496 - F/U HFpEF, PT for Meniscal Tears, Eating Disorders, Last Times
Take 3 – Practical Practice Pointers©
Thanks to an astute Take 3 reader, Jon Sweet, MD, who is a General Internist and the Chair of the Carilion Clinic Department of Internal Medicine, regarding the Take 3 Pointer in the May 12 Edition on the diagnosis and management of heart failure with preserved ejection fraction. Jon caught Mark with his critical thinking skills guard down.
He writes: “The publication seems "all in" for SGLTii for HFPEF. There was no real discussion of overall value. The published cost-effectiveness data to date, concludes that SGLT2i for HFPEF, at current costs in the US., is either low value or intermediate value, depending on specific patient characteristics. This will likely change over the years when costs come down significantly. There is some clinical benefit, of course, but these are modest compared to HFrEF, and almost entirely attributed to reduction in HF hospitalizations. The current guidelines state that SGLT2i for HFpEF is a 2a indication ("reasonable"), the same as ivabridine for appropriately selected patients HFrEF patients. The other meds in the chart have a 2b rating ("might be reasonable") for HFpEF, the same as digoxin for HFrREF.”
“Of course, cost-efficacy analyses are not intended for individual patient decision- making, but they are important for the high-value care of populations. SGLT2i for HFpEF are likely a somewhat better value for younger patients with HFmrEF (40-50%) and low-value for older patients with HFpEF and EF>60, but there is consensus that SGLT2i for HFpEF are currently low (to possibly intermediate) value from a societal standpoint.”
Great clinical wisdom Jon. Thank you!
From the Literature
1) Physical Therapy for Meniscal Tears
Meniscal tears are a common injury to the knee, and we are conditioned to look for them because they are frequently perceived as a “fixable” condition (as opposed to osteoarthritis or other more chronic conditions). Partial meniscectomy is a surgery that can remove the damaged part of the meniscal cartilage, leaving behind a “smooth and solid” meniscus. The ESCAPE study was a randomized trial of partial meniscectomy compared with physical therapy (PT) for meniscal tears that demonstrated superior functional outcomes for physical therapy at two years. These recommendations have already begun to make their way into guidelines, and the authors are publishing five- year follow up results from this study.
The study was a randomized controlled trial of arthroscopic partial meniscectomy vs. 8 weeks of semi-weekly PT for MRI confirmed symptomatic meniscal tear in patients 45- 70 years old. For practical purposes, only the outcome assessments (validated patient- reported functional surveys and radiographic appearances) were blinded. 321 patients were initially enrolled, but only 139 in each group were analyzed at 5 years. Of note, 32% of patients in the PT group still ended up having surgery for their injury, mostly within the initial 2-year period. There was a non-inferiority analysis performed for the primary outcome (functional survey), which specified an 11-point difference in a 100 point scale score as the threshold for non-inferiority. Both the intention to treat and the as-treated analyses (crude and adjusted) showed that PT was non-inferior to surgery at 3, 6 and 12 months as well as 2 years and 5 years. There were similar non-inferiority findings for the radiologic and symptomatic osteoarthritis findings.
Patients with knee injuries frequently want “their MRI” to assess the need for surgery. Having to counsel them on the benefits of PT prior to imaging feels sometimes like gatekeeping for the insurance company, but this study provides us a valid non-surgical option. The authors of this study note that they had to pay for the complete course of the PT for the participants in this trial as the Dutch government health insurance does not cover PT. Here in the US, PT adherence is hampered by the specialty co-pay assigned to it by most insurers. Hopefully with evidence like this, we can reduce the patient obligation for this useful intervention.
· Noorduyn JCA, van de Graaf VA, Willigenburg NW, et al. Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial. JAMA Netw Open. 2022;5(7):e2220394. Link
From the Guidelines and the American Psychiatric Association (APA)
2) Evaluation and Management of Persons with Eating Disorders
The lifetime prevalence of eating disorders in the US is approximately 0.80% for anorexia nervosa (AN), 0.28% for bulimia nervosa (BN), and 0.85% for binge-eating disorder (BED). These disorders are associated with increases in all-cause mortality and deaths due to suicide. Morbidity and mortality among individuals with an eating disorder are heightened by the common co-occurrence of health conditions such as diabetes and other psychiatric disorders, particularly depression, anxiety, PTSD, obsessive-compulsive disorder (OCD), ADHD, and substance use disorders.
The APA recently updated its 2006 guideline with the goal of enhancing the assessment and treatment of eating disorders. The guideline committee used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) process to develop the guideline, allowing for the balancing of benefits and harms to determine guideline recommendations and strength of recommendations. Based on this approach, some notable recommendations for primary care clinicians include (adapted):
Assessment and Determination of Treatment Plan:
· Screen for the presence of an eating disorder as part of an initial evaluation for a patient with a psychiatric disorder. (1C)
· Initial evaluation of a patient with a possible eating disorder should include assessment of (1C)
o height and weight history (e.g., maximum, minimum, recent changes);
o presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors (e.g., rumination, regurgitation, chewing and spitting);
o patterns and changes in food repertoire (e.g., breadth of food variety, narrowing or elimination of food groups);
o presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors (e.g., laxative use, self-induced vomiting), and use of medication to manipulate weight;
o percentage of time preoccupied with food, weight, and body shape;
o prior treatment and response to treatment for an eating disorder;
o psychosocial impairment secondary to eating or body image concerns or behaviors; and
o family history of eating disorders, psychiatric illnesses, and medical conditions (e.g., obesity, inflammatory bowel disease, diabetes mellitus).
