Staying Alive, Staying Alive!

In the past couple of years, the American Heart Association’s emphasis on CPR has been on the chest compressions, rather than the traditional method that also includes rescue breathing. The AHA’s message boils down to this: if you witness a teen or adult suddenly become unconscious, call 911 and start pressing hard and fast in the center of the victim’s chest (to the beat of the disco song “Staying Alive”.)  A recent study was published in Resuscitation (Current knowledge of and willingness to perform Hands-Only CPR in laypersons) which demonstrated that while less than 20 percent of laypersons knew about hands-only CPR, around 75 percent would be willing to perform it on a stranger. However, since four out of five cardiac arrests happen at home, the life you save is more likely to be someone close to you- not a random stranger. Effective CPR doubles or triples the victim’s chance of survival. As physicians, we can help educate our patients about Hands-Only CPR via posters in exam rooms or perhaps a link on our website to the AHA one minute video.

Taking it one step further, how many of you have been trained on automatic external defibrillators (AEDs)? I will confess that this week was my first instruction on an AED, though obviously in my medical training I had used standard defibrillators. AEDs are virtually everywhere in our communities- at schools, health clubs, malls, grocery stores, churches, golf courses, airports, and restaurants. Although the specific laws vary from state to state, AEDs are now required in many public facilities. While an AED is simple to use, the old med-school dictum of “see one, do one, teach one” certainly has given me a much higher comfort level the next time I witness an arrest.

Systematic reviews have repeatedly confirmed similar predictors of survival from out-of-hospital cardiac arrest; primarily that survival is better in the setting of a witnessed arrest (whether it is a bystander or EMS), and when chest compressions are deeper and faster (goal of at least 100 compressions/minute.) Unfortunately, overall survival from cardiac arrests outside of the hospital has not changed in the past several decades; it remains at 7.6%.

If you have not yet been trained, taking a brief AHA course would be ideal. Meanwhile, if you have an AED at work, we would like to encourage you to at least take 5 Minutes to literally open up the machine and familiarize yourself with the procedure. And bring a colleague.

See our Topics: Cardiac Arrest; Asystole; Arrythmias, APB’s; Arrhythmias, AVNRT; Arhythmias, Ventricular Tachycardia

Jill Grimes, MD, FAAFP

Family Physician, Author & Educator

 Associate Editor 5-Minute Consult

www.jillgrimesmd.com

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Hot Updates for Your Practice

Watchful Waiting for Children > 6 Months with Otitis Media

AAP/AAFP have issued an update of the 2004 otitis media guideline.  It supports the recommendation for a strategy of the option of watchful waiting for patients older than 6 months with non-severe unilateral otitis media, and for children greater than 24 months with non-severe OM (bilateral or unilateral). Amoxicillin remains the first choice for most situations, with exceptions of amoxicillin treatment in past 30 days, history of recurrent OM, known resistance to Amoxicillin, or presence of purulent conjunctivitis.

Lieberthal AS et al. Pediatrics 2013 Mar 1; 131:e964. (http://dx.doi.org/10.1542/peds.2012-3488)

 

Autism Increased Prevalence Due to Increased of Previously Undiagnosed Children

A National Survey of Children’s Health (NSCH), conducted by the Centers for Disease Control, reported a significant increase from the 2007 survey in the prevalence of parent-reported Autism Spectrum Disorder (ASD) among children aged 6–17; going from 1.16% in 2007 to 2.00% in 2011–2012.  The authors concluded much of this prevalence increase was the result of new diagnoses of children with previously unrecognized ASD.   

 National Health Statistics Report 2013; Vol 65:  http://www.cdc.gov/nchs/data/nhsr/nhsr065.pdf

 

Vitamin D Deficiency in Pregnancy increases risk of adverse outcomes.

Systematic Review found women with insufficient Serum 25 OH Vitamin D levels (< 30 ng/mL) had an increased risk of Gestational Diabetes, Pre-Eclampsia, SGA, and bacterial vaginosis.  Outcome data still pending to demonstrate if addressing the deficiency lowers risk of adverse outcomes.

BMJ 2013; 346: f1169 (http://www.bmj.com/content/346/bmj.f1169)

Frank Domino, MD

Robert Baldor, MD

Jeremy Golding, MD

SAD, Watt Might Help

Yes, it’s flu season (keep encouraging flu vaccines!) but don’t forget winter also brings another seasonal malady– Seasonal Affective Disorder (SAD). This depressive disorder was formally named only a few decades ago. SAD affects over half a million people each winter, resulting in many patients seeing their primary care physicians for SAD symptoms.

Who gets seasonal affective disorder? It’s most common in women (3:1 over males) and young adults 20-30 years old, but it is seen in across the spectrum. January and February are the most common months SAD is diagnosed.

What are the complaints? Often fatigue, weight gain and recurrent illness are the primary issues, rather than simply “sadness”. The symptoms range from a mild case of “winter blues” to serious depression.

What is the cause? There are different theories, most of which are linked to hours of sunlight. There is disruption in our circadian rhythms as well as decreased seratonin secretion during winter months, and of course, less Vitamin D.

Prevention? Light therapy (using full spectrum light bulbs in your home and work) or consciously spending more time outside in the sunlight can help prevent S.A.D.

Treatment? Light therapy is the treatment of choice with the least side effects. Anti-depressant medications (Buproprion is the only one FDA indicated, but SSRI’s such as fluoxetine are also used), and Vitamin D replacement (if low) have also shown effectiveness in improving symptoms.

Light therapy aims to artificially increase exposure to light during the time of year when our natural daylight is limited. Typically light therapy is performed by sitting in front of a light therapy box, which simply gives off bright light similar to natural outdoor daylight (rather than standard light bulbs). During the session, the person may read, write or even eat- he or she does not need to focus on the light.  Although most people with SAD will require the therapeutic intensity of a light therapy box, many people with mild symptoms will respond to full spectrum light bulbs replacing their normal light sources at home.

Does light therapy work for other depressive disorders? Maybe. More studies are needed as we try to find depression treatments that do not carry large side effect profiles, and light therapy is a perfect example. Bright light therapy has been effectively used to improve symptoms in chronic depression, post-partum depression (baby blues), premenstrual depression and sleep cycle disorders.

What to do?  Identify SAD in your patients this time of year, encourage them to try full spectrum light therapy, and consider full spectrum light bulbs to prevent recurrence next fall.

- Jill Grimes, MD,  Frank Domino, MD

OC OTC?

ACOG waded into some controversial waters recently by issuing a position paper advocating over-the-counter (OTC) availability of oral contraceptives (OC).

They make several arguments in support of their position:

Unintended pregnancy remains a major problem in the US. About half of all pregnancies each year are unintended, and half of these pregnancies are terminated. Health outcomes are less good for women and their infants when pregnancy is unintended, and such pregnancies are economically burdensome to society.

Problems with access to prescription birth control and the cost of Rx methods interfere with obtaining contraception and lead to ‘gaps’ (unintended discontinuation, errors) in use.

There is no medical reason why STD screening and cervical cancer screening need to be linked (as they traditionally have been) to OC access.

Most women would be interested in OTC access, and can “self-screen” for safe use (such access already exists around the world in most countries).

OCs are quite safe, with venous thromboembolism (VTE) risk around 1 per 1000 women-years of use. The risk of spontaneous VTE during pregnancy may be as much as double this, and is five times greater in the post-partum period. From a purely health standpoint, it is much riskier to be pregnant or post-partum than it is not to be pregnant!

Those opposed to OTC OC cite concerns about whether women can self-screen for contraindications to hormonal contraception, about whether safety and efficacy will be good when the med is not prescribed, and they express concern that women will stop coming in for recommended preventive care, like Chlamydia screening (sexually active women under age 25) and  pap testing (women over age 21). Some have raised concerns that OTC birth control increases teens’ likelihood of risky sexual behavior.

No data exists to support these concerns.

Regardless of what public policy makers decide, there are several KEY principles to good prescribing practice for contraceptives:

“Unlink” contraception from the pelvic exam. Women should not need to have an exam to receive a prescription. Encourage STI testing (urine NAAT testing is highly accurate!), but don’t require anything but a health review.

Provide many months or a year supply. Continuation rates are best if women do not need to come in for follow-up or call for refills. There is no need to check a followup blood pressure in the large majority of healthy women.

Learn how to do “Quick Start” – no need to wait for the next menstrual period to begin!  See http://rhedi.org/contraception/quick_start_algorithm.php for the algorithm.

