Imperfect prevention strategies against malaria and cancer

Two recent articles in American Family Physician highlight new prevention and detection strategies against age-old health threats. In "Malaria: Prevention, Diagnosis, and Treatment," Drs. S. David Shahbodaghi and Nicholas Rathjen review not only prescribing prophylaxis for travelers to malaria-endemic regions, but also "the first malaria vaccine approved for widespread use ... for the prevention of P. falciparum malaria in children living in endemic areas," which has already been given "to more than 1 million children in Ghana, Malawi, and Kenya." In a previous blog post, Dr. Jennifer Middleton discussed the World Health Organization's endorsement of Mosquirix and research evidence that it lowers the incidence of malaria infection, complications and death in combination with seasonal chemoprophylaxis.

A New York Times article elaborated on the financial, logistical, and trust challenges of getting an estimated 100 million vaccine doses into children's arms every year. A full series of Mosquirix consists of 4 doses administered between 5 and 18 months of age. Its limited (40%) efficacy compared to other malaria vaccines in development has raised concerns that "every dollar directed to Mosquirix now is a dollar less for developing other tools" and paying for low-tech prevention measures such as distribution of insecticide-treated bed nets.

Despite a 27% decline in cancer mortality in the U.S. over the past two decades, cancer trails only heart disease as the leading cause of death, and most cancer types do not have screening tests recommended by the U.S. Preventive Services Task Force (USPSTF). A Diagnostic Tests article by Dr. Natasha Pyzocha discusses the Galleri test, a highly promoted blood test that is used to detect more than 50 cancer types in older adults. The test's manufacturer recently reported results of a prospective study of the test that detected a "cancer signal" in 1.4% of participants, 38% of whom ultimately had cancer confirmed after additional diagnostic testing. A much larger study currently underway in the United Kingdom's National Health Service should go a long way toward determining if this test is a "game changer" or "overhyped" for improving cancer outcomes and mortality.

Several other multi-cancer early detection (MCED) tests are in various stages of development, and the future impact of MCEDs on family physicians who may be ordering these tests in practice is uncertain. A review in the American Journal of Medicine mentioned "concerns about patient counseling, costs, frequency of testing, patient anxiety, and subsequent testing for a positive result." Similarly, the director of the National Cancer Institute's Division of Cancer Prevention wrote that "there is still a substantial level of uncertainty and many unknowns surrounding these tests," including "how best to maximize their benefits and minimize their potential harms." Until more definitive studies demonstrate that the benefits of MCEDs exceed the harms, I advise physicians and patients against ordering or undergoing any of these tests.

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This post first appeared on the AFP Community Blog.

Can Amazon cure all that ails U.S. primary care?

This summer, Amazon purchased the One Medical national chain of primary care practices for nearly $4 billion. As David Blumenthal and Lovisa Gustafsson recently wrote in the Harvard Business Review, the success of the online retail giant's health care venture is hardly assured. One doesn't need to be a practicing family physician with health policy expertise to know that U.S. primary care is chronically overworked and underfunded, and as a result, medical student interest in primary care specialties has been anemic for the past two decades. As I discussed in a previous Medscape commentary, international primary care comparisons are less than flattering. The "fundamental question," asserted Blumenthal and Gustafsson, is: "Can profit-driven entrepreneurship and bottom-up innovation make the U.S. health care system work anywhere nearly as well as those in places like France, Sweden, Norway, Australia, the Netherlands, New Zealand, Germany, and Switzerland?"

A new analysis of the time needed to provide all recommended preventive, chronic disease, and acute care to a hypothetical adult primary care panel of 2500 patients produced a mind-boggling (and mathematically impossible) estimate: 26.7 hours per day, with more than half allocated to preventive care. (It's no wonder that urgent care facilities, staffed largely by primary care physicians and advanced practice clinicians, are growing like weeds everywhere.) Even in a team-based primary care model where medical assistants and nursing staff take on much of the preventive and chronic disease care and the physician only handles the really hard stuff, the authors estimated that 9.3 hours per day would be needed, with nearly one-third allocated to documentation and inbox management. How many aspiring doctors envision a future where they spend 3 hours per day on electronic health record (EHR) tasks?