· Perform a comprehensive review of systems and physical examination. (1C)
· Laboratory assessment should a CBC, CMP. (1C)
· EKG should be done for those with a restrictive eating disorder, severe purging behavior, and those taking medications are known to prolong QTc intervals. (1C).
· Have a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team. (1C)
· Those who require nutritional rehabilitation and weight restoration have individualized goals set for weekly weight gain and target weight. (1C)
· Include an eating disorder–focused psychotherapy. (1B)
· Adolescents and emerging adults who have an involved caregiver should be treated with eating disorder–focused family-based treatment. (1B)
· Adults should be treated with eating disorder–focused cognitive-behavioral therapy and that a serotonin reuptake inhibitor (e.g., 60 mg fluoxetine daily) also be prescribed, either initially or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment. (1C)
· Adolescents and emerging adults who have an involved caregiver be treated with eating disorder–focused family-based treatment. (2C)
· Should be treated with eating disorder–focused cognitive-behavioral therapy or interpersonal therapy, in either individual or group formats. (1C)
· Adults with binge-eating disorder who prefer medication or have not responded to psychotherapy alone should be treated with either an antidepressant medication or lisdexamfetamine. (2C)
I decided to include this as both a reference, and more importantly, to heighten our awareness of these disorders which are often easy to overlook in a busy practice until they are well-established and manifesting significant symptoms – and much more difficult to treat. There is evidence that the prevalence of eating disorders has increased due to social media influence, particularly among adolescents, making it even more vital that we in primary care are on the lookout for them. In reading multiple commentaries in preparation for this Pointer, it’s also interesting to consider how our culture’s seeming obsession with food (“Low Carb”, Keto, etc.) in the midst of the increasing prevalence of obesity may indicate a collective pattern of “disordered eating” when it comes to food.
Also, the third reference is a comprehensive review article from the American Family Physician that provides additional details regarding screening and resources.
· Crone C et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders. Am J Psychiatry 180:2, Published online 1 February 2023. Link
· APA Treatment of Patients with Eating Disorders: Pocket Guide for Clinicians. Link
· Klein D, Sylvester J, Schvey N. Eating Disorders in Primary Care: Diagnosis and Management. Am Fam Physician. 2021;103(1):22-32. Link
From PeerRxMed ( www.PeerRxMed.org )
3) The Art of Taking Nothing for Granted
Recently I saw a long-time patient who had celebrated her 99th birthday since her last visit She’s in remarkably good health, but she seemed disappointed when I told her we could follow-up in 6 months. “Can we make it three months?” She asked. “I might not be here in 6 months. Besides, I’m planning on getting some new outfits for my 100th birthday, and I want to be sure to show you.” We hugged as she prepared to leave. It was a longer hug than I would normally have felt comfortable with. Then, as she prepared to walk out the door, she turned around and said, “By the way, I sure love being your patient.” “I love caring for you as well,” I replied.
Then yes, I got tearful. She was right. Statistically, that might very well be the last time we see each other. The fact is that for everything we do and for everyone we love,
there will be a “last time.” This has certainly been one of the many sobering reminders of the COVID pandemic. And while we “know” this cognitively, if we are willing to stop and reflect on our actions, we don’t always live in a way that demonstrates our awareness of the fleeting nature of those precious present moments. At least that’s the case for me, and I have a sneaking suspicion for you as well.
I’ve blogged before about the “last time meditation” from the ancient Greek philosophy of Stoicism. The premise is quite simple – one is asked to consider, “if I knew this were the last time I was ever doing , or being with , how would I show up differently than I am presently showing up?” In other words, the Stoics recognized that every moment represents a finite opportunity to savor your life. While at first blush that can seem a rather dark question, given the “reality check” of the last 3 years, the question takes on a much sharper focus and perhaps provides a greater sense of urgency.
Indeed, there are “last times” that will be happening in your week this week. Even in your day today.
Over the course of this year, I’ll have the opportunity to connect with many in my extended family. Much has happened since I’ve last seen some of them; graduations, job changes, relationship joys and challenges, new babies, medical diagnoses, financial struggle and success, and deaths of friends and relatives. So, in the midst of laughter and light-hearted fun, I have set an intention to be sure I am showing up fully and taking nothing for granted, knowing that there are likely some “lasts” that are happening and I don’t want to look back with regret at having missed them.
What’s happening in your week that you want to be sure to be fully present for? In those moments, consider taking a pause to perform a brief “last time meditation.” And when appropriate, be sure to tell those who are important to you how much you love and appreciate them. Even if it’s not the “last time,” you’ll be glad you did – and so will they.
Mark and John
Carilion Clinic Department of Family and Community Medicine
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