Provide an ADVANCE Rx of “the morning after” pill (post-coital contraceptive) levonorgestrel “Plan B”or ulipristal “Ella” to ALL sexually active teens and to most women not using high-effectiveness birth control. Encourage patients to fill it before it is needed!

Advocate for free or inexpensive OC! In a study published this year, free birth control reduced pregnancy rates in teens from 34 per 1000 to 6 per 1000 (Peipert J, et al. Obstet Gynecol. 2012 Dec;120(6):1291-7.). Pharmacies like Target may offer a specific bargain-rate generic for $10 for a three month supply.

Discuss and prescribe long-acting contraception like IUD’s, Depo-Provera, and Nexplanon/Implanon. These are the most effective methods of contraception and may be used in nulliparous women and in women with multiple sexual partners.

Excellent resources for more contraceptive information and free, high-quality patient education materials:

www.rhedi.org Center for Reproductive Health Education in Family Medicine

www.arhp.org Association of Reproductive Health Professionals

ACOG statement:

http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/Over-the-Counter_Access_to_Oral_Contraceptives

- Jeremy Golding, MD

Are You Ordering Routine Screening HIV Tests? Why NOT?

Physicians in private practice settings with lower prevalence of HIV disease may be unaware that back in 2006, the CDC released revised HIV screening recommendations.  They included one-time routine screening testing for ALL patients 13-64 years of age. Additionally, all patients seeking treatment for any STD should be routinely screened for HIV during “each visit for a new complaint, regardless of whether or not the patient is known or suspected to have specific behavior risks for HIV infection.”

On November 20, 2012, the USPSTF got on board and issued a draft recommendation for routine HIV screening for all people 15-65 and all pregnant women regardless of age.

Why would these organizations suggest such universal testing? In populations where the prevalence of undiagnosed HIV disease is greater than 0.1%, voluntary HIV screening is as cost-effective as screening for hypertension. Over 1.2 million Americans are living with HIV disease, yet an estimated 25% of them do not know they are HIV-positive. Early recognition and treatment of HIV disease dramatically improves outcomes, and has also been shown to change behaviors and decrease transmission of the virus.

Like all STDs, HIV crosses economic, political and social divisions, and if we only test those patients we believe to be at high risk, we will be missing cases within our practices. Acute HIV infection is often missed because the symptoms overlap with mono, influenza or other viral illnesses, and HIV is not in the original differential.

How often should we screen? Annual screens are indicated for those patients at higher risk, which includes the classic groups (sex workers, injection drug users, partners of HIV+ individuals, men who have sex with men, or partners of any of these groups) AND everyone who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.

Do we need lengthy consents and counseling before testing? No. As long as the patient knows the test will be performed, a separate consent form is not required. Clinicians should offer a brief explanation of the disease and test, and provide the patient an opportunity to ask questions or “opt-out” of testing (as we ideally should do with any testing, of course).

In medical school, we learned you can’t find a fever if you don’t check a temp. Let’s follow the CDC’s recommendations and fully implement routine HIV screening so we don’t miss the opportunity for early diagnosis and treatment that can literally change our patients’ lives.

Remember World AIDS Day on December 1st.

See Related 5MCC Patient Handouts: Coping with an HIV Diagnosis; HIV and Plasma Viral Load Testing; HIV Infection in Women; HIV Treatment; How to Reduce Your HIV and AIDS Risk

See Related 5MCC Topics: HIV Infection and AIDS; HIV and AIDS in Pregnancy; HIV/AIDS, Urologic Considerations; HIV Infections, Pediatric; HIV-Related Neuropathy; Sexually Transmitted Infections

On Screening and Treatment

Maybe the fault lies with “House,” or “ER.”  Whatever the cause, patient expectations about what health care can do are often not consistent with reality.  And when expectations are high, disappointment can follow.

A recent study in the Annals of Family Medicine (Ann Fam Med. 2012; 10(6): 495-502) looked at patients’ expectations and the actual benefits from a variety of screening and treatment interventions.  Perhaps not unsurprisingly, patients’ expectations are far greater than what we can deliver.

This study asked patients to rate how many people (out of a population of 5,000 over the age of 50) would benefit from a variety of medical interventions.  On average, the patients overestimated  the benefits by more than 85%!

Breast Cancer: The survey asked patients to estimate how many of the 5,000 women  screened with an annual mammogram over a  10 year period would  avoid  death from breast cancer.  The correct answer is less than 15 out of the 5,000 women (NNT = 337-2,500).  However, 90% of the respondents thought mammography was much more effective at preventing death.

Colon Cancer: The survey asked patients to estimate how effective yearly fecal occult blood testing would be in preventing death from colon cancer.  Once again the respondents grossly overestimated the benefit of this intervention. Correct answer is 5-10 out of 5,000 (NNT = ~600).  (By the way, the best data we have on colonoscopy to prevent death gives a NNT of 1,250 (J Med Screen. 2001;8(3):125-7)).

Hip Fracture Prevention: For this issue, the survey asked, “out of 5,000 people with osteoporosis treated with a bisphosphonate for 10 years, how many hip fractures would be prevented?”  The correct number is about 50 out of 5,000 (NNT = 90).  Over 80% overestimated this benefit.

Cardiovascular Disease Prevention: finally the survey queried about using drugs for treating  hypertension and hyperlipidemia for the primary prevention of CHD in 5,000 people.  The correct answer was 75-85 people would need to be treated to prevent 1 CHD event over 10 years; almost 70% of respondents overestimated this benefit (if you want more on the limited efficacy of treating hypertension, see our blog on “What is Adequate Blood Pressure Control”).

So, what does this tell us?  Our patients (and maybe us, too) believe the current benefits of medicine are better than they can actually achieve.

Keep these limited benefits in mind when you counsel patients about screening and treatment.  Give them hope, and help them make good decisions.  If you want more on the efficacy of these interventions, check out our chapters on each topic; and to dig deeper, check out:  http://www.tripdatabase.com/; a great online resource to help you keep the benefits of a variety of interventions in perspective.

- Frank J. Domino, MD

What is Adequate Blood Pressure Control?

The current HEDIS measures on blood pressure control tell us the “goal” is a systolic BP of <140 mmHg and a diastolic BP of <90 mmHg.  Seems like a no brainer, right?  It was, until recent publications began to call this goal into question.

A recent study found, for adults over age 50, having a diastolic of >90 mmHg might not increase mortality if the systolic is <140 mmHg (J Gen Intern Med. 2011 July; 26(7): 685–690).  And, in those under 50 years, a diastolic over 90 mmHg increases risk.

Confused?  A 2012 Cochrane Systematic Review of 9,000 patients found no benefit to treating “Mild Hypertension” which was defined as Systolic BP of 140-159 mmHg and Diastolic BP of 90-99 mmHg.  And, the relative risk of an adverse event was 4.8 (Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD006742).

For those with Type 2 Diabetes, the best outcomes from the ACCORD trial were found when the treatment goal was a systolic BP of <140 mmHg (N Engl J Med 2010;362:1575-1585), rather than the previous treatment parameter of <130/<80.

So what is a busy provider to do?  First, make sure your patients really have hypertension.  A 2011 study of those classified as having resistant hypertension (needing 3 or more meds to control BP) found 1/3 of the patients had white coat hypertension (Hypertension. 2011; 57: 898-902).  If insurers won’t cover 24 ambulatory BP monitoring, have the patient buy an inexpensive automated BP cuff, check their pressures twice a day, keep a log, and after collecting data for 1  week, mail it in.

Next, don’t hold the salt.  Yes, I said DO NOT hold the salt. A Cochrane review says most people who restrict salt obtain very little BP benefit (Cochrane Database Syst Rev. 2011 Nov 9;(11):CD004022).  Salt restriction in Whites with hypertension reduces the BP by 5/<3 mmHg, Blacks <6/<2.5 mmHg.  Asians with systolic BP get the best benefit at 10/<3 mmHg reduction.  What about the DASH diet?  This was a 30 day trial of a variety of interventions; no idea of its true efficacy.

What lifestyle changes really make a difference?  Aerobic exercise, just 20 minutes each day for 5 days a week, improves BP control AND lowers CHD risk.  Smoking cessation.  And 2008 meta analysis says meditation, practiced daily, is also effective (Am J Hypertens. 2008 Mar;21(3):310-6).

Hypertension is an important disease; do not take it lightly.  But, diagnose and treat it appropriately, and your patients will live happier, and longer.

- Frank J. Domino, MD