on its promise in health care?
A case study published in NEJM Catalyst described Kaiser Permanente (KP) Medical Group's implementation of AI scribes using smartphone microphones to document more than 300,000 patient encounters across all medical specialties:
The response from physicians who have used the ambient AI scribe service has been favorable; they cite the technology’s capability to facilitate more personal, meaningful, and effective patient interactions and to reduce the burden of after-hours clerical work. In addition, early assessments of patient feedback have been positive, with some describing improved interaction with their physicians. Early evaluation metrics, based on an existing tool that evaluates the quality of human-generated scribe notes, find that ambient AI use produces high-quality clinical documentation for physicians’ editing. Further statistical analyses after AI scribe implementation also find that usage is linked with reduced time spent in documentation and in the EHR.
Saturday, April 20, 2024
Reducing harms associated with PSA screening
Magnetic resonance imaging (MRI) is increasingly being used as a triage strategy for men with suspected prostate cancer to avoid unnecessary biopsies while still detecting clinically significant cancers at curable stages. A 2024 systematic review and meta-analysis of 72 studies (n=36,366) examined associations between MRI Prostate Imaging Reporting & Data System (PI-RADS) findings, clinical data, and clinically significant prostate cancer. Compared to performing prostate biopsies on all patients, avoiding biopsies in patients with PI-RADS category 3 or lower lesions and PSA density of 0.10 or less reduced unnecessary biopsies by 30% and missed 1 in 17 significant tumors. Increasing the PSA density threshold to 0.15 reduced unnecessary biopsies by 48% and missed 1 in 15 significant tumors.
Several randomized trials are evaluating the effectiveness of a screening strategy combining MRI and a PSA-based biomarker risk score (e.g., 4-Kallikrein Panel) to determine which patients with abnormal PSA levels should be biopsied. The ProScreen trial, involving more than 60,000 Finnish men aged 50 through 63 years, recently reported preliminary results from its baseline screening round. Researchers found that compared to the usual care group, men invited for screening were more likely to have high-grade prostate cancer detected (1 per 196 men) at the cost of also being more likely to have low-grade prostate cancer detected (1 per 909 men). Whether these small differences will lead to meaningful improvements in prostate cancer mortality will not be known for at least several years.
A systematic review published on April 7 in JAMA reiterated the importance of continuing to use cancer-specific mortality as the primary outcome in randomized trials of cancer screening. The authors evaluated the strength of correlations between reductions in stages 3 and 4 cancer (a proposed surrogate outcome for trials of multicancer screening tests) and reductions in cancer-specific mortality in 41 published randomized trials of screening for breast, colorectal, lung, ovarian, prostate, and other cancers. They found high correlations for ovarian and lung cancers, but only a moderate correlation for breast cancer, and weak correlations for colorectal and prostate cancers.
Saturday, April 6, 2024
Should race be incorporated into weight management decisions?
I have a personal stake in the answer to this question. For most of my adult life, my body mass index (BMI) has ranged between 22 and 25 kg/m2, which is considered to be in the normal range (the threshold for overweight is a BMI of 25, and obesity a BMI of 30). But it turns out that I've been overweight for most of that time if one applies a race-specific definition of overweight (BMI greater than 23) for individuals of Asian descent. Where did this race-based cutpoint come from, and is it still relevant in an era when we generally frown on using race as a surrogate for social determinants of health in making clinical decisions?
The story starts more than two decades years ago, when an expert committee convened by the World Health Organization (WHO) examined associations between BMI, body fat percentage, and risk factors for type 2 diabetes and cardiovascular disease in studies of Asian populations. They found that at similar BMI levels, Asian adults have higher body fat percentages and more metabolic risk factors than White adults. Although the WHO declined to formally establish different BMI thresholds for overweight and obesity in Asian populations, it suggested "additional trigger points for public health action": BMI greater than 23 represents "increased risk" and BMI greater than 27.5 represents "high risk."
In 2015, the American Diabetes Association (ADA) examined evidence from 4 cohort studies in Asian American populations and concluded that Asian American adults should be considered for diabetes screening if they have a BMI greater than 23, based on the prevalence of type 2 diabetes in this population being roughly equivalent to that in White Americans with a BMI greater than 25. (The U.S. Preventive Services Task Force recommends screening for prediabetes and diabetes in nonpregnant adults aged 35 to 70 with a BMI of 25 or greater, but it alludes to the ADA's lower threshold for Asian Americans in its practice considerations.) Notably, the studies cited by the ADA included virtually no persons of Chinese descent, despite Chinese being the largest Asian American subgroup. So this guideline does not necessarily apply to me.
However, a 2009 study of a large cohort (n=36,386) of Taiwanese civil servants and schoolteachers over age 40 found that all-cause mortality increased significantly at BMIs greater than 25, analogous to the increase in mortality seen in White populations with obesity (BMI > 30). Taiwanese adults with BMIs from 23 to 24.9 had no difference in all-cause mortality compared to persons with lower BMIs but showed a nonsignificant trend toward increased cardiovascular mortality that was not modified by smoking status. That this study suggested a nearly identical risk threshold as studies in other Asian American populations would argue that I am not exempt.
A more recent comparative study of minority populations living in England found that South Asians with lower BMIs had the highest risk of developing diabetes, followed by Arab, Chinese, Black, and finally White populations. Presumably, race and ethnicity were self-identified. Similarly, a 2023 scientific statement from the American Heart Association found that the risk of coronary artery disease appears to be highest among South Asian and Filipino Americans and lowest among Chinese, Japanese, and Korean Americans, but cautioned that limited disaggregated data precluded making clinical recommendations based on race or ethnicity. As a JAMA news article recently noted, the common practice of national surveys lumping diverse ethnic groups into a single "Asian" obscures disparities within those groups and frustrates efforts to achieve health equity.
My admittedly selective review of the data leads me to believe there is probably some value to considering more intensive lifestyle counseling and metabolic screening in Asian patients with BMIs between 23 and 25, like me. But what do we do about the rising numbers of American adults of mixed race? Perhaps "precision medicine" will eventually find a way to integrate genetic and environmental risks and let clinicians dispense entirely with numeric thresholds and race categories, but I would be surprised if this occurs before the end of my career in medicine.
Saturday, March 23, 2024
HPV vaccination is highly effective but remains underused in the U.S.
In 2019, a Medicine by the Numbers in American Family Physician summarized a Cochrane review of 26 randomized, controlled trials comparing HPV vaccines to placebo. The authors found that vaccination reduced the risk of precancerous cervical lesions (cervical intraepithelial neoplasia [CIN] grades 2 or 3 and adenocarcinoma in situ) with numbers needed to treat (NNT) ranging from 55 to 73, depending on participants’ baseline HPV status. A 2021 observational study of girls and young women in England found that vaccination at ages 16-18, 14-16, and 12-13 years was associated with reductions in cervical cancer of 34%, 62%, and 87%, respectively. Remarkably, a study published this year found that 30,000 Scottish women who received at least one dose of HPV vaccine at age 12 or 13 had developed zero cases of invasive cervical cancer 11 to 20 years later!
Nonetheless, HPV vaccination coverage among U.S. adolescents remains lower than that for other childhood vaccines. Although coverage has gradually increased over time, an analysis of 2022 National Immunization Survey (NIS) data found that only 69% of 13 year-olds and 77% of 17 year-olds had received at least one dose, and 50% and 68% of these respective age groups were up-to-date (had received 2 doses if starting the series before age 15, or 3 doses if starting later). In comparison, 90% of 17 year-olds had received a least one dose of tetanus, diphtheria, and acellular pertussis (Tdap) and at least 2 doses of measles, mumps, and rubella (MMR) vaccines.
Historically, children living in socioeconomically disadvantaged households have been less likely to be up-to-date on immunizations. The Centers for Disease Control and Prevention’s Vaccines for Children program, which celebrates its 30th anniversary this year, aims to eliminate disparities in access by providing vaccines at no cost to children who are uninsured, Medicaid-eligible, American Indian or Alaska Natives.
A recent study of the 2017-2021 NIS examined factors associated with the intent to vaccinate by socioeconomic status and education level among parents of adolescents who had not received HPV vaccine. Participating parents were considered “advantaged” if their income was greater than 200% of the federal poverty level and they had at least a high school education; parents with lower incomes who had not completed high school were considered “deprived.” Surprisingly, 65% of advantaged parents of unvaccinated adolescents reported no intent to vaccinate in the future, compared to 41% of parents in the deprived group. Reasons for not vaccinating also differed between the groups: the advantaged group most often cited “safety concerns,” while the deprived group reported “lack of knowledge,” “not recommended,” and “not needed.” These data suggest that HPV vaccine hesitant parents may respond to different approaches.
In a 2015 AFP editorial, Drs. Herbert Muncie and Alan Lebato advised presenting the vaccine’s benefit as cancer prevention rather than focusing on HPV as a sexually transmitted infection, and taking a non-judgmental approach when explaining the recommendation to vaccinate:
To improve acceptance of immunizations, physicians must be knowledgeable about vaccine safety and effectiveness, and non-judgmental about parents' beliefs. … Hesitant parents may respond to the CASE method: the physician corroborates the parents' concerns, talks about his or her own experience with the vaccine, summarizes the science about vaccine effectiveness and safety, and explains advice in terms of the child's health.
Regarding safety, the World Health Organization’s Global Advisory Committee on Vaccine Safety has repeatedly found no evidence of a causal association between HPV vaccination and a variety of serious adverse effects.
Thursday, March 7, 2024
Deadly drivers and the limits of preventive counseling
I believe that I'm a pretty safe driver. I don't use my phone in the car except for calls on my Bluetooth hands-free system, I come to a complete stop at stop signs even when no one else is around, and I never get in the driver's seat after I've been drinking. During the fall of 2020 and spring of 2021, though, I paid more attention than usual to driving safely. Our auto insurance company offered a discount for installing a device in my car that monitored my driving behavior, and my then 15 year-old son (in Utah, the minimum age for a learner's permit is 15) began learning to drive.
There has been a lot of media attention in recent months to the increase in distracted driving and its deadly consequences since the start of the pandemic. After falling for decades thanks to legislation mandating safety features such as airbags to a low of 32,479 in 2011, annual traffic-related deaths (including pedestrians) gradually rose, then spiked during the pandemic from 38,824 in 2020 to 42,795 in 2022. This statistic is similar to the 48,000 firearm homicides and suicides that occur in the U.S. every year.
Why have traffic-related deaths been going in the wrong direction? A New York Times Magazine story highlighted deferred road maintenance, larger and more powerful vehicles, aggressive driving and road rage, and the perennial culprit, intoxicated drivers. A recent analysis of data from the National Highway Traffic Safety Administration found that 1 in 5 deaths of child passengers in motor vehicle crashes involved an alcohol-impaired driver (blood alcohol concentration > 0.08 g/dL), and the more impaired the driver was, the less likely the child was to be wearing a seat belt.
A Vox story pointed the finger at smartphones, noting that a company that sells a more sophisticated version of the device I installed in my car a few years ago - an app that measures phone motion and screen interaction while driving - found that in 2022, drivers interacted with their phones on nearly 58% of trips (an average of 2 minutes, 11 seconds per hour), more than one-third while driving over 50 miles per hour. This is when they knew the app was monitoring their behavior; one wonders if they would have been on their phones even more without it.
The difference between a medical and a public health problem is often merely a matter of perspective. For example, the solution to the medical problem of hypertension is to screen patients for high blood pressure and put the ones whom we diagnose on medications and/or encourage them to be more physically active and eat differently. But treating high blood pressure as a medical problem has been an abysmal failure. According to the National Health and Nutrition Examination Survey, of the one-third of Americans who had hypertension from 2017-2020, more than half had uncontrolled blood pressure (>140/90 mm Hg) and even among patients taking blood pressure medication, nearly one-third had uncontrolled blood pressure. Zoom out from the office setting to communities, counties, and states, and it's easy to see that hypertension is really a public health problem: too much sodium in food, too little access to safe places to exercise without a gym membership, difficulty getting a primary care appointment due to insufficient supply and uneven distribution, and so on.
Is impaired driving a medical or a public health problem? I got a lot of flak from readers when I wrote in a Medscape commentary that I would report to law enforcement a patient who declined to stop driving while high on cannabis. Clinical guidelines recommend counseling parents and guardians about keeping their children in rear-facing car seats until age two, using age and size-appropriate car and booster seats, and having children age 13 and younger ride exclusively in the back seat. With any adolescent approaching the minimum age for a learner's permit (16 years in Pennsylvania), I spend time during the well-child visit discussing the dangers of driving and texting, substance use before or while driving, and getting into a car with an impaired or distracted driver. Perhaps my counseling has saved a few lives over the past 20 years, but it's never been proven that this type of counseling improves health outcomes.
However, the evidence is clear that public health interventions and laws reduce motor vehicle crash injuries and deaths. The Community Preventive Services Task Force has evaluated a long list of interventions that save lives by reducing alcohol-impaired driving and increasing use of child safety seats, seat belts, and motorcycle helmets. The Vox story cited data that associated the passage of "hands free" phone laws with reductions in phone motion and driver distractions, but a lack of enforcement may cause these bad habits to reassert themselves over time.
Tuesday, February 27, 2024
Birthday blessings
The following is a guest post from my sister-in-law, Dr. Therese Duane, a trauma surgeon who is blogging about her medical mission in Uganda. You can read more about the essential work she and her colleagues have been doing at Mercy Trips Healthcare Outreach.
**
As a little girl growing up in a big family, there were few things that I could actually call my own. Not only did I share a room, but for a long time my sisters and I even shared a twin bed. Going clothes shopping meant venturing into another sister’s closet for hand-me-downs, and toys belonged to whomever could run away fast enough without tripping and getting tackled by the rest of us. But there was one thing we could call our own, and that was our birthday—although I did share mine with an uncle and George Washington.Still yet, in our home, my mother made an effort for each of her seven children to have a special birthday. I have fond recollections of sleepovers filled with giggles, scary movies, and not enough sleep that always culminated in Mickey Mouse pancakes my mother would prepare especially for me. I knew I was loved.
If someone had told me 40 years ago that I would have spent my birthdays in Uganda doing medical mission work, I am not sure I would have believed them. And yet, here I am turning 54 years old and instead of giggles with my girlfriends, I am getting chuckles from children who—despite being far from home undergoing painful procedures—still manage to share their smiles with strangers.
Caring for all these families, many of which are large, reminds me how the gift of family is universal. I see many women struggling with fertility with few options. One 42-year-old with only one child came to have her fibroids removed so she could carry another pregnancy to term, as she had previous miscarriages. Sadly, her evaluation demonstrated enormous tumors that were compressing her pelvic organs and causing significant pain. After explaining that her only option was removal of her uterus and more biological children weren’t possible regardless of surgery, I could see the devastation. She left clinic having been informed of the risks of delaying surgery and never returned, choosing instead to be in pain than accept the inevitable. Other women come in with many children, and want more, but need surgery for another complaint. Hence, fertility awareness education is incredibly important for this impoverished country so that couples can make healthy decisions for themselves as they cherish their gift of family.
So, as this birthday comes to a close, I have already been privileged to bring a baby boy into this world through a c-section for one patient and remove a diseased ovary of a different woman, preserving her other, healthy ovary in the hopes that this will help her future fertility. In Uganda, general surgery is certainly general as we provide a wide array of service to the best of our ability. We strive to ensure that the gift of family is embraced, preserved, and expanded based on God’s will and that every person knows they are loved.
Wednesday, February 21, 2024
Appreciation (the changing of the guard)
Originally posted on Common Sense Family Doctor on February 7, 2018.
**
The February 1, 2018 issue of American Family Physician marked the first time since 1988 that a family physician other than Dr. Jay Siwek was serving as the journal's editor-in-chief. Dr. Siwek, who bade farewell to readers in a poignant, memory-filled editorial in the January 15 issue, will stay on as editor emeritus. This month, Dr. Siwek introduced his successor, longtime associate editor Dr. Sumi Makkar Sexton. You can read about Dr. Sexton's extensive qualifications and experience in Dr. Siwek's latest piece and learn about her plans for the future of AFP, which include making journal content more usable at the point of care, in her introductory editorial.
It has been my good fortune to know Jay and Sumi for the past 20 years, since I arrived at Georgetown University School of Medicine as AFP's medical editing fellow in the summer of 2004. Both played critical roles in my development as a family physician and medical editor, during and after my one-year fellowship. It was Jay, in his previous capacity as Chair of Georgetown's Department of Family Medicine, who hired me as a junior faculty member and supported each of my subsequent promotions to assistant, associate, and full professor. After I left the department for several years to work as a medical officer at the Agency for Healthcare Research and Quality and earn a master's degree in public health, it was Jay who convinced me to return and deploy my new skills to direct the department's health policy fellowship and eventually take on other leadership and teaching positions in population health.
On the other hand, it was Sumi, as the editor of Tips from Other Journals (an AFP department that ended in 2013) who continued to hone my writing and evidence-based medicine skills for years after my fellowship ended. Under her supervision, from 2005 to 2010 I wrote more than 60 summaries of primary care-relevant research studies for AFP. And after my first post-fellowship clinical position unexpectedly fell through, it was Sumi who hired me to see patients at her thriving practice, Premier Primary Care Physicians, which was an early adopter of innovations such as electronic medical records and advanced-access scheduling.
As AFP's new deputy editor, I have worked closely with Sumi and Jay for the past several months to support their changing of the guard at editor-in-chief, and I look forward to many more years of collaborating with them both. Moving on from Dr. Siwek to Dr. Sexton is an important transition, but the best-read journal in primary care won't miss a beat.
Friday, February 16, 2024
Looking for a balanced approach to America's illicit drug use problem
In an earlier post about my frustrating experience serving on a District of Columbia grand jury that handled indictments for drug-related offenses, I wrote approvingly about Portugal's novel approach to decriminalizing illicit drug use. In short, rather than receiving criminal sentences and jail time, people caught using small amounts of drugs in Portugal receive citations and are offered counseling and medical treatment. Since then, the city of San Francisco and the state of Oregon have both implemented versions of Portugal's non-punitive approach, with mixed results.
A January 31 New York Times article compared Portugal to San Francisco, which saw its overdose death rate spike during the pandemic to more than twice the national average. Addiction treatment in San Francisco is fragmented and rarely accepted by people caught using drugs: "From May 30 [2023] to Jan. 4, just 25 people accepted treatment after an arrest, in a city where tens of thousands of people use drugs regularly." Harm reduction programs in San Francisco, unlike in Portugal, do not always push clients toward treatment. The culture of the California city is more libertarian than conservative Portugal, where drug use is discouraged and stigmatized. Finally, the drug response in San Francisco is not guided by a comprehensive strategy. The public health department and law enforcement agencies are divided on how much of the approach to recreational drug users should be carrots versus sticks, and other than reducing the overuse rate, the city has no clear goal.
A February 7 NPR story examined Portland, Oregon's experience with decriminalization of drug possession since a state ballot measure passed in November 2020: "So far, police have handed out more than 7,000 citations, but as of December, only a few hundred people had called the hotline to get assessed for a substance use disorder. And even fewer accessed treatment through the citation system." Opioid-related overdose deaths across the state rose from 280 in 2019 to 956 in 2022, though given the rise of fentanyl and homelessness and the impact of the pandemic on health care services, it's hard to know if the new approach contributed to the difference. The story quoted an addiction medicine physician arguing that the primary drivers of Oregon's rising overdose toll are "our decades-long, underbuilt system of behavioral health, substance abuse disorders, shelter and affordable housing" - not the decision to treat drug use as a medical problem rather than a crime.
The U.S. health care system is a culprit, too. Not only is a sizeable percentage of our population uninsured at any given time, people with drug use disorders are overrepresented in that group. And if you can afford to see a doctor, you can't necessarily find one willing to prescribe medications for opioid use disorder. My friend and fellow family physician, Dr. Corey Fogleman, recently co-authored a column in the Lancaster newspaper that observed how and why our county's outcomes have positively diverged from the rest of the state of Pennsylvania:
Lancaster County health care providers are unique in their willingness to provide buprenorphine treatment for opioid use disorder. Further, the Lancaster General Hospital Family Medicine Residency Program teaches this care to every medical student and medical resident educated in our system. Since 2016, Lancaster County has increased buprenorphine prescribing by 79% compared to a statewide average of 30%.This has paved the way for crucial gains in fighting the opioid epidemic. Lancaster County has observed a notable and consistent downward trend in mortality due to this disease. Overdose deaths reached a peak in 2017, with more than 30 deaths per 100,000 residents that year. In 2022, per capita overdose deaths in Lancaster County dropped below 20 per 100,000 residents (106 total deaths). By comparison, Pennsylvania as a whole continues to observe a gradual upward trend in overdose fatalities, from 35 to more than 40 deaths per 100,000 residents during the same time frame (there were 5,155 total overdose deaths in the commonwealth in 2022).
Sunday, February 11, 2024
Prenatal and congenital syphilis cases continue sharp rise in the U.S.
Last November, the Centers for Disease Control and Prevention (CDC) reported that cases of congenital syphilis in the U.S. had soared 755% over the past decade, peaking at more than 3,700 in 2022. The CDC’s review of that year’s cases revealed that nearly 90% were potentially preventable, resulting from a lack of timely testing and adequate treatment. An analysis of 2017-2019 Medicaid claims in 6 Southern states (Georgia, Kentucky, Louisiana, North Carolina, South Carolina, and Tennessee) found that despite state laws mandating prenatal syphilis screening, actual screening rates ranged from 56% to 91%.
In a previous blog post, I discussed how the diversion of public health personnel and resources during the COVID-19 pandemic had hampered contact tracing efforts to prevent the spread of syphilis and other sexually transmitted infections (STIs). Since June 2023, syphilis treatment has been affected by a global shortage of injectable benzathine penicillin, leading the CDC to advise prioritizing its use for infections in pregnant patients and babies with congenital syphilis (doxycycline can be used for infections in non-pregnant persons).
Although the U.S. Preventive Services Task Force recommends screening for syphilis in nonpregnant patients at increased risk so that persons testing positive can be treated to break the chain of infection, the number of syphilis cases in the U.S. continues to rise. The CDC’s latest Sexually Transmitted Infections Surveillance Report documented more than 207,000 cases in 2022 – a 17 percent increase over 2021 and the highest number reported since 1950. Few communities were spared; at least one case of congenital syphilis was reported in 47 states and the District of Columbia.
An editorial in the January 2024 issue of American Family Physician reviewed the management of STIs during pregnancy. At a minimum, all pregnant patients should receive screening for syphilis in the first trimester, with repeat screening recommended at 28 weeks and delivery for patients at high risk or living in high-prevalence communities. Clinicians should have a “low threshold of suspicion” for atypical presentations:
Although the classic syphilitic chancre is a single, sharply demarcated, painless ulcer, only 30% of patients have this presentation. Chancres may be hidden (e.g., in the cervix or rectum) or absent. Opt-out screening is essential because a large National Institutes of Health study found that 49% of pregnant women with syphilis from 2012 to 2016 had no identifiable risk factors.
A recent New England Journal of Medicine article reviewed the evaluation and management of neonates with congenital syphilis.
As my colleague Dr. Jennifer Middleton wrote, the CDC has proposed a novel prevention strategy called doxy-PEP (doxycycline preexposure prophylaxis for syphilis and other STIs) for cisgender men who have sex with men and transgender women who have sex with men with an STI diagnosis in the last year. Unfortunately, a recent trial of doxy-PEP in cisgender women in Kenya who were receiving HIV PrEP found no reduction in STI incidence, though participants’ overall adherence to doxycycline was low.
**
This post first appeared on the AFP Community Blog.