Oh, but it gets even better (and by better, I mean worse). A fascinating history of time organization in U.S. outpatient medicine published in the Annals of Internal Medicine traced the evolution of physician practice from sporadic home visits or open "office hours" to appointments based on standard 15-minute blocks. As appointment schedulers migrated from individual doctors' front offices to distant call centers, personalized time allocation based on the complexity of the patient and his or her specific concerns became a thing of the past:

The centralization and standardization of outpatient scheduling have lessened the system's ability to acknowledge and accommodate the individual needs and natures of specific patients and physicians. This tradeoff creates special challenges for primary care, a field whose effectiveness relies heavily on strong relationships and trust. Without the ability to accommodate patients and physicians as individuals, health care systems risk robbing primary care of its value and losing the trust of both parties.

A commentary about primary care burnout in Health Affairs Forefront  noted that our singular talent for building relationships - frequently, the reason we are drawn to generalist specialties like family  medicine - is being wasted in the design of the current health care system:

The focus of primary care has become largely administrative, sending results electronically, clarifying and approving refills, responding to patient messages, closing care gaps, addressing billing inquiries, and, of course, documenting everything by midnight. ... The result: It is increasingly rare to have those magical moments between a primary care provider and patient in which time flies because we are listening intently to each other, bearing witness, and offering a steadfast presence and commitment to longitudinal care. Instead, exchanges are increasingly composed of a two-sentence request in Arial font (“My knee still hurts. I need a referral to ortho.”) followed by a single word response (“Done.”). Our greatest skills are in listening, connecting, and collaborating within and across highly complex systems. It is a skill we rarely get to use.

Dr. Thomas Bodenheimer, a longtime general internist and Professor of Family and Community Medicine at UCSF, argued in a recent essay that the two keys to "revitalizing primary care" are a substantial increase in the percent of health expenditures dedicated to it and building fully-staffed inter-professional teams that are able to care for large primary  care panels and reduce physician burnout. No more tinkering around the edges with initiatives like "patient-centered medical homes" and financial incentives for "transitional care" and "care management." Rhode Island and Oregon have led the way by mandating that commercial insurers increase their percentage of primary care spending. Federal action will be required to equalize the monetary value of a 30-minute office visit with a 30-minute colonoscopy (currently, the former is valued at 40% of the latter).

So can Amazon cure all that ails U.S. primary care? I imagine a customized health shopping homepage where a percentage of every purchase is funneled directly to One Medical, where vans with Amazon's distinctive emblem drop off colorectal and cervical cancer self-screening tests at all hours, where the subscription Prime channel airs a hit show starring two attractive and empathic family physicians who emphasize relationship-based care like their predecessor, Marcus Welby, MD. You won't see them spending hours in the EHR after hours. Instead, their every word will be documented by attentive scribes - either real-life or artificial intelligence-enabled versions. Medical students will clamor to be them. Family medicine departments and residency programs will perpetually expand to keep pace with demand. And our primary care system will be the envy of the world.

Gabapentin increases postoperative risks in older adults

Although gabapentin is effective at relieving some types of neuropathic pain, namely diabetic neuropathy and postherpetic neuralgia, it is notably ineffective for treating other types, such as radicular low back pain. A 2019 editorial in American Family Physician warned of potential unintended consequences of using gabapentinoids (gabapentin and pregabalin) as alternatives to opioids for pain management. The authors observed that "as many as one in three patients taking therapeutic doses will experience dizziness or somnolence"; also, the U.S. Food and Drug Administration issued a safety communication about gabapentinoids causing serious breathing problems in patients with chronic respiratory diseases and older patients.

Illicit use of gabapentin is playing an increased role in opioid-related overdoses, according to a May 2022 report from the Centers for Disease Control and Prevention. The report found that between 2019 and 2020, toxicology results detected gabapentin in almost 10% of fatal overdoses recorded in 23 states and Washington, DC. Misuse of gabapentin occurs for several reasons: "to enhance the effects of opioids," "to achieve a 'high' when preferred substances [are] unavailable," and "to self-treat withdrawal or pain."

A recent cohort study in JAMA Internal Medicine examined gabapentin use in the perioperative period (within 2 days after major surgery) and in-hospital adverse events in nearly 1 million patients aged 65 years or older. More than 3 in 4 patients underwent orthopedic surgeries. Overall, 12.3% were prescribed gabapentin perioperatively. Those patients were statistically more likely to experience delirium, receive a new prescription for an antipsychotic drug, and develop pneumonia than gabapentin non-users. In persons using gabapentin, the risk of delirium was higher with chronic kidney disease and a high burden of comorbidities.

An accompanying commentary pointed out that the study results "are consistent with what is now a growing body of literature suggesting that gabapentin may not be the windfall medication for perioperative pain management that surgeons hoped it might be for decreasing opioid use," particularly in older adults:

We need to unwind the automaticity of gabapentin use in the perioperative period. For example, in this study, 80% of gabapentin users received gabapentin on the day of surgery, suggesting that it was started prior to any patient report of pain, representing an opportunity to de-escalate gabapentin use for some patients. Second, engaging patients and caregivers in their care could allow us to better manage expectations for pain control in the perioperative period. A multimodal approach needs to be patient centered and flexible. Finally, aside from swapping out one potentially problematic medication for another, nonpharmacological techniques that might be used to treat pain should be considered.

This post first appeared on the AFP Community Blog.

The evidence is in: WIC improves maternal and child health

Food insecurity is increasingly recognized as a modifiable social determinant of health. The American Academy of Family Physicians has endorsed "sustained funding for evidence-based policies and programs to eliminate disparities in healthy food access, including ... the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC)." In a 2019 editorial about interventions to reduce maternal mortality, Drs. Katy Kozhimannil and Andrea Westby recommended postpartum screening for food insecurity. But how strong is the evidence that WIC improves maternal and child health?

Since 2012, American Family Physician's Implementing AHRQ Effective Health Care Reviews feature has summarized dozens of primary care-relevant systematic reviews from the Agency for Healthcare Research and Quality's Effective Health Care Program with accompanying clinical commentaries. A team of investigators in this program recently reviewed maternal and child outcomes associated with WIC and published a synopsis of their report in Annals of Internal Medicine. Investigators identified 82 studies that examined associations between WIC participation and maternal, birth, infant, and child health outcomes.

Based on direct evidence from 49 studies, they concluded that WIC participation likely reduces the incidence of preterm birth, low birth weight, and infant mortality. Lower strength of evidence suggested WIC is associated with less inadequate gestational weight gain and alcohol use and better diet quality during pregnancy, and it may increase child preventive care visits and immunizations. WIC was not associated with differences in breastfeeding rates or premature (before 4 months) introduction of solid foods. Children of families receiving WIC had better diet quality, increased household purchasing of healthy foods compared to less healthy foods and beverages, and higher cognitive development than WIC-eligible children not receiving benefits. There was insufficient evidence that WIC reduced childhood obesity or affected health status or risk of hospitalization.

The U.S. Department of Agriculture (USDA) found that food insecurity in households with children declined to its lowest rate in two decades in 2021, despite the negative impact of the COVID-19 pandemic on the economy. The nonpartisan Center on Budget and Policy Priorities observed:

About 10.2 percent of U.S. households were food insecure in 2021, meaning they struggled to afford enough food for an active, healthy life year-round. That the rate held steady during the pandemic — when accounting for statistical noise it’s not significantly different from the 10.5 percent rate for 2019 and 2020 — is a testament to robust relief measures policymakers enacted. These include Economic Impact Payments, an expanded Child Tax Credit, improved unemployment insurance, and expanded food assistance, along with [the Supplemental Nutrition Assistance Program]'s built-in ability to respond to increased need.

On the negative side, food insecurity increased from 2020 to 2021 in households without children and for women and older people living alone. Households headed by Black, Hispanic, and American Indian / Alaska Native persons were more likely to experience food insecurity than other households. Finally, the expiration of temporary pandemic emergency relief measures, such as free meals for all children attending public schools, may worsen food insecurity in low-income families.

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This post first appeared on the AFP Community Blog.

Malcolm Gladwell on trust in medicine and the devaluing of primary care

This week I'm back in Washington DC, attending and presenting educational sessions at the American Academy of Family Physicians FMX (Family Medicine Experience), the first in-person version of this conference since 2019. For me the highlight of this conference is usually the invited celebrity speaker, someone with an inspirational story outside of medicine: past speakers have included political pundits Mary Matalin and James Carville and Aron Ralston, who survived a canyoneering accident in which he had to cut off his own arm to save his life. But this year's speaker, the author and podcaster Malcolm Gladwell, topped them all. I've been a huge Gladwell fan since I read The Tipping Point, avidly listen to his Revisionist History podcast (and featured a past episode on philanthropy on this blog), and couldn't wait to hear what he had to say yesterday to an audience of family physicians who have spent the past two plus years fighting pandemic misinformation.

The theme of his talk was that the decline in trust in medicine and public health that has manifested as tenacious resistance to Covid vaccination among certain demographics and/or areas of the country may have less to do with true anti-science sentiment and more to do with people having a hard time adjusting to strange new things. He shared several examples of this phenomenon in other fields: focus groups panning pilots of television sitcoms that ended up becoming classics (e.g., the Mary Tyler Moore Show, All In The Family, Cheers, and Seinfeld); the near rejection of the prototype of a mesh office chair that ended up earning billions of dollars for its inventor; and the Marines transforming its service from the misfits of the U.S. military to "the Few, the Proud" elite branch that we know today. Gladwell noted that trust in a profession doesn't always correlate with its effectiveness, and that pouring billions of dollars into amazing technological solutions to the pandemic (vaccines and antiviral treatments) while neglecting to support the family doctors whose job it is to persuade patients, based on preexisting trusting relationships, to accept these medical innovations was "nuts." (I made a similar point in an editorial in the Annals of Family Medicine last year). It's no wonder that many of our patients turned to the well established - but totally ineffective - drugs hydroxychloroquine and ivermectin instead.

Public health holds many stories of initial mistrust in effective interventions. Gladwell talked about how despite clear evidence showing that supplementing water or salt with iodine eliminated goiter, there was widespread public resistance to the idea ("I'll take my chances with the goiter"). The same thing happened when health officials proposed adding fluoride to water to prevent dental caries. This time, though, one official got clever and announced that fluoride would be added to the municipal water supply on a certain date, then when numerous people experienced adverse effects from drinking water on that date, mentioned that he had actually delayed the date but forgotten to tell anyone. So there is reason to hope that one day, receiving annual flu and Covid-19 vaccines will be less about one's partisan allegiances and more about following your doctor's common sense recommendation to protect yourself and others against severe illness and death.

Neurosyphilis, ocular syphilis, and otosyphilis are don't-miss diagnoses

When a patient with a history of migraine headaches presents with a "severe frontal headache and left-eye blurred vision and pain," neurosyphilis is unlikely to be foremost in the differential. Even after she mentions a two-month history of a diffuse maculopapular rash, clinicians may feel reassured because it doesn't involve the palms and soles. But syphilis, the great imitator, was in fact the eventual diagnosis in this patient, the subject of a case report published in Cureus.

In the August issue of American Family Physician, Dr. Jennifer Jones-Vanderleest reviewed detection and treatment of neurosyphilis, ocular syphilis, and otosyphilis, which can occur at any stage of syphilis regardless of immune status. Early neurosyphilis (within the first few years of infection) can present with "headache, dizziness, altered mental status, cranial neuropathies, motor and sensory deficits, meningitis, or stroke." Neurosyphilis is diagnosed with the combination of neurologic signs and symptoms and reactive syphilis serology and cerebrospinal fluid (CSF) tests. The 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines recommend that patients with neurosyphilis be treated with 18 to 24 million units of aqueous crystalline penicillin G per day for 10 to 14 days, administered as a continuous infusion or 3 to 4 million units intravenously every 4 hours. These patients should be tested for HIV and be offered HIV preexposure prophylaxis if HIV negative. After treatment, normalization of the serum RPR titer predicts normalization of CSF parameters; thus, repeated CSF sampling is not needed unless the patient is HIV positive and not receiving antiretroviral therapy.

As I discussed in a previous post, the incidence of syphilis in the U.S. has been rising steadily for the past two decades (beginning in my third year in medical school and continuing throughout my family medicine residency and practice) due to stagnant health department funding for contact tracers and the recent impact of the COVID-19 pandemic. Far from being ancient history, "in 2020, 133,945 cases of all stages of syphilis were reported, including 41,655 cases of primary and secondary syphilis," according to the CDC. Although a disproportionate number of cases occur in men who have sex with men, rates in women have increased sharply since 2016. A current review of the epidemiology, natural history, diagnosis and treatment of syphilis is available in the Journal of Lancaster General Hospital.

A draft recommendation statement from the U.S. Preventive Services Task Force (USPSTF) reaffirmed the importance of screening adolescents and adults at increased risk for syphilis infection. The USPSTF also recommends that all pregnant patients be screened for syphilis as early as possible in pregnancy. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend rescreening women at high risk for syphilis at 28 weeks of gestation and again at delivery to prevent congenital syphilis.

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This post first appeared on the AFP Community Blog